To a psychiatrist, a personality disorder is an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture. It is pervasive, stable over time and inflexible, has an onset in adolescence or early adulthood, and leads to distress or impairment. Personality disorders are manifested in the way one thinks and perceives the environment, the way emotions are expressed or withheld, the way impulses are inhibited or exhibited, and the ways interpersonal relationships are formed.
Personality traits are enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are less inflexible and maladaptive than those of the disorder and cause less impairment. There are a number of studies of personality disorders in the DSM.
Unlike the other psychiatric disorders discussed so far, personality disorders are not discrete, conveniently definable entities that one can diagnose with ease. It is more useful to think that, for each Pathway, clients will have some traits that are maladaptive and dysfunctional. Identifying them will inform and enhance counselling work. Clients with more florid disorders (more obvious behavioural symptoms) will probably fall into pathway 2 or 3.
Antisocial Personality Disorder (ASPD) is the most prevalent and most studied personality disorder related to problem gambling. A person with aspd can be quite charming, but is usually superficial. He or she induces certain gut feelings of uneasiness in interaction as he or she usually has a pervasive pattern of disregard for and violation of the rights of others that started at a very young age. The person’s history clearly shows law-breaking behaviour, deceitfulness, conning others for personal profit or pleasure, impulsivity with regard to violence or failure to plan ahead, irritability and frequent aggressiveness, reckless disregard for safety of self or others, consistent irresponsibility, and a fundamental lack of remorse.
One problem of the DSM definition of ASPD is its heavy focus on antisocial behaviours, rather than the antisocial psychology or mindset. Some influential researchers (e.g., Cleckley, 1976; Hare, 1983) have defined antisocial personality through a more dynamic, psychological approach. They found the following to be some of the core psychopathic features (modified from Gabbard, 1994):
- superficial charm with variable intelligence, and a general lack of emotional reactivity
- disavowal of personal responsibility, unreliability, untruthfulness
- lack of remorse, shame, or humanness, as manifest in multiple exploitive relationships
- a history of versatility in criminal activities (i.e., involved in more than one kind of crime, may include violent crimes)
- poor judgment and failure to plan life, failure to learn from experience
- interactions characterized by power and manipulation rather than attachment.
As well, the more “successful” antisocial person is more likely to have evaded legal prosecution, and tends to have narcissistic features (grandiose fantasy, behaviour and self-importance, need for admiration, and lack of empathy) mixed with antisocial features (Kernberg, 1984).
I will focus on ASPD in this section, not to suggest that all problem gamblers have ASPD, but because understanding the underlying dynamics of ASPD will more likely be of use in and inform the counsellor’s work. A small number of the clients we encounter will have a “purer” form of ASPD, but the majority may just have some antisocial traits. As we will see, clients with ASPD may arrive in mostly pathway 3.
- Up to one-third of the prison population has been diagnosed with pathological gambling (Lesieur, 1984).
- In adolescent boys, frequent gambling activities are significantly related to antisocial behaviour, as surveyed in 75,900 high-school students (Stinchfield et al., 1997).
- Between 15% to 40% of pathological gamblers qualify for a diagnosis of aspd (vs. a prevalence of 3% in males and 1% in females in the general population) (Blaszczynski et al., 1989).
Research efforts have attempted to avoid labelling a client ASPD if his or her antisocial behaviour is only indirectly related to the problem gambling behaviour (e.g., lying and cheating and stealing desperately to obtain gambling money). ASPD has to be diagnosed based on a history of a pervasive primary problem that had its origin before the age of 15, and manifestations that go beyond gambling. It is an important question in clinical practice since the two diagnoses have some significant overlap and it is generally believed that a true sociopathic/antisocial individual would not benefit from any conventional treatments (see Treatment Issues below).
On other personality issues, some psychologists have found that problem gamblers showed significant deficits in adaptability, tolerance for ambiguity, ability to moderate impulses, and inhibition of action in situations when it would be adaptive to do so (McCormick et al., 1987). Others found that “thrill and adventure seeking” character traits in children are highly related to their selecting the riskiest options, without considering the situation; these children are thought likely to become problem gamblers later in life (Miller & Bymes, 1997). One study surveyed 21,000 high-school students, and found that those with problems related to gambling had significant increases in risky behaviour, such as substance abuses, weapon carrying, fighting, driving offences — all related to impulsivity and conduct/antisocial problems (Proimos et al., 1998). These authors believe the same children are particularly vulnerable to develop gambling problems later in life as well.
