Are there clinical, psychopathological and therapy outcomes correlates associated with self-exclusion from gambling? Journal of Behavioral JUAN C. URÍSZAR1,2 , ANAHÍ GASPAR-PÉREZ1,3 , Addictions ROSER GRANERO3,4,5 , LUCERO MUNGUÍA1,3,4 , 12 (2023) 2, 522–534 MILAGROS L. LARA-HUALLIPE1,3 , BERNAT MORA-MALTAS1,3 , ISABEL BAENAS1,3,4 , DOI: 10.1556/2006.2023.00018 MIKEL ETXANDI6 , MÓNICA GÓMEZ-PEÑA1,3 , © 2023 The Author(s) LAURA MORAGAS1,3 , CLAUDIA SISQUELLAS1 , FERNANDO FERNÁNDEZ-ARANDA1,3,4,7 and SUSANA JIMÉNEZ-MURCIA1,3,4,7p 1 Clinical Psychology Unit, University Hospital of Bellvitge-IDIBELL, Barcelona, Spain FULL-LENGTH REPORT 2 Sub-Directorate General for the Regulation of Gambling, Directorate General for Taxation and Gambling, Secretariat of Finance, Ministry of the Economy and Finance, Generalitat de Catalunya, Barcelona, Spain 3 Psychoneurobiology of Eating and Addictive Behaviors Group, Neuroscience Program, Bellvitge Biomedical Research Institute (IDIBELL), 08908, Barcelona, Spain 4 Ciber Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, Madrid, Spain 5 Department of Psychobiology and Methodology, Autonomous University of Barcelona, Barcelona, Spain 6 Department of Psychiatry, Germans Trias i Pujol Hospital, Barcelona, Spain 7 Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain Received: October 14, 2022 • Revised manuscript received: February 23, 2023 • Accepted: April 30, 2023 Published online: May 26, 2023 ABSTRACT Background and aims: Self-exclusion in gambling disorder (GD) is considered a measure to decrease the negative consequences of gambling behavior. Under a formal self-exclusion program, gamblers request to be banned from accessing to the gambling venues or online gambling. The aims of the present study are: 1) to determine sociodemographic characteristics of a clinical sample of seeking-treatment patients with GD who are self-excluded before arriving at the care unit; 2) to identify personality traits and general psychopathology of this clinical population; 3) to analyze the response to treatment, in terms of relapses and dropouts. Methods: 1,416 adults seeking treatment for GD, who are self-excluded completed screening tools to identify GD symptomatology, general psychopathology, and personality traits. The treatment outcome was measured by dropout and relapses. Results: Self-exclusion was significantly related to female sex and a high sociodemographic status. Also, it was associated with a preference for strategic and mixed gambling, longest duration and severity of the disorder, high rates of general psychopathology, more presence of illegal acts and high sensation seeking rates. In relation to treatment, self-exclusion was associated with low relapse rates. Conclusions: The patients who self- exclude before seeking treatment have a specific clinical profile, including high sociodemographic status, highest severity of GD, more years of evolution of the disorder and high emotional distress rates; however, these patients’ presents better response to treatment. Clinically, it could be expected that this p Corresponding author. strategy could be used as a facilitating variable in the therapeutic process. E-mail: sjimenez@bellvitgehospital.cat KEYWORDS gambling disorder, self-exclusion, sociodemographic characteristics, clinical profile, treatment outcome Journal of Behavioral Addictions 12 (2023) 2, 522–534 523 INTRODUCTION This is considered a restrictive form of protection used by gamblers who seek either achieving abstinence or reducing gambling behaviors (Motka et al., 2018). It consists of the Gambling Disorder (GD) has been recently recognized as an gambler’s request to be banned from accessing the gambling addictive disorder. It is characterized by being a persistent venues or online gambling, under a formal self-exclusion and recurrent gambling pattern that causes clinically sig- program carried out by the government regulators (Ley 13/ nificant impairment or discomfort, adversely affecting psy- 2011, de 27 de Mayo, de Regulación Del Juego, 2011) or by chosocial functioning and physical and psychological health the gambling provider (Gainsbury, 2014). (American Psychiatric Association, 2013). In adult popula- The characteristic that defines self-exclusion is that it can tion, research estimates that between 0.1 and 5.8% of the only be carried out if the gambler formally expresses his or general population reach diagnostic criteria for gambling her wish to be denied access to online gambling or gambling problems, and between 0.7 and 6.5% present these gambling venues for a period of time (Gainsbury, 2014). In either case, problems throughout their lives (Calado & Griffiths, 2016). the formalization of self-exclusion expresses an initial The etiology of GD involves genetic and environmental determination to put an end to problem gambling by using factors, making it a multi causal disorder (Potenza et al., this protective tool that has been shown to decrease the 2019). Being young and a man are factors associated with negative impact of gambling behaviors, and can be used as a the development of GD (Calado, Alexandre, & Griffiths, preventive measure against the possibility of relapse (Dick- 2017; Sharman, Butler, & Roberts, 2019; Turner et al., 2018). son, Derevensky, & Gupta, 2008). It has also found that having a low socioeconomic can be a Self-exclusion has become a good support for therapeutic risk factor (Subramaniam et al., 2015; Volberg, McNamara, treatment due to four reasons: 1) a voluntary action of the & Carris, 2018). gambler based on his/her decision; 2) the Country Admin- In terms of other psychological characteristics, GD has istration is the ultimate organization responsible for been associated with