The Effect of Self Stigma Tailored Cognitive Behavioral Therapy on Gambling Disorder
Phase: NA
Conditions: Gambling Addiction, Gambling Disorder, Gambling Disorder Treatment, Stigma, Stigma of Mental Illness, Self Stigma, CBT, Cognitive Behavioral Therapy
Sponsor: Ege University

STUDY PROTOCOL
The Effect of Self Stigma Tailored Cognitive Behavioral 
Therapy on Gambling Disorder 
NCT Number: NCT06943963
Document Date: December 20, 2025

Contents
1. Study Overview
2. Objectives
3. Study Design
4. Methods
a. Study Protocol Summary
b. Study Protocol Details
5. Statistical Analysis Plan
6. References
7. Informed Consent Form

1. Study Overview
The primary aim of this study is to evaluate the effectiveness of the psychotherapy 
method used in the research by comparing the severity of self-stigmatizing thoughts and 
gambling severity between pre-test and post-test measurements among adults diagnosed 
with Gambling Disorder who receive standard addiction treatment (control group) and 
those  who  receive  cognitive-behavioral  psychotherapy  adapted  to  self-stigma  in 
Gambling Disorder (SSCBT) in addition to standard addiction treatment (intervention 
group).
The secondary aim of the study is to assess the sustainability of the intervention’s effect 
one month after the intervention. This will be done by comparing the difference between 
follow-up and post-test scores of self-stigmatizing thought severity and gambling severity 
among intervention group and control group.
The final aim of the study is to investigate whether the decrease in self-stigmatization 
severity, influenced by the intervention, mediates the reduction in gambling severity.
2. Objectives
H1: There is a significant decrease in the Self-Stigma Scale (SSS) scores of individuals 
diagnosed with Gambling Disorder following the CBT-based intervention adapted for 
self-stigma.
H2: There is a significant decrease in the South Oaks Gambling Screen (SOGS) scores of 
individuals diagnosed with Gambling Disorder following the CBT intervention adapted 
to address self-stigma.
H3: There is a significant decrease in the SSS follow-up scores one month after the CBT 
intervention, compared to pre-intervention scores, in individuals diagnosed with 
H4: There is a significant decrease in the SOGS follow-up scores one month after the 
CBT intervention, compared to pre-intervention scores, in individuals diagnosed with 
Gambling Disorder.
H5: There is a significant difference in SSS score changes over time between individuals 
diagnosed with Gambling Disorder who received standard treatment only and those who 
received standard treatment plus CBT-based self-stigma intervention.

H6:  There  is  a  significant  difference  in  SOGS  score  changes  over  time  between 
individuals diagnosed with Gambling Disorder who received standard treatment only and 
those who received standard treatment plus CBT-based self-stigma intervention.
3. Study Design
Stratified randomized controlled trial
Participants were stratified based on their Self-Stigma Scale scores using the SPSS 
software, and within each stratum, they were randomly assigned to the intervention and 
control groups. To prevent selection bias, random assignment to groups was conducted 
by an independent researcher. The researcher who implemented the intervention had no 
influence or bias regarding the assignment of participants to the experimental or control 
groups.
Assessment Interview:
During the assessment interview, the following steps were conducted:
(1) Participants were provided with detailed information about the study.
(2) They were informed about the measurements to be conducted and the timeline of data 
collection.
(3) Participants were told that they would be randomly assigned to one of two groups via 
a computer program and that one of these groups would be placed on a waitlist.
(4) Informed consent forms tailored to both the intervention and control groups were 
signed and a copy was given to the participants.
(5) All data collection instruments were administered to evaluate participant eligibility 
and obtain baseline data (t0).
(6) Participants were informed that they would be contacted again regarding their group 
assignment, and the interview was concluded.
Randomization:
After the premeasurement interviews, participants who met the inclusion criteria based on 
the data collected were identified. Each participant was assigned a case number. 

After randomization:
(1) Participants in the intervention group were contacted, informed of their group 
assignment, and scheduled for their first therapy session.
(2) Participants in the control group were informed that they were placed on the waitlist.
(3) Participants who were found ineligible based on exclusion criteria were informed that 
they could not participate in the study.
SSCBT Intervention:
Participants in the intervention group received SSCBT, in accordance with the study 
protocol. Sessions were held weekly, lasting 50 minutes each. The intervention consisted 
of four sessions completed over approximately four weeks per participant.
Participants who attended only one, two, or three sessions were considered to have not 
completed the intervention. Those who completed the intervention but did not participate 
in the follow-up session were also considered dropouts.
Post-Test and Follow-Up Assessments:
The Self-Stigma Scale (SSS) and the South Oaks Gambling Screen (SOGS) were used 
at post-test and follow-up stages. Post-test assessments (t1) were conducted one month 
after the start of the intervention (i.e., the date of the first therapy session). Follow-up 
assessments (t2) were conducted approximately one month after the post-test.
4. Methods
Study Protocol Summary
1. Participants fill out the informed consent form and case report form.
2. Baseline Scores: Pre-test measurements (Self Stigma Scale & South Oaks Gambling 
Screen) are taken before SSCBT
3. Intervention
4. Post-test (Self Stigma Scale & South Oaks Gambling Screen) measurements are taken 
after intervention.

