- Initiation is the first PMBOK Guide knowledge area and is designed to start the project off on the right foot. First, it uses a project charter defini- tion to formally authorize the defined initiative; this action links to subse- quent management steps in the project.
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Using your knowledge of the psychology of addictive behaviour, explain some of the reasons for Sam’s addiction to gambling. (10 marks) Outline the theory of planned behaviour as a model for addiction prevention (4 marks) Discuss the effectiveness of public health interventions in reducing addictive behaviour.
Gambling activities are present in almost every culture (). Although most individuals who gamble do not develop gambling-related problems, 1–3% of the adult population and even higher proportions of adolescents develop pathological gambling. This disorder is characterized by a progressive and maladaptive pattern of gambling behavior that leads to loss of significant relationships, job, educational or career opportunities and even commission of illegal acts. Societal costs of pathological gambling are estimated at over 5 billion dollars annually (2). Individuals who meet some, but not full, criteria for pathological gambling are often considered problem gamblers (2–), a condition that affects an additional 1.3% to 3.6% of the population and is also associated with substantial individual suffering and societal burden. Few pathological gamblers seek treatment, although about half appear to recover on their own (,). Gamblers Anonymous (GA) is the most popular intervention for pathological gamblers, but less than 10% of attendees become actively involved in the fellowship, and overall abstinence rates are low (2). Several medications have shown promise in the treatment of PG, but to date there are no FDA-approved medications for this disorder. Cognitive–behavioral therapy (CBT) has shown efficacy in the treatment of pathological gambling ().
As with all psychiatric disorders, cultural factors such as the beliefs and values of one’s group, its normative patterns of help-seeking behaviors and, in the case of immigrants, the process of acculturation, often play an important role in the initiation and maintenance of problem and pathological gambling (). Furthermore, culture can powerfully influence the phenomenology of the disorder and the type of treatment acceptable for the patients (,). We present the case of a woman with pathological gambling whose beliefs, deeply rooted in her culture, contributed to the perpetuation of her disorder. A description of how these beliefs were also manifest in the patient’s family further illustrates the role of culture in the patient’s behavior. The case also serves to exemplify the use of CBT for pathological gambling and how the assessment of the patient’s beliefs helped tailor the intervention to make it culturally consonant while still eliciting behavioral change.
Cognitive-Behavioral Therapy for Pathological Gambling
We present a case of a patient with pathological gambling based on a cognitive-behavioral relapse prevention skills manual (,) that has shown efficacy in a large randomized trial (). It consisted of 10 weekly 60-minute psychotherapy sessions. The primary treatment goal was gambling abstinence.
CBT is intended to help stop gambling behavior by helping the patient acquire specific skills using exercises introduced in each therapy session. Semi-structured homework assignments are used to facilitate practice and reinforcement of the skills learned during the week’s session. Treatment provides an overall framework to facilitate lifestyle changes and restructure the environment to increase reinforcement from non-gambling behaviors.
During therapy, therapist and patients track gambling and non-gambling days, and patients are strongly encouraged to reward themselves for non-gambling days (,). Patients are taught to break down their gambling episodes into their precipitants (triggers), the thoughts and feelings that ensue, and the evaluation of both positive and negative consequences of their behavior. This process, called functional analysis, is one of the components of CBT. It is typically learned in the early stages of treatment and used throughout it, as needed. It consists of an analysis of the chain of thoughts, feelings and actions that lead the individual to place a bet, as well as an analysis of the advantages and disadvantages of gambling versus non-gambling. The purpose of functional analysis is to help patients realize that although the short-term consequences of gambling are pleasant (having fun or the possibility of winning some money), the long-term consequences are often very severe and include not only financial problems, but also difficulties with the family, friends, work or the law. Functional analysis helps the patient understand their gambling activities from a behavioral perspective and identify steps that can be taken to stop the process at different points, so that they can effectively reduce the probability of gambling in the future in response to similar situations ().
Patients are also taught to brainstorm for new ways of managing both expected and unexpected triggers and to handle cravings and urges to gamble. Throughout the treatment patients are provided with tools and skills, such as engaging in alternative pleasant activities or calling a friend when experiencing cravings, to abstain from gambling. These skills help patients cope with triggers both internal (e.g., boredom, irrational beliefs) and external (e.g., turning down an offer to gamble, not entering gambling venues).
Each session concludes with a weekly tracking form to record triggers, cravings, or interpersonal difficulties and response strategies for those situations. Therapy also includes one session dedicated to addressing irrational thoughts. In the final session, the patient is encouraged to discuss possible events over the next ten years and consider how these events may affect future decisions to or not to gamble.
Case Presentation
Ms. A was a 51-year-old Haitian woman who immigrated to the United States with her family when she was 25 years old. She married soon after her arrival, settled in a large city in the East Coast, and had two daughters. At the time of treatment, Ms. A had been working as a secretary for a business office for over 20 years.
Ms. A started gambling in Haiti at an early age, occasionally betting small amounts of money on domino games and local lotteries. Initially, her gambling behavior did not have any immediate adverse consequences although, paralleling the effects of early substance use, it may have predisposed her for pathological gambling in adulthood (). At the age of 30, five years after her arrival in the United States, Ms. A began to gamble periodically in hopes of improving her financial situation. Over the next ten years, she began to lose increasing amounts of money playing slot machines at casinos. By age 40, Ms. A would often spend the entire weekend sitting at the slot machines without sleeping, and eating only snacks. After a few years of intense gambling activity, she was able to stop on her own without treatment. However, at age 45, she relapsed, a common experience among pathological gamblers (), into playing lottery tickets.