high levels of impulsivity (Mestre-Bach ensuring that self-exclusion is carried out efficiently; 3) there et al., 2020; Steward et al., 2017) deficits in decision-making, is an official record with the gambler’s identification data emotional regulation, harm avoidance and low self-direction and; 4) this record has to be available to land based or online (Canale, Vieno, Griffiths, Rubaltelli, & Santinello, 2015; gambling operators (Australian Communications and Media Leeman & Potenza, 2013; Mallorquí-Bagué et al., 2016; Authority, 2023; Direcció General d’Ordenació del Joc, 2023; Moragas et al., 2015; Wyckmans et al., 2019). Moreover, Gambling Commission, 2022; National Council on Problem several comorbidities have been reported in GD as substance Gambling, 2014; National Responsible Gambling Pro- use disorders (SUD) (Grant & Chamberlain, 2020; Petry, gramme, 2023; Responsible Gambling Council, 2023). Stinson, & Grant, 2005; Rash, Weinstock, & Van Patten, Some systematic reviews that have analyzed the effec- 2016), affective disorders (Dowling et al., 2015; Karlsson & tiveness of self-exclusion programs in the last 16 years in Håkansson, 2018; Rodriguez-Monguio, Errea, & Volberg, different international jurisdictions (Motka et al., 2018; Sally, 2017) and personality disorders (Dash et al., 2019; Petry 2014), have found that self-exclusion rates in online et al., 2005; Vaddiparti & Cottler, 2017) which have been gambling range from 5.4 to 11%, while in land-based associated with worse treatment outcomes (Stevens, King, gambling a variation of 0.6 and 17% has been found (Motka Dorstyn, & Delfabbro, 2019). et al., 2018). The characteristics of self-exclusion are However, not all risk factors are individual, there are different in each country such as; the information offered factors directly related to the gambling industry which offer about the gambling problem (which may lead the problem a legal and easy accessibility environment. Advertising gambler to seek therapy or to consider self-exclusion as a strategies also contribute to its normalization, as well as the mere administrative action), the place where the self-exclu- internet platforms which increased online gambling (Abbott, sion can be carried out, the way to manage the self-exclusion 2007; Bramley, Norrie, & Manthorpe, 2019; Echeburúa, (online web, e-mail or postal mail) or the cancellation of the 2000, 2010, Petry, 2006; Potenza, 2006). self-exclusion (Ladouceur, Sylvain, & Gosselin, 2007; Motka Different strategies have been implemented to reduce or et al., 2018). In relation to the duration, studies have re- minimize the harm caused by GD. The scientific community ported that a person can self-prohibit from 6 months to 5 has been participating in the development of harm mini- years (Motka et al., 2018), while other authors suggest that mization models, as well as the promotion of responsible the self-prohibition can be carried out for a period of one gambling (Blaszczynski, Ladouceur, & Shaffer, 2004; Hing & year and then it can be renewed (Ladouceur et al., 2007; McMillen, 2002) in which the gambling industry, supports McMahon, Thomson, Kaner, & Bambra, 2019); other au- associations for gamblers and public administrations are thors propose that the self-exclusion could be irreversible involved (Departament d’Interior; Relacions Insitucionals i (Ladouceur et al., 2007; Nowatzki & Williams, 2002). Participació de la Generalitat de Catalunya, 2010; Departa- Regarding people who use self-exclusion, sociodemo- ment de Salut de la Generalitat de Catalunya, 2017; Minis- graphic characteristics, such as gender, age, educational level terio de Sanidad, 2018). or economic level, are not fully known. According to current Within the responsible gambling programs, one of the literature (Abbott, 2019b; Kotter, Kräplin, Pittig, & Büh- key models is self-exclusion from gambling (Drawson, ringer, 2019; Motka et al., 2018; Strohäker & Becker, 2018) Tanner, Mushquash, Mushquash, & Mazmanian, 2017). the average age of people that self-exclude ranges between 524 Journal of Behavioral Addictions 12 (2023) 2, 522–534 forty and forty-five years and they are mostly men. More- problems, with significant short- and long-term improve- over, those who have banned themselves from online ments, both in individual treatment and in the group gambling are, on average, 10 years younger than those who modality (Abbott, 2019a; Ginley, Rash, & Petry, 2019; have banned themselves from gambling venues. The same Merkouris, Thomas, Browning, & Dowling, 2016; Petry, studies mentioned that those self-excluded people are mostly Ginley, & Rash, 2017). However, research (Abbott, 2019a; single and unemployed. Research has also found that the Yakovenko & Hodgins, 2021) has reported that most at-risk mental health of people who self-excluded is affected as they gamblers do not seek psychological treatment with a pro- have symptoms of anxiety, depression and SUD, as well as fessional and, when they do, the likelihood of dropout or alterations in social and work life (Hayer & Meyer, 2011; relapse is high. Abbott (2019a) highlights in his systematic Kotter et al., 2019). review the lack of treatments that include the needs of In spite of the protective role of self-exclusion, research different gamblers with GD and their individual comor- has found that the greater the accessibility of gambling or bidities, as well as the lack of research evaluating and the ease of evading self-exclusion measures, the less harm identifying the efficacy of online, industry measures and self- minimization of the gambling problem will be (Hayer & exclusion in interventions. Meyer, 2011; Strohäker & Becker, 2018). This may be related Therefore, the present study