5. Follow up (Self Stigma Scale & South Oaks Gambling Screen) measurements are 
taken 1 months after the end of the intervention.
Intervention Plan
Session 1: Psychoeducation 1
•
Addressing Gambling Disorder from a bio-psycho-social perspective.
•
Explaining the concepts of social stigma and self-stigma.
•
Providing information on Cognitive Behavioral Therapy (CBT).
•
Presenting the cognitive-behavioral model related to self-stigmatization in 
individuals with Gambling Disorder.
•
Exploring the impact of emotions and cognitive distortions.
Materials:
Operant learning model of Gambling Disorder, progressive model of stigma, progressive 
model of self-stigma, bio-psycho-social CBT model.
Session 2: Psychoeducation 2
•
Examining self-stigmatizing thoughts and their impact on behaviors.
•
Identifying automatic thoughts relevant to the individual's criteria using cognitive 
techniques.
•
Introducing cognitive awareness and the foundations of cognitive restructuring 
through evidence examination techniques.
Materials:
Emotion-thought-behavior connection, thought and emotion analysis, evidence vs. 
counter-evidence example and practice, thought-emotion reevaluation.
Session 3: Psychoeducation 3

•
Aligning behaviors with personal values.
•
Addressing cognitive restructuring and behavior change goals.
•
Enhancing the individual's self-awareness.
Materials:
Values model, reminder summary, vicious cycle diagram.
Session 4: Psychoeducation 4
•
Interaction of emotions, thoughts, and behaviors.
•
Increasing awareness of personal life and experiences.
•
Discussing foresight and preventive strategies.
•
Relapse prevention strategies and termination.
Materials:
Integrated summary of addiction and self-stigma, example triggering thoughts, relapse 
prevention form.
 
Homework Assignments
Homework is a method used in CBT interventions to reinforce the therapeutic process. 
The goal is to help participants internalize the intervention by engaging with assigned 
tasks between sessions. These assignments remain with the participant and serve as a 
summary of the therapeutic process.
•
Homework 1: Problem List – Aims to assess the participant’s current awareness 
of the issue at hand.
•
Homework 2: A-B-C (Illustrated)- Aims to realize and recognize one’s emotions 
and thoughts in specific situation.

•
Homework 3: New Book, Old Book – Encourages the participant to explore their 
emotions, thoughts, and alternatives.
•
Homework 4: Behavioral Experiment Form – Provides an opportunity for the 
participant to identify and work on personal cognitions during the cognitive restructuring 
process.
•
Homework 5: Relapse Prevention Form – Helps participants document new 
experiences and serves as a reminder of session content for cognitive restructuring 
purposes.
STUDY PROTOCOL DETAILS
Measurement Tools

Self Stigma Scale
The Self-Stigmatization Scale is a measurement tool that enables individuals to identify 
their perspectives regarding their illness or a specific condition, as well as the self-
directed stigmas they apply. The scale was originally developed in English in 2010 by 
Mak and Cheung to assess and evaluate self-stigmatization levels in individuals with 
mental disorders. It was adapted into Turkish in 2019 by Emelnur Ulusoy.
The scale consists of three subdimensions—cognitive (19 items), affective (14 items), 
and behavioral (6 items)—with a total of 39 items. The cognitive subscale includes items 
1, 2, 4, 5, 6, 10, 11, 12, 13, 18, 21, 26, 27, 29, 30, 31, 34, 35, and 38; the affective 
subscale includes items 3, 8, 15, 16, 17, 22, 23, 24, 25, 28, 32, 33, 37, and 39; and 
the behavioral subscale includes items 7, 9, 14, 19, 20, and 36. The items are rated on a 4-
point Likert scale. The total score that can be obtained from the scale ranges from 39 to 
156.
Mak and Cheung, the developers of the scale, noted that no cut-off score is used in 
evaluation; instead, the midpoint of the total score (78) is taken as a reference. In the 
Turkish adaptation of the scale, a total score of 72 or higher out of a maximum of 144 is 
considered to indicate a high level of perceived self-stigmatization (Ulusoy & Ulus, 
2022). In the context of our study, the internal consistency of the scale was tested based 
on the pre-test data collected from participants (n=26) to determine whether the scale had 

an adequate level of reliability. While the original 39-item version of the scale had a 
Cronbach’s alpha coefficient of .89, the Turkish-adapted version used in this study, 
which was reduced to 36 items, yielded an alpha coefficient of .88. When the subscales of 
the instrument were examined separately, the Cronbach’s alpha values were found to 
be .78 for the cognitive subscale, .83 for the affective subscale, and .76 for the behavioral 
subscale. These results indicate that both the overall scale and its subscales demonstrated 
an adequate level of reliability within the research sample. Permission for the use of the 
scale was obtained from Emelnur Ulusoy via email on September 13, 2023.

South Oaks Gambling Screen
The South Oaks Gambling Screen – Turkish Version (SOGS-T) is a 19-item self-report 
scale used to screen for Gambling Disorder (GD) and assess its severity. The SOGS-T is 
designed  to  evaluate  individuals'  gambling  habits  and  the  social,  financial,  and 
psychological problems resulting from these behaviors. The scale consists of "yes" or 
"no" response items, with some items formatted as multiple choice. Each “yes” response 
is scored as one point. Evaluation is based on the total score obtained from the scale.
Originally developed by Lesieur and Blume (1987), the scale was adapted into Turkish 
by Duvarcı and Varan (2001). The scale is scored between 0 and 19 points. A total score 
of 5 or more indicates possible GD, while a score of 8 or more suggests probable GD. 
The  Cronbach’s  alpha  coefficient  of  the  scale  was  found  to  be  0.85.  No  special 
permission is required for the use of the scale.
Intervention Details
Cognitive  Behavioral  Therapy  Adapted  to  Self-Stigmatization  Perception  in 
Gambling Disorder:
When creating the four-session therapy model, Albert Ellis's REBT, Aaron T. Beck's 
CBT,  and  Donald  Meichenbaum's  Cognitive  Behavioral  Modification  (CBM)  were 
utilized under the umbrella of CBT.

