Nina Littman-Sharp
Looking for solutions to specific triggers
The next step in mapping out the best route to change is for clients to develop some very individualized coping strategies. Once it is clear what triggers gamblers, and what purpose gambling serves in their lives, they and their counsellor can start developing some solutions that are specific to the problem. Some of this work is fairly straightforward. For instance, a person who is triggered by being in a corner store with tickets available may need to learn to reorganize his or her shopping so as to avoid corner stores. Triggers that involve specific places, people, times of day, or other concrete circumstances are often relatively easy to deal with; in these cases, the most obvious solution may well get the best results.
Triggers involving thoughts or feelings can be more difficult to access, but are still amenable to direct strategies. Someone who is triggered by thoughts that he or she can make money at gambling may need to develop skills in altering those thoughts early in the process. A gambler who is triggered by anger will need to find ways to cope better with such feelings, including anything from self-talk to learning communication skills to extricating him- or herself from a chronically conflictual situation.
Of course, it is rare that only one strategy suffices, as most problem gamblers experience multiple triggers. The goal is to send clients away with a toolbox full of strategies, with the ability to make up their own as circumstances demand. They should be able to anticipate what might trigger them, analyze any urges that they experience and develop their own coping tools.
Changes over time
Appropriate strategies will also change over time. Avoidance strategies are often more effective at the beginning, when a client is struggling to emerge from old patterns and is very triggered by being in gambling situations. This is the time for clients to avoid carrying much money, to stay away from areas with gambling venues, to keep very busy, etc. Incidentally, it is not necessary for every gambler to operate with the same empty pockets. Some high rollers are unlikely to bet in small amounts and can safely carry an amount that is somewhat less than their minimum bet. Of course, those addicted to tickets will have more difficulty finding a minimum amount, and may have to manage on very little money day-to-day.
As time goes on, new and healthier patterns of behaviour become established. It then becomes more effective for the client to learn to cope with, not avoid, triggering situations. Gambling is very accessible, widely advertised and frequently discussed. Money, available or lacking, is a fact of life. Gambling clients will need to be able to deal directly with these triggers as they come up, and counsellors need to help them to be prepared.
The issue of returning to “normal” gambling
Just like substance abusers, many problem gamblers hope to be able to return to a normal level of the behaviour. They may or may not be realistic in their ideas about the outcome, but it is essential for the counsellor to explore the client’s beliefs, to find out if he or she is still hoping to win, or clinging to other cognitive distortions. Usually, clients say that they genuinely enjoy the activity, and hate to give it up. Sometimes the very thought of giving up gambling forever is enough to prevent a person from seeking or continuing in treatment. It can also lead to repeated attempts at controlled gambling, which are reactive and poorly planned.
There are a couple of useful approaches to this issue. One is to suggest that the client not make a decision “for life” at that point in time, but simply commit to whatever period of abstinence feels acceptable to him or her, with the expectation that he or she will make a new decision as that time approaches. Generally, by the end of the initial period the client has had a chance to experience the positives of not gambling, has new sources of enjoyment and greater stability, and is in a better position to make an informed (and less emotional) decision.
Whatever the counsellor’s opinion, it is generally best to remain neutral about what the client decides, while making sure that the client has all the information he or she needs, and is weighing the various factors realistically. A decision matrix is often helpful in this regard. It can be far more effective to lay out the matrix in terms of risks and benefits of gambling than it is to assure the client that disaster will follow if he or she gambles again. The matrix will enable clients to discover for themselves that the risks far outweigh the possible benefits. Absolutes from the counsellor will tend to make the clients think about exceptions.
There will, of course, be some clients who will choose to attempt non problem gambling, either from the beginning of treatment or later on. If they have looked at all the issues carefully, and have decided that the risks are worth the benefits, they will almost certainly gamble, whether or not their counsellor approves. Any advice given them will, of course, depend on the counsellor’s belief system. Generally, planned returns to gambling, carefully hedged round with protective measures (such as severe limits on the money available), and backup plans, are better than uncontrolled experiments. There is nothing to stop the counsellor sharing his or her concerns about risk, while accepting clients’ rights to make their own decisions. Individuals who do a good job of their return to gambling (generally high-functioning and earlier in the addiction process) can be supported in their efforts. Those who do poorly will have avoided the disaster of an unplanned return, and having experienced again the sense of being out of control, will likely be more motivated to work on abstinence.