had the following aims: 1) to with what some studies have reported, that the longer a determine the sociodemographic characteristics of a clinical person spends in a gambling establishment and the greater sample of treatment-seeking patients with GD who are self- the accessibility is, the more likely they are to self-exclude excluded before arriving at the care unit; 2) to identify several times, since some people return to gambling venues personality traits and general psychopathology of this clin- at the end of their self-exclusion period (Sharman et al., ical population; 3) to analyze the response to treatment, in 2019; Strohäker & Becker, 2018; Turner, Shi, Robinson, terms of relapses and dropouts, by comparing patients who McAvoy, & Sanchez, 2021). were already self-excluded when they requested treatment Therefore, more effective relapse methods based on the with those who were not. profiles of people who resort to self-exclusion are needed to The starting hypothesis is that patients who come to the add to psychological treatments (Sharman et al., 2019; unit requesting treatment for GD that have previously self- Strohäker & Becker, 2018; Turner et al., 2021). In addition to excluded present a specific profile which differentiates them that, having a better knowledge of the socio-demographic, from other patients, as higher severity and duration of the psychopathological, personality and gambling behavior disorder, and higher psychopathology. In relation to treat- profiles of people who ask for self-exclusion before seeking ment response, self-prohibition will be associated with better professional treatment can contribute to designing preven- outcomes. tion programs that are more oriented towards the target population (people with gambling problems who are un- aware of this protection strategy), and to strengthen the METHODS decision of those that have already self-excluded. In the clinical setting, psychological treatment programs, Participants such as motivational interviewing (MI), have proven to be The total sample of the study consisted of 1,416 treatment very effective options for the treatment of GD, helping to seeking adults who met criteria for GD. All of them were increase the patient’s motivation and commitment to the attended at the Behavioral Addictions Unit of the Depart- behavioral change required in therapeutic treatment (Law- rence, Fulbrook, Somerset, & Schulz, 2017; Yakovenko, ment of Psychology of Bellvitge University Hospital, be- Quigley, Hemmelgarn, Hodgins, & Ronksley, 2015). tween 2005 and 2020. The patients were evaluated by a group of psychologists and psychiatrists who are experts in Recently, telephone intervention and Internet-based CBT the GD field, both, in assessment and treatment. interventions, virtual reality and serious video games have Distribution by sex was 161 women (11.4%) and 1,255 been shown to reduce the severity of gambling problems and men (88.6%). 74.9% (n 5 1,060) of the participants had not improve quality of life (Abbott et al., 2018; Bouchard et al., self-excluded previously, while 25.1% (n 5 356) had used 2017; Castrén et al., 2013). Mindfulness has also been shown this resource before attending the first consultation. to be effective in reducing gambling behavior (De Lisle, Dowling, & Allen, 2012; Lakey, Campbell, Brown, & Goodie, 2007) both at the end of treatment and at follow-up Measures (McIntosh, Crino, & O’Neill, 2016). Some authors have Diagnostic Questionnaire for Pathological Gambling ac- proposed Mindfulness as an effective adjunct to CBT and cording to the Diagnostic and Statistical Manual of also as a relapse prevention strategy after standard CBT Mental Disorders (DSM) criteria (Stinchfield, 2009). This (Toneatto, Vettese, & Nguyen, 2007). self-report questionnaire consists of 19 items that evaluate The most widely used and especially effective therapy in the DSM-5 diagnostic criteria for GD (American Psychiatric the treatment of GD is remains the cognitive behavioral Association, 2013). The Spanish version (Jiménez-Murcia therapy (CBT) (Choi et al., 2017; Menchon, Mestre-Bach, et al., 2009), which has achieved good psychometric prop- Steward, Fernández-Aranda, & Jiménez-Murcia, 2018), as it erties, was used: α 5 0.81 for the general population and has been shown to reduce gambling behavior and related α 5 0.77 for the clinical sample. For this study, the total Journal of Behavioral Addictions 12 (2023) 2, 522–534 525 number of DSM-5 criteria for GD was analyzed as a measure document (administrative resolution) indicating their iden- of gambling severity. tity and self-exclusion conditions. Their data are incorpo- Symptom Checklist-Revised (SCL-90-R) (Derogatis, rated into an administrative record that is sent daily to the 1990). This checklist is used to measure various psycho- gambling establishment, so they have an updated instrument logical and psychopathological symptoms. It is made up of to control access for self-excluded. 