Helping Professionals

Perhaps the best model for bridging and integrating seemingly opposing philosophies and approaches to problem gambling is presented by Alex Blaszczynski in his book Overcoming Compulsive Gambling (1998). Blaszczynski’s “Pathways Model of Problem Gambling” combines psychodynamic, social-learning, biological and addiction models by postulating three major entry pathways into problem gambling. By doing so, Blaszczynski illuminates the possibility that there are elements of truth in each and that taken together, they can provide a holistic understanding of each unique problem gambler. This holistic approach, a product of “informed eclecticism” (Miller & Hester, 1989), provides a framework for assessment and treatment planning that facilitates our efforts to be intentional in our work with problem gamblers and to match our interventions to the specific needs and circumstances of our clients.

The Pathway 1 Gambler

Pathway 1 proposes that problem gambling is linked to the environment and learning and that people in this group do not necessarily have any pre-existing psychological problems or history. With access to gambling, they may experience early large wins, intermittent wins, and really enjoy the excitement. These factors combine to form a gambling habit. These gamblers may develop psychological problems as a result of gambling, such as anxiety, depression and substance use, but it is just a reaction to the negative consequences of gambling. They may also form distorted views of the probabilities and odds of winning and develop cognitive distortions about such concepts as luck and control. Cognitive distortions hold them in a habitual pattern of gambling that can lead to chasing losses and the accompanying consequences. These clients may meet the criteria for pathological gambling at the peak of their gambling disorder.

Clients presenting from this pathway can best be helped with limited interventions. A cognitive approach (see Section Cognitive Therapy ) based on helping the client understand his or her erroneous beliefs about winning and his or her true lack of control over outcomes of the games, coupled with assisting him or her to deal with the emotional and financial consequences, is usually all that is needed. In-depth or long-term psychotherapy tends to be counter-productive since the gambling problems did not stem from hidden or underlying psychological problems. These gamblers tend to be high-functioning individuals, who have the internal resources to deal with most life problems, but who are conditioned and thus trapped into gambling. Recovery goals for pathway 1 gamblers may range from harm reduction to abstinence.

Prevention Strategies for Pathway 1 Clients

This pathway involves distorted concepts, ideas and notions about gaming outcomes through gambling experiences. These risk factors can be addressed through accurate education about the games and how the outcomes are determined. This sort of education needs to happen before the gambling is initiated. We learn through our experiences, but gamblers need to know that winning is the exception not the norm and that if they have an early win or winning streak, it is just a fluke. People also need to be warned of the dangers of playing “systems.”

The Pathway 2 Gambler

Pathway 2 proposes that some people are vulnerable to developing problem gambling because of psychological factors such as difficulties managing stress or dealing with crisis situations. Its key characteristic is that a psychological problem existed before one’s gambling problem that leaves the gambler emotionally vulnerable. Thus, gambling is seen either as a way to escape the problem or as a potential solution. Pathway 2 gamblers may have poor coping and problem-solving skills due to inadequate role models or past trauma. They may be anxious, depressed, isolated or bored. A number of life situations may lead to psychological distress, such as relationship difficulties or dissatisfaction in present employment. Gamblers in this group tend to be stuck in certain life situations and lack the skills needed to move forward. Gambling may instil a sense of hope, increasing their desire to gamble.

The course of treatment may involve cognitive therapy coupled with psychotherapy to deal with past traumas. Problem solving and skills training may also be required. This can best be accomplished in a group setting. The complexity of the treatment plan and length of treatment may be longer than for gamblers in pathway 1. As in pathway 1, the recovery goals for pathway 2 gamblers may range from harm reduction to abstinence.

Prevention Strategies for Pathway 2

Clients In general, gamblers need to understand their own personal emotional vulnerabilities that may lead to risky gambling behaviours or gambling problems. Examples of such vulnerabilities are depression, anxiety and stress. Skills training that concentrates on dealing more effectively with emotions may help gamblers, especially youth, to avoid using gambling to deal with these emotional risks.