It is important, incidentally, to remind the client that it is not the first or second successful attempt that decides the issue, but the effect of repeated gambling over the longer term. As with substance abuse, it is common for the client to be successful at controlling his or her behaviour for the first couple of trials, but for the third episode to turn into a binge.
Coping with multiple or unexpected triggers
People who are actively trying to change may cope quite well with a single familiar trigger. However, a combination of triggering circumstances is more likely to overwhelm their new coping skills. For instance, a client may become adept at avoiding gambling situations in his daily routine. He may be able to refute thoughts that he can win at gambling, and may even feel more relaxed about his financial situation as he begins to get it organized. Imagine, however, that one day a creditor threatens garnishment, our client’s business customer wants to meet at a sports bar, decides to pay our client in cash, and the playoffs start. At this point, resistance is likely to crumble. Clients who suffer a lapse at such a time need to hear that they are neither stupid nor incapable of change; they simply have not yet had the chance to cover all the bases. It is very important to give clients positive feedback on the changes they do manage to make, and to remind them that they are learning and making progress. Then they need practical strategies for when they are feeling overwhelmed by triggers.
Another situation that often leads to lapses is an unexpected trigger for which the client is not prepared. For instance, those who are handling local triggers well may be triggered when on vacation. An unexpected bonus or a new credit card in the mail are very common triggers, which the client would do well to be prepared for in advance. It is generally up to the counsellor to raise such possibilities, as the client rarely thinks of them, even when they have occurred in the past.
Categories of coping strategies
Coping strategies, like triggers, can be broken down into behavioural, cognitive and affective categories, as in the following chart. Behavioural strategies might be taking some physical action — avoiding gambling venues, joining a gym, or cutting up credit cards. Cognitive strategies include catching distorted thinking about the chances of a win, or keeping healthy goals in mind and planning ahead, or self-reminders that urges pass. Affective strategies might be recognizing and accepting feelings, and writing or talking about them to work them through. Many clients tend to focus on only one, or perhaps two of these three areas. For example, clients may prefer to intellectualize but not act, or a person may be all feeling and action, but may never think ahead. Coping strategies tend to be more effective if all three areas are made use of in a reasonably balanced fashion (figure 8).
Of course, the most effective coping strategies are those the clients think of for themselves. Creativity in this area should be encouraged; often the most useful ideas are the ones that would never have occurred to the therapist, but which fit right in with the client’s own lifestyle or world view. Often metaphors from the client’s work or leisure interests are very effective. For instance, business analogies work well with entrepreneurs, teaching analogies with educators. One person in the film industry found the snap of the scene board a helpful metaphor for switching her mind onto a scene other than gambling.
Impulsivity
As with any addictive behaviour, many gambling relapses involve impulses. Research indicates that there is an overlap between impulse control disorders, such as Attention Deficit Hyperactivity Disorder, and problem gambling (e.g., Specker et al., 1995). Even when there is a biological basis for impulsivity, the most effective coping strategies have to do with avoiding triggers, rather than dealing with them in the moment. Preparation is key. For instance, one of the most effective ways of dealing with an impulse to gamble is to limit ready access to money. Money can always be obtained sooner or later, but planning can ensure that it cannot be obtained on impulse. In another example, clients subject to impulsive behaviour may decide to call a supportive friend if they have an urge. In this case, they need to pave the way for that strategy ahead of time, have the number and a quarter ready, and a back-up plan if the friend is not home. Waiting to decide on a strategy until the urge is upon them is equivalent to trying to read the instructions on the fire extinguisher by the light of the flames.