90 items that measure 9 dimensions of primary symptoms: Self-exclusion granted considering two variables: the somatization, obsession-compulsion, interpersonal sensi- geographical area in which the gambler will not be allowed tivity, depression, anxiety, hostility, phobic anxiety, para- accessing gambling establishments (Region of Catalunya and noid ideation and psychoticism. Furthermore, this test 190 gambling venues) and the period of time that the self- yields: (a) a global severity index (GSI), to measure general ban will last (between 1 and 5 years mandatory period that psychological distress; (b) a positive symptom distress in- can be extended indefinitely at the gambler’s will). Gambling dex (PST), to assess the intensity of symptoms; and (c) a establishments are required by law to verify the identity of total of positive symptoms (PSDI), indicating self-reported the person who wants to access the venue. An adult chosen symptoms. The Spanish adaptation (Derogatis, 2002) was by the gambler can enforce self-exclusion by also signing the used for this study, with good psychometric indices and ban document. This implies that, when the gambler decides mean internal consistency of 0.75 (Cronbach’s α). In the to cancel his or her self-exclusion the support person must study sample, consistency indices were in the very good agree and sign this decision. (α 5 0.83 for hostility) to excellent range (α 5 0.98 for the global indexes), with the only exception of paranoia (α 5 0.74, good). CBT program Temperament and Character Inventory – Revised CBT was implemented in all participants; the treatment (TCI-R) (Cloninger, Przybeck, Syrakic & Wetzel, 1999). consisted of 16 weekly group sessions of 90 min each. All This questionnaire assesses seven personality dimensions: sessions were structured within an outpatient program in the four associated with temperament (search for novelties, Behavioral Addictions Unit of a third level, high complexity harm avoidance, rewards dependence and persistence) and hospital. The main objective of the treatment was to achieve three character dimensions (self-direction cooperation and full abstinence from all types of gambling by providing self-transcendence), and gathers information of 240 items. training in self-control and emotional regulation strategies. The Spanish version (Gutiérrez-Zotes et al., 2004) that was The complete program was presented and developed by used, showed adequate internal consistency (mean value of qualified clinicians, experts in problem and disordered Cronbach’s α 5 0.87), with a variation of the consistency gambling for more than 20 years. indexes from good (α 5 0.70 for searching for news) to very The topics addressed in the intervention included: psy- good (α 5 0.84 for persistence and self-transcendence). choeducation regarding the disorder (the onset and devel- Other measures. A semi-structured interview under the opment of the disorder, vulnerability factors, diagnostic supervision of a staff clinical psychologist with more than criteria), stimulus control (money management, avoidance 20 years of experience in the field of gambling disorder was of potential triggers, self-exclusion programs), response conducted to collect additional data from the patients. This prevention (alternative and compensatory behaviors), tool was developed by the research team, and it has been cognitive restructuring focused on illusions of control over routinely used in the treatment unit for the assessment at gambling and magical thinking, emotion-regulation skills baseline. The interview included sociodemographic features training and other relapse prevention techniques. Patients related to sex, marital status, education level, employment were also encouraged to ask a close relative (or significant status and the socio-economic position index according to other) to act as a co-therapist, to help them throughout the Hollingshead’s scale (this scale generated a classification treatment. based on the employment status, the participants’ level of Throughout the process, participants received feedback education and the occupational prestige) (Hollingshead, regarding the improvement of their self-efficacy and all ef- 2011). Patients were also asked about the variables related to forts made to achieve recovery were reinforced. Changes in gambling (illegal behavior, preference for gambling, type of gambling behavior and overall psychological state, as well as platform (online or land-based), gambling debts, use of learned skills, were assessed by analyzing incidents, potential some substances (tobacco, alcohol and other illegal drugs), relapse/s, alternative activities carried out and attainment age of onset on gambling behavior, and duration of level with the treatment guidelines. gambling activity. Treatment outcome was measured by dropouts and re- lapses. A relapse indicated that patients presented a full gambling episode in any type of gambling for money and Self-exclusion not only in their problem game(s). Failure to attend three Self-exclusion is collected during the semi-structured inter- consecutive CBT sessions without notifying the therapist view as a self-reported data. Self-exclusion is an adminis- was considered a criterion for dropout. A full description of trative procedure that the patients ask to the corresponding this CBT program has been previously published (Jiménez- governmental office is before going to the hospital Unit to Murcia, Aymamí-Sanromà, Gómez-Peña, Álvarez-Moya, & seek treatment. The self-excluded gamblers obtain an official Vallejo, 2006). 526 Journal of Behavioral Addictions 12 (2023) 2, 522–534 Procedures The increase in type-I error due the use of multiple statistical significance test was controlled with the familywise All participants in the study voluntarily sought treatment Finner’s method (Finner & Roters, 2001). One relevant for GD and were diagnosed according to the DSM-5 advantage of this procedure is allowing modeling censored criteria (American Psychiatric Association, 2013). Before data, which occurs if patients withdraw from the study initiating outpatient treatment, individuals completed all (arrive to alive at the end of the follow-up, or is lost in the the questionnaires utilized in this study and a semi-struc- follow-up without event occurrence at last measurement tured interview under the supervision of a staff psycholo- time). In this work, the presence of a relapse was considered gist. After the baseline assessment, all