Screening for ASPD
The average gambling client may have multiple behaviour problems that fit some of the behaviour criteria of aspd. However, the counsellor needs to inquire whether the client has an early history of behavioural problems such as a conduct disorder in childhood (i.e., before age 15), as this is a prerequisite to and is highly associated with aspd. To truly get a sense of such a client’s personality, even by professionals, takes time and collaborative information.
ASPD clients often have a family history of criminality. Exploring family history will help to consolidate the diagnostic impression. As well, the client’s attitude toward the family history will reveal how likely the client’s chances of changing are.
Most problem gamblers with ASPD may not be willing to come for treatment for their gambling problem. When they do, it is often because of a court order, or for secondary gain, such as pretending to be in therapy to show they are concerned, or even hoping to learn ways to better their gambling. Often one has a distinctly uncomfortable reaction to the true antisocial personality client. That reaction is an informative way of guiding one to better understand the therapeutic relationship. The “hopefully treatable” clients are those who are genuinely remorseful, and have good insight into their problems.
Issues to Consider while Counselling
Most clients with aspd are male (8:1 male-female ratio). They may be intimidating and present with demanding, threatening attitudes. They need to be contained from early on. It is key to have a stable, persistent and thoroughly incorruptible therapeutic relationship — be absolutely scrupulous about maintaining normal procedures in therapy. These clients may continue to test limits, but they may back off when they see that the counsellor is unyielding about boundaries.
ASPD clients have a tendency to hysterical, psychosomatic behaviours (e.g., blaming their “huge headache” for violent behaviour). Drawing their attention to emotional experience by helping them make connections to their internal emotional states will be challenging, but will help keep the intensity of the therapy in check, and prevent some acting out in forms of antisocial or impulsive (e.g., gambling) behaviour.
ASPD clients tend to have little capacity to learn from experience and show lower-than-usual levels of anxiety regardless of the severity of the problem — avoid interpretations of unconscious material and focus on confronting the “here-and-now” antisocial or undesirable behaviour. Persistently drawing clients’ attention to the potentially painful consequences of reckless gambling may help them recognize the extent of the problem.
ASPD clients often use environmental factors as excuses for their criminality and misdemeanours, externalizing all responsibility (e.g., “[the victim] deserved what he got”). Confront the client’s denial and minimization of antisocial behaviour. Expressing moral outrage or disapproval is often indicated (ASPD clients will view neutrality as a sign of hypocrisy) — make clients aware of their pervasive denial and externalization of responsibility and prompt them to accept responsibility for their behaviour.
ASPD clients usually lack empathy, and tend to have very little capacity to feel depressed, anxious or guilty. As a result, they may have very little concern for others despite their destructive behaviour. They may have significantly burdened others but confronting them about their gambling having caused their parents to go bankrupt may not get very far. Expectations have to be set accordingly.
ASPD clients tend to be prone to envy and vengeance, greatly motivated to “get even” and enjoy destruction, humiliation and domination. Needless to say, many gambling activities provide venues to satisfy such proclivities. Examining these issues may bring some insight and help clients see that their need for revenge only results in further destruction in gambling.
When the ASPD clients refer to feeling depressed, it often refers to a state of enraged resentment at the world for not conforming to their wishes, a reaction accompanied by feelings of emptiness and boredom (Gabbard, 1994) — clarifying this will focus the clinical work at hand, and eliminate false expectations of working to alleviate a depression.
ASPD clients’ suicide attempts tend to grow out of narcissistic injury or rage, rather than melancholic depression — times of arrest, bankruptcy or a great humiliating loss at a gambling venue are such times. (The antisocial client who has a genuine depression, or anxiety or psychotic disorder usually stands a better chance of successful treatment.)
ASPD clients are difficult and are frequently dissatisfied with the results of therapy. The counsellor must rigorously monitor his or her own countertransference (unconscious reaction, such as disbelief, denial, collusion and condemnation) to help maintain professional boundaries and personal objectivity.
It is difficult for ASPD clients to progress in treatment — avoid having excessive expectations of improvement. Focus on practical skills, such as teaching appropriate and effective coping strategies. Some forensic psychologists and psychiatrists believe that, overall, patients with ASPD are unlikely to benefit from treatment. Only a few highly organized settings, such as a therapeutic community or active treatment programs in some prisons, have reported some success (Reid, 1985). ASPD clients are notorious for doing very poorly on a general psychiatry ward, due to their assaultive, aggressive, exploitive and manipulative behaviours.
