Nina Littman-Sharp
Levels of functioning
The differences between gamblers and substance abusers affect treatment in many ways. First, gamblers are generally not impaired, although there are physical effects of problem gambling, including adrenaline highs, anxiety or poor self-care. There may even be biochemical changes in the brain, although the evidence for this is not clear (Carlton & Manowitz, 1988; Kraft, 1999). Some gambling clients suffer from concurrent disorders, such as bipolar disorder, depression or personality disorders, which have a serious effect on the treatment process. However, on average, gambling clients are healthier than substance abusers and are often quite high-functioning individuals, with many skills and competencies. This is especially true of later onset problem gamblers. It is also not unusual to see someone, gambling heavily since their teens, with a good career and many supports; when this is the case, the treatment process is much easier. issues involving money
Money as a Trigger
Although substance abusers are frequently triggered by money, this is even truer for gamblers. It is usually necessary to address their access to money very early in treatment. Their belief that gambling can be used to make money, of course, also needs to be addressed. Such cognitive distortions are a much greater issue than they are for substance abusers. Apart from drug users who deal, most substance abusers do not have the opportunity to make money through their addiction.
Debt and Financial Crises
Debts can be overwhelming for problem gamblers. Substance abusers certainly get into debt, but when an individual can incur a loss of thousands in one night, the issue of debt load becomes dramatic. Any concerns about money or debt, bills or rent, pay cheques or savings, can be a trigger for problem gamblers. Family members’ own serious money worries can trigger the gambler, as can other pressures on gamblers to pay what they owe. Problem gamblers are far more likely than substance abusers to come into treatment in financial crisis, with the crash either imminent or in progress.
Family crises frequently follow hard on the heels of financial crises, largely because of the family’s loss of trust and sense of betrayal. Clients may be dealing not only with loss of money, status or employment, but also with the threatened or actual loss of relationships. If the client is over focused on money as a goal, he or she will tend to see it as the answer to the family crisis as well, overlooking the harm the relationship has suffered in other ways. This motivates him or her even more to try for one more win in the hope of resolving the crisis.
Money and Conditioned Impulsivity
It is also common for frequent gamblers to be conditioned to use any access to money or credit for an immediate trip to a gambling venue, without losing any time and with very little thought. For instance, the gambler, desperate to pay urgent bills, may go to elaborate lengths to obtain money, only to gamble it away the first hour he or she gets it. Methods for directly addressing this kind of conditioned impulsivity will be discussed in more detail below.
Erroneous Beliefs about Money
It is a mistake to assume that all problem gamblers have the same set of erroneous beliefs. Each client has his or her own patterns of cognitions about money, debt and gambling. One may rationalize that unused money is “extra.”Another may use the positive mood that comes with increased funds to justify a “feeling” of being lucky. A third may be triggered by a conviction that the only way debts can be paid is in a quick lump sum, rather than over time. A fourth may see gambling as a business investment, which is bound to pay off eventually if he or she persists. The counsellor needs to help the client to identify these cognitions, their patterns and interrelationships, and encourage their re-examination.
Winning
Clients who continue to gamble will win occasionally. This creates a setback in a way that a drinking binge does not. Gamblers tend to be in and out of treatment more than other clients, probably because it is possible to win, enabling them to believe that the problem is solved. They may pay off debts, and have a feeling of well-being, which is rarely the case for a substance abuser after a binge. However, gamblers who have reached the stage where they invariably gamble their winnings will experience much more regret and depression after a lapse.
Access
Another difference for gamblers has to do with availability. Gambling has become socially acceptable and very easy to access. For those who gamble in corner stores it is almost unavoidable. It is not possible to avoid handling money in the same way that one can avoid handling cocaine. So much access gives very little time for thought between impulse and action.
Similarities
Treating problem gamblers differs from treating substance abusers, but there are probably more similarities than differences. Counselling skills acquired in treating other addictions are highly transferable to problem gambling. Similar issues can be, for instance, the addictive behaviour being used to change mood states, impulsivity, escape, risk-taking and short-term versus long-term thinking. In any addiction, experiences of controlled use can lead to overconfidence. Effects on family, employment and self-esteem have many parallels. Most importantly for this chapter, gambling clients also benefit from a careful examination of their gambling triggers; they need to address these, and to develop new strategies for coping.