patients were treated for patients who reported the presence of any gambling with a standardized 16-week cognitive-behavioral therapy episode during the treatment. Dropout was considered for (CBT) intervention described in a previous section. Pa- patients who abandoned the course of the treatment. tients did not receive any kind of compensation for their Different Kaplan-Meier curves were modeled for the pres- participation and signed informed consent was obtained ence of relapses and dropouts. from all of them. Ethics Statistical analysis The present study was carried out in accordance with the Statistical analysis was done with Stata17 for Windows latest version of the Declaration of Helsinki. The University (Stata-Corp, 2021). Chi-square tests compared pro- Hospital Clinical Research Ethics Committee approved the portions between the groups and t-test for independent study (Refs. 34/05, 307/06), and signed informed consent sample procedures compared means. Effect size was esti- was obtained from all participants. mated with Cohen’s-h (for difference between pro- portions) and Cohen’s-d (for difference between means). Non-parametric tests were used since the expected counts RESULTS for the crosstabs were higher than 5, and regarding the t-test procedures, according to the central limit theorem the distribution of sample mean values tends to follow Descriptive for the sample the normal distribution regardless of the population dis- The distribution for sex was n 5 1,255 men (88.6%) versus tribution if the sample size is large enough. For these n 5 161 women (11.4%). Most participant were single standardized coefficients, threshold 0.50 was considered (47.0%) or married (38.1%), and only 14.9% were divorced. for moderate-medium effect size and 0.80 for large-high Participants reported primary or less education level effect size (Kelley & Preacher, 2012). (54.2%), secondary (36.7%) and university (7.1%); 55.6% Next, a logistic regression was performed to obtain the were employed while 44.4% unemployed. Within social best predictors of the self-exclusion based on all the mea- indexes, mean-low to low level correspond to 82.0% of the sures at baseline. Stepwise procedure and hierarchical pro- sample, and 18% correspond to mean to high level. The cedure were used. In the first block all the sociodemographic mean age of the participants was 42.1 yrs-old (SD 5 14.5). features were entered, and the statistical predictors were automatically selected and fixed. In the second step, the Prevalence of self-exclusion gambling measures were tested (onset and duration of the The number of patients who reported lifetime self-exclusion gambling problems, the DSM-5 criteria for GD, gambling was n 5 356 (prevalence 5 25.1%, 95% confidence interval preference, gambling modality and debts due to the [95% CI]: 22.9%–27.4%). Stratified by sex, n 5 297 men gambling activity), and those significant contributors were reported self-exclusion (prevalence 5 23.7%, 95% CI: also selected and retained. In the third block, the personality 21.3%–26.0%), and n 5 59 women (prevalence 5 36.7%, profile (TCI-R scales) was included, and in the last block the 95% CI: 29.2%–44.1%). Table 1 shows the evolution of the global psychopathological distress (SCL-90R GSI) and the prevalence of patients who reported self-exclusion during presence of other comorbid addictions (tobacco, alcohol and the period of recruitment data. drugs). The goodness-of-fit of the final model was assessed with the Hosmer-Lemeshow test (p > 0.5 is interpreted as Variables associated to self-exclusion at baseline adequate fitting), and the global discriminative capacity with the Nagelkerke’s pseudo-R2 coefficient. Considering the sociodemographic features (Table 1), the Kaplan-Meier estimator obtained and compared the likelihood of self-exclusion was increased among women, cumulate survival curves for the rate of dropout and relapses patients with higher education levels and higher socioeco- during the treatment, and Long-Rank method compared the nomic status. survival functions. Survival method allows measuring the Considering the clinical data (Table 2), self-exclusion probability of patients “living” (survive without the presence was related to the duration of the GD related problems, of the outcome, in the study without dropout and without higher number of DSM-5 criteria for GD, worse psychology the presence of relapse episodes) for a certain amount of state (concretely, in the SCL-90-R scales obsessive-compul- time after the beginning of the treatment plan (Aalen, sive, depression, anxiety, hostility and GSI), higher novelty Borgan, & Gjessing, 2008). seeking, and lower persistence. Self-exclusion was also Journal of Behavioral Addictions 12 (2023) 2, 522–534 527 Table 1. Comparison for the sociodemographic data Self-exclusion: no Self-exclusion: yes (n 5 1,060) (n 5 356) n % n % p |h| p Sex Women 102 9.6% 59 16.6% <0.001 0.21 Men 958 90.4% 297 83.4% Civil status Single 482 45.5% 184 51.7% 0.113 0.12 Married 418 39.4% 121 34.0% 0.11 Divorced 160 15.1% 51 14.3% 0.02 Education Primary or less 599 56.5% 168 47.2% 0.002p 0.19 Secondary 397 37.5% 152 42.7% 0.11 University 64 6.0% 36 10.1% 0.15 Employment Unemployed 484 45.7% 144 40.4% 0.087 0.11 Employed 576 54.3% 212 59.6% Social index High 12 1.1% 6 1.7% 0.031p 0.05 Mean-high 49 4.6% 24 6.7% 0.09 Mean 100 9.4% 50 14.0% 0.14 Mean-low 369 34.8% 121 34.0% 0.02 Low 530 50.0% 155 43.5% 0.13 Mean SD Mean SD p |d| Age (yrs-old) 42.49 14.55 41.07 14.38 0.110 0.10 Note. SD: standard deviation. p Bold: significant comparison. associated to strategic and mixed gambling preference, on- patients who search for therapy for GD and previously self- line and mixed modality of