Dual diagnoses are common with individuals who engage in pathological gambling. Mental disorders that may co-occur with pathological gambling include: mood disorders, anxiety disorders, attention-deficit/hyperactivity disorder, personality disorders, and substance abuse (American Psychiatric Association, 1994; Nora, 1996). The problems associated with these dual diagnoses are important to recognize and address if TR interventions are to be effective.

There is a high incidence of depression among pathological gamblers, especially women (Blaszczynski & McConaghy, 1989; Murray, 1993). A recent study of pathological gamblers reported that 80% of the female subjects and 64% of the male subjects met the diagnostic criteria for major depression (Specker et aL, 1996). According to the American Psychiatric Association (1994), 20% of the pathological gamblers in inpatient settings are reported to have attempted suicide.

Anxiety disorders also are common among pathological gamblers, again especially female gamblers. A recent study of pathological gamblers reported that 73% of the female subjects and 16% of the male subjects met the diagnostic criteria for anxiety disorders (Specker et al., 1996). Stress often triggers gambling episodes, and pathological gamblers are prone to stress related medical conditions (American Psychiatric Association, 1994).

Research indicates that between 35-50% of pathological gamblers have attention deficit disorder (Rugle, 1993). Attention deficit disorder is characterized by problems in attention related to planning, anticipating the consequences of one's actions, processing one's experiences, and moderating responses (Castellani & Rugle, 1995). In addition, increased rates of both borderline and antisocial personality disorders have been reported in pathological gamblers (American Psychiatric Association, 1994, Rugle, 1993). According to Rugle, individuals with borderline personality disorder are prone to boredom, lack a clear sense of identity or personal values, and exhibit a tendency to perceive individuals and situations as either all good or all bad. Individuals with antisocial personality disorder exhibit a lack of empathy for the feelings or rights of others, violate the laws and mores of society, and respond impulsively to situations without clear regard for the consequences.

Lastly, 30-50% of pathological gamblers abuse alcohol or other drugs (McGurrin, 1992). Approximately 20% of the people in treatment for alcohol/drug abuse are also pathological gamblers.

As is true for all of the clients served through TR, it is extremely important to conduct extensive assessments to appropriately match the needs of each patient with the exact supports and interventions needed. While knowledge of the diagnostic criteria, general subtype of gambling, and possible dual diagnoses may be important, knowledge of the specific presenting problems of each client is essential (Blaszczynski & Silove, 1995). For example, the TR interventions for an individual with attention deficit disorder who seeks feelings of self-worth, belongingness, and risk from gambling would be quite different from those for an individual who seeks escape from anxiety through gambling.

Factors that Influence Pathological Gambling

The literature presents many different variables that may influence whether an individual will gamble pathologically and whether they will maintain a recovering lifestyle. Consensus among scholars and practitioners does not exist on these issues. However, the following factors were identified consistently in the literature and provide the foundation for the discussion of possible TR interventions which will follow. The factors that influence the development, maintenance, and recovery from pathological gambling include arousal needs, cognitive variables, affective variables, and social variables (Brown, 1986).

Arousal Needs Jacobs (1989) posited that one of the factors that predisposes an individual to pathological gambling is being in a chronically stressed state of either hyperarousal or hypoarousal. According to Jacobs, gambling becomes a way of bringing arousal into the desired range. This arousal modulation plays a major role in pathological gambling (Brown, 1986; Walters, 1994a).

According to Jacobs (1989), hyperaroused individuals will seek to decrease arousal. Some gambling activities, such as video poker and slot machines, are very repetitive. Interaction with the machine in a clear, straightforward, repetitive manner can become almost hypnotic, and allows the individual to disassociate (Rugle, 1993). The narrowing of attention to the game alone diverts attention from the more complex, threatening challenges of daily life (Blaszcaynski & Silove, 1995). The individual can block out the stresses of life in an attempt to relax. One of the major rewards of gambling that is reported by pathological gamblers is escape from reality and life's stresses. Of course, gambling provides only a temporary respite for individuals who gamble pathologically and creates many more problems than it cures.

