The expansion of conventional gambling venues in Ontario, and the emergence of a variety of new gambling opportunities, has prompted significant concerns within the public health community regarding the proliferation of problem gambling.
In the first of a three-part series published in the March 2003 OMR, the Toronto-based Centre for Addiction and Mental Health’s Problem Gambling Project provided an overview of the impact of problem gambling on individuals and their families, as well as patient screening and assessment methods that can be used by physicians in the medical office. This month, the Problem Gambling Project addresses the topic of treatment and referral of problem gamblers.
Approaches to treatment
Physicians often represent the problem gambler’s first point of contact in the health-care system. Thus, physicians are in a unique position to screen, identify, and, if necessary, refer patients to one of Ontario’s 45 designated problem gambling treatment centres. There are two standard treatment approaches used by therapists and counsellors in treatment facilities: brief solution-focused therapy, and cognitive behavioural therapy. Brief solution-focused therapy centres on identifying immediate solutions to concrete problems presented by the client/patient.
- Cognitive behavioural therapy attempts to reduce excessive emotional reactions and self-defeating behaviour by modifying the faulty or erroneous thinking and maladaptive beliefs that underlie these reactions.
- In addition to these treatment approaches, many counsellors are using an organizational framework that helps to determine the appropriate level and type of treatment for a particular patient. Developed by Australian-based clinical psychologist and professor Dr. Alex Blaszczynski, this approach to treatment planning — referred to as the “Pathways Model” — integrates environmental, personality, developmental, cognitive, learning theory, and biological factors.
- The Pathways Model also maintains that comorbid psychiatric and medical conditions often associated with problem gambling must be addressed concurrently with the problematic gambling behaviour.
Pathways Model
The reasons why an individual develops a gambling problem are both wide-ranging and complex. A sociological, psychological and biological history of the gambler can help to establish an understanding of the factors that contributed to the development of the gambling problem, and guide the therapist in creating a comprehensive treatment plan that will work best for the patient. According to Dr. Blaszczynski, problem gamblers can be categorized into one of the following three pathways or subgroups: non-pathological or normal, emotionally vulnerable, or biologically based or impulsive. There are, however, certain “common elements” found in all problem gamblers, regardless of the subgroup into which they fall. The first common element relates to public policy issues, which include factors such as availability and access to gambling venues — i.e. the increased opportunity to gamble is associated with higher prevalence rates. The second element involves the role of classical and operant conditioning. Studies have shown that gambling creates feelings of excitement, dissociation, and increased heart rate. Wins occur intermittently, and can produce an excitement level that is described as being similar or equivalent to a drug-induced high. The repeated pairing of these feelings of excitement with the stimuli associated with the gambling environment can elicit urges to gamble, which result in a habitual pattern of gambling. Rosenthal and Lesieur observed that a gambler experiences levels of excitement in response to exposure to gambling situations or cues. In addition, the anticipation to gamble can create as much, or more, excitement as when the gambler is actually gambling. The third common element among problem gamblers is cognitive distortions — the two most common of which include “illusion of control,” and the “gambler’s fallacy.” Gambling is based primarily on randomness, and while randomness cannot be controlled, many gamblers attempt to control or alter the outcome of a gambling event by developing and following elaborate “systems,” or superstitious behaviour. The gambler’s fallacy is a phenomenon that may occur after an individual has experienced several losses in a row. The gambler believes that his or her luck will surely change, and that a win is just around the corner. As a result, bigger bets are placed, and the gambling continues, despite the losses. The behaviour of some problem gamblers can be attributed to this type of irrational thinking or cognitive distortion, which often leads to bad judgment and poor decision-making. While the elements described above are, to some degree, common to all problem gamblers, there are also several factors that distinguish one subgroup from another.
Normal problem gamblers
Normal problem gamblers are characterized by a stable childhood and family history. Their gambling and problem gambling occurs later in life, as opposed to starting in their teens or early twenties. They have a shorter period of excessive gambling, and their financial problems are less severe. This type of gambler has an absence of pre-morbid psychopathology, and symptoms of depression and anxiety are attributed to financial and relationship difficulties because of loss of money, and the amount of time spent gambling. For many, the depression and anxiety subsides after the gambling is brought under control, and financial and relationship issues are addressed. At the height of their gambling disorder, some normal problem gamblers may find it impossible to stop gambling despite their efforts to quit, and can benefit from counselling with a gambling therapist. Therapeutic approaches that work well with this group include cognitive behavioural therapy, and brief solution-focused therapy. Cognitive behavioural therapy addresses the unique and unusual beliefs and attitudes that many problem gamblers have regarding control, luck, prediction and chance. Educating problem gamblers about odds and probability involved in gambling — with particular regard to their game of choice — can also be useful in dispelling cognitive distortions about the game. The use of brief solution-focused therapy is also appropriate because the normal problem gambler does not have pre-morbid psychopathology, making the required treatment mode less intense. This approach encourages patients to identify times when they have applied appropriate coping strategies and problem-solving skills to other areas in their life. This assessment of patients’ skills can help to motivate and encourage their success in dealing with the problems they are facing because of their gambling behaviour. Normal problem gamblers tend to do very well in treatment, and are often successful at making changes to their problem gambling behaviour in a short period of time, and with minimal treatment intervention. They are also more successful than the other two subgroups at controlled gambling.