The relapse occurred after having very vivid dreams that she interpreted as depicting number combinations she should play in the lottery. Growing up in Haiti, she had learned to look for symbols in her dreams since, in her culture, dreams were believed to convey important life messages often represented by numbers. As a teenager in her country, books about dreams and numbers were very popular, and she read them fervently. She would also frequently gather with her family members to discuss her dreams and their meanings, and agree on the numbers the dreams suggested should be played on the lottery. These conversations about dreams and numbers among her family members continued to be an important topic in their almost daily conversations after immigrating to the US.
As the duration of her relapse lengthened, Ms. A gambled greater amounts of money and more frequently. She became increasingly preoccupied with thoughts about gambling and number combinations. Her continuous efforts to reduce or stop gambling resulted in irritability and restlessness. Although she was aware that she was losing more money than she was winning, she would often gamble the day after losing money in hopes of winning back (“chasing”) her losses. She concealed the extent of her gambling and her financial situation from her family. Occasionally, she had suicidal ideation, but never made any suicide attempts, which are common among pathological gamblers ().
As a result of her gambling behavior, Ms. A. began to experience financial problems. One of Ms. A’s primary motivations to seek treatment was the constant arguments with her husband about the monetary constraints caused by her gambling activities. She also felt ashamed and guilty about the money spent gambling over the years. Although she experienced financial difficulties due to the gambling behavior, Ms. A did not commit any illegal acts to finance her gambling activities, nor did she rely on others to bail her out of financial difficulties.
Ms. A reported that her gambling did not interfere with her work and household chores because it only took her a few minutes during the day to purchase tickets at convenience stores located close to her workplace and home. She never missed days at work and performed her work well. She only noted mild difficulties concentrating at work during the minutes prior to the lottery deadline. She did, however, note the impact of gambling on her social activities. She reported being more socially withdrawn, spending less time with her daughters, and increasing conflict with family members due to her overall irritability.
Although comorbidity is common among pathological gamblers (–), Ms. A did not meet full criteria for any other psychiatric disorder. She did, however, report experiencing several depressive symptoms over the past few weeks, including little interest or pleasure in doing things, feeling guilty, and becoming easily annoyed or irritable. Thus, the patient met the following DSM-IV criteria for pathological gambling: 1) increased preoccupation with gambling; 2) having the need to gamble increasing amounts of money to achieve excitement; 3) unsuccessful efforts to stop gambling; 4) restlessness and irritability when trying to stop gambling, 5) after losing money gambling, returning another day in order to get even (“chasing” her losses); 6) hiding the extent of her gambling from her family; and, 7) feeling she was jeopardizing her relationship with her husband as a result of her gambling. Although Ms. A did not report: 1) gambling as a way to escape from problems or in order to relieve a dysphoric mood; 2) commiting any illegal acts to finance her gambling; or, 3) relying on others to provide money to relieve her financial situation, overall Ms. A manifested a persistent and recurrent maladaptive gambling behavior that met 7 of 10 DSM-IV diagnostic criteria for pathological gambling (five or more are needed for a diagnosis of pathological gambling), and was not accounted for by a manic episode.
Treatment
Since the initial treatment contact, Ms. A clearly stated her main goals were to abstain from gambling and improve her financial situation and her relationship problems. One of her main concerns was that although she had been able to abstain from gambling in the past, she found herself unable to do so after her last relapse. At the initial evaluation, Ms. A scored 20 on the Yale Brown Obsessive Compulsive Scale adapted for Pathological Gambling (PG-YBOCS), a valid and reliable measure of pathological gambling severity (with range 0–40).
Early in treatment, Ms. A soon identified her dreams and visions as her main triggers for gambling. She described two types of dreams. In one type of dream, either Ms. A actually “saw” numbers, or one or more characters in the dream disclosed “winning” numbers. These dreams were very vivid and constituted very strong triggers to gamble. The other type of dream, to which she referred as visions, was more common and happened throughout the day. Those dreams contained images and actions of different individuals she knew, including family members, friends, coworkers, and neighbors. For these visions, Ms. A had predetermined number conventions derived from Haitian culture and conversations with her family. That is, the images and actions she saw conveyed number combinations. As an example, she would describe a dream in which she saw an unknown little girl talking to her uncle. Ms. A said that dreaming about children meant the number 32, while dreaming about a male family member represented the number five, leading her to create different sets of numbers with these three digits. In other dreams, the numbers were more obvious, such as in a dream in which she saw herself walking on a street and seeing a license plate with a certain number. Ms. A typically woke up everyday and started attributing numbers to the images that appeared in her dreams and visions. She would write down the numbers and generate a list of different combinations to buy a series of lottery tickets that day. Depending on the results of the first drawings, she would generate a new series of combinations for the next drawing. Ms. A. also reported other triggers for gambling (15), including her wish to solve her financial problems, her family’s constant involvement in gambling activities, and the sight of gambling advertisements or convenience stores that sold lottery tickets.
Having identified a variety of triggers, Ms. A. began to address them to minimize the possibility that they would results in gambling. For example, she started making the conscious effort to avoid recalling her dreams. This was difficult due to her longstanding habit of recalling them, but was effective in controlling her gambling behavior. She also stopped carrying with her the list of numbers generated in the morning, and later replaced generating the list with doing her weekly therapy homework assignments. During treatment, therapist and patient maintained a tracking graph on a grid of gambling and non-gambling days. Graphing all gambling and non-gambling days together onto a sheet, the patient was able to visualize her progress. After the third session, the patient was able to notice that she had decreased the amount of money spent on gambling and bought lottery tickets every other day rather than daily.