According to Jacobs (1989), hypoaroused individuals will seek to increase arousal. For some individuals, gambling provides stimulation and removes the discomfort of physiological underarousal and boredom (Walters, 1994a). Studies suggest that gambling is frequently motivated by the desire to experience excitement or to escape boredom (Walters), Research suggests that sensation seeking is associated with pathological gambling (Brown, 1986-, Coyle & Kinney, 1990@ Wolfgang, 1988). although it seems to vary based on the preferred type of gambling activity; that is, horse racing versus slots (Coventry & Brown, 1993). According to the American Psychiatric Association (1994), most individuals with pathological gambling report that they want the "action" or the "rush" even more than the monetary winnings. Many pathological gamblers increase over time the amount that they wager in order to maintain the desired level of excitement.

Cognitive Variables

Cognitive variables include distortions in thinking and perception that individuals have about themselves, their situation, and the odds (Brown, 1986). These cognitive distortions are instrumental in the gambler's misperception of the probability of winning (Sylvain, Ladouceur, & Boisvert, 1997) and can contribute to anxiety (Seaward, 1994) and depression (Beck, Wright, Newman, & Liese, 1993). Cognitive variables also include the inability to weigh and process information for effective decision-making.

Irrational thinking. Cognitive distortions are very instrumental in the maintenance of pathological gambling. Common cognitive distortions include illusions of control, selfserving attributions, and faulty belief% related to recouping losses. The illusion of control is very prevalent among pathological gamblers (Blaszczynski & Silove. 1995; Griffiths, 1990; Ladouceur, Gaboury, Dumont, & Rochette, 1988), and is represented by individuals' belief in their ability to defy chance. Pathological gamblers have the unfounded belief that somehow they can "beat the system" or that they have an "edge" (Blaszczynski & Silove, 1995). They believe that through their behaviors, skill, or luck, they can influence chance events (Rugle, 1993) or gain the advantage over probability. Examples of irrational thoughts include carrying "lucky" fetishes to bingo games, placing bets on the numbers that coincide with family members' birthdays, playing a slot machine that has recently paid out, and belief that a certain routine when playing the machines makes a difference. The highest levels of illusions of control exist in slot machine players, a game of complete chance (Blaszczynski & Silove).

Faulty attributions regarding the causes of wins and losses also are necessary to support the maintenance of pathological gambling. Gamblers often attribute their wins to their 11 strategies" or "knowledge" (internal, stable attributions), but make elaborate complex extemal attributions for their losses. For example, if someone wins in sports betting, the attribution would be that their knowledge of sports teams was responsible for the win. Since their knowledge will remain high, they should continue to win. If the team loses, they may blame it on players being uncharacteristically out of synch, unanticipated bad weather, an unexpected number of turnovers, but not on their own knowledge or skill. Even after a loss, they will believe that unanticipated negative events such as these are unlikely to happen again, and that their knowledge and skill will assure a win in the future.

Finally, pathological gamblers often hold the irrational belief that the only or easiest avenue that they have for recouping extensive losses is to continue gambling. This "chasing of losses" is irrational because probability suggests that the gambler is much more likely to lose than win. However, pathological gamblers often continue to gamble after a significant loss, oftentimes betting larger amounts and taking greater risks, under the belief that it is the only way to recover their losses (American Psychiatric Association, 1994).

Poor coping skills. Pathological gamblers are deficient in both the the number of coping skills to which they have access and their flexibility in using them (McCormick, 1994). That is, they have difficulty evaluating which coping skill is most appropriate in a particular situation. Pathological gamblers often do not believe that they have the ability to deal with life's problems or their day-to-day responsibilities or relationships (Rugle. 1993).

Ineffective coping strategies are very common with pathological gamblers. In a study which compared the coping strategies of inpatient pathological gamblers and individuals who abuse substances, McCormick (1994) reported that pathological gamblers used significantly more escape/avoidance, confrontive, and distancing coping strategies. Escape strategies are used to avoid the problems at hand, rather than deal with them. Distancing strategies include detaching oneself from the situation and minimizing its significance. Confrontive coping strategies rely on aggression to address problems. The ineffective coping responses of pathological gamblers can include gambling, alcohol/drugs, lying, procrastination, and emotional and physical distancing.