The Pathway 3 Gambler

Pathway 3 proposes that some gamblers have predisposing biological factors that may contribute to the development of gambling problems. Warning signs include a history of a wide range of impulsive behaviours from early childhood onwards. Pathway 3 gamblers:

All these behaviours tend to point to biological disorders related to abnormal levels of brain functioning. Dealing with clients who are coping with a disorder in addition to a gambling problem involves a number of specific considerations and is thus addressed in the Section titled “ Special Treatment Issues: Concurrent Disorders. ”

Clients in this group tend to need the most complex interventions, ranging from pharmacological interventions to intense psychotherapy. A number of care providers may need to be involved in treating co-existing disorders, such as ADHD, personality disorders, or major depressions. Abstinence from gambling is usually recommended to assist in sorting through the various problems. The counsellor may recommend that the client attend Gamblers Anonymous for ongoing structure and support. The recovery goal for pathway 3 tends to be abstinence.

Prevention Strategies for Pathway 3 Clients

This pathway is more complex. However, the risks in this pathway may be addressed by alerting gamblers to the known connections between mental health issues and/or addictions and problem gambling. Screening gambling clients during assessment may turn up personal problems such as adhd and impulsiveness. Making clients aware of such problems may help them to take protective measures.

The Pathways Model of Problem Gambling helps counsellors understand the complexity and severity of each client’s gambling problems and provides guidance in determining the appropriate treatment and resources that best match clients’ needs. Few problem gamblers follow only one path but more often an individual displays a predominant pathway with elements of one or two other pathways. All characteristics are equally important to identify and bear on treatment needs. For example, a counsellor must consider the various needs of a gambler who is predominantly pathway 2 but has characteristics of pathway 3. Pathway 2 needs may include cognitive-behavioural therapy, coping skills and psychotherapy, whereas an examination of pathway 3 may discover a history of mild ADHD, a disorder in which additional treatments need to be explored. It is important to remember that the outcome or consequences of each pathway (usually a crisis that motivates someone to seek professional help) appear very similar but the dynamics of each pathway are different and therefore require different treatment strategies.

Blaszczynski’s Pathways Model of Problem Gambling provides an excellent framework for directing services to the individual needs of a client. However, it remains a framework, with details yet to be filled in. Past research on matching client variables such as personality, personal history, strength of craving and client-held values, to particular forms of therapy (such as behavioural-cognitive or psychodynamic) undertaken with the goal of predicting successful therapeutic outcomes, have yielded conflicting and inconsistent results (Luis, 1999; Stockwell, 1999; Walters, 1999). What has been found, however, is that the interpersonal dynamics (interactions between the counsellor and client) of a treatment session were more important (Stockwell, 1999). Refer to Section “ Setting Up a Problem Gambling Program ,” for further discussion of matching client goals and treatment approach.

The implications of the importance of interpersonal dynamics make it seem odd that the amount of time invested into developing and evaluating specific addiction treatments has not been matched by detailed study of what goes on throughout counselling sessions that contributes to a client’s recovery. Rollnick (1998) notes that the idea that specific interventions can be matched to particular stages may be oversimplified and not compatible with the shifting nature of personal readiness to change. It is thus proposed that matching needs to take place on a more fundamental level: matching the topic of conversation, how the client is spoken to and most importantly, the counsellor’s ongoing pursuit to match his or her style and techniques to the client’s motivation level and readiness to change. The stages of change model (Prochaska & DiClemente, 1998) is a significant advance toward this goal.

The Stages of Change model (Prochaska & DiClemente, 1998) proposes that addictive behavioural change proceeds through a predictable series of stages. The client moves from being unaware, under-aware or unwilling to do anything about his or her problems (Pre-contemplation stage), to considering making changes (Contemplation stage). Thus, the initial two stages involve building motivation. Strengthening one’s motivation to change characterizes the final two stages as the client then moves to prepare to make changes (Preparation stage), to taking action and finally to maintaining the behavioural change over time (Action stage: Stages of Change Model).