Inhibitory control is a complex executive function, and there are many points where the process can break down in the brain. The individual may never have developed an effective way of stopping herself when she had an impulse to do something. However, if impulsivity is approached as a skill deficit, it is possible to improve the level of control with practice. On the other hand, lack of practice can lead to deterioration. Even average individuals (such as Blaszczynski’s “normal” subgroup) can experience deterioration in their inhibitory circuitry through under use. It is not unusual to see gamblers with a history of appropriate self-control having difficulty dealing with their impulses after a long period in which they indulged themselves. It may be helpful to start any practising with areas easier to handle than gambling urges. For instance, one client characteristically rolled through stop signs. He accepted a suggestion to work on coming to a full stop each time. With practice, this new way of driving became habitual, and he found that the learning generalized to a variety of situations; he became more able to pause and think before acting. Even if the learning does not generalize, changing any habit will enhance the client’s self-efficacy.
The role of habit
Blazczynski’s pathways model mentions the role of habitual gambling behaviour in the development of the problem. This issue may be underestimated in treatment. Clients who have adequate motivation and many good strategies, but who constantly relapse, may well be having difficulties because they have not altered habitual behaviours. The following analogy on the development of river channels is very useful in helping clients understand the issue of habit: Flowing water wears down channels. Over time it will be more and more likely to stay in the same channels. Attempts to reroute a river will require blocks to the old channel and a lot of digging to start a new direction. Initially great vigilance will be needed to keep water from going back into the old channel, but eventually the new one will get deeper, and will be easier and easier to maintain. The old channel will still be there; long-term maintenance will be required to keep the water out of it. And the higher up on the mountain the process is started, the easier the change will be. Rerouting a fully formed river is very heavy work; better to start at its beginning. Thus clients learn that they need not only to stop old routines, but to develop new ones; to be vigilant about maintaining the changes, especially at first; and that the task will get easier after the initial heavy work. They also learn to catch the process early, before they have given themselves permission to gamble and are so caught up that they feel swept away.
The river analogy corresponds directly to our knowledge of the development of neural pathways in the brain (Grossberg, 1982; Hart, 1983). Frequently repeated behaviours create extremely accessible neural pathways. Unused pathways are eventually extinguished.
Working in detail When people are trying hard to alter an overlearned habit, many change strategies falter, not because the individual is not motivated, but because he or she did not know how to take care of the details. For instance, if the gambler is letting his or her spouse handle his or her paycheque, how will the person avoid withdrawing the money from the bank as usual? How exactly would the person like to alter his or her routine? What if the spouse is not around that day? What if the cheque comes early? What if he or she needs groceries? If the client does not learn to cover all the bases, the result is often continued gambling and a feeling of failure, further damage to self-esteem, and an increased likelihood that the person will drop out of treatment, feeling hopeless or hooked back into gambling. Making serious changes in one’s life can feel like an overwhelming task unless it is broken down into manageable details. Clients who learn this skill are much more likely to succeed.
An example of attention to detail is some work with Mike, a client of the author’s who spent most of his weekly paycheque on gambling. Initial discussions included a plan to immediately pay off bills and buy groceries with the paycheque, so as to leave little left with which to gamble. The gambling continued, however. Mike’s urges started on payday, and at the bank he did not stick with the plan. The next week the plan was written out, with amounts specified for each bill, and Mike found this much easier; he paid his bills and did not gamble. Having the figures on a piece of paper helped him to break out of the routine and take a different path.
It is also important for clients to plan for less likely contingencies in their lives. Often they will dismiss a low-percentage risk, but they should be encouraged to plan just in case. For instance, what is the chance that their friend at work will invite them to the track? Five per cent? That’s enough of a chance that they should plan how they would handle it. Preparation for upcoming events or contingencies is extremely important. Back-up plans are vital. The counsellor needs to ask the client what could go wrong with the strategies they are mapping out. Such questions are never in a context of being negative or discouraging, but always by way of encouraging clients to have backups to their backups. Clients need to learn not to take their plans at face value, but to identify the weak spots so that they can cover them in advance. This can be a good technique for helping overconfident clients become more realistic.