The patient also started to actively avoid some other gambling triggers. She avoided the convenience store close to work, and stopped watching gambling T.V. shows and advertisements, including the lottery results. She contacted the customer service at the casinos she used to visit, requesting that they stop sending her their invitations and publicity. She purposely kept busy during the hour prior to the lottery deadline, to avoid buying lottery tickets for the next drawing.
For Ms. A, the most effective strategy to abstain from gambling was to conduct functional analyses every time she experienced urges to gamble. Describing her gambling activities, the patient talked about the anxiety she experienced before buying lottery tickets and the frustration, shame, and guilt she felt once the results were published and she was confronted by the amount of money lost that day. Conducting functional analyses allowed the patient to see how, despite a few wins, the overall result was always monetary loss and greater debt. The patient gradually started to feel less excited about thoughts of winning. Eventually, even winning became an anxiety-provoking situation.
The patient experienced intense frustration on one particular occasion when she had a dream about the winning number, but did not feel the dream with enough strength. She hedged her bets, rather than put all her money on the winning number. This experience filled her with doubt on her abilities. She started to experience her ability to foresee the future in visions and dreams as an unpleasant responsibility. In the past, stressful familial events had also appeared in her dreams before they happened, but she had been unable to influence those events, a very painful experience. She realized now that, similarly, “knowing” the correct number did not lead her to win. As a result, her gambling activities were making her financial situation worse. At that time, around the midpoint of the treatment, the patient’s PG-YBOCS scores had decreased to 11. Tracking the number of gambling days revealed the patient was now gambling once or twice a week.
The therapist conceptualized the knowledge acquired through her dreams as a special type of erroneous belief. Erroneous beliefs are commonly found in gamblers and often manifest as beliefs in “lucky days” and “lucky streaks”. They can also include ignorance of the true probabilities of winning and failure to understand the independence of events (“I lost three times on this slot machine, so I should win soon”).
In CBT, at least an entire session is generally devoted to understanding and challenging erroneous beliefs. The purpose is to help the patient identify their thinking errors regarding their odds of winning. However, in this case, given the strong family and cultural support for the patient’s cognitions, the therapist’s approach was to subtly question Ms. A’s beliefs, without confronting them directly. The therapist focused on having the patient recognize that the dreams and visions did not consistently provide her with winning numbers, rather than challenging the irrationality of the belief. This approach, and the patient’s progressive perception of her dreams and visions as a burden, strengthened the patient’s decision to ignore her dreams and visions related to gambling. In so doing, a main trigger of her gambling was removed.
During subsequent sessions, the therapist coached Ms. A on assertiveness and gambling refusal skills. It was difficult for the patient to control her urges to buy lottery tickets after participating in “number conversations” with her family members or coworkers. She decided during one of these sessions to tell her mother and sisters about her wish to abstain from gambling. However, after two weeks of abstinence, Ms. A lapsed one day. She bought a lottery ticket after one of her sisters told her a very vivid dream that she believed to be the winning number for the next drawing. Using the gambling tracking chart, the patient was able to see that weekends, when she spent longer hours with her family members, represented a risk.
This lapse led Ms. A to identify family members and conversations about numbers as additional triggers to gamble. Ms. A had to reiterate to her family members to avoid discussing numbers, dreams, or visions when she was present. This was difficult initially, as her family would pressure her to continue gambling, given its importance in family life and beliefs. However, Ms. A eventually prevailed and found it helpful to avoid these conversations. Having the strength to voice her opinions and wishes also raised her self-esteem and self-efficacy. Around that time, she learned that one of her brothers had a gambling problem when they were living in Haiti. This knowledge increased her motivation to remain abstinent, as she remembered the financial struggle her brother experienced before immigrating to the United States.
The last two sessions served to solidify Ms. A’s gains and refine her skills. The patient had already achieved abstinence and felt strong and confident. Her urges were mild. The patient spent more time in alternative pleasant activities, such as physical exercise, going out with friends or to church, helping organize holiday festivities, and participating in other community activities. She also spent more time with her husband and daughters during the weekdays and attended social gatherings with them.
Although Ms. A. had initially reported that her gambling activities never affected her work, toward the end of treatment, she noticed an improvement in her ability to concentrate and complete tasks more efficiently. Her abstinence helped improve her relationship with her husband, with whom she now argued less. She was also excited about being able to buy more things for her home as a result of not spending money on gambling. At the end of the tenth session the patient’s PG-YBOCS gambling scores had decreased to 2, within the normal range. The gambling tracking chart now was an upright line, since she had not gambled for a month on a row. The process of tracking non-gambling days increased Ms. A’s perception of control of her gambling behavior, and she reported it became a strong motivation to remain abstinent.
After completing the 10 weekly sessions, Ms. A continued to come to therapy for monthly follow-up sessions. At follow-up, 10 months later, Ms. A continued to abstain from gambling. During these sessions, the therapist and patient continued working on strengthening the skills learned during the acute treatment and brainstorming alternatives to gambling. The patient was also referred to a therapy group for women who want to remain abstinent from gambling, which Ms. A found helpful. It is likely that Ms. A will require continuous treatment and follow-up for pathological gambling. If the patient’s preferences or situation change, other therapeutic alternatives, such as medication for other psychiatric symptoms, motivational interviewing, or Gamblers’ Anonymous, could also be considered.
Case Discussion
Pathological gambling is a common disorder with severe consequences for patients and their families. At present, the treatment with best empirical support is CBT. This case describes its general principles, and provides an example of how CBT techniques can be adapted depending on the characteristics of each patient. In particular, the case of Ms. A illustrates the contribution of beliefs, especially those part of a cultural system, to the perpetuation of a patient’s disorder; the influence of family members’ attitudes, moved by their cultural beliefs and values, in shaping behavior; and the consideration of these issues to guide specific interventions, such as challenging irrational thoughts or helping patients devise strategies to change their behavior in a culturally-congruent manner.