Client-Therapist Relationship 
This four-session adapted therapy model is designed based on psychoeducation, cognitive 
restructuring, and relapse prevention techniques. In the therapeutic process, the client-
therapist relationship varies depending on the content and technique of the session, and a 
certain degree of role flexibility is adopted. The intervention process was created and 
prepared by the researcher who was trained in the field of Cognitive Behavioral Therapy 
and had experience in conducting individual sessions with this approach.
Session1: Psychoeducation
The first session primarily consists of psychoeducation. At the beginning of each session, 
a brief psychoeducational section related to the topic to be addressed is planned. 
Psychoeducation includes the educational aspect of the intervention. In this process, the 
therapist adopts the "teacher-student" role emphasized in Albert Ellis's Rational Emotive 
Behavioral Therapy (REBT) approach (Corey, 2015, p. 347). This approach aims to lay 
the groundwork for rational thinking patterns while strengthening the trust and 
collaborative relationship between the client and the therapist. According to Beck and 
Weishaar (1989), collaboration is one of the cornerstones of CBT and a fundamental 
building block of an effective therapeutic process.
Sessions 2 and 3: Cognitive Restructuring
In these sessions, cognitive restructuring exercises are conducted with the client. The 
client summarizes the previous session, sharing what they have learned, then submits the 
assigned homework to the therapist. After a brief psychoeducational segment, rational 
reevaluations and reinterpretations are made on the homework. Alternative thoughts 
tailored to the client's individual and cultural characteristics are developed.
During this process, the therapist adopts the Socratic dialogue approach emphasized in 
Beck's Cognitive Therapy (CT) model. The therapist’s attitude includes empathetic 
accompaniment, sincerity, and warmth, providing active guidance that facilitates the 
client’s self-discovery (Weishaar, 1993). This relational dynamic supports the client's 
development of internal awareness and the creation of alternative cognitive strategies.

Session 4: Relapse Prevention
The final session focuses on relapse prevention, which involves preparing for life 
situations that may trigger challenging emotions and thoughts. At this stage, Donald 
Meichenbaum's Cognitive Behavioral Modification (CBM) model is utilized. Throughout 
the session, the client engages in mental imagery exercises related to triggering life 
situations and develops positive future plans.
The planning process is structured based on the coping skills model of CBM and includes 
skill acquisition and rehearsal. During this phase, the therapist demonstrates a flexible 
attitude sensitive to the individual and cultural characteristics emphasized in 
Meichenbaum’s CBM model (Corey, 2015, p. 373). The therapist's approach aims to 
strengthen the client's ability to cope with future challenges.
Session Content
Session 1
Introduction of the practitioner and participant, and mood state control.
Pre-test administration.
Session Goal: Psychoeducation
Psychoeducation topics:
a. The bio-psycho-social definition of Gambling Disorder (GD).
b. Introduction to the stigma process and self-stigmatization.
c. Introduction to Cognitive Behavioral Therapy (CBT).
1.a. Contrary to popular belief, GD is not a bad habit but rather a disease. Studies have 
defined it as a multifaceted disorder with biological, psychological, and social 
components (APA, 2021). As with any disease, in the case of GD, an individual will have 
difficulty overcoming the illness on their own without seeking professional help.
An example: "If I have a runny nose, I'm coughing, and my eyes are slightly red, what do 
you think is wrong with me?"
"Flu/cold."
"Even if you're not a doctor, I see that you made a quick deduction. What did you base 
this conclusion on?"

"Based on the symptoms you mentioned."
"The symptoms of the flu/cold are familiar to us and so obvious that we can make a quick 
judgment about who might have the disease. When we talk about an illness, we refer to 
defined, common symptoms. GD also has symptoms, just like a cold. However, we can't 
diagnose someone with GD as quickly as we can with a cold because the symptoms are 
not as visible. The symptoms of GD are mostly in our minds. There are certain cognitive 
processes, such as thought patterns, decision-making processes, and risk-taking 
behaviors, that manifest as symptoms (Grant et al., 2017). Just like with a cold, we 
observe the symptoms of GD, and experts in this area can create a treatment program to 
address these symptoms."
This explanation aims to increase the hope of individuals with GD regarding treatment 
and to support their self-compassion.
"There are biological processes involved in the emergence of GD, but psychological and 
social processes are also influential. Now, I want to talk about a learning model that 
affects this process. We have certain types of motivation that help us learn a behavior and 
then decide whether to continue that behavior (Czerny et al., 2008). Our motivation also 
determines how frequently the behavior we decide to continue will occur (Bozkurt, 2023, 
p. 127). In continuation of the definition, psychoeducation on behavior formation is 
carried out using Figure 1.