Practice and rehearsal
Learning is more effective if the plans are rehearsed ahead of time, during interviews or in group. A gambler (as is often the case) with a history of competence in daily life, who is generally a quick learner, may be overconfident about his or her ability to follow through on plans without rehearsal. Alternatively, depressed clients may avoid rehearsal because of lack of energy or drive, and feel helpless when the time comes. Clients need to be reminded that knowing what they should do is not the same thing as doing it. Having the client practise these new strategies in sessions, and rehearse them internally, seems to make a big difference to follow-through. Imaginal desensitization, discussed elsewhere in this manual (see Section 3.7, Behavioural Techniques), is an example of one specific way of rehearsing new responses to old situations. Rehearsal helps people to rewire the circuits, to begin the development of new habits. People have more confidence in strategies they have rehearsed, and more belief that they themselves are actually capable of carrying them out. The trick is to get the new behaviour into their repertoire in the first place, or to revive it if it has fallen into disuse.
Positive substitutes
It is very difficult to take a major activity out of one’s life without something to replace it. Many clients relapse when they have allowed themselves so few enjoyments (usually because they are repaying debts and/or punishing themselves) that their lives become impossibly restricted. This area for problem gamblers is very similar to substance abusers. They need to learn some other way to achieve whatever gambling gives them, or they will feel very deprived. It may be activities they used to enjoy, which they have dropped, or new activities they’d like to try, but positive substitutes are essential.
New activities should in some way provide the kind of benefit that the individual received from gambling. Risk-takers may need challenges, money seekers may want to consider part-time jobs, those seeking escape may need harmless ways to focus on something other than their troubles for a few hours. Exercise helps many clients a great deal, as does laughter. Even a pleasant distraction for half an hour can take some pressure off and help them get some perspective. No activity will truly replace the thrill of gambling, but clients can eventually learn to accept a more moderate level of thrills, accompanied by a more stable and positive mood overall.
As with substance abuse, clients may initially experience little enjoyment from their new pursuits. They may need the reassurance that eventually, if they persist, they will begin to find pleasure in activities other than gambling.
Clients also need to reward themselves for success in meeting their goals, particularly in the short term, before the longer-term benefits become apparent. It can be particularly helpful for clients to promise themselves a little money — often far less than they would have gambled — for tangible items or pleasant outings, as long as they stick to their goals for a particular day or week. (Of course, clients who promise themselves gambling as a reward are signalling to their counsellor that they are not as far into the action stage as they might have appeared.)
Long-term relapse prevention
Once clients have the immediate triggers under control, they can feel there is little left to work on; they may come to counselling sessions apparently with little to discuss. At this point, longer-term relapse prevention issues need to be addressed. It is important for individuals to look at what their own early warning signs for relapse might be. Just being aware of the specific signals that have indicated trouble in the past can be very helpful. These can be discussed individually, or brainstormed in groups. Then, of course, clients need to decide what specifically they will do about these early warning signs if they occur. See Avoiding Relapse for an assignment we have used for this purpose.
Although useful as a list of ideas, it provides only a general outline of a plan; more detail is required. Homework assignments, which may include planning and carrying out detailed strategies, are important in helping the client feel mobilized and responsible for his or her own change process. Another approach is for the client and counsellor together to examine what has worked in the past in avoiding relapse. Journaling is helpful, to keep clients aware of what is going on in the back of their minds. If they can catch the process before they give themselves permission to gamble, they have a much better chance of avoiding problems. Clients also need to look ahead to see what high-risk situations might be coming up in the longer term, so that they can plan how to handle them: moves, job changes, children moving out, etc. Long-term relapse prevention will probably include goal setting across a number of life areas. For some clients, the overall shape of their lives needs to change in important ways for them to deal with their addiction.
This section has covered the elements of a cognitive-behavioural approach to change and change maintenance in problem gamblers. The emphasis has been on practical strategies, tools and techniques that can be taught to our clients, to enable them to gain control over their behaviour, and to move forward with their lives.
References
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Blaszczynski, A. (1998). Overcoming Compulsive Gambling: A Self-Help Guide Using Cognitive Behavioural Techniques. London: Robinson.
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Specker, et al. (1995). Impulse control disorders and attention deficit disorder in pathological gamblers. Annals of Clinical Psychiatry, 7 (4), 175-179.