Irrational beliefs are important factors in the initiation and maintenance of many psychiatric disorders, including pathological gambling. Identifying them, pointing out their consequences, and progressively challenging them are key aspects of CBT. For example, special dates, playing numbers encountered during the day, or lucky days, create in some patients a sense of possessing a special knowledge that putatively increases their chances of winning. Those beliefs can be powerful triggers to gamble even after long periods of abstinence, and often trigger a relapse. It is not uncommon to find pathological gamblers who act on the numbers they see in their dreams. For Ms. A, however, dream and numbers interpretation were particularly important because they had been part of her belief system since her childhood, long before she developed a gambling problem. Furthermore, in her case, the belief that dreams foretold the numbers to play on a given day was supported by her family and her culture.
For these reasons, it was anticipated that engaging Ms. A in viewing this belief as irrational would be difficult. Subtly and progressively questioning her beliefs, as was done in this case, was an adjustment of a CBT technique to the patient’s culture, since standard treatment usually challenges cognitive distortions more directly. Challenging her belief directly would have probably appeared to be minimizing the patient’s and her family’s cultural norms. This could have led the patient to argue for the “truth” of symbolism in dreams, make her refuse to use CBT techniques and possibly cause her to leave treatment prematurely, feeling misunderstood or misjudged. Because the patient had come to treatment due to her gambling losses, it was believed that focusing instead on the less central belief of the ability of dreams to provide winning numbers would be much more effective with her.
By doing so, the patient was able to distance herself from her gambling behavior, as she started to perceive throughout treatment that her number system was unreliable. For example, as the therapist explored the triggering effect of dreams, she asked the patient about her experience with the dreams, their accuracy at predicting winning numbers, and her feelings about her failure to win despite playing the numbers suggested by the dreams. These questions helped create discrepancy between the patient’s beliefs (and wishes) and reality. Building the challenge to these beliefs, the therapist was able to engage the patient in treatment and help her begin avoiding external and internal triggers.
Knowledge about the role of these beliefs in the lives of the patient and her family was also crucial in this case. Following a period of abstinence, the patient suffered a lapse to gambling when her sister urged her to play certain numbers that she had interpreted from a dream. Contrary to relapses, where the patient returns to the addictive behavior for an extended period of time, brief lapses such as what occurred with this patient can be very useful to the treatment of addictive disorders. Although much of the relapse prevention treatment approach focuses on helping the patient build skills to avoid relapse, lapses can help the therapist and the patient identify situations for which the patient needs more help. These lapses can be best used therapeutically if they occur while the patient is still in treatment, because then the patient and therapist can quickly analyze the lapse and incorporate the lessons learned into the treatment. The lapse that occurred during Ms. A’s treatment helped her to identify her family discussions about dreams and numbers as triggers to gamble, and allowed the therapist and the patient to explore ways of dealing with them.
The lapse was also instrumental in helping the patient set limits with her family in conversations on gambling, numbers, and dreams. Solely pursuing an approach focused on setting limits could conflict with her cultural norms of family interactions, which valued harmony among family members, and fail to elicit from her family’s support. Given the familial endorsement of these beliefs about dreams and numbers, however, finding an acceptable way of setting limits was a key aspect of achieving and maintaining abstinence from gambling. Rather than readily teaching the patient feedback and assertiveness approaches often used in mainstream American culture, eliciting from Ms. A how limits could be set within her family and culture made it easier for her discuss her difficulties with her family and enlist their support in not having those conversations in her presence (had this approach not worked, Ms A and the therapist would have considered alternative strategies and developed additional skills to be more assertive if necessary).
Ms. A’s approach also exemplifies the broader aspects of how family or other support systems can be helpful in stopping gambling. Although the family was a trigger to gambling, it also provided an important image for Ms. A that strengthened her resolve to remain abstinent from gambling-- her brother’s experience. This fact was particularly important given that several studies suggested that pathological gambling may have a familial component. Consistent with those studies, associations have been reported between pathological gamblers and allele variants of polymorphisms at dopamine receptor genes, the serotonin transporter gene, and the monoamine-oxidase A gene (–). Twin studies have also suggested a genetic component in the etiology of problem and pathological gambling ().
Conclusion
We have presented the case of a Haitian woman that illustrated the role of culture in the phenomenology and treatment of pathological gambling. The case showed how cultural beliefs can contribute to the etiology of psychiatric disorders, how the manifestation of symptoms can vary by culture, and how CBT can be integrated within belief systems of different cultures.
Cultural perceptions related to psychiatric disorders may also influence treatment-seeking behaviors. For cultures with highly permissive beliefs towards gambling, it might be difficult to label certain gambling behaviors as a psychiatric disorder, which could consequently reduce the likelihood that individuals in need will seek services.
The advantages of learning about the patient’s culture to provide appropriate and efficacious treatment have been well established (). Those benefits include the ability to build trust, to demonstrate openness and interest by recognizing cultural belief systems and the role they play in the initiation and maintenance of a patient’s condition, and to adapt the treatment to use those beliefs as help rather than barriers to treatment.
Acknowledgments
Supported in part by NIH grants DA019606, DA020783, DA023200 and MH076051 (Dr. Blanco), MH60417 and DA022739 (Dr. Petry), the New York State Office of Alcoholism and Substance Abuse Services (Dr. Blanco) and the New York State Psychiatric Institute (Drs. Oquendo and Blanco).
Footnotes
Disclosures All authors declare no competing interests.
