The concept of mindfulness originated from Buddhist contemplative practice approximately 2500 years ago. Today, it has been increasingly integrated into a variety of health care programs in order to address issues such as chronic pain (e.g., Gardner-Nix, 2009; Morone et al. 2008), mental health problems (e.g., Segal et al. 2012), dealing with cancer (e.g., Mackenzie et al. 2007), and addictions (Bowen et al. 2011). Toneatto et al. (2007)) speculated on the role that mindfulness could play in problem gambling recovery. The purpose of the current study was to further this body of research by evaluating whether a mindfulness-based approach could be successfully integrated into the problem gambling treatment service offered by the Problem Gambling Institute of Ontario (PGIO) at the Centre of Addiction and Mental Health (CAMH) in Toronto.
Overview of mindfulness-based approaches
Marlatt (1985a) was one of the first researchers in the addiction field to recognize the potential for the use of meditation as a coping strategy for individuals who were at risk for relapse. He suggested that practicing meditation could help in relapse prevention (RP) by providing benefits such as reducing stress and achieving balance in one’s life. “[O] ne of the most significant effects of regular meditation practice is the development of mindfulness — the capacity to observe the ongoing process of experience without at the same time becoming ‘attached’ or identifying with the content of each thought, feeling, or image. Mindfulness is a particularly effective cognitive skill for the practice of RP. If clients can acquire this ability through the regular practice of meditation, they may be able to ‘detach’ themselves from the lure of urges, cravings, or cognitive rationalizations that may otherwise lead to a lapse” (p. 319).
Jon Kabat-Zinn (1990) pioneered the implementation of mindfulness in western medicine through the development of his Mindfulness-Based Stress Reduction (MBSR) program. His intent was to treat patients at the University of Massachusetts Medical Centre who suffered from chronic pain and a variety of other medical issues (e.g., living with HIV infection, heart disease, etc.). The focus of mindfulness-based approaches, also called acceptance-based approaches, is on one’s relationship to thoughts and emotions. The aim of the MBSR approach is for clients to become aware of and accept, without judgment, their present moment experience and to learn to see thoughts and emotions as passing mental events. Note that the goal is not to change anything about one’s experience, but, as defined by Jon Kabat-Zinn (1990), to “pay [ing] attention in a particular way: on purpose, in the present moment, and non-judgmentally” (as cited in Bowen et al., 2011, p.46). In mindfulness practice the client is encouraged to cultivate an attitude of curiosity, openness, friendliness, non-judgmental awareness, and acceptance of one’s present moment experience. These attitudes are emphasized through teaching and learning about such themes as non-judging, patience, beginner’s mind, trust, non-striving, acceptance and letting go (see Bowen et al., 2011).
Since Kabat-Zinn’s initial work, mindfulness-based approaches have been integrated into a variety of other therapies/programs including: Mindfulness-Based Cognitive Therapy (MBCT, see Segal et al. 2002), Mindfulness-Based Relapse Prevention (MBRP, Bowen et al. 2011), Dialectical Behaviour Therapy (DBT, see Linehan, 1993) and Acceptance and Commitment Therapy (ACT, Hayes et al. 1999). A core element of a number of these programs (e.g., MBSR, MBCT, MBRP) is that they all follow an 8-week group protocol utilizing similar mindfulness meditation practices such as mindful eating, the body scan, sitting meditation (i.e., mindfulness of the breath, body, sounds, thoughts and emotions), mindful walking, and Yoga.
Relation of problem gambling to mindfulness-based approaches
An important area of problem gambling research involves investigating the cognitive factors that contribute to a gambler’s difficulty in controlling the impulse to engage in repeated, persistent gambling (see Petry, 2005; Toneatto, 1999, for reviews). For example, many problem gambling behaviours (e.g., chasing, incremental betting) are the result of erroneous beliefs about the concept of randomness (Toneatto et al., 1997; Turner, 1998; Turner et al. 2006). Yet even if people are taught about the concept of independence of random events, the act of gambling itself can overpower what they have learned (see Benhsain et al. 2004; Sevigny and Ladouceur, 2003). Furthermore, people with gambling problems have reported going into a trance-like state while gambling, which suggests that problem gambling often involves automatic thoughts that take place outside of awareness (see Jacobs, 1988; Gupta and Derevensky, 1998).