The stages of change model represents parts of a dynamic process of motivational change rather than a static framework. For example, clients may cycle back and forth often through the various stages before finally terminating the problem behaviours and initiating new healthy behaviours. Often clients may present in the contemplation or preparation stage. Yet if the client gambles and experiences a win during this phase of treatment, he or she may quickly cycle back to the pre-contemplation stage. This is because the client believes that winning money will take care of the problems that were created by gambling, not by a lack of money. The counsellor’s task is to identify and understand which stage each client may be in and to “match” the pace of the client’s readiness to make changes with the use of appropriate interventions to assist them in moving forward. Thus, in the preceding example, the therapist will help raise the client’s awareness to the fact that his or her problems stemmed from gambling and that a win isn’t a solution but a temporary relief.

Problem gamblers may not always come to treatment ready to change their gambling behaviours. However, they may be highly motivated to deal with financial problems, relationship difficulties or other problems caused by gambling. If so, they are in the action stage for dealing with these particular problems. It is important to assist the client in dealing with the problems he or she presents and then try to link the solution back to the gambling problem. For example, a client under extreme financial pressure notes that he or she wants to try to lessen this pressure. If referring the client for financial counselling lessens this sense of anxiety and pressure, then the client needs to become aware of the fact that gambling caused the pressure and it will continue to do so should problem gambling behaviour continue. A client’s state of readiness is influenced by his or her perception of the importance of change and confidence to change. Thus, change must be intentional and client participation in the formulation of treatment goals is essential.

A client’s readiness helps determine appropriate strategies the counsellor can use with the client. Both cross-sectional and longitudinal research (Prochaska, DiClemente & Norcross, 1992) indicate that experiential processes such as motivational interviewing and value clarification techniques (refer to Figure 2: Decisional Balance Sheet, Solution-Focused Brief Therapy , for an example of value clarification techniques) are most helpful and more often used in earlier stages of change. Behavioural processes, such as limiting the number of credit cards one owns and writing feelings in a journal, are most important and more often used in later stages.

Motivational interviewing (Miller & Rollnick, 1991) is a directive, client centred counselling style aimed at helping clients to recognize and do something about their problematic behaviour. Motivational interviewing has been found to be particularly useful within the problem gambling population as a method of counteracting the characteristic ambivalence of gamblers and the variable reinforcement nature of gambling. Motivational interviewing is flexible in its application with a variety of therapeutic approaches and techniques (for example, it may be used within the framework of SFBT, cognitive or cognitive-behavioural therapy) and within all client contact (see Gambling Treatment Services Flow Chart,).  

Gamblers usually find themselves ridden by conflicting motivations. Part of them wants to change their gambling behaviours because of the negative consequences of gambling. Another part may be motivated to continue gambling because there is always a possibility of winning again. Some gambling clients make immediate changes at the initial motivational interview — they are suddenly free from the paralyzing effects of conflicting motivations as they realize the fallacy of their faulty logic about winning. For others, motivational interviewing may be a prelude to treatment and further therapeutic work.

Motivational issues also arise in the preparation and action stages. Doubts and struggles will persist and action plans need to be motivational. Assessing the client’s motivation to change can be done formally, using any range of questionnaires. It can be accomplished less formally by drawing a line (representing a motivational continuum) and asking the client to note where he or she would place him- or herself on it. Miller and Rollnick (1991) describe five broad principles underlying motivational interviewing. Following is an outline of the basic motivational principles that have been applied to problem gambling clients.

Principle 1: Express Empathy

• Acceptance facilitates change.
• Skilful, reflective listening is fundamental.
• Ambivalence about changing gambling behaviours is normal.

Through skilful, reflective listening, the counsellor tries to understand the gambler’s feelings, thoughts and perspectives without confronting, judging or criticizing. This approach does not see the gambler as pathological or incapable. The gambler’s thinking is understandable (through cognitive and psychological principles) given his or her experiences. For example, if a gambler hits three in a row, he or she may experience this as meaningful. Humans are wired to create meaning from random events. The gambler may create meaning out of this random event by thinking that it occurred for a reason, say because of his or her skill, and that the win is the only way to pay the rent or make a down payment on a car. As the counsellor explores the meaning structures of the client, an attitude of acceptance and respect allows the client the freedom to continue expressing psychological difficulties and distorted cognition about gambling.

Principle 2: Develop Discrepancy

• Awareness of the consequences of gambling is important.
• A discrepancy between gambling and important goals will motivate change.
• The gambler should present the arguments for change.