References
Discuss The Learning Approach To Explaining Initiation Of Gambling System
Abstract
Gambling, including pathological gambling and problem gambling, has received increased attention from clinicians and researchers over the past three decades since gambling opportunities have expanded around the world. Gambling disorders affect 0.2–5.3% of adults worldwide, although measurement and prevalence varies according to the screening instruments and methods used, and availability and accessibility of gambling opportunities. Several distinct treatment approaches have been favorably evaluated, such as cognitive behavioral and brief treatment models and pharmacological interventions. Although promising, family therapy and support from Gamblers Anonymous are less well empirically supported. Gambling disorders are highly comorbid with other mental health and substance use disorders, and a further understanding is needed of both the causes and treatment implications of this disorder. This article reviews definition, causes and associated features with substance abuse, screening and diagnosis, and treatment approaches.
INTRODUCTION
This paper offers a balanced review of major contemporary perspectives on substance abuse and gambling. This paper should be of great assistance to the reader in developing the multidisciplinary foundation that is unique to the addictive behaviors such as gambling and substance use and treatment fields. We do hope that students and in-service professionals find the review of theory and research to be provocative enough to cause them to reconsider their conceptions of gambling and substance use. This paper should serve to strengthen understanding of divers theoretical perspectives on addictive behavior such as gambling and substance use in helping communities and individuals effectively address these problems.
DEFINITIONS OF GAMBLING
Wildman[1] suggests that the important thing to remember about gambling is that it is “a conscious, deliberate effort to stake valuables, usually but not always currency, on how some event happens to turn out.”
There are also “quasi-gambling” activities, such as stock market and real estate investments that can be used as opportunities to gamble, and so must be counted in any survey of gambling activity. How often a person is involved as well as the sum of money involved may be used as a rough criterion for considering an activity as “gambling.” It has also been suggested that unless there is some sort of excitement or thrill involved in the pursuit of an activity, it probably isnot gambling. Some people, for instance, do not consider buying lottery tickets or raffle tickets for charitable purposes as gambling, and yet there is clearly some anticipation or excitement involved in the purchase of these tickets, whether or not a large amount of money or time is invested in their purchase. A combination of excitement and level of involvement is perhaps the best means to determine what is or isnot gambling. The limits of what is considered “gambling” behaviour have shaped the definitions of “problem” gambling that are used, and how problem gambling is measured. Wildman[1] provided a useful summary of the theories that explain why people gamble [Table 1]. All of these explanations are used to treat people affected by problem gambling. For those who believe that gambling was an important behaviour in human evolution, as well as for those who look at gambling as a generator of excitement and stimulation, the biological school of thought on problem gambling suggests that there are genetic predispositions toward gambling — problem gambling in particular. Thus, measurable chemical changes occur in someone who either has this predisposition, or who develops problem gambling behaviour. Medical treatment is necessary in these cases.
Table 1
A more behavioural approach to gambling and problem gambling believes these behaviors derive from social learning, either as a focus of socialization, or a result of reinforcement. This approach also encompasses the personification of luck, and other superstitious forms of thinking often seen in social and people affected by problem gambling, a manifestation of “primitive magical or religious ceremonies” [Table 1]. Cognitive behavioural treatment approaches are the logical approach if gambling behaviour is seen as linked to specific environments or subject to specific triggers.
Those who see gambling as a rational behaviour might be more likely to suggest that gamblers a) see that gambling is strictly for fun, or b) feel that they can make a profit at it. Cognitive behavioural approaches to gambling problems are also the most likely means of treatment for those who see gambling as a rational behaviour. Teaching gamblers the odds of their favorite games often changes their belief that gambling can be profitable. However, none of the explanations for gambling behaviour outlined in the table above provide an appropriate rationale as to why some gamblers develop gambling problems. For that, we need to look at a multi-dimensional approach. For instance, Wildman suggests that all of these explanations may be present, to varying degrees, in the same individual.
GAMBLING ADDICTION
Problem gambling is an urge to gamble despite harmful negative consequences or a desire to stop. The term is preferred to compulsive gambling among many professionals, as few people described by the term experience true compulsions in the clinical sense of the word. Problem gambling often is defined by whether harm is experienced by the gambler or others, rather than by the gambler's behavior. Severe problem gambling may be diagnosed as clinical pathological gambling if the gambler meets certain criteria.
Problem gambling has most often been conceptualized and defined in the past as an addiction or medical problem, because this was a familiar framework for both policy makers and clinicians, and because of the surface similarities between gambling problems and alcohol and other drug problems. Rosenthal's[12] definition is perhaps the best place to start in terms of defining problem gambling, because it is broadly accepted by psychiatrists, many psychologists, and Gamblers Anonymous members, and is also the foundation for the influential Diagnostic and Statistical Manual's criteria for problem gambling:
A progressive disorder characterized by a continuous or periodic loss of control over gambling; a preoccupation with gambling and with obtaining money with which to gamble; irrational thinking; and a continuation of the behaviour despite adverse consequences.
This definition, like the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, is behaviorally based, and sees gambling as a disorder that one either has or doesnot have. It captures most of the important behaviors that are seen with severe problem gambling, but only indirectly includes the consequences of gambling. Of course, it is because of the consequences that most gamblers end up in treatment. In addition, by calling gambling a “disorder” the definition suggests that those who have gambling problems are in some qualitative way different from those who do not. The literature suggests that this is not true.
PATHOLOGICAL GAMBLING
Extreme cases of problem gambling may cross over into the realm of mental disorders. Pathological gambling was recognized as a psychiatric disorder in the DSM-III, but the criteria were significantly reworked based on large-scale studies and statistical methods for the DSM- IV. As defined by American Psychiatric Association, pathological gambling is an impulse control disorder that is a chronic and progressive mental illness.
