This study investigates the activities and perceptions of counselors providing PG treatment, covering the treatment content they offer, the types of change techniques they prioritize, and how they perceive their clinical competence when working with clients with PG. The results showed that CBT and MI, the two treatment types with the most robust scientific support hitherto, form the most commonly offered treatment for PG in Sweden. Overall, addressing motivation during treatment was viewed as the most important type of change technique, a factor that can be considered a prerequisite for other interventions. According to the principal components analysis, about one-third of the counselors were prioritizing “standard CBT” content in their treatment, while a minority were focusing on assessment, families, and exposure strategies. Furthermore, counseling more clients monthly was associated with higher levels of role security, adequacy, and legitimacy in carrying out their clinical tasks.
The most common prioritization of change techniques in treatment was using a range of what we termed a “standard CBT” toolkit. This mirrors the collection of strategies put forward by Rodda et al.  as helpful in reducing gambling behavior; after analyzing responses from 489 gamblers, Rodda et al. suggest that interventions for PG should target cognitions such as reminding oneself of negative consequences from gambling, feedback on gambling behavior, planning ahead and craving management, resembling the “standard CBT” component identified in the present study. In addition, a review of types of change techniques reported in clinical trials  found that relapse prevention was the most common type of change technique, utilized in 60% of studies, followed by cognitive restructuring, behavioral substitution (termed “alternative activities” in the present study) and stimulus control. All four of these techniques were rated among the six most important change techniques in the present study, preceded only by motivation and craving management.
Interestingly, the strategy of stimulus control varies over time and between countries. A majority of counselors (82.8%) in the present study rated the utilization of self-exclusion from gambling, a stimulus control strategy, as crucial or very important. This change technique refers to the national register introduced in Sweden in 2019 where citizens can self-exclude from all licensed gambling and direct commercials for a period of one, three, six, or 12 months. However, concerns have been raised that a large proportion of individuals with PG continue to gamble outside the licensed market [33, 34] and that relying on self-exclusion might impact the motivation to continue treatment and lead to premature dropout. In this way, the external nature of stimulus control such as self-exclusion tools and limiting access to money can be associated with persons with PG depriving themselves of the opportunity to gain internal stimulus control of the type provided by exposure-based strategies and relapse prevention techniques. External and internal stimulus control strategies can, optimally, function as complementary to one another. Nevertheless, access to effective self-exclusion tools—even without complementary treatment—constitutes a public health strategy that contributes to reducing the negative impact of online and land-based gambling .
Somewhat surprisingly, gender, age, and the number of years of clinical work with PG were not associated with any of the factors of SAAPPQ, whereas seeing more clients monthly was positively correlated with higher willingness, adequacy, and legitimacy. The direction of causality is not known but one can speculate that willingness to work with clients with PG might influence a counselor to see more clients. On the other hand, gaining experience from the assessment and treatment of clients with PG can be reflected in increased adequacy and legitimacy in the execution of one’s work. Other unmeasured factors could influence this association, such as working in an environment that promotes role security in the clinical task, a factor more likely to be present for counselors working at specialized PG units, in addition to their having the opportunity to treat PG clients regularly.
Gaining sufficient clinical experience in the field of PG can be challenging due to low rates of treatment-seeking among individuals with PG. About 5–12% of individuals with PG report seeking any formal help, suggesting that a large majority deal with their problems outside formal treatment systems [19, 36]. PG-related stigma is one of the most frequently cited barriers to seeking help  and mental health stigma, in general, has a wide-ranging negative impact on the lives of individuals suffering and affects the allocation of resources to healthcare, as a systematic review concludes . In addition to low rates of treatment-seeking, discontinuing treatment is common; a meta-analysis reports that 39.1% of clients with PG drop out of treatment . This might cause a vicious circle where counselors do not obtain sufficient experience, affecting their clinical competence and possibly also the quality of their treatment skills and the attractiveness of treatment. Repetition and deliberate practice are pivotal in developing expert skills  and for the development of clinical skills within medical education  and, in this study, for self-perceived role security in the treatment of PG.
Offering CBT was positively associated with higher perceived role adequacy in the present study. This might be at least partly due to the often-emphasized skill within CBT of psychoeducation as a part of the treatment and the availability of treatment manuals with CBT content. Nevertheless, delivering CBT for PG requires training, supervision, and an organization that supports evidence-based treatment, factors highlighted as important when implementing treatment within the addiction care . More clarity in the provision of PG treatment, perhaps through specialized units, might contribute to increased role security among counselors and facilitate help-seeking through a clear path to access help.
Substantial challenges exist in transferring research and policy into clinical practice. The implementation of evidence-based methods within addiction care is dependent on the consensus of researchers, treatment administrators, clinicians, and patients, where both ethical and financial incentives are of importance . The complexity among clients and multiple tasks at hand can thus present obstacles in adhering to manual-based treatment interventions.
Another difference between research and practice is the basic profession of the counselor, which is hypothesized to influence the core competence and the delivery of treatment. It should be noted that the CBT evaluated in clinical trials is commonly delivered by clinical psychologists with specific PG training and supervision . Nevertheless, the current study did not find any significant differences in perceived role security between counselors with different lengths of professional training.
One strength of the current study is the proportion of counselors included, most likely representing most practicing PG counselors in Sweden at the time of data collection. A second strength is the finding that further investigation is needed regarding role security among PG counselors, where additional studies into the conceptualization of role security and the psychometric properties of the SAAPPQ are needed. Some limitations also need to be addressed. One regards the lack of a baseline measure of counselors’ characteristics and competence before the new legislation was introduced in 2018 and the impossibility of thus tracking changes in the counselors’ role security over time. Calculating the exact proportion of active counselors responding to the invitation was difficult due to changes in the workforce and a lack of information on the number of active PG counselors the previous year. However, the recruitment strategy was extensive, both through official channels and a mailing list containing those who participated in PG education.
Additionally, the possible bias in the responses due to self-report and social desirability are limitations that might slant the results towards the over-reporting of recommended treatments. However, personal data on the respondent were not collected, to counteract this risk and thereby increase the internal validity of the responses. Also worth noting is that the sample consisted of many counselors with limited clinical experience. This circumstance might be a product of the strategy of increasing the availability of treatment geographically through educating more counselors, while the number of individuals with PG seeking treatment remains low. A final remark is that the study was conducted in April 2021 when the restrictions due to the COVID-19 pandemic were in place, limiting physical contact in parallel with recommendations to work from home, if possible, which impacted the availability of on-site group treatment.
To our knowledge, this is the first study investigating PG counselors on a national level. Given the development of addiction treatment, starting in the mid-twentieth century when paraprofessionals transitioning to counselors were the most common treatment providers and moving towards increasing prevalence of healthcare professionals in the early twenty-first century , it is important to track this continuing professionalization and its impact on practice. The dissemination of treatment due to new legislative acts and re-organization of treatment offers an opportunity to investigate emerging practices within the helping systems.