Figure 1. The Operant Learning Model of Gambling Disorder.
"When a behavior is exhibited and the person receives a desired, pleasurable outcome, 
they are motivated to continue that behavior and establish a frequency of behavior that 
aligns with their lifestyle. In the case of Gambling Disorder (GD), this could be seen as a 
reward gained from gambling.
However, our behaviors are not only motivated by rewards. When a person realizes that 
by engaging in a certain behavior, they can distance themselves from an undesirable or 
unpleasant situation, they may also be motivated to continue that behavior (Blaszczynski 
& Nower, 2002). In GD, this is the individual's attempt to distance themselves from 
boredom,  negative  thoughts,  pessimistic  expectations,  self-judgment,  or  any  other 
negativity in their surroundings (Nower et al., 2004; Gupta et al., 2004).
The compulsive processes lead to negative emotions. Our brain, evolved for survival, 
asks the question, "What made me happy?" in response to these stressful processes. 

Addiction involves the activation of the dopaminergic pathways in the brain, specifically 
in the nucleus accumbens, which is highly active during pleasurable activities (Wanat et 
al., 2010). Brain imaging studies reveal that the nucleus accumbens is highly active 
during pleasurable activities, as indicated by its increased intensity and glowing on the 
scan. The mind records this activity. During distressing, stressful life events, the mind 
recalls that gambling was the activity that brought pleasure and resorts to this familiar 
route to experience the quickest relief (Riley, 2014). In our sessions, we will focus more 
on which negative emotions and thoughts the behavior is helping you avoid."
After defining operant learning motivated by negative reinforcement, the participant is 
invited to share their own experiences related to this concept. The model is personalized 
by adding the individual’s own experiences to the created table. The participant is 
encouraged to analyze their experiences through a theoretical framework, facilitating 
understanding.
"What we are referring to here—the boredom, negative emotions, and negative thoughts 
the person wants to escape from—can arise or intensify depending on the way the 
individual evaluates themselves, their environment, and their future. These ways of 
evaluation are influenced by the socio-cultural structure we live in and our biographical 
stories."
1.b. Stigmatization.
Using Figure 2, the concept is introduced to the participant in 
an interactive way.

Figure 2. The Progressive Model of Stigmatization. (Created by the researcher, based on 
the work of Corrigan et al., 2011).
“We learn and adopt the perspectives of the society we grow up in, using them to create 
shortcuts in our lives. Let's take a look together at what kind of beliefs might exist in our 
unconscious societal processes regarding people who gamble, based on the table you see 
here.
Initially, what negative beliefs can you identify about people who gamble? Considering 
the societal perspective, how do you think people with Gambling Disorder (GD) are 
perceived?"
"Unreliable, unable to form a family... etc."

Since the most frequently stated stereotype by participants is "unreliable," we will 
continue with this example of the stereotype "unreliable."
"The societal conclusion that people who gamble are unreliable is a thought. If we add an 
emotional component to this thought, it transforms into a prejudice. What kind of 
emotion do you think is felt toward those who are considered unreliable?"
"Disappointment, anger, anxiety... etc."
Since the most frequent emotional response mentioned by participants is "anger," we will 
continue with the emotional response of "anger."
"After the thought that people who gamble are unreliable, if someone feels anger, they 
have now formed a prejudice. What kind of behavior do you think someone with such 
thoughts and emotions would exhibit towards a person diagnosed with GD?"
"They wouldn’t want to engage, would keep their distance, would speak badly about 
them... etc."
"When  behaviors  motivated  by  prejudice  start  to  be  exhibited,  we  can  talk  about 
discrimination. When all these components come together, the process of stigmatization 
is complete. We made these definitions with your help, and I understand that you assume 
the thoughts, feelings, and behaviors you’ve identified towards people who gamble are 
widespread in society and your environment, is that correct?"
The aim is for participants to gain awareness of the concept of stigmatization by sharing 
their personal experiences with it. By discussing the destructive effects of stigmatization, 
the goal is to foster empathetic collaboration.
"The experience of stigmatization causes the individual to become indistinguishable from 
the stigmatized issue (Matthews, 2019, p. 19). For example, the term ‘gambler’ is a 
stigmatizing expression that creates the misconception that gambling is an inseparable 
part of the individual’s character. In contrast, using ‘a person with GD’ separates the 
person's character from the disorder. This usage emphasizes that the person is someone 
with a treatable diagnosis.

Figure 3. The Progressive Model of Self-Stigmatization (Adapted by the researcher from 
Corrigan et al., 2011).

1.c. Self-Stigma. "How do you relate to people who make you feel stigmatized? How do 
you  manage  your  experience  of  stigma  in  your  environment?"
"I distance myself; I leave, I try not to see them... etc."
"The experience of stigma leads individuals to emotionally challenging processes that are 
difficult to cope with (Horch & Hodgins, 2013; Corrigan et al., 2011). It often results in 
distancing  from  people  and  environments  where  the  experience  occurs,  leading  to 
feelings of exclusion (Prizeman ve ark., 2023). The individual becomes aware of society's 
stigmatizing attitudes and, upon recognizing themselves as part of the stigmatized group, 
begins to internalize these labels (Luoma, 2010). They evaluate the prevailing social 
stigmas and may start to accept some as valid (Corrigan et al., 2011). For example, 
‘People say that those who gamble is unreliable. I gamble, I lie, I borrow money and fail 
to repay it. Therefore, I must be unreliable too. People are right to think this way.’ As a 
result of this process, the individual begins to self-stigmatize.
"One of the most significant challenges of self-stigmatization is that, while an individual 
may try to cope with external stigma by withdrawing from stigmatizing environments, 
they cannot escape the self-stigmatizing thoughts in their mind and continue to be 
exposed to them. The experience of self-stigmatization often leads to overwhelming 
emotional states such as shame, guilt, a desire to hide, decreased self-esteem, and 
hopelessness. Due to the persistent exposure to self-stigmatizing thoughts and distressing 
emotions, the individual’s self-perception becomes increasingly negative, leading to 
social isolation (Atlam et al., 2024), secrecy (Luoma et al., 2007), barriers to help-
seeking,  and  a  lack  of  motivation  to  change,  often  expressed  as  ‘Why  try?effect’ 
(Corrigan et al., 2009). This results in decreased self-efficacy, harm to motivation for 
change, and increased depressive symptoms.
"Furthermore, this process reinforces negative reinforcement mechanisms, as described in 
operant conditioning (Şekil 1), where the individual engages in gambling behavior as a 
means of escaping negative experiences (Weatherly & Cookman, 2014). Once self-
stigmatization emerges as a consequence of gambling disorder (GD), it becomes one of 
the maintaining factors, playing an active role in the individual's life.