Pathological gambling is now defined as persistent and recurrent maladaptive gambling behavior meeting at least five of the following criteria, as long as these behaviors are not better explained by a manic episode:
Preoccupation. The subject has frequent thoughts about gambling experiences, whether past, future, or fantasy
Tolerance. As with drug tolerance, the subject requires larger or more frequent wagers to experience the same “rush”
Withdrawal. Restlessness or irritability associated with attempts to cease or reduce gambling
Escape. The subject gambles to improve mood or escape problems
Chasing. The subject tries to win back gambling losses with more gambling
Lying. The subject tries to hide the extent of his or her gambling by lying to family, friends, or therapists
Loss of control. The subject has unsuccessfully attempted to reduce gambling
Illegal acts. The subject has broken the law in order to obtain gambling money or recover gambling losses
Risked significant relationship. The subject gambles despite risking or losing a relationship, job, or other significant opportunity
Bailout. The subject turns to family, friends, or another third party for financial assistance as a result of gambling
Biological bases. The subject has a lack of norepinephrine.
As with many disorders, the DSM-IV definition of pathological gambling is widely accepted and used as a basis for research and clinical practice internationally.
BIOLOGICAL BASES
According to the Illinois Institute for Addiction Recovery Recent evidence indicates that pathological gambling is an addiction similar to chemical addiction. It has been seen that some pathological gamblers have lower levels of norepinephrine than normal gamblers.
According to a study conducted by Alec Roy, M.D. formerly at the National Institute on Alcohol Abuse and Alcoholism, norepinephrine is secreted under stress, arousal, or thrill, so pathological gamblers gamble to make up for their under dosage.
Further to this, according to a report from the Harvard Medical School Division on Addictions there was an experiment constructed where test subjects were presented with situations where they could win, lose or break even in a casino-like environment. Subjects’ reactions were measured using functional magnetic resonance imaging (fMRI), a neuron-imaging device similar to a magnetic resonance imaging (MRI). And according to Hans Breiter, MD, co-director of the motivation and Emotion Neuroscience Centre at the Massachusetts General Hospital, “Monetary reward in a gambling-like experiment produces brain activation very similar to that observed in a cocaine addict receiving an infusion of cocaine.”
Deficiencies in serotonin might also contribute to compulsive behavior, including a gambling addiction.
RELATION TO OTHER PROBLEMS
As debts build up people turn to other sources of money such as theft, or the sale of drugs. A lot of this pressure comes from bookies or loan sharks that people rely on for capital to gamble with. Also, a teenager that does not receive treatment for pathological gambling when in their desperation phase is likely to contemplate suicide. A total of 20% of teenagers that are pathological gamblers do consider suicide. This according to the article High Stakes: Teens Gambling with Their Futures by Laura Paul.
Abuse is also common in homes where pathological gambling is present. Growing up in such a situation leads to improper emotional development and increased risk of falling prey to problem gambling behavior. Pathological gambling is similar to many other impulse control disorders such as kleptomania, pyromania, and trichotillomania. Other mental diseases that also exhibit impulse control disorder include such mental disorders as antisocial personality disorder or schizophrenia.
PREVALENCE
According to a variety of sources, the prevalence (i.e., extent of existing cases) of problem gambling is 2-3% and pathological gambling is 1% in the United States, though this may vary by country. By contrast, about 86% of Americans have gambled during their lives and 60% gamble in a given year. Interestingly, despite the widespread growth in gambling availability and the increase in lifetime gambling during that past 25 years, past year problem gambling has remained steady. Currently, there is little evidence on the incidence of problem gambling (i.e., new cases).
Available research seems to indicate that problem gambling is an internal tendency, and that problem gamblers will tend to risk money on whatever game is available, rather than a particular game being available inducing problem gambling in otherwise “normal” individuals. However, research also indicates that problem gamblers tend to risk money on fast-paced games. Thus, a problem gambler is much more likely to lose a lot of money on poker or slot machines, where rounds end quickly and there is a constant temptation to play again or increase bets, as opposed to a state lottery where the gambler must wait until the next drawing to see results.
Dopamine agonists, in particular pramipexole (Mirapex), have been implicated in the development of compulsive gambling and other excessive behavior patterns (e.g., PMID 16009751).
GAMBLING AND SUBSTANCE ABUSE: A COMPARISON
Gambling is commonly thought of as an addiction, even though it is not included with other addictions in the DSM-IV.[13] In describing diagnostic categories for problems related to alcohol and other drugs, the DSM-IV uses the term substance-related disorders, which includes, among others, alcohol, amphetamines and caffeine. Gambling problems are referred to as pathological gambling, which is listed as one of six disorders under impulse-control disorders.
The DSM-IV recognizes two levels of severity with the substance-related disorders — substance dependence and substance abuse. Substance dependence is distinguished from substance abuse by several diagnostic criteria, the most significant difference being that the presence of tolerance and withdrawal are required for a diagnosis of dependence. If tolerance and/or withdrawal are present, a diagnosis of abuse cannot be made. In comparison, only one level of problem severity is considered for gambling — pathological gambling.
A review of the diagnostic criteria of these disorders suggests some similarity between them. Substance dependence is described as “a maladaptive pattern of substance use, leading to clinically significant impairment or distress.” The DSM-IV then itemizes seven diagnostic criteria, of which at least three need to be present during a 12-month period to warrant a diagnosis of substance dependence. The same definition is used for substance abuse, with only one diagnostic criterion needing to be present during a 12-month period to warrant the diagnosis. However, it is essential to note that although the description for abuse is the same as dependence, the diagnostic criteria are much different. Most notably, the criteria of tolerance and withdrawal, which are included in the criteria for dependence, are absent in the diagnostic criteria for abuse.