gambling, and the presence of excluded have been identified. Findings indicated that fewer illegal behavior and debts due to the gambling activity. patients are using self-exclusion prior to seeking treat- Table 3 contains the result of the logistic regression ob- ment (25.1%). tained to select the significant contributors of the self- Moreover, it has been found that self-exclusion was more exclusion based on the set of variables registered at baseline. related to female gender, but results of other studies have According to this multivariate model, the likelihood of self- been inconclusive in this sense. While some authors exclusion was increased for women, patients with longer (Håkansson & Widinghoff, 2020) found this same associa- duration of the GD, higher severity of the GD symptom level tion with female sex in online gamblers, the systematic re- (higher number of DSM-5 criteria), gambling preference views by Motka et al. and by Kotter found greater different o non-strategic games, higher levels in novelty association of self-exclusion with male sex (Kotter et al., seeking and cooperativeness and lower scores in persistence. 2019; Motka et al., 2018) and still other studies have found no relationship between sex and self-exclusion (Håkansson Survival analysis for the treatment outcome & Henzel, 2020). The results of these studies show the het- No differences between the groups were found for the risk of erogeneity of the population with GD and even the possible dropout in the treatment (R 5 33.5% for patients without involvement of other factors, such as sociodemographic self-exclusion versus R 5 28.3% for patients with or cultural. It is known that in recent years the incidence of self-exclusion; p 5 0.350). However, the risk of relapse was GD in women has been increasing (Gainsbury, Russell, lower among patients who reported lifetime self-exclusion Blaszczynski, & Hing, 2015; Stevens, Dorstyn, Delfabbro, & (R 5 14.1% versus R 5 23.0%; p 5 0.042) (Fig. 1). King, 2021) and some studies have characterized women Considering the rate of the treatment outcomes modeled diagnosed with this disorder (Jiménez-Murcia et al., 2020; with the Kaplan-Meier method (Fig. 2), cumulate survival Lara-Huallipe et al., 2022), but due to the lack of research curves for dropout achieved no statistical differences on self-exclusion, the performance of this strategy in this comparing patients with and without self-exclusion (Long- population is still unknown. Rank: p 5 0.342), but the presence of relapse episodes were Although studies have shown that GD is more associated registered with greater speed among patients without self- with low educational level and socioeconomic status (Hing, exclusion (Long-Rank: p 5 0.048). Russell, Tolchard, & Nower, 2016), present findings indicate that self-exclusion is more frequent among individuals with a higher educational level and higher social positions. These DISCUSSION results correspond with other research indicating a rela- tionship between self-exclusion and higher sociodemo- In this study, sociodemographic characteristics, personality graphic status (Yakovenko & Hodgins, 2021). Primarily, this traits, general psychopathology and response to treatment of relationship has been found in self-excluding online 528 Journal of Behavioral Addictions 12 (2023) 2, 522–534 Table 2. Comparison for the clinical data Self-exclusion: no Self-exclusion: yes (n 5 1,060) (n 5 356) Onset, duration and severity of GD Mean SD Mean SD p |d| Onset of the GD related problems (yrs) 30.14 11.72 28.99 11.67 0.109 0.10 Duration of the GD related problems (yrs) 5.95 6.56 6.79 6.90 0.041p 0.12 Number or DSM-5 criteria for GD 6.82 2.03 7.41 1.71 <0.001p 0.31 Psychopathology (SCL-90-R) Mean SD Mean SD p |d| Somatization 1.00 0.83 1.05 0.89 0.393 0.06 Obsessive-compulsive 1.15 0.82 1.28 0.86 0.016p 0.15 Interpersonal sensitivity 1.04 0.84 1.14 0.87 0.058 0.12 Depression 1.53 0.92 1.65 0.98 0.040p 0.13 Anxiety 1.06 0.83 1.18 0.86 0.012p 0.14 Hostility 0.93 0.84 1.07 0.92 0.008p 0.16 Phobic anxiety 0.51 0.69 0.53 0.70 0.640 0.03 Paranoia 1.01 0.81 1.00 0.81 0.866 0.01 Psychotic 0.93 0.77 1.01 0.81 0.115 0.10 GSI 1.09 0.72 1.18 0.75 0.038p 0.12 PST 46.90 22.12 48.83 21.94 0.154 0.09 PSDI 1.93 0.61 1.99 0.60 0.096 0.10 Personality (TCI-R) Mean SD Mean SD p |d| Novelty seeking 107.64 13.36 113.23 13.27 <0.001p 0.42 Harm avoidance 98.82 15.65 100.76 17.73 0.052 0.12 Reward dependence 99.95 14.06 99.18 14.07 0.369 0.05 Persistence 112.64 19.98 106.77 19.41 <0.001p 0.30 Self-directedness 128.30 19.83 126.04 21.28 0.068 0.11 Cooperativeness 129.19 15.12 129.59 17.34 0.679 0.02 Self-transcendence 63.14 14.02 62.43 14.87 0.415 0.05 Other clinical measures (prevalence) n % n % p |h| Gambling preference Non-strategic 613 57.8% 131 36.8% <0.001p 0.42 Strategic 204 19.2% 97 27.2% 0.19 Mixed 243 22.9% 128 36.0% 0.29 Gambling modality Offline 966 91.1% 299 84.0% <0.001p 0.22 Online/mixed 94 8.9% 57 16.0% Illegal behavior 260 24.9% 121 35.5% <0.001p 0.23 Debts due to gambling 561 52.9% 211 59.3% 0.038p 0.13 Tobacco 619 58.4% 196 55.1% 0.270 0.07 Alcohol 178 16.8% 47 13.2% 0.109 0.10 Illegal drugs 113 10.7% 34 9.6% 0.553 0.04 Note. SD: standard deviation. p Bold: significant comparison. Table 3. Logistic regression model B SE p OR 95% CI for OR Sex (1 5 men/0 5 women) 1.008 0.197 <0.001 0.365 0.248 0.537 Duration of GD (years) 0.032 0.010 0.001 1.033 1.013 1.053 DSM-5 total criteria for GD 0.131 0.039 0.001 1.139 1.055 1.230 Gambling preference <0.001 Strategic versus non-strategic 1.042 0.174 <0.001 2.834 2.013 3.989 Mixed versus non-strategic 0.987 0.158 <0.001 2.683 1.970 3.654 Mixed versus strategic 0.055 0.176 0.756 0.947 0.670 1.338 TCI-R Novelty seeking 0.027 0.005 <0.001 