"Do any of these emotions feel familiar to you? Do you find yourself experiencing these 
emotions in your daily life? How often and how intensely do you feel them?"
Following this explanation, the question aims to encourage participants to share their own 
experiences, reflect on memories, and develop awareness of the emotions they have felt 
and the  moments in which self-stigmatization was active. All participants reported 
experiencing emotional responses such as shame, guilt, and decreased self-esteem.
1.d. Cognitive Behavioral Therapy.
Figure 4. Conveying the Cognitive Behavioral Therapy Model from a Biopsychosocial 
Perspective (Özdel et al., 2021).

Within the scope of our study, we will examine the stigmatizing thoughts and their 
effects that emerge as a result of the activation of self-stigmatization perception, based on 
the cognitive-behavioral therapy (CBT) approach. As seen in the circular diagram (Şekil 
4), the components of physiology, emotion, thought, behavior, and situation interact 
bidirectionally, forming a continuous cycle in human life. If we are talking about change, 
we  must  observe  changes  in  these  components.  This  change  should  be  planned 
systematically, step by step. Initially, it makes sense to target a component that we have 
control over.
"Is it within your power to change your physiological responses according to your goals 
and intentions?"
"No."
"Can you snap your fingers and change the situation you are in?"
"No."
"Are you capable of instantly replacing distressing emotions with supportive ones?"
"No."
"Can you eliminate your distressing thoughts simply by deciding not to think them 
anymore?"
"No."
"But is it within your control to change, reduce, or manage a behavior?"
"Yes."
"Then, in our initial phase, our goal in addressing the negative experience of self-
stigmatization perception will begin with the behavioral component."
The Function of Homework (Corey, 2015, pp. 343-386):
The concept of homework, which is inherent in cognitive-behavioral therapy, is 
introduced, emphasizing that assignments related to session content will be planned at the 
end of each session. Participants are encouraged to complete their assignments before the 
next session. Homework serves to ensure that self-stigmatization perception is not only 
focused on during the 60-minute weekly sessions but remains an active part of the 
participants' awareness throughout the four-week process. This helps integrate session 
topics into daily life, encouraging active engagement in the therapeutic process.

Session 1 – Homework 1: Illustrated Thought Record Form (Figure 5)
This form has been obtained from the website of the "Association for Cognitive 
Behavioral Psychotherapies." Due to the nature of self-stigmatization, guilt and shame 
emotions are often triggered. This homework aims to support participants' awareness 
through in vivo applications. Guilt and shame are treated as signals, functioning as an 
alert system. Participants are instructed to recognize when these emotions are triggered 
and, at that moment, direct their attention to identifying the specific self-related thought 
that is active. They are then asked to record these thoughts.
Figure 5. A-B-C (Illustrated), Association for Cognitive Behavioral Psychotherapies, 
2024.
1.e. Session 1 – Homework 2: Problem List (Figure 6).
This form is taken from the website of the "Association for Cognitive Behavioral 
Psychotherapies." The goal is for the participant to think about and write down their 

change goals, making the key areas they wish to intervene in for life goals that align with 
their values clear to themselves.
Figure 6. Goal Setting Form II, Association for Cognitive Behavioral Psychotherapies, 
2024.
Session 2
Session Goal: Cognitive Restructuring

Cognitive restructuring aims to discover the dysfunctional automatic thoughts that affect 
an individual's life and to question and reduce belief in these thoughts through the 
evidence examination technique (Dryden, 2002). Beginning to question dysfunctional 
automatic thoughts allows for the possibility of replacing them with functional thoughts 
in later sessions.
At the beginning of the session, the homework discussed in the previous week is 
reviewed. Since the homework provides examples from the participant’s personal life, it 
helps personalize the session content. The examples from the thought record form 
(Figure 5) will highlight the thoughts that will form the basis for cognitive restructuring 
techniques. Before discussing the homework, psychoeducation materials supported by 
visuals are provided to explain how emotions are formed (Figure 7). Then, attention is 
brought back to the cycle discussed in Session 1, and the examination of thoughts in the 
context of the cyclical relationship (Figure 4) between emotion, thought, behavior, and 
physiology is explained. The reciprocal interactions between thoughts and emotions, as 
well as the motivational tasks of generating behavior, are defined. Events and situations 
are discussed in their raw form, devoid of emotion and thought. 
Events and situations are addressed as they are—stripped of emotions and thoughts. The 
interaction between emotion, thought, and behavior is discussed through a case example, 
which is visualized and presented using the material in Figure 7.

