Monday, April 24, 2006

Psychotherapy for Compulsive Gambling

Slot machines are coming to Pennsylvania. Like most psychologists who don't work near a casino, I don't see many gamblers. When the slot machine law was initially enacted, I took some continuing education credits to brush up. It taught me how little we really know about gambling.

Mostly, psychologists see gamblers when their luck has run out and their lives are in a shambles. We'll be seeing more of those people as casinos become more common. I just reviewed an on-line book on gambling , [Sorry, this link is dead--F. O. 8/27/2009] dated 1999. It's a little old, but not much has changed since it's publication. It's also a little thin on treatment, but it does have some good data. For those that are into diagnostics, they have a copy of the diagnostic criteria for pathological gambling.

The current issue of the APA Monitor has an article entitled, Gamble at Your Own Risk , which discusses some research on controlling compulsive gambling. The article reports on two studies. In the first, they found that even people well-versed in the probabilities of gambling, will still do it. In one study, students in an introductory statistics class got intensive education in the probabilities of winning at gambling. They still gambled at the same rate as students in a control group.

In the second study, a casino was set up, using a computerized roulette game. Warnings, such as, "If you bet more to make up your losses, you're likely to lose more money" and "If you continue to gamble, you'll eventually lose money," were flashed on the screen. Not surprisingly, students receiving the warnings did gamble less money. But come on, do you think you'll ever see warnings in a casino?

Generally, treatment for pathological gambling follows the addictions model. The goal is not to "recover," but instead to stay in recovery for the rest of one's life. To assist in this process, the clinician must address at least four areas:

1. The negative effects of gambling on the client. The goal is to help the client see that gambling is the cause of all their major problems. Once they are convinced that not gambling will improve their life, they can be engaged in therapy. I always begin by taking a history from my clients. For problems like gambling, the client may find it very traumatic to recount their gambling behavior. Having the client write an autobiography, linking major events in their life to gambling may be a very emotional experience, too.

2. Education about pathological gambling. There are two issues here: First, gamblers need to understand gambling itself, and see that the odds are generally stacked against them. Their unrealistic beliefs about gambling, such as the belief that they can make up for their losses, need to be challenged.

Second, they need to understand their own addictive behavior. For me, the best explanation of gambling comes from basic learning theory. People do what they are reinforced (rewarded) for. There are two rewards for gambling. First, there is a "high" to gambling; a thrill that people report when they are about to pull the lever, lay their money on the table, or watch the outcome of a game or race. That high is very rewarding for the gambler. Second, the behavior is intermittently reinforced. That is, they are rewarded by winning just often enough to keep people playing in the face of their losses. Combining the immediate reinforcement of the high with the intermittent reinforcement of winning makes the gambling behavior very resistant to treatment.

3. Repairing the damage. Pathological gambling does tremendous damage to people's lives. The client needs a great deal of supportive therapy to deal with the financial or legal fallout from the gambling. It's not unusual for a person to have repeatedly run up tens of thousands of dollars in debts, leaving the family struggling to get by. Often, the gambler has embezzled money from their employer, also and may be up on charges as well. In addition to individual therapy, family or marital therapy is necessary to heal the anger that loved ones feel over the client's behavior. The clinician must be careful to support the client, help him or her over the difficulties, but not to minimize or excuse the behavior.
4. Support for abstinence. It might be possible for some gamblers to return to controlled gambling, but I think the risk is too great. The client needs to go to Gambler's Anonymous on a regular basis. Family members should go to Gam-Anon , too.

As the gambler abstains from gambling, they will experience cravings, just like an addict. These cravings are a vital part of recovery. In therapy, they can be used to help the client understand the role of gambling in their lives. Abstinence reveals how gambling filled the holes in the gambler's life. Filling those holes with healthy behavior is a vital part of recovery.
Working with addiction is always frustrating. In some ways, gambling is the worst of the addictions. Substance abusers can avoid their drug of choice fairly effectively. However, with the proliferation of lotteries, casinos, and Internet gambling, the recovering gambler is never far from the scene. Relapses are common with gambling, and are much more catastrophic than with substances. A drunk can go on a bender and then climb back on the wagon. A gambler can relapse and lose $10,000, in a weekend, literally erasing all the good work he had done.

In conclusion, therapy is a mix of educational, supportive, and confrontational treatments. Knowing when to implement them is challenging, to say the least. Gamblers often do enter and maintain their recoveries, although it can be a difficult road there.

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