1.027 1.017 1.038 TCI-R Persistence 0.016 0.003 <0.001 0.984 0.978 0.991 TCI-R Cooperativeness 0.013 0.004 0.003 1.013 1.004 1.022 Fit statistics Hosmer-Lemeshow test: p 5 0.487; Nagelkerke’s-R2 5 0.157 Note. SE: standard error. OR: odds ratio 95% CI: 95% confidence interval. Journal of Behavioral Addictions 12 (2023) 2, 522–534 529 Prevalence (%) 58.8% 60% 50% 43.5% 42.1% 40.0% 40.5% 40% 33.3% 30% 25.7% 26.3% 28.0% 20% 22.9% 23.7% 25.0% 20.0% 17.9% 17.5% 10% 13.2% 0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Fig. 1. Evolution of the prevalence of patients with self-exclusion Fig. 2. Cumulate survival curves gamblers (Motka et al., 2018), as many of them resort to psychopathology, with these results similar to those found in controlling the physical environment to place limits on this study (Lévesque, Sévigny, Giroux, & Jacques, 2017; gambling behavior and time spent on this activity (Siemens Moragas et al., 2015). Another important result is that self- & Kopp, 2011). exclusion is associated with more years of evolution and It is possible that this higher sociodemographic status of greater severity of GD. Previous researches also described self-excluding gamblers allows them to have access to more that self-exclusion was related to greater gambling problems information about the consequences of GD behavior and (Håkansson & Henzel, 2020). Therefore, these results could better awareness of responsible gambling (RG) measures. In indicate that people seeking treatment may use self-exclu- this regard, the Health Belief Model (HBM) proposes that a sion as a strategy to regulate gambling behavior and their person will carry out a behavior change or a behavior to take consequences. In the same vein, other studies found that the care of their health until they have a minimum of motiva- more gambling behavior the participants engaged in, the tion, necessary information on the subject, perceive them- more they sought help from a health professional to abstain selves vulnerable to having a possible condition, consider from gambling behavior (Hing, Nuske, Tolchard, & that it could have significantly serious consequences, or Russell, 2015). perceive a benefit in changing their behavior to reduce the Additionally, it was found that those who self-exclude impact of the severity of the condition (Rosenstock, Strecher, have more gambling debts and have committed more illegal & Becker, 1988). Studies that have investigated the impor- behaviors than those who do not use this strategy when tance of awareness in RG from the HBM have found that seeking treatment. Findings from other research suggest that those who had greater awareness of RG tended to self- criminal behaviors such as theft, forgery, and fraud are exclude more and were more likely to seek professional help related to GD (Folino & Abait, 2009; Grant & Potenza, 2007) (Tong, Chen, & Wu, 2019). and that those who commit these illegal acts also have sig- Concerning gambling profile, an association was found nificant money debts (Potenza, Steinberg, McLaughlin, between self-exclusion and preference for strategic and Rounsaville, & O’Malley, 2000). Interestingly, a higher mixed gambling and the online and mixed modality of gambling severity is reported in those who engage in crim- gambling. Several studies showed that strategic gambling is inal behaviors related to GD (Ledgerwood, Weinstock, related to greater symptoms of GD and higher levels of Morasco, & Petry, 2007). These behaviors could be an 530 Journal of Behavioral Addictions 12 (2023) 2, 522–534 important reason for patients seeking treatment to self- administrations is required to maintain self-exclusion for exclude, since another of the main reasons for people to longer periods. resort to this strategy are financial problems (Motka It is known that few people with gambling problems seek et al., 2018). professional treatment (Loy, Grüne, Braun, Samuelsson, & In the clinical profile, self-exclusion turned out to be Kraus, 2018), so it is necessary to strengthen intervention more associated with greater emotional distress, since par- and prevention programs. As a prevention, early self- ticipants who self-excluded showed more obsessive-compul- exclusion strategy can avoid future financial, psychological sive traits, depression, anxiety and hostility. Moreover, in and social problems related to GD. And as a treatment terms of personality these patients presented higher sensation strategy, self-exclusion can reduce GD symptoms and its seeking but less persistence in comparison with the other negative consequences. To this end, further studies are patients without self-exclusion. This coincides with other needed to characterize the sociodemographic and clinical studies that have found a maladaptive personality profile in profile of individuals who self-exclude when seeking patients with GD With traits of high impulsivity, irritability, treatment. In sum, these findings could contribute to less self-direction, anxiety, depression, obsessive-compulsive generate other lines of research to understand the efficacy of traits and novelty seeking (Gervasi et al., 2017; Jiménez- this strategy in GD and in this vein, new treatments could Murcia et al., 2014; Mestre-Bach et al., 2019). include self-exclusion as one of the components of Other research has found that sensation seeking is a treatment. significant predictor of the severity of this disorder (Sav- vidou et al., 2017). This sensation seeking trait would also explain why the patients in this study continue over the CONCLUSIONS years with gambling behaviors despite the negative conse- quences. Additionally, lower levels of persistence, common Patients who self-exclude before seeking treatment have a in