Figure 7. Explanation of the connection between emotion, thought, and behavior. Özdel, 
(2023). Cognitive Behavioral Therapy Training [Created by the researcher using a CBT 
training visual].
For example, “You are walking down the street and notice someone you know walking 
towards you. Then, you both walk past each other without greeting.” When we describe 
what happened without interpreting it, it is referred to as the “raw event.” Now, let's add 
a thought to this event: "See, they didn't want to greet me." What kind of emotional 
response would you expect if you interpret the situation with this thought?" Answers 
typically include anger, frustration, and sadness. "As you can see in this hypothetical 
example, when I describe the event without any interpretation, no emotional response 
arises. However, once we add a thought, we can talk about strong emotions." Based on 
this thought and these emotions, how would you behave towards this person? Answers 
included, "I would ignore them, I wouldn’t pick up their calls."
Let's talk about a different thought for the same event. If the thought “Poor thing, they 
didn’t even see me, they were so distracted” is considered, what kind of emotional 
response would you expect? Responses generally include concern, worry, and pity. 
"What would the behavioral response be to these thoughts and emotions?" The responses 

included, "I would call them in the evening, ask how they’re doing." Similar responses 
were gathered.
In this example, attention is drawn to the behavioral outcome. It is explained that even 
though the raw event remains unchanged, the way it is interpreted alters the dominant 
emotional  response  and  the  resulting  behavioral  reaction.  The  participant’s  three 
experiences, brought in through the homework, are simplified to "raw events," and it 
becomes clear how strongly the thoughts related to guilt and shame, which were the 
focus of the homework, appear in these experiences. The self-stigmatizing thoughts that 
the participant identifies by directing their attention to their thoughts during moments of 
guilt and shame over a week are simplified to make them easier to analyze (Figure 8).
Figure  8. Thought  and Emotion Analysis. Adapted from Akkoyunlu and Türkçapar 
(2012).
For example, a heavy thought such as “Even if I stop gambling, my mother/spouse and 
those around me will still think I am gambling and will not stop talking about me as a 
gambler.” is simplified to “Even if I quit, no one will believe me.” for analysis. Using 
this method, three thoughts identified by the participant throughout the week are also 
simplified and examined. For each identified thought, the participant is asked to rate the 
distress it causes on a scale of 1 to 10 (e.g., 10/10) and to evaluate their belief in the 
thought on a scale of 0 to 100 (e.g., 90%). The "evidence review" technique is then 
applied to all three thoughts (Figure 9). 

Figure  9.  Example  of  Evidence  and  Counter-Evidence.  Dönmez  (2023).  Cognitive 
Behavioral Therapy Training [Created by the researcher using a CBT training visual].
In the evidence review technique, the participant is asked to list experiences in their life 
that support the given thought (Akkoyunlu & Türkçapar, 2013). While listing the 
evidence, assumptions, interpretations, and feelings are not considered valid evidence; 
instead, the participant is expected to describe actual events. For example, “Even though 
I am not gambling, my mother said, ‘You’ve been looking at your phone a lot—are you 
gambling again?’” or “While we were talking, my spouse said, ‘You want to quit now, 
but tomorrow you’ll want to gamble again.’”
In the next step, the participant is asked to generate counter-evidence for the same 
thought. Similar to the first part, concrete behaviors and experiences are preferred, and 
even  the  smallest  counter-evidence  is  noted  without  omission  (Figure  10).  If  the 
participant  struggles  to  generate  counter-evidence,  they  are  encouraged  to  imagine 
themselves as a lawyer in a courtroom who must find evidence to win the case, even if 
they do not personally believe in it (Akkoyunlu & Türkçapar, 2013). A sample list is 
provided to clarify the process (Figure 9).

Figure 10. Evidence and Counter-Evidence Application. Created by the researcher 
based on Akkoyunlu and Türkçapar (2012).
Examples of counter-evidence may include experiences such as: “I am not giving up. 
There was a time when I didn’t gamble for a month, and gradually, people’s attitudes 

toward me changed. I spent more time with my friends, and they noticed that I had quit. 
I received positive feedback. I was able to set aside money to pay off my debts. My 
mother tried to support me and constantly praised me. My spouse and I even went out 
for dinner one evening.”
The  collected  evidence  and  counter-evidence  for  the  examined  thought  are  then 
evaluated. The outcome is discussed objectively by considering both the number and 
quality of the supporting and opposing pieces of evidence (Figure 10).
Figure 11. Thought and Emotion Reassessment. Created by the researcher based on 
Akkoyunlu and Türkçapar (2012).
The participant’s initial distress level and belief percentage regarding the thought are 
reassessed, and any changes are recorded (Figure 11). Attention is drawn once again to 
the power of the thought in generating and intensifying emotions, using a personalized 
example tailored to the participant’s life.
Assignment 2: "New Book/Old Book" Worksheet (Figure 12). – At the beginning of 
the session, the stigmatizing thoughts discussed are written in the Old Book section of the 
worksheet. In the New Book section, the participant is asked whether they want to keep 
these thoughts or not. For each thought they do not wish to keep, they are tasked with 
writing an alternative thought in the New Book section by the next session. The first 
cognitive restructuring session is then concluded.