Identifying triggers
As with substance abuse, a good assessment of a problem gambler includes a functional analysis of the gambling behaviour, to help identify what triggers the behaviour, and what function it plays in the individual’s life. It is easy to forget, when we see a lot of misery associated with gambling, that it can have many positive attributes. On the other hand, counsellors new to the gambling field often worry about what they can possibly do to lure heavy gamblers away from the glamour and excitement of casinos. It can be intimidating to feel one has to compete with such seductive glitter, and, in fact, the atmosphere does trigger some gamblers. Like other positives, it is important to look at the needs associated with the trigger. Does the atmosphere make a lonely person feel welcome? A person with low self-esteem feel admired? Does the person need stimulation and excitement to counteract depression?
The inventory of gambling situations
There are a variety of techniques that can help identify triggers. One instrument, developed in part by the current author, is the Inventory of Gambling Situations (Littman-Sharp et al., 1999), a questionnaire that identifies an individual’s risk situations for heavy gambling. It is based on the Inventory of Drinking Situations (ids) (Annis, 1986), which has been used for some years for the same purpose with problem drinkers.
The current version of the IGS provides scores in 11 subscales, or categories of risk situations. Several are derived from the subscales of the Inventory of Drinking Situations. Five new scales have emerged as distinct factors for problem gamblers. An initial analysis of the data has produced some interesting findings. A chart with the subscales of both the ids and the IGS suggests some differences between the triggers in the two addictions, as well as some similarities. Although there is a great deal of overlap, there also seem to be some triggers that are identifiable specifically in problem gamblers.
Interestingly, the data (Turner, Littman-Sharp et al., 1999) suggest that chasing losses correlates, not to worrying about debt, but to dreaming of winning. This may seem somewhat counterintuitive. It could be that debts constitute a trigger that gets individuals to the gambling situation, but by the time they lose and start chasing, they have forgotten about their debts and are dreaming of winning instead. Thoughts about winning may represent an escape from or replacement for thoughts about debts. Or perhaps once someone has lost enough, the focus is on achieving a big win, because nothing else seems to be enough to redeem the situation.
Early data also seem to indicate that pleasant emotions and a need for excitement may be very closely related. This suggests that individuals who gamble when they are in a good mood are also looking for the stimulus of risk-taking.
Women score higher on all of the subscales than men, except one: confidence in skill. The differences are at a high level of significance in some areas that are more usually associated with female gamblers: negative emotions, conflict with others and social pressure. However, unlike their traditional “escape gambler” image, women as well as men tend to gamble when their mood is positive, for excitement and to win money. They also believe in their gambling skills, but not, on average, as strongly as men do.
Once the inventory is completed, a client sees the results in chart form (see figure 4, Client Profile Using Inventory of Gambling Situations), as well as a printout of their highest risk situations. The IGS is generally used interactively to help clients focus on their areas of risk for relapse. Some clients come in already aware of their worst triggers and may already be addressing such issues. However, they may be unaware of less intense or less frequent triggers, which could still lead to relapse. For instance, someone who has dealt with some urges and temptations (e.g., availability) may be less aware of being vulnerable to cognitive distortions (confidence in skill), and needs to address this with the counsellor. It can also be helpful to examine responses to individual items. With 63 items, there are generally some that apply to the client that have not been considered before. The IGS can be a good awareness-raiser in these areas.
Other Methods of Identifying Triggers
Self-monitoring is helpful in identifying gambling triggers, as it is with other problematic behaviours. Self-monitoring, or journaling, is also good for identifying patterns over time. An example of a self-monitoring form can be seen by clicking here. It is important to have the client note what preceded the urge to gamble, rather than the gambling itself. It is the decision to gamble, not the act itself, that needs to be the focus point.
Antecedent-behaviour-consequences (ABC)
Another familiar approach is the ABC model, or Antecedent-Behaviour- Consequences. This simple analysis can help clients identify the triggers, and both the positive and negative consequences of their behaviour (figure 5).
This model can be helpful in outlining the circular nature of the sequence of triggers → gambling → consequences/triggers. It is important to discuss how both the positive and the negative consequences of gambling act as triggers in their own right.
Decision matrix
Another way to outline the relationship between triggers and consequences is in a basic matrix as shown in figure 6. In this exercise, consequences are divided into positive and negative, short- and long-term. Clients soon pick up on the fact that the positive consequences mostly end up in the short-term quadrant, and the negative in the long-term.
Brainstorming
Another technique is to brainstorm a list of triggers, divided into events, thoughts and feelings, often with connecting arrows drawn between those that relate to each other (figure 7).
Of course, a detailed discussion between the counsellor and the client, tracing events back from gambling to trigger, is often the best method of clarifying what the patterns might be, perhaps using the materials mentioned from one or more of these techniques.
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