most patients with gambling problems but more specif- specific clinical profile. This self-exclusion refers to patients ically in this group of patients with self-exclusion, could with a high sociodemographic status, greater severity of GD, justify the fact that they request and withdraw from it several more years of evolution of the disorder and greater general times over time. psychopathology related to higher emotional distress; how- In relation to treatment, participants who self-excluded ever, these patients present lower relapse rates. Clinically, it were found to have a better response and showed lower could be expected that this strategy could be used as a relapse rates. These results are consistent with the results facilitating variable in the therapeutic process. reported by some self-exclusion programs in the treatment The evidence in this study has several limitations and of GD, which show that self-exclusion can decrease additional questions for future research. As expected, the gambling behaviors, improve financial conditions, improve sample sizes of the groups were not homogeneous, as the psychological well-being (decreasing anxiety and depression prevalence of the disorder is not balanced between different associated with gambling), and minimize the harms related gambling subtypes or sex. Also, data only included short- to this disorder (Gainsbury, 2014; Kotter et al., 2019), thus term therapy outcomes, so it would be interesting for future self-exclusion could be a predictor of treatment response. studies to include longitudinal data of long-term outcomes. However, there is still a lack of research evaluating the Additionally, self-exclusion may imply a bias risk. long-term effectiveness of self-exclusion not only as a harm minimization strategy, but also as an important component that could be used in the treatment of individuals already Funding sources: Financial support was received through the diagnosed with GD. Findings from Gainsbury’s systematic Ministerio de Ciencia, Innovación y Universidades (grant review showed one of the shortcomings of self-exclusion was RTI2018-101837-B-100) and from Ministerio de Sanidad, that most gamblers who use this strategy do not sign an Servicios Sociales e Igualdad (FIS PI20/0132). The research official agreement, either in an administrative office or with was also funded by the Delegación del Gobierno para el Plan a mental health professional (Gainsbury, 2014). However, Nacional sobre Drogas (2019I47 and 2021I031), CIBER this was not the case for the patients in this study, since all of Fisiología Obesidad y Nutrición (CIBERobn) is an initiative them had fulfilled the legal administrative requirements for of ISCIII. We thank CERCA Programme/Generalitat de this purpose. Catalunya for institutional support. Fondo Europeo de From the clinical perspective, there is limited research on Desarrollo Regional (FEDER) “Una manera de hacer the treatment of GD and self-exclusion. There have been Europa”/“A way to build Europe”. RG is supported by the some brief interventions on motivation and self-manage- Catalan Institution for Research and Advanced Studies ment for participants with GD in the face-to-face and online (ICREA-Academia, 2021-Programme). AGP is supported by modality that include the self-exclusion strategy at the same a pre-doctoral Grant of Fundación Carolina and the Secre- time (Gainsbury, 2014; Yakovenko & Hodgins, 2021). taría de Relaciones Exteriores de los Estados Unidos Mex- However, self-exclusion has not been fully adhered to in the icanos (Foreign relations secretary of the United States of programs, as some participants report defaulting to this Mexico). IB was supported by Instituto de Salud Carlos III measure and continue to gamble. That suggests that a strong through the grant CM21/00172 (co-funded by European collaboration between care centers, associations and the Social Fund. ESF investing in your future). Journal of Behavioral Addictions 12 (2023) 2, 522–534 531 Authors’ contribution: JCU, AGP, FFA, RG and SJM Calado, F., & Griffiths, M. D. (2016). Problem gambling worldwide: contributed to the development of the study concept and An update and systematic review of empirical research (2000– design. RG performed the statistical analysis. LM, MLLH, 2015). Journal of Behavioral Addictions, 5(4), 592–613. https:// BMM, IS, ME and CS aided with data collection. JCU and doi.org/10.1556/2006.5.2016.073. AGP wrote the original manuscript. FFA and SJM obtained Canale, N., Vieno, A., Griffiths, M. D., Rubaltelli, E., & Santinello, M. funding. MGP, LM, FFA and SJM revised the manuscript (2015). Trait urgency and gambling problems in young people by and provided substantial comments. All authors had full age: The mediating role of decision-making processes. Addictive access to all study data. Behaviors, 46, 39–44. https://doi.org/10.1016/j.addbeh.2015.02.020. Castrén, S., Pankakoski, M., Tamminen, M., Lipsanen, J., Conflict of interest: FFA and SJM received consultancy hon- Ladouceur, R., & Lahti, T. (2013). Internet‐based intervention oraria from Novo Nordisk and FFA editorial honoraria as for gamblers in Finland: Experiences from the field. Scandina- EIC from Wiley. The rest of the authors declare no conflict vian Journal of Psychology, 54(3), 230–235. https://doi.org/10. of interest. The funders had no role in the design of the 1111/sjop.12034. study, in the collection, analysis, or interpretation of data, in Choi, S. W., Shin, Y. C., Kim, D. J., Choi, J. S., Kim, S., Kim, S. H., & the writing of the manuscript, or in the decision to publish Youn, H. C. (2017). Treatment modalities for patients with the results. gambling disorder. 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