Figure 12. Old Book – New Book Exercise. Dönmez (2023). Cognitive Behavioral 
Therapy Training [Training Visual].
Session 3
Session Objective: Cognitive Restructuring / Behavioral Adjustment
The New Book/Old Book assignment from the second session is reviewed. This exercise 
helps reinforce the participant’s motivation by encouraging them to develop alternative 
thoughts aligned with their personal values (Figure 12).
Psychoeducation: Values.
Values are a dynamic process that begins to develop in early childhood through the 
interaction of various internal and external factors and continues throughout life. They 
are a set of fundamental beliefs and principles that define what is considered good, right, 
important, and desirable by individuals, groups, or societies (Yazıcı, 2014). Values serve 
as internal guides that influence thoughts, behaviors, and decisions, extending from 
individual identity to societal norms (Schwartz, 2009).

Figure 13. Values Model.
The relationship between gambling disorder, the values  of the individual, and self-
stigma is discussed in Figure 13. As a result of Behavioral Addiction, self-stigmatizing 
thoughts lead individuals away from the motivation to pursue life goals that align with 
their values (Corrigan et al., 2009). The material and emotional resources that would 
help the individual pursue goals in line with their values are exhausted or harmed in the 
gambling process, causing their lifestyle to automatically drift away from these goals. 
When an individual starts doing things that contradict their values and begins living a 
life that no longer aligns with their values, they develop various negative thoughts and 
emotions  about  themselves  and  once  again  become  subject  to  the  attack  of  self-
stigmatizing thoughts. The more the individual feels they have strayed from their values, 
the  more  intense  the  self-stigmatizing thoughts are likely to become (Corrigan & 
Kleinlein, 2005; Norman et al., 2008).

The intrusive thoughts related to the person’s detachment from their values, such as "I’m 
not  doing  what  I  know  is  right,"  "I’ll  lose  my  reputation,"  "I  am  a  failure  and 
inadequate," "I no longer recognize myself," trigger feelings of guilt, shame, loss of self-
esteem, inner conflict, alienation, dissatisfaction, unhappiness, self-criticism, depression, 
anxiety, and a sense of disconnection (Atlam et al., 2024). This can have deep effects on 
the individual’s self-perception and mood.
The increase in inner conflict, harsh self-criticism, and experiences of disconnection 
resulting from behaviors and lifestyle that contradict one’s values can lead to mental 
health issues such as depression and anxiety in the long term. By the end of this process, 
the individual may feel pessimistic, hopeless, and anxious. Struggling to cope with these 
overwhelming emotions and thoughts, the individual may turn back to gambling, which 
is recorded in their mind as a pleasurable activity (Figure 13). This leads back to the 
starting point and perpetuates the vicious cycle (Figure 14).
As a result of Behavioral Addiction, the self-stigmatization perception becomes one of 
the factors that sustain the addiction.
Figure 14. Reminder Summary.
The factors that lead to a lifestyle and evaluation style disconnected from the individual’s 
values  due  to  their  behavioral  addiction,  and  that  sustain  the  perception  of  self-
stigmatization, are examined using the vicious cycle flower (Figure 15a). Immediately 
afterward, the current behaviors that support a life aligned with their values, as well as 
potential behavioral changes, are explored using a second cycle flower. At the end of the 
session, the participant is given the value-consistent cycle flower (Figure 15b) for further 
reflection.

Figure 15.

Figure 15a.
Figure 15. Figure 15a. Vicious Cycle Flower, Association of Cognitive Behavioral 
Psychotherapies, 2024 (Adapted). Figure 15b. Value-Consistent Cycle Flower (Adapted 
by the researcher).
At the end of the session, it is reminded that the intervention’s power for the targeted 
change in thoughts and emotions lies in behaviors, and the cycle used in the first session 
is revisited.

Moving away from self-stigmatizing thoughts and the distressing emotions they create is 
possible by distancing oneself from maintaining behaviors. At the end of the 3rd session, 
the individual gathers examples from their own life related to maintaining behaviors and 
behaviors  that  guide  them  toward  living  according  to  their  values  and  prepares  a 
behavioral experiment for the homework at the end of the session. This is expected to 
activate  a  decision-making  process  based  on  their  experiences  to  determine  which 
behaviors to maintain in life.
Homework 3: Behavior Experiment (Figure 16)

Figure 16. Behavioral Experiment. Cognitive Behavioral Psychotherapies Association, 
2024 (Adapted).
For the behavioral experiment to be implemented, an example behavioral experiment that 
aligns with the individual's values in the areas they aim to change, based on the "goal list" 
homework  given  in  Week  1,  is  planned  together.  Change  is  not  easy.  Before  the 
behavioral experiment is conducted, predictions about how the individual will feel and 
think are discussed, and the intensity of the predicted emotions and thoughts is rated on a 
scale from 0 to 10. After the behavioral experiment is completed, the validity of these 
predictions is reconsidered. After the individual carries out the behavioral experiment, the 
impact on their self-stigmatizing thoughts is evaluated in the "Did it work?" section. 
Scoring in this area is done on a scale of 0-100, and attention is drawn to the effective 
parts.
Session 4
Goal: Relapse Prevention
Psychoeducation: The Contribution of Self-Stigmatization Perception to Relapse