Impulse control. Pathological gambling is considered an impulse disorder (American Psychiatric Association, 1994). According to Rugle (1993), pathological gamblers have difficulty tolerating negative emotions and separating thoughts and feelings, as well as a tendency toward all or nothing thinking. Pathological gamblers also have difficulty in planning and organizing, have low frustration tolerance, and move quickly from impulse (such as cravings) to action. Research suggests that pathological gamblers have even less impulse control than people who are alcoholic or abuse other drugs (Castellani & Rugle, 1995).

Affective Factors

Affective factors include negative emotions such as boredom, low self-esteem, anxiety, and depression (Brown, 1986). While many researchers argue that these negative emotional states induce the gambling behavior, (Brown; Firestone, 1993; Hendriks, Meerkerk, Van Oers, & Garretsen, 1997), there is also evidence that pathological gambling contributes to these negative emotions.

Sensation seeking and boredom proneness. Sensation seeking is a personality trait characterized by the seeking of novelty, challenge, and complexity (Zuckerman, 1979). Gambling is often motivated by the desire for excitement (Bruce & Johnson, 1992, 1995), stimulation (Chantal & Vallerand, 1996), and the "rush" (Cotte, 1997). Individuals who gamble pathologically perceive that gambling provides more opportunity for risk and sensation seeking than other recreation involvements (Coyle & Kinney, 1990).

Some studies have reported that boredom proneness, rather than sensation seeking, characterizes the pathological gambler. Boredom can be defined as "a state of mental weariness and dissatisfaction produced by lack of interest or activity" (Blaszczynski, McConaghy, & Frankova, 1990, p. 36). While sensation seeking suggests an active seeking of novel experiences, boredom proneness is characterized as being dissatisfied, underaroused, apathetic, and easily bored (Blaszczynski et at.). While boredom proneness and depression share similarities, boredom proneness is characterized by a lack of interest and connectedness to one's environment, as well as intolerance of boredom, rather than sadness (Farmer & Sundberg, 1986). According to Kusyszyn (1990), the thrills associated with gambling provide individuals with the sense that they are "alive."

Low self-esteem. Self-esteem is comprised of two components (Mruk, 1995). The two components are a sense of worthiness and a perception of competence. For some individuals who gamble pathologically, gambling is a means of enhancing self-worth, and controlling fears associated with feelings of inadequacy, insecurity, and powerlessness (Walters, 1994a). According to Jacobs (1989), an essential precursor to pathological gambling is a feeling of personal inferiority and rejection. Through gambling, individuals can create an alternative identity designed to enhance personal feelings of power, importance and control (Walters), prestige, risk-taking, and competence (Holtgraves, 1988). The obvious difficulty with boosting one's self-esteem through gambling is that gamblers often are "losers" which can undermine self-esteem. To recapture the positive sense of self, the gambler feels compelled to gamble again (Jacobs).

Social Variables

The social problems experienced by individuals who gamble pathologically can be varied. These issues include: the residual effects of family of origin issues, unwillingness to seek social support, difficulty with intimacy, stress in the family, and bonds with gambling friends.

According to Jacobs (1989), the source of the low self-esteem of pathological gamblers is often a dysfunctional family of origin. Pathological gamblers often come from families where alcohol/drug/gambling abuse existed (American Psychiatric Association, 1994). Individuals whose parents were uninvolved, disrespectful, lacked warmth, and did not provide clear expectations often lack selfesteem (Mruk, 1995). Individuals raised in dysfunctional families may not have had the opportunity to learn effective relationship skills within their families (Curran, 1983). Many of the problems experienced by the pathological gambler, such as lack of trust (Abbott, Cramer, & Sherrets, 1995) and difficulty in expressing feelings (Steinberg, 1993), are common in individuals from dysfunctional families.

Pathological gamblers, especially women, also have a high incidence of being victims of physical and sexual abuse. Although not all physical and sexual abuse occurs within the family of origin or adult family context, much of it does. The rates of physical and sexual abuse experienced by women who are pathological gamblers ranges from 60%-75% (Franklin, 1996; Specker, Carlson, Edmonson, Johnson, & Marcotte, 1996).