Psychological or emotionally vulnerable problem gamblers
Emotionally vulnerable problem gamblers are defined by a dysfunctional and traumatic childhood and family history. Common risk factors include physical, sexual and emotional abuse, and poor coping or problem-solving skills. They also suffer from moderate levels of psychopathology, such as clinical depression and anxiety, and may be more at risk for adopting other addictive behaviours. Negative emotions, and an inability to manage stress (both negative and positive), are the significant factors that impact on their problem gambling behaviour. For these gamblers, the excitement of gambling allows them to distract or dissociate themselves from their negative feelings, and helps them to temporally avoid feelings of depression. The goal is to help the emotionally vulnerable patient to develop better stress management and problem-solving skills. Cognitive behavioural therapy is a good technique to use with these patients because it helps them to identify high-risk situations, and allows them to develop appropriate coping strategies to deal with gambling urges and temptations. However, feelings of depression and anxiety do not always decrease after the emotionally vulnerable patient has stopped gambling. In some cases, the patient may benefit from medication and psychotherapy to treat symptoms of clinical depression and anxiety. The emotionally vulnerable problem gambler can be more challenging to deal with, and may spend a longer time in treatment, than the normal problem gambler. Gambling can increase rapidly during times of stress and crisis, making abstinence a more viable choice for this group.
Biologically based or impulsive problem gamblers
A small number of gamblers fall into the impulsive problem gambler pathway. The inability of these individuals to stop gambling is greater than that of the normal or emotionally vulnerable problem gambler. Factors such as cognitive distortions, misunderstanding of the odds, and emotional vulnerability all have an impact on this subgroup of problem gamblers. However, the biologically based problem gambler is impacted primarily by an early history of neurological or neurochemical dysfunction related to impulsivity and attention deficit features. Biologically based problem gamblers often experienced difficulty learning, concentrating, or paying attention in school. They tend to be easily bored, find it difficult to stay committed to long-term goals, and need a lot of stimulation to maintain focus. Impulsive problem gamblers usually gamble in binges, and begin gambling at a very early age (teens or early twenties). They experience severe financial difficulties, and their binge-like behaviour and loss of money can bring the onset of serious depression, increasing the risk of self-harm, substance abuse, or criminal behaviour. This subgroup of problem gamblers is definitely the most challenging group to work with, and responds poorly to treatment. Cognitive behaviour therapy is useful in that it allows these patients to identify their problem, and helps them to better understand and develop coping skills that will modify their impulsive behaviour. In addition, this group can benefit from the use of psychotropic medications to deal with their impulse disorder.
Concurrent treatment
Problem gambling often overlaps with other mental and physical health conditions, as outlined above, and must be addressed, since it can complicate therapy for these other conditions. Physicians who refer patients to a problem gambling treatment agency, or who learn to provide these interventions themselves, must also be prepared to simultaneously treat concurrent disorders. For example, an individual can develop depression due to the sequalae of problem gambling, or depression can lead to problem gambling. A clinician might not be able to determine which problem came first, or if one problem will resolve by treating the other, unless both issues are dealt with over time to determine the relationship of the conditions. Another common — if often overlooked — condition that may need to be addressed involves the underlying issues of physical and sexual abuse. For complex cases where a problem gambler has suicidal behaviours, psychiatric consultation should be considered. As noted in Part I of this series, the impact of problem gambling on an individual’s family/spouse can be enormous. Therefore, family intervention must also be considered. Physicians may want to refer some patients to a social worker or case management agency to help cope with the devastating financial debt that often occurs following a gambling crisis.
Additional resources and information
Physicians who wish to refer a patient to a problem gambling service in their area may contact the Ontario Problem Gambling Helpline at 1-800-230-3505.
To obtain a clinical consultation with a gambling therapist, physicians may contact the Problem Gambling Project at the Centre for Addiction and Mental Health at 1-888-647-4414.