Pathological gambling is described as “persistent and recurrent maladaptive gambling behaviour,” similar to the description for substance dependence and abuse. There are 10 diagnostic criteria, of which at least five need to be present to warrant a diagnosis of pathological gambling. The criteria are worded in the present tense, suggesting that the criteria need to be present at the time of the diagnostic interview to warrant the diagnosis.
An examination of the respective diagnostic criteria indicates a similarity between the disorders. For example, two of the criteria for substance dependence are tolerance and withdrawal; two concepts most commonly associated with the ingestion of a substance, like alcohol or other drugs. Tolerance in relation to substance dependence is described as a need for markedly increased amounts of the substance to achieve intoxication or desired effect. One of the criteria for pathological gambling is a need to gamble with increasing amounts of money in order to achieve the desired excitement. This is quite similar to the definition of tolerance.
Similarly, the concept of withdrawal, described in the criteria for substance dependence as “the development of a substance-specific syndrome due to the cessation or reduction in substance use that has been heavy and prolonged,” is also identified as a criterion for pathological gambling. It is not labeled as withdrawal, but is described as being restless or irritable when attempting to cut down or stop gambling.
Another criterion for substance dependence includes “a persistent desire or unsuccessful efforts to cut down or control substance use.” Pathological gambling involves “…repeated unsuccessful efforts to control, cut back, or stop gambling.”
Additional similarities include the presence of preoccupation, compromising social, occupational or recreational activities and legal problems (which are not included in the criteria for dependence).
The criteria depart in only two areas of diagnosis. Substance dependence includes a criterion that refers to the substance use continuing despite the individual knowing that continued use of the substance is likely to result in recurrent physical or psychological problems. The criteria for pathological gambling do not address this issue. On the other hand, the criteria for pathological gambling emphasize the negative impact on family and friends in three criteria, while impact on others is not addressed in the criteria for substance dependence.
It is not clear why pathological gambling is positioned with impulse control disorders in the DSM-IV, since there appears to be more similarities between pathological gambling and substance-related disorders than there are between pathological gambling and impulse-control disorders, at least in terms of their diagnostic criteria.
In a more general sense, Marlatt et al. defined addictive behaviour as:
A repetitive habit pattern that increases the risk of disease and/or associate personal and social problems. Addictive behaviors are often experienced subjectively as “loss of control” — the behaviour contrives to occur despite volitional attempts to abstain or moderate use. These habit patterns are typically characterized by immediate gratification, often coupled with delayed, deleterious effects. Attempts to change an addictive behaviour (via treatment or self initiation) are typically marked with high relapse rates.[14]
From Marlatt's definition, gambling and substance disorders share a number of addictive behaviour characteristics, again suggesting a phenomenological similarity.
Many similarities exist in terms of how substance dependence/abuse and pathological gambling are treated. Professional and self-help interventions are available for both disorders. The concept of matching the individual to the appropriate professional or self-help (or both) intervention appears to be an important factor in determining outcomes for both disorders. Substance dependence treatment relies more on residential services, including withdrawal management and treatment, than does pathological gambling. Medical intervention is likely more frequently required for individuals with substance dependence.
There is a similar range of therapeutic modalities and orientations available for both disorders, including individual, group and family modalities, as well as cognitive-behavioral and psychodynamic approaches.
Substance abuse and gambling share a common controversy in treatment planning: Abstinence vs. reduced use/gambling as a treatment goal. The scientific research and ideological argument on substance dependency and abuse has been well documented. Far less research has been done into the viability of goals of reduced gambling, but the ideological argument for and against abstinence/reduced goals has been imported from the substance abuse literature into the gambling literature. It remains a contentious issue in both fields.
Both disorders are recognized to have potentially serious deleterious effects on family members. Recent literature on children of alcoholics identifies the developmental, interpersonal, and emotional issues involved in a family where there is a parent with a substance dependency or abuse problem. Studies on children of pathological gamblers have found increased health-threatening behaviors (such as smoking, overeating, substance abuse, gambling), dysphoria, and deficits in functioning.[15]
One significant difference between the two disorders is that problem gambling is recognized as a more cognitively based disorder than substance dependence or abuse. Most researchers[] have concluded that excessive gamblers characteristically demonstrate core cognitive distortions in their belief systems about their ability to win at gambling. These beliefs can persist even when the gambler continues to lose at gambling. It is essential to assess the gambler's beliefs about his or her ability to win. Some gamblers also have cognitive distortions not only about their ability to win, but also their need for excitement, and a correlating distorted belief that they will not be able to function without the excitement that they derive from gambling. Cognitive therapy is required to identify, challenge, and modify cognitive distortions, or relapse to gambling is likely (because the gambler believes that he or she is going to win if he or she gambles). Other interventions may be appropriate and effective (e.g., behavioural therapy, family therapy, impulse control training, etc.), but cognitive assessment and therapy will be a cornerstone of the treatment plan.
Substance abuse may involve minimizing one's use, and an underestimation of the effect one's use has on life areas as well as family members may be evident. However, these characteristics are typically interpreted as defense mechanisms (unconscious attempts to deal with what are perceived as attacks against one's ego, or self), rather than, as in problem gambling, cognitive distortions in one's belief system — misinterpreting the outcomes and cause-effect relationships involved in gambling.