According to McCormick's research (1994), the pathological gambler has poorly developed skills in seeking personal or emotional support. He suggested that this may be especially true of men who perceive that needing support from another is a sign of weakness. Narcissistic gamblers who want to maintain the image of superiority and power may have a particularly difficult time asking for help to deal with their problems (McCormick). This inability to seek social support can create significant roadblocks for the pathological gambler in recovery. Without social support, they must rely on their old ineffective coping strategies. Social support has been demonstrated repeatedly to be crucial in the maintenance of recovery (Walker, 1993).

Individuals who develop pathological gambling often experience difficulty maintaining emotionally intimate and nurturing relationships with others (McGurrin, 1992). It is not difficult to see how an individual with poor self-esteem, inability to trust, difficulty expressing feelings, and fear of rejection might experience difficulty in relationships. For pathological gamblers, gambling-based relationships become alternatives to meaningful social interaction and interpersonal intimacy and commitment (Berman & Siegel, 1992).

As pathological gambling progresses, the pathological gambler often withdraws both physically and emotionally from the activities of the family (Walters, 1994a). Pathological gamblers become estranged from others and fail to attend family functions, express affection, or share interest in a sexual relationship with their spouses (Walters). Because of the funds going into gambling, family members may often have to do without necessities or curtail their activities due to lack of money. Family members are frequently embarrassed when debt collectors call or they lose their electrical power due to an unpaid bill. Family members find that they can no longer trust the pathological gambler. The financial, emotional, and social consequences of living with a pathological gambler can create great stress within the family (Berman & Siegel, 1992).

Pathological gamblers often find the sense of unity and belonging that may be lacking in other aspects of their lives through interaction with other gamblers. The lives of individuals who gamble often revolve around the action of the gambling environment, friendships with other gamblers, and beating the system together. According to research conducted by Ocean and Smith (1993), individuals who do not have a positive sense of identity outside of the gambling environment perceive that they are "somebody" in the gambling world. However, while gambling may elevate the pathological gambler's status in the gambling world, it leads to a marginalization from mainstream society, including the family (Ocean & Smith). As a result of this devaluing of the gambler in mainstream society, the pathological gambler will turn even more to the gambling environment to receive a positive sense of self.

Treatment Approaches

Many treatment programs for pathological gamblers include group and individual therapy; educational sessions on addictions and pathological gambling; interventions designed to address the restitution of debt, such as pressure relief groups and financial counseling; and 12 step meetings, such as Gamblers Anonymous. Cognitive-behavioral models of addictions treatment are becoming increasingly common, and have received strong research support (Hester & Miller, 1995; Maude-Griffin et al., 1998; Sylvain, Ladouceur, & Boisvert, 1997). Cognitive-behavioral models of addictions treatment often include cognitive therapy (Blaszczynski & Silove, 1995), coping/stress management (McCormick, 1994), relationship and communication skills (Monti, Rohsenow, Colby, & Abrams, 1995), and the establishment of an alternative, reinforcing nongambling life-style (Walters, 1994b). An effective TR specialist will understand the overall treatment context, and provide a TR program that complements and extends the efforts of the other treatment disciplines.

As previously discussed, individuals who gamble pathologically bring an array of potential issues to treatment. Some of these issues, such as physical and sexual abuse, are beyond the scope of direct practice of TR specialists. It is extremely important that TR specialists do not address issues that exceed their professional training (American Therapeutic Recreation Association, 1990; National Therapeutic Recreation Society, 1990). However, it behooves the TR specialist to be aware of these issues as they may affect an individual's response to TR interventions.

Many of the problems presented by pathological gamblers, however, can be addressed appropriately through TR interventions. The remainder of this paper will discuss the TR interventions that may be most salient in the treatment of the pathological gambler. The interventions presented are not the exclusive domain of TR; however, there is an expectation by the profession that TR specialists have the knowledge and skills necessary to implement them (Kinney & Witman, 1997). Again, the reader is cautioned that every individual who gambles pathologically brings different issues to treatment, and interventions should address the specific needs of each client.

Stress Management

Stress is a common cause of relapse (Walters, 1994b). It is very important for individuals to acquire the ability to handle "high risk" situations that might threaten their recovery, such as social pressure to gamble, anxiety, interpersonal conflict, financial pressures, and boredom (Marlatt, 1996). Therefore, it is essential that TR specialists provide individuals recovering from pathological gambling with the stress management skills necessary to maintain recovery. First, pathological gamblers may need to acquire the cognitive skills necessary to regulate their affect and manage feelings of anxiety, fear, and depression (Walters, 1994b). Second, they must acquire confidence in their ability to respond to the challenges in their lives, and to cope effectively with their day to day responsibilities and relationships (Sylvain et aL, 1997). Third. they may need to learn alternative methods to modulate the discomfort of hypoarousal or hyperarousal (Blaszczynski & Silove, 1995).