The goal of revealing discrepancy is to amplify in the gambler’s mind the difference between his or her gambling behaviour and broader goals. This “cognitive dissonance” is the cornerstone of cognitive therapy with gambling clients and is discussed more fully in the section on cognitive therapy. When the client understands that the long-term outcome of gambling losses conflicts with important personal goals such as success, family happiness, health or positive self-image, then change is likely to occur.

Principle 3: Avoid Argumentation

• Arguments are counterproductive.
• Defending breeds defensiveness.
• Resistance is a signal to change strategy.
• Labelling is unnecessary.

Clients do not need to accept a label, “problem gambler,” in order to see that they have problems related to their gambling and that they can take action to deal with these problems. While motivational interviewing is confrontational because its purpose is to increase awareness of an existing problem and the need to deal with it, dialogue has a gentle, persuasive manner. The counsellor may be fully aware that the gambler cannot win in the long term. However, the gambler’s experience may have taught him or her that, with persistence, he or she will win. If the counsellor gives accurate information to the gambler about the odds of winning and the gambler does not accept these facts, a more appropriate strategy may be to have the client self-monitor his or her gambling and put safeguards in place. In the long term, the gambler will draw personal conclusions about the odds and will realize the need to change. This may seem like a long process with potential risks for further harm, but the client will nonetheless remain engaged with treatment.

Principle 4: Roll with Resistance

• Momentum can be used to good advantage.
• Perceptions can be shifted.
• New perspectives are invited but not imposed.
• The client is a valuable resource in finding solutions to problems.

In motivational interviewing it is assumed that clients are resourceful and possess insights and ideas for solving their own problems. For example, problem gamblers are often very resourceful in finding money to gamble and may even be actively trying to solve their financial problems when they present for treatment. Using this momentum to assist the client through his or her financial difficulties may help the client see that there are financial solutions other than gambling. As clients realize that they can solve problems without gambling, their reliance on gambling will decrease. During this process, the counsellor must still help the client realize that gambling caused the initial financial problem.

Principle 5: Support Self-Efficacy

• Belief in the possibility of change is an important motivator.
• The client is responsible for choosing and carrying out personal change.
• Gambling is not the only option — there are alternatives to gambling.

Self-efficacy, the client’s belief that he or she can succeed at a task or that he or she can change, is the key motivational element in the process of changing problem gambling behaviours. This factor comes to play an important role when gamblers realize that their efforts at gambling will not pay off. If their gambling has been giving them “false hope” of success, they may wonder what they have to fall back on now. The general goal for the counsellor is to help clients see that they have the ability to cope and to overcome obstacles without gambling. Gambling is based on false hope, and self-efficacy instils real hope.

References

Blaszczynski, A. (1998). Overcoming Compulsive Gambling: A Self-Help Guide Using Cognitive Behavioural Techniques. London: Robinson. Lopez, V. (1998). Treating pathological gambling. In V.

Lopez (Ed.), Treating Addictive Behaviours (2nd ed.). New York: Plenum Press.

Miller,W. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behaviour. New York: The Guilford Press.

Prochaska, J. & DiClemente, C. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviours. In V. Lopez (Ed.), Treating Addictive Behaviours (2nd ed.). New York: Plenum Press.

Pochaska, J.O., DiClemente, C. & Norcross, J.C. (1992). In search of how people change: applications to the addictive behaviours. American Psychologist, 47, 1102-1114.

Rollnick, S. (1998). Readiness, importance, and confidence. Critical conditions of change in treatment. In V. Lopez (Ed.), Treating Addictive Behaviours (2nd ed.). New York: Plenum Press.

Rollnick, S. & Morgan, M. (1995).Motivational interviewing: Increasing readiness for change. In A.Washton (Ed.), Psychotherapy and Substance Abuse: A Practitioner’s Handbook. New York: The Guilford Press.

San, L. (1999). Future research directions and the impact of the match project on research technology in the addictions. Addiction 94 (1), 55-77.

Stockwell, T. (1999). Should a few hours of therapy change behaviour 3 years later? Addiction, 94 (1), 50-52.

Walters, G. (1999). The Addiction Concept: Working Hypothesis or Self-fulfilling Prophesy? Toronto: Allyn & Bacon.