According to Toneatto et al. (2007), “[d] istinguishing mental events from the responses to them provides a choice to the gambler regarding how best to respond, rather than react, to gambling related cognition. It is argued that improving gambler’s mindfulness can help them overcome the erroneous beliefs and automatic behaviours associated with problem gambling. Learning to relate differently to gambling cognitions may be as important as, if not more important than, challenging the specific content of the thoughts” (Toneatto et al., 2007, p. 94).
We believe that if people learn how to be aware of their thoughts by practicing mindfulness techniques, the urges and cravings that often drive a person to gamble, or relapse to gambling, can be overcome. For example, Bowen et al. (2011) uses an “urge surfing” analogy to help clients cope with the intensity of their cravings. Riding the wave of craving (e.g., the urge to gamble) is like riding on a surfboard without being submerged by the intensity of the wave. The idea is that through this meditation exercise, clients become aware of their urges but are not ruled by them. The keys are learning to recognize the impermanence of all experience and understanding urges as passing, mental events that do not have to be acted upon or fought.
In recent years there has been a growing literature on the relationship between mindfulness and problem gambling (see de Lisle et al. 2012; Shonin et al. 2013b). According to de Lisle et al. (2012) the literature indicates that there is an inverse relationship between dispositional mindfulness and psychological distress, and this may be mediated by a number of factors including emotional, cognitive, and behavioural flexibility. For example, Lakey et al. (2007) found a significant negative correlation between gambling problems and mindfulness amongst undergraduate students. In a second study they showed that mindfulness was related to performance on two risk-related judgment and decision-making tasks. Lakey et al. (2007) speculated that “greater attention to and awareness of ongoing internal and external stimuli that characterizes mindfulness may represent an effective means of mitigating the impulsive and addictive responses and intemperate risk-attitudes of individuals with PG” (p. 1708). A 2011 study by de Lisle et al. (as reported in de Lisle et al., 2012) replicated some of these findings with two samples of treatment-seeking problem gamblers. They found that problem gamblers had lower levels of dispositional mindfulness than normative samples of adult community members and university students, and “that dispositional mindfulness was negatively related to gambling urges, gambling pre-occupation, problem gambling severity, gambling expenditure, and gambling frequency” (de Lisle et al., 2012, p. 721).
A study by Riley (2012) examined a type of experiential avoidance called thought suppression and found that thought suppression was positively related to problem gambling, whereas mindfulness was negatively related to problem gambling. De Lisle et al. (2012) reviewed the evidence for a number of different mechanisms that may be involved in mindfulness including dealing with issues such as a myopic focus on reward, psychological distress, rumination, thought suppression, and improving emotional, cognitive, and behavioural flexibility. De Lisle et al. (2012) note that the relationship between “mindfulness and problem gambling behaviour is likely to be very complex” (p. 731) because mindfulness is itself a complex construct. They also discuss a number of theoretical models of how mindfulness may be related to problem gambling.
Very few studies have evaluated the clinical application of mindfulness for problem gambling. Two case studies have been published that describe the use of mindfulness (see de Lisle et al., 2012), and in both cases, mindfulness was successful in helping the client towards recovery. In addition, two studies have examined the efficacy of Dialectical Behaviour Therapy (DBT) which includes mindfulness as a component of the treatment. Korman et al. (2008) used a DBT model to provide an integrated treatment for problem gambling, anger, and substance abuse. They found that the integrated treatment model reduced substance use, but no measure of specific mindfulness skills were reported. Recently, Christensen et al. (2013) reported an evaluation of the use of a modified DBT approach with treatment-resistant problem gamblers. They found that mindfulness improved significantly from pre-test to post-test.
The current study is an evaluation of a mindfulness group that was run as part of the standard treatment offered at PGIO in Toronto. A mindfulness group was first run in 2010 and incorporated into the standard treatment for clients at PGIO in 2011. The data described in this paper was used to evaluate part of the regular treatment program and not collected as a research project. The study was not a controlled study; the project assessed the extent to which the participants reported improving their levels of mindfulness over the course of the therapy. Because the clients were in an overall treatment program, isolating the part of their recovery resulting from the mindfulness group rather than other components of their treatment (e.g., case management, other groups) was not possible. Therefore outcome data on gambling behaviour was not collected.
This paper reports on the data from three groups that were evaluated in terms of how well they learned to use mindfulness techniques to deal with their gambling-related problems. The evaluation used a pre-test and post-test to determine if the participants improved in their level of mindful awareness. In addition, after the 8-week course was complete, the participants answered a course reflection questionnaire. We hypothesized that the participants would show a substantial improvement in their mindful awareness of their moment-to-moment experiences.