One stress management approach to the regulation of affect is cognitive therapy. Through cognitive therapy, TR specialists can help clients learn to identify the negative, irrational thoughts that may be contributing unnecessarily to their stress, and replace them with more rational, positive thoughts (Carr-uthers, 1995). Cognitive therapy is based on the premise that excessive and uncomfortable emotional reactions and self-defeating behaviors are created by maladaptive thinking (Beck et at., 1993). According to Blaszczynski and Silove (1995), most cognitive therapies share the following assumptions: thoughts affect feelings and behaviors, thoughts can be brought to conscious awareness and evaluated, dysfunctional or irrational thoughts can be modified, and the modification of thoughts should result in changed behaviors. TR specialists can teach their clients about the relationships between thoughts, feelings, and behaviors; help them to identify the cognitive distortions and irrational beliefs that interfere with their recovery and enjoyment of life; and encourage them to replace these distortions and beliefs with realistic and rational beliefs (Carruthers; Hood & Krinsky, 1996).

Cognitive therapy has another important function in the treatment of clients who gamble pathologically (Walters, 1994b). As was mentioned previously, these individuals often have beliefs that affect directly the maintenance of gambling behaviors, such as illusions of control, biased evaluations of their own skill or knowledge, misperceptions of randomness, rationalizations, and justifications (Walters. 1994a). In many treatment facilities, all members of the treatment team, including TR specialists, are expected to assist the recovering pathological gambler in identifying, confronting, and changing the irrational thoughts that will undermine recovery. Cognitive therapy is a primary emphasis in most relapse prevention programs (Rugle, 1993).

Although changing one's thoughts is a very helpful practice in the management of stress and "high risk" situations, there are times when it is best to take constructive action to minimize or eliminate the stressor. It is important that the pathological gambler learn to assess a stressful situation to determine if there is any constructive action that he or she can take to alleviate the stressful situation. If there is any constructive action that can be taken, it should be taken. It is characteristic of pathological gamblers to use the coping strategies of escape/avoidance or distancing, rather than the more effective strategies of accepting responsibility and problem solving (McCormick, 1994). Active strategies for problem solving and responding to high risk situations should be learned in treatment. TR specialists can facilitate this active coping style by having clients identify the stressors that may threaten their recovery, their degree of confidence in their ability to manage the stressors, and coping strategies that will increase their confidence in high risk situations (Carruthers, 1995).

Clients in treatment for pathological gambling can also acquire skills in monitoring and reducing physiological arousal (hyperarousal). Relaxation techniques, such as progressive relaxation, meditation, imagery, and exercise can be helpful in the regulation of the stress response (McCormick. 1994; Walters, 1994b). These interventions are included in many TR programs. Research suggests that they make a positive contribution in the treatment of people with addictions when used in conjunction with other interventions (Stockwell, 1995).

A key problem in stress management for pathological gamblers is impulse control and, therefore, it should be emphasized in any program implemented by a TR specialist. As mentioned previously, pathological gamblers often ]cap from cue to response without consideration of the potential risks involved. The positive short term consequences of their behaviors (the thrill of placing the bet) often exceed the less immediate and generally more negative long term consequences of betting. Impulse control interventions provided by TR specialists should focus on slowing down the decision making process. Systematic problem solving should be emphasized. According to McCormick (1995), pathological gamblers may need to be taught how to break presenting problems into parts, fully explore each of the options, weigh the pros and cons of each option, choose a solution, try it, and evaluate it. Helping pathological gamblers to separate their thoughts, feelings, and actions will minimize typical short cut thinking. and will assist them in regulating their own impulses (Castellani & Rugle, 1995).

Self-Esteem Interventions

Kusyszyn (1990) suggested that gambling can contribute to feelings of self worth, and a perception that one is affecting one's environment. Affecting one's environment through gambling creates a feeling of joy without much effort.

