1314 Westwood Blvd
Los Angeles, CA 90024
Problem gamblers use deceit and lies as freely as racing forms, lotto tickets, or other gambling paraphernalia. A person in the grasp of a gambling disorder uses a tremendous amount of secrecy and manipulation to squander any available financial resources, so much so, that their families often feel as though their “money is on fire”. Treatment of both problem gamblers and their families is what I call “Addiction Plus”. As therapists, we need to use all that we know about addiction, plus employ treatment for impulsive and comorbid disorders.
Nancy Petry's (2005) review of studies summarized that 4-6% of the U.S. population are “Disordered Gamblers”. At least 85% of Americans gambled $84.8 billion at casinos, card clubs, racetracks, lottery purchases and remote/internet games. (Casino City North American Alliance, 2006) They've also been involved in unregulated gaming in most sports betting, raffles, family games and hand held games. Pathological Gambling (DSM-IV) with five out of ten symptoms, comprises 1-2% of the population, whereas, “problem gamblers” (with one or two symptoms) make up an additional 3-4% of the population. As we know, Pathological Gambling is an Impulse Control Disorder and requires knowledge of addiction, plus how to deal with behavioral patterns similar to treating impulsive adolescents.
Problem gamblers affect eight to ten other people in their lives (Lobsinger & Beckett, 1996) and need our help as much as the families of any addict or mentally ill person. Spouses and family members often have their own psychological problems, believe the gambler is having an affair or is a mythomaniac because of their lying and deceit.
Research also shows gamblers who seek psychological treatment often have co-occurring mood, anxiety and personality disorders. Petry (2005) summarized recent studies showing as many as 37% of disordered gamblers have Major Depression; 22% are Bipolar; 41% have Generalized Anxiety Disorder; and 18% have Panic Disorder. Dr. Petry also reports many disordered gamblers also have personality disorders (PD). Disordered Gamblers indicate 28% have Obsessive Compulsive PD; 23% have Antisocial PD; 24% have Paranoid PD; and between 13 to 15% have Histrionic, Avoidant and Schizoid personality disorders. My clinical experience is that there are high numbers with Narcissistic PD and Borderline PD, but available studies to date to support that assertion are small and inconsistent in numbers. “When dealing with problem gamblers, the therapist needs to be prepared for treating dual disorders,” is quite an understatement.
Treating disordered gamblers is more difficult than most of the alcoholics and addicts I have treated during the past 25 years. These aberrant gamblers are usually in their desperation phase and seek treatment later than alcoholics. Of course their “money is on fire” from their mounting debts as they continue lying during their escalating gambling problems.
Four helpful and largely effective Cognitive Behavioral Therapy (CBT) treatment techniques assist gamblers and their families in getting a start on the road of recovery. To begin with, functional analysis involves diagramming triggers which initiate gambling, and evaluating both the positive and negative consequences of gambling (Petry, 2005). Disordered gambling clients are often surprised when asked about positive aspects of their gambling. They may actually need to be prompted to think about the escape, the excitement or the “big-win dream”. Negative consequences such as loss of job or spouse, guilt, or depression are easier to identify when “sober” and hurting. The functional analysis helps the gambler see the larger picture with both positive and negative consequences. It is appropriate as AA says to, “Think it through.”
A second technique is to reinforce non-gambling. In the recovery field this is also known as “breaking through their denial”. Abstinence from gambling is usually seen as the goal although harm reduction theories obviously provide assistance. “Lapses” for gamblers tend to be more common than with treatment for other addictions. Therefore, our therapeutic challenge is to help them get “back in the saddle” ASAP should a lapse occur. With this technique, the gambler is encouraged to keep track of any gambling thoughts or triggers on a daily basis and to reward and bolster non-gambling behavior.
A productive way to reinforce non-gambling behavior is to review a long list of pleasant, safe activities with clients. As with other addictions, by the time clients seek treatment, their world and choices have narrowed greatly. They can only think of a few things they like to do (except gamble). As we brainstorm with the clients, their list can grow exponentially. Previous activities are boring and devoid of passion. “Too often nothing is as intense or pleasurable as the unrestrained crazy wagering…This is known as behavioral toxicity, a process by which other rewards lose attractiveness.” (McCown, 2007) This is reversible as neurotransmitters and other activities help rebalance the gambler (and family as well).
If they have a non-gambling day, the client can select a reward like a relaxing bath, a favorite TV show, or indulgent dessert. Recently a client said she forgot how much she loves to take her dog on a hike, which is obviously good for the both of them. Longer term abstinence is reinforced with larger rewards like a new CD, a weekend out of town with a friend, watching a sporting event, dinner out or a new item of clothing. CBT recommends withholding rewards if the client has gambled that day. If the client is suicidal, we need to assess whether withholding of pleasure-full events is appropriate at this time.
A third technique to assist this very complex clientele involves utilizing supportive relationships. We all know that not all family members are supportive and we may need to assist our clients in determining who is supportive of their non-gambling. Religious affiliations, support groups and Gamblers Anonymous (GA) offer helpful relationships. My experience is that GA is not yet as strong and helpful as AA, but it is certainly better than a former poker buddy. I usually begin by having my clients list all of their relationships. Then we mutually focus on those who are supporters. Of course, sponsorship, steps, service and giving “therapy” at meetings help gamblers with their daily commitment.
Stress management is a fourth technique I use out of the many possible options available. Problem gamblers often need help assertively telling their gambling aunt not to visit, confronting a co-worker, having a GA Pressure Relief meeting, or telling a spouse about a debt. These disordered gamblers were impulsive when wagering and want capricious recovery and seek the “quick fix”. Gamblers, who often have trust issues, still need direction with decision-making, relaxation and perhaps systematic desensitization. Their emotional and physical health is often in shambles. They frequently require encouragement to see a physician, help with monitoring “awfulizing” thoughts, assistance in choosing healthier nutrition and expanding their exercise program.
Families of disordered gamblers are quite codependent and often passively dependent. Family treatment may necessitate crisis management and direction. They can also use support from groups like Gam-Anon and Codependents Anonymous. While monitoring for their safety may be necessary, their involvement with the gambler in treatment often doubles the gamblers' recovery rates.
Gary Lange, Ph.D. is a licensed Marriage and Family Therapist in private practice in Rancho Mirage, CA.
Copyright 2011 Dr. Eric Geffner's Gambling Treatment Program. All rights reserved.
1314 Westwood Blvd
Los Angeles, CA 90024