Figure 17. Integrative Summary of the Nature of Addiction and Self-Stigmatization.
A summary of the relationship between addiction and self-stigma is illustrated in Figure 
17. Addiction is a disease that follows a pattern of recovery and relapse. Addiction is a 
brain disease. Certain regions in the brain are responsible for reward and pleasure 
systems. Like other addictions, gambling is a disease in which a person struggles to 
maintain control once they start, and it is impulsive and repetitive in nature (Potenza et 
al., 2019). Just like alcohol and substances activate the brain's reward mechanism, 
gambling also activates it in a similar way (Darçın et al., Noyan, 2023, p. 50). Resisting 
impulsive  urges  becomes  more  difficult  in  processes  where  emotion  regulation  is 
challenging. During periods when overwhelming emotions take over, the repetitive nature 
of addiction is more likely to emerge. The strongest factor triggering overwhelming 
emotions is the thoughts that arise along with the individual's perception, interpretation, 
and evaluation of life events. As one of the symptoms of Gambling Disorder (GD), the 
increased effectiveness of cognitive distortions exposes the individual to self-stigmatizing 
thoughts. With the presence of overwhelming emotions, which are difficult to regulate, 

accompanying self-stigmatizing thoughts, the individual's vulnerability increases, making 
them  more  susceptible  to  impulsive  urges.  This  vulnerability,  combined  with  the 
repetitive nature of addiction, may lead the person to face relapse.
This cycle is examined within the context of factors in the participant's life that could 
lead to potential risks in the future. This examination is carried out using the Cognitive 
Behavioral Psychotherapies Association's "Relapse Prevention" form (Figure 18).
Self-stigmatizing thoughts can either be weakened or reinforced by making inferences 
about what significant others in the environment may think (a cognitive distortion called 
"mind reading"). In the first stage of the relapse prevention phase, possible mind-reading 
thoughts are listed as examples, and the participant is asked to choose those that seem 
familiar. The current belief about these selected thoughts is rated on a scale from 0 to 10. 
Afterward, the participant is asked to consider whether these thoughts align with the 
belief that the money won from gambling was acquired in a manner consistent with their 
and significant others' values, and to rate this belief on a scale of 0 to 10. These thoughts 
are then used in the relapse prevention form to identify high-risk situations and triggers, 
which are marked as potential triggers. The reevaluation of these thoughts is expected to 
provide cognitive restructuring regarding the outcomes of gambling disorder while also 
helping the individual to recall the values of both themselves and the significant others in 
their life.
Example Trigger Thoughts:
1. "If I make money, people will love me again."
2. "If I buy a house or car, my family will respect me again."
3. "If I make enough money, everything will get better."
4. "People around me expect me to make money."
5. "If I become rich, people will speak well of me."
6. "If I don't achieve great success, no one will value me."
7. "I need to make a lot of money to forgive myself."
8. "If I don't make money, my friends will distance themselves from me."

9. "I must make money to prove I've overcome my gambling addiction."
10. "If I am financially successful, my relationship with my family will improve."
11. "People will only take me seriously once I am rich."
12. "To gain respect in society, I need to have money."

Figure 18. Relapse Prevention Form, Association for Cognitive Behavioral 
Psychotherapies, 2024.
The questions "What have I learned?" and "Which were the most beneficial?" on the 
worksheet remain unanswered. Instead, participants respond to the questions "How can I 
prevent relapse?", "What are my high-risk situations?", and "What are the warning 
signs?" to enhance awareness of risk factors in their lives and to recognize early signs 
before entering a progressive relapse process.
The question "What should I avoid to maintain control?" encourages individuals to 
identify high-risk environments, situations, or behaviors and take responsibility for their 
choices. Additionally, the question "What can I do if I lose control?" is answered to 
emphasize that experiencing a slip does not inevitably lead to a downward spiral; instead, 
it reinforces the idea that there is always an option to regain control.
The continuation of the worksheet is included in this form so that participants can keep it 
with them and record their experiences until the follow-up session scheduled for one 
month later.

In the event of a relapse, the individual is asked to answer the questions “How can I 
interpret  this?”,  “What  have  I  learned  from  this?”,  and  “What  could  I  have  done 
differently afterward?” with the aim of determining their perspective on the experience 
and fostering a constructive evaluation of their situation.
The questions “What have I learned?” and “Which insights were the most beneficial?”—
if not answered immediately—are assigned as a reflective task for the participant to 
consider and write about until the follow-up session one month later. This approach aims 
to reinforce the topics covered during the sessions, ensuring that the individual continues 
to engage with them even in the absence of ongoing meetings.
5. Statistical Analysis Plan
The normality of continuous variables was assessed using the Skewness-Kurtosis test and 
the Shapiro-Wilk test. Data obtained from pre-measurements, post-measurements, and 
follow-up measurements were analyzed using appropriate parametric tests to evaluate 
whether differences in self-stigmatization perception and gambling severity between the 
experimental and control groups were statistically significant.
For continuous variables that followed a normal distribution, descriptive statistics were 
reported as mean and standard deviation, while categorical variables were presented as 
frequency and percentage. The Mixed Design ANOVA was used to compare dependent 
variables across different time points between groups. To assess the changes in dependent 
variables over time, the interaction term (independent variable time) was included in the 
Repeated Measures ANOVA.
The assumptions for variance analysis were checked, and no violations of these 
assumptions were found. Descriptive information about participants in the experimental 
and control groups, along with the statistical results from the analyses, were presented in 
tables. A significance level of p < 0.05 was considered statistically significant.
Statistical calculations were performed using STATA (version 13.0) and SPSS (version 
25) statistical software. Hayes' Process was employed to test the mediation hypothesis, 

with a 95% confidence interval and a p-value < 0.05 considered significant.
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9. Informed Consent Form