According to some authors (Rosenthal, 1993; Walters, 1994a), poor self-esteem is an important treatment issue for pathological gamblers. Pathological gamblers often experience feelings of being inadequate, inferior, and unwanted (Jacobs, 1989). Jacobs suggested that much of the motivation for gambling is an attempt to alter one's sense of identity. According to Walters, pathological gamblers benefit from interventions that will allow them to explore their sense of adequacy and self worth. It is important that they can replace old means of coping with low self-esteem, such as gambling, with more constructive options for building a positive sense of self. If pathological gamblers do not address self-esteem issues while in treatment, they may be more predisposed to relapse. Self-esteem issues were identified by TR professionals who work in the area of addictions as one of the most important treatment needs of individuals in recovery (Hood & Krinsky, 1997/98).

Self-esteem interventions implemented by TR specialists may focus on both aspects of self-esteem, perceptions of personal worthiness and competence. A variety of approaches can be used by therapeutic recreation specialists to assist the client in exploring their sense of personal worthiness. Negley (1997) recommended that clients be introduced to the following process: (a) explore the "messages" they received while growing up that have impacted their views of themselves; (b) examine the internal dialogues that perpetuate a sense of worthlessness; (c) identify core beliefs and change them when they are destructive; (d) and make life choices, including leisure, work, and relationships, that are consistent with an authentic and positive sense of self.

The second component of self-esteem, the enhancement of the perception of competence, is a well accepted domain of TR services. Oftentimes, clients do not perceive that they have the ability to be successful in situations and, therefore, they avoid them (Austin, 1997).

According to Bandura (1997), self-enablement occurs when individuals believe that they have the knowledge and competencies necessary to impact the quality and direction of their lives. Individuals' beliefs are shaped by past experiences, what others say, what they see, and their internal feelings (Bandura). TR specialists can help clients develop a sense of competence by structuring opportunities for success, providing positive and constructive feedback, providing successful models with whom the clients can relate, and helping the clients correctly interpret their arousal levels (Austin). Gambling often provides the individual who gambles pathologically with a feeling of competence, achievement, and worth. It is important that the recovering pathological gambler has other avenues for the attainment of these feelings. High-investment leisure activities, other than gambling, provide one avenue for the attainment of a strong perception of competence (Mannel & Kleiber, 1997).

According to Mruk (1995), there is empirical and clinical support for self-esteem interventions that are theoretically sound, systematic, include assessment, and have a warm and accepting facilitator. In general, effective selfesteem enhancing techniques include: acceptance and caring by the therapist, consistent affirming feedback, cognitive restructuring (generating positive self-talk). heightening awareness of self-esteem issues and enhancement opportunities, modeling, problem-solving, successful response to challenge, and practice (Mruk).

Communication and Relationship Skills Many models of addictions treatment (i.e., relapse prevention, coping skills training, and community reinforcement) emphasize the importance of social and relationship skills to recovery (Hester & Miller, 1995). Because relationship difficulties are a "high risk" area for many recovering individuals, it is imperative that they have a good repertoire of skills. Social and relationship skills that are important include: refusal skills, compliments and criticism, listening, conversation, developing social supports for recovery, conflict resolution, and assertiveness (Monti et at., 1995). These models of treatment have received empirical support (Hester & Miller). The specific social problems that may threaten recovery are: poor social support seeking skills, difficulty with intimacy and commitment, family stress, and a lack of nongambling friends.

Social support for recovery is an important need to be addressed by TR specialists (Hood & Krinsky, 1997/98). Some of the issues that can be addressed include: identification of types of support needed, identification of individuals/groups from whom to seek social support, strategies for seeking the necessary support, and continued expansion of social supports (Monti et al.. 1995). New social supports often help the recovering individual navigate recovery, and lessen the likelihood that the individual will return to former gambling relationships.