Last but not least — protect yourself . Mental health workers, by nature, often tend to give clients the benefit of the doubt. This leads to downplaying the serious problems of the antisocial clients. Clinicians who have an extraordinary need to be all-effective and all-giving may be easily manipulated by the ASPD clients into an unending battle. At times they may even end up unwittingly colluding with clients, minimizing their pathology in order to make sense of the situation, and as a result blaming themselves for being ineffective and inadequate.
As a rough guideline, some clinical features that contraindicate extensive counselling or psychotherapy are (modified from Gabbard, 1994):
- a history of sadistic, violent behaviour toward others that resulted in serious injury or death
- a total absence of remorse or rationalizing such behaviour
- a historical incapacity to develop emotional attachments to others
- an intense countertransference elicited in the clinician, characterized by fear of predation, even without clear precipitating behaviour on the part of the client.
There is no known effective pharmacological treatment for ASPD. However, medications are used to treat concurrent psychiatric conditions. Medically-legally, the use of rehabilitation and treatment, as an alternative to incarceration for problem gamblers who have committed crimes, is a highly controversial subject. There is evidence that the prison term itself will promote spontaneous remission (Walters, 1997). Others view pathological gambling as a mitigating factor that should be considered when courts deliberate sentencing (Rosenthal & Lesieur, 1996). At present, there are no clear guidelines in this area. Refer to Legal Questions .
Case study: antisocial personality disorder
Mr. D is a 40-year-old divorced salesman who works for a heavy industry corporation. He has three children who are in the custody of their mother. He has occasional phone contacts with the children but finds it a “hard” thing to do since he is always “nagged” by his ex-wife for being “behind” in child support. He finds his single life “not bad” and is enjoying the freedom. He came for help because his gambling debt is “getting out of hand.”
On inquiry, Mr. D has been referred because his company has demanded that he seek treatment or face a lawsuit. He has, over the years, charged over $180,000 to different company expense accounts. He reported no other problem but the “stress” of fearing that his company will take action against him. He is losing some sleep and finds things less enjoyable than before. He claimed that he has used all monies in casino gambling (though the places he frequented were not in operation until a year ago). In private, Mr. D related that he was somewhat indignant that the company was so serious about the expenses, as some of the spending was “definitely legit,” and the company was “underpaying” him anyway. Also, keeping track of the money wasn’t really “his job,” but the company’s.
He revealed that his parents, who often fought with each other and paid little attention to him, always gave him money to get him “out of their hair.” He recalls no particular discipline at home, although he was frequently in detention at school, and was expelled from several schools. As a teenager, he was almost charged for reckless driving of a stolen vehicle and for using illegal drugs, but somehow his parents “got him free.” He had several jobs, but walked away from most of them because he “would not put up with anybody who had no respect for him.”He felt quite proud of his ability to assert himself and commented that the companies “deserved to be left in a lurch.” He got his current job through an ex-girlfriend, who “got tired of” supporting him and asked him to work. He gave himself credit for landing this job because he “used some creativity” with his résumé and impressed his employers. His girlfriend later left him when she discovered he was seeing other women. Mr. D thought she was being “uptight,” He thought she understood they had an open relationship. Mr. D’s marriage ended a few years ago on similar grounds. In addition, his ex-wife had discovered his lies about his educational background. When asked how he felt about these relationships, he added, “maybe it’s for the best.” Otherwise, he had no major psychiatric, medical or drug treatment history (though he endorsed alcohol binges and “soft drugs” that are just “part of his life”).
Mr. D asked with interest how the counsellor could help him, as “most” of his money was spent on the roulette table at the casino, where he enjoyed the status of an MVP. This was a relatively “new” hobby, and he loved the “action,” the “lady luck,” and the envious awe people showered on him when he won. He wished he had more money of his own, but blamed his company for providing him with the means to gamble. Thus they were responsible for “playing a part” in getting him into debt. He thinks he has a gambling problem and would like “as much help as he can get,” including a letter from the counsellor to his employer to state his willingness to get help. He attended a number of counselling and group sessions, and appeared to be quite enthusiastic, but he participated only superficially, and after two months was never heard from again.
Applying the Pathways Model
This client has quite a “classic” presentation of ASPD, though he had not been in jail in the past, which puts him in a somewhat higher functioning level among ASPD. He may look like a pathway 1 client, as his troubles didn’t start until the gambling debt became an issue. He may look like a pathway 2 client, given his initial attitude and ability to lie and manipulate, and his presenting as a troubled and suffering soul who couldn’t help himself and fell for gambling. His history of impulsivity and lack of planning is also somewhat consistent with pathway 3. He is likely to be a very difficult client since he is not genuinely interested in therapy, and may placate the counsellor or blame the counsellor for his own failure, etc. In this case, he dropped out of treatment.
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