Another aspect of treatment planning, and treatment where the two disorders vary distinctly, is in relation to the gambler's financial situation. Treatment for pathological gambling typically includes a major focus on financial assessment, which includes issues like access to cash; cheque control, credit card control, debt resolution strategies, and financial planning (refer to Section 5.2, “Finances and the Gambling Client”). A financial crisis is often the issue that prompts a gambler to seek counseling. Because many gamblers are heavily indebted, attempting to deal with indebtedness by returning to gambling to win money (a cognitive distortion) can be a relapse factor if their financial crisis is not addressed and managed appropriately. It is not uncommon, particularly in the early stages of counseling, to suggest that the gambler surrender access and control of financial matters to his spouse, or another trusted person, as a preventive measure. Preventing or reducing access to money (and therefore eliminating the means to gamble) is considered good practice.
Counselors must be completely comfortable discussing money management with clients, including incomes, net worth, financial liabilities (credit cards, mortgage, loans), and budgeting. This requires not only the knowledge to advise the client on these matters (or to refer them), but also being psychologically comfortable doing so.
Clients with substance abuse problems may also have some financial pressures related to the cost of their use, but money and financial issues do not take a central role in the treatment plan as they do with counseling gamblers. For many counselors not accustomed to working with gamblers, this approach may represent a dramatic departure from how they might typically counsel alcohol- and drug-using clients. Accepting and dealing with the integral role of financial matters with gambling clients may require professional development for the substance abuse counselor.
TREATMENTS OF GAMBLING ADDICTION
Every gambler is unique and so needs a recovery program tailored specifically to him or her. What works for one gambler will not necessarily work for you. The biggest step in treatment is realizing you have a problem with gambling. It takes tremendous strength and courage to own up to this, especially if you have lost a lot of money and strained or broken relationships along the way. Do not despair and do not try to go it alone. Many others have been in your shoes and have been able to break the habit.
Gamblers anonymous
Is a twelve-step recovery program patterned after Alcoholics Anonymous. A key part of a 12-step program is choosing a sponsor. A sponsor is a former gambler who has time and experience remaining free from addiction and can often provide invaluable guidance and support.
Cognitive-behavioral therapy
Cognitive-behavioral therapy (CBT) for problem gambling focuses on changing unhealthy gambling behaviors and thoughts, such as rationalizations and false beliefs. It also teaches problem gamblers how to fight gambling urges, deal with uncomfortable emotions rather than escapes through gambling, and solve financial, work, and relationship problems caused by the addiction. The goal of treatment is to “rewire” the addicted brain by thinking about gambling in a new way. A variation of cognitive behavioral therapy, called the four steps program, has been used in treatment of compulsive gambling as well. The goal is to change your thoughts and beliefs about gambling in four steps; re-label, re-attribute, refocus, and revalue.
What is cognitive behavioral therapy? CBT is a form of psychotherapy that emphasizes the role of thinking in how we feel and in what we do. There are actually several different types of CBT, but what they are is not as important as what they can do. Each of them is time-limited. That is, they do not last forever. Patients do not continue to go for CBT sessions for years like they would for traditional psychotherapy. Instead, they take place for a certain period of time, usually about 16 sessions. CBT is a collaborative process between the therapist and the patient. It is based on the idea that our thoughts cause our feelings and behaviors, and not external people, places, and things. The benefit of getting CBT is that patients/clients can change the way that they think to feel and/or act better – even if the situation does not change. Table 2 describes some reasons for gambling and offers some solutions to avoid or control gambling.
Table 2
Compulsive and problem gamblers often need the support of their family and friends to help them in their struggle to stop gambling. But the decision to quit has to be theirs. As much as you may want to, and as hard as it is seeing the effects, you cannot make someone stop gambling.
If a family member has a gambling problem, other members of family may have many conflicting emotions. They may try to cover up for a loved one or spend a lot of time and energy trying to keep him or her from gambling. At the same time, they might be furious at their loved one for gambling again and tired of trying to keep up the charade. The gambler may also have borrowed (or even stolen) money from other family members with no way to pay it back. He or she may have sold family possessions or run up huge debts on joint credit cards. When faced with the consequences of their actions, a gambler can suffer a crushing drop in self-esteem. This is one reason why there is a high rate of suicide among problem gamblers.
When someone has an addiction problem the best thing is, of course, that he comes out of that situation himself. However, this requires a lot of self-discipline and motivation from the gambler. If he can’t do it on his own, there are several possibilities to get help. But in this case too, the success of the treatment depends on the motivation of the gambler to handle the addiction. In the first place, there are self-help groups run by Gambling Anonymous (GA). They work more or less the same way as the Alcohol Anonymous groups (AA). The basic thought of these groups is that you have an addiction problem and will always have an addiction problem, even if you never drink alcohol again or do not gamble anymore. The only thing you can do is to stop gambling because you will never be able to deal with the pleasures of gambling.
Another possibility is ambulatory assistance, for example, through outpatients’ clinics of psychiatric hospitals or addiction institutions, or through clinics for alcohol and drugs abuse. By having conversations with the patient, a solution is sought for his problems. Also debt restructuring can be part of this therapy. In more serious cases, admission to a clinic is necessary. The treatment of a gambling addiction is mainly focused on helping the patient to stop gambling. In this period, the treatment is aimed at an inventory of the problems; a list of debts is made and a plan is developed to pay them off, deals are made about who controls the money, relationship problems are dealt with, and underlying problems are looked at. Sometimes, gambling has to do with the sudden death of people around the person, neglect, or feelings of inferiority. Sometimes stopping gambling leads to serious psychological and somatic problems. It is preferable to involve partners or parents during the treatment. The people around the addict often turn out to have this need. They can play an important role in the arrangements about the control of money, debt repayment, etc. The treatment lasts on an average of 6 months.
Footnotes
REFERENCES
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Discuss The Learning Approach To Explaining Initiation Of Gambling Meaning
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