While many interventions related to interpersonal intimacy and commitment, such as marriage and family counseling, are clearly beyond the professional scope of TR practice, TR specialists can assist clients in becoming more assertive in the expression of their feelings, wants, and needs (Austin, 1997). Assertiveness training, which emphasizes verbalization of feelings, conflict resolution, and refusal skills, is an essential component of a treatment program for many pathological gamblers (McCormick, 1994; Walters, 1994b). The inability to effectively cope with feelings and to respond to conflict can trigger relapse (Blaszczynski & Silove, 1995), and undermines selfesteem (Mruk, 1995). Assertiveness training often includes: characteristics of nonassertive, aggressive, and assertive behaviors; assertive rights; assertive principles and techniques; and practice. In order for individuals to acquire competence in assertiveness, it is very important that opportunities for modeling and role playing the skills be provided (Monti et al., 1995).

Pathological gambling puts great strain on a family. Yet one of the factors that contributes to staying in recovery is the presence of positive family relationships that the pathological gambler values enough to resist gambling (Walters, 1994b). TR specialists can help recovering gamblers and their family members increase their pleasant interactions and activities. It is important that families in recovery focus on the creation of positive interactions, not just the discussion of problems (O'Farrell, 1995). TR specialists may play a key role in helping families reestablish positive interactions through shared leisure experiences.

The maintenance of recovery often requires surrendering old friendships with other gamblers, and developing new friendships that are not constructed around gambling. The lack of "non-using" friends was identified by TR "experts" as one of the most important problems facing people with addictions (Hood & Krinsky, 1997/98). There are a number of issues related to friendships that are important for TR specialists to address. They include: stages of relationships, relationship initiation skills, and relationship maintenance skills (Hood & Krinsky).

Leisure Education

Leisure education, as an essential component of recovery, has wide support in many addiction models including relapse prevention, coping skills, and community reintegration (Hester & Miller, 1995). Leisure has a direct relationship to many of the TR interventions already addressed. For example, the topic of leisure should be infused into the TR stress management, self-esteem, and social skills interventions. There is evidence that leisure can serve as a buffer against stress (Coleman & Iso-Ahola, 1993). Involvement in challenging, successful leisure activity can enhance selfesteem through the elevation of perceptions of competence and causality (Kelley, Coursey, & Selby, 1997). In addition, leisure is often the context through which relationships are initiated and maintained (Iso-Ahola & Park, 1996; Mannell & Kleiber, 1997).

There is a more direct link between leisure and recovery from pathological gambling. The link is that gambling itself is a leisure activity that is often pursued for fun, excitement, challenge, and entertainment (Bruce & Johnson, 1992; Chantal & Vallerand, 1996; Saunders & Turner, 1987). In most treatment programs, the recovering gambler is encouraged to substitute adaptive leisure pursuits for gambling activities (Blaszczynski & Silove, 1995). Substitution of new behaviors for addictive behaviors has been found to be an effective factor in the maintenance of recovery (Edwards, Oppenheimer, & Taylor, 1992). The possibility of relapse is lessened if recovering individuals becomes involved in activities and relationships that are satisfying and reinforcing, and those activities and relationships will be sacrificed if the individual returns to gambling (O'Farrell, 1995; Walker, 1992). It is clearly within the scope of practice for TR specialists to help the recovering pathological gambler identify meaningful, enjoyable leisure activities, as well as constraints to participation; develop confidence in their leisure skills so that they will be comfortable approaching new leisure situations; and obtain the decision making and planning skills necessary to enact a leisure plan that supports their recovery.

Brown (1986) suggested that the substitution of "respectable" or "quiet" activities for the loss of gambling is usually unsuccessful and that the substitution of more sensational activities may be more effective. These new opportunities for fun, excitement, and challenge can then serve as "substitute dependencies" (Edwards et al., 1992) or "positive addictions" (Dimeff & Marlatt, 1995). One of the principal excuses given by pathological gamblers for betting is that they are trying to relieve boredom (Walters, 1994) or to escape from their feelings and thoughts (Rugle, 1993). Gambling, as a leisure activity, may produce high levels of arousal, the narrowing of attention on the activity at hand, and escape from life problems to a restricted world (Brown, 1986; Kusyszyn, 1984). These outcomes of gambling are similar to the attributes of most flow activities. If the consequences of involvement in these activities is less destructive than gambling, then the substitution would be considered by some authors (Edward et al.; Dimeff & Marlatt) to be positive. This perspective suggests that individuals in recovery should be encouraged to find other leisure activities that bring high levels of fun, excitement, action, and challenge, and provide opportunities for escape.

While it may be helpful for the recovering pathological gambler to substitute other flow activities for gambling, TR specialists should exercise caution when assisting clients in the substitution of activities. Any flow activity has the potential to become addictive (Csikszentmihalyi, 1990). Coyle and Kinney (1990) suggested that pathological gamblers should be encouraged to consider how they might be "transferring their addictive tendencies into other areas of their lives" (p. 38). They argued that this transfer of addiction to other areas of leisure may not be positive.

There is support in the pathological gambling literature for this concern. According to Jacobs (1989), all addictive behavior is motivated by the desire to dissociate from a negative sense of self-identity, and to escape a negative reality. Involvement in these substituted flow activities could become addictive as well. According to Rugle (1993), it is essential in treatment to begin to explore one's defensive structures, and to begin to reconstruct a positive sense of self that does not require unhealthy defenses. Rugle argued that recovering individuals must learn to understand, accept, and tolerate uncomfortable feelings. Furthermore, she argued that the old defensive structures must be dismantled, and new structures that allow for authentic acceptance of self and others must be created. Therefore, substituted leisure activities that allow for the presentation of unhealthy defenses are contraindicated.

It would seem that the introduction of alternative leisure activities that are fun, exciting, and challenging is a positive intervention if they serve the constructive purpose of allowing the individual to enjoy recovery, enrichen relationships, forge a positive self-identity, and experience personal growth. They may be less constructive if they become yet another way of running from one's feelings, thoughts, and external world. It would appear that substitution of activities would be most effective when it occurs within the context of a program that also addresses coping skills, self-esteem, and relationships.

One final point related to the substitution of alternative leisure activities bears mentioning. When an individual is trying something new in their leisure, such as a new activity or establishing new friendships, it may take some time and effort before the activity becomes enjoyable or the relationship feels comfortable. Prior to treatment, pathological gamblers may not have valued persistence or handled frustration well. It is important that recovering individuals have realistic expectations of their new leisure experiences and relationships. Gambling may have been a quick fix. Enjoyable leisure may take some time and commitment to develop, but will be more valuable in the long run.

The discussion thus far suggests that constructive leisure can be a positive force in recovery from pathological gambling. However, it must be recognized also that leisure can represent a high risk context for pathological gamblers. Pathological gamblers experience great difficulty in dealing with urges and cravings (Castellani & Rugle, 1995). Certain internal and external cues associated with leisure may signal the urge to gamble, including a long weekend with nothing to do, a Monday night football game, guests in from out of town who want to visit a casino, or a celebratory event. TR specialists should assist pathological gamblers in identifying the leisure situations that are "high-fisk" for them and planning appropriate new responses. According to Blaszczynski and Silove (1995), exposing the pathological gambler to a cue either directly or through imagery, practicing techniques for successfully managing the stimulus, positive self-talk, and stress management techniques are all helpful for the management of high risk situations.

Conclusion

With the increasing incidence of pathological gambling, it is essential that TR specialists prepare themselves to address the recovery issues of this client group. TR has an important role to play in the treatment of individuals with pathological gambling. Problems associated with pathological gambling that TR specialists can address include tendencies toward under or over arousal, maladaptive thought processes, anxiety, poor coping skills, poor impulse control, low self-esteem, lack of social support, difficulty maintaining friendships and interpersonal intimacy, boredom proneness, and lack of constructive leisure. These problems may be addressed concurrently by professionals from a variety of disciplines on the multidisciplinary team, including TR specialists, counselors, social workers, psychologists and occupational therapists.

The TR interventions that may be most effective with pathological gamblers include stress management, self-esteem programs, communication and relationship skills training, and leisure education. While many of these interventions are not the sole domain of TR specialists, they do fall within the scope of direct practice in TR. Many of the problems and recommended interventions identified for pathological gamblers are similar to those of other addictions, although some differences are evident as well.

Specific TR protocols for the treatment of pathological gamblers have not yet been developed. However, the literature on pathological gambling provides a solid foundation for the development of such protocols. The development of protocols, and the study of the impact of the protocols through efficacy research, is a crucial next step in the treatment of pathological gamblers through TR services,

1 Appreciation is extended to the Associate Editor and two anonymous reviewers for their thoughtful feedback on an earlier version of this manuscript.

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