WHY PATHOLOGICAL GAMBLING ADDICTION IS DIFFICULT TO TREAT
INTRODUCTION
First and foremost, you have to define pathological gambling addiction before you can answer the question why pathological gambling addiction is difficult to treat. For casual reading the exact meaning is not important but for research purposes you have to define the exact meaning because the outcome depends on your definition.
Gambling addiction can be healthy addiction. For example, many gamblers buy magnum, Toto or any other jackpot games on a weekly basis. They consider the game as a small easily affordable entertainment expenses. Yet they have a chance to profit out of these expenses when they hit a jackpot.
It is common knowledge that expenses do not yield return. However, a broad spectrum of business enterprises has discovered the power of jackpot-like rewards. They start to offer prizes to encourage big spenders or lucky spenders. In a way, they attempt to mimic gambling.
These business enterprises are all supported by healthy gambling addiction. However, gambling addiction can become unhealthy or even pathological for a number of reasons.
You should note that at the moment there is no consensus among the authorities on the terminologies of pathological gambling, problem gambling and professional gambling.
Pathological gambling refers to a chronic inability to resist the impulse to gamble. The term is usually limited to cases where the gambling causes serious damage to a person’s social, vocational, or financial life. Often referred to as compulsive gambling and less frequently as disordered gambling, it is considered by most to be an impulse control disorder. It is not synonymous with problem gambling.
Problem gambling refers to gambling activity that causes difficulty for the individual but does not meet the standards for pathological gambling. Sometimes referred to as “at-risk,” “in-transition” or “potential pathological” gambling, though it is not known at what rate problem gamblers become pathological gamblers.
Professional gambling refers to one who gambles as a way to make part or all of their living. Often confused with pathological gamblers, professional gambling is characterized by limited risks, discipline, and restraint, items all lacking in the pathological gambler. Professional gamblers wager on games with skill elements rather than games of chance, and wait to bet until the odds are more in their favour.
In my opinion, professional gambling is an unqualified and unstable profession. It lacks many important characteristics of established traditional professions like docotrs, lawyers, accountants, engineers, architects. In fact, professional gamblers can lose control, go on gambling tilt and exhibit chasing behaviour. Hence, professional gamblers can also become problem or pathological gamblers.
WHY PATHOLOGICAL GAMBLING ADDICTION IS DIFFICULT TO TREAT
This article attempts to explain the possible reasons behind the poor prognosis in treating patients with pathological gambling addiction. The poor results of treatment in turn progressively expand the need for research information on pathological gambling.
In two large national U.S. surveys, 36%–39% (success rates) of the individuals with a lifetime history of DSM-IV pathological gambling did not experience any gambling-related problems in the past year. In other words, 61%-64% (failure rates) of the individuals who had tried to quit gambling had relapsed back into a lifestyle of pathological gambling within a year.
Although most people can gamble occasionally, such as occasional Saturday night social poker games, betting on major sporting events with friends, playing a slot machine while on vacation, some gamblers lose control. Pathological Gambling is characterized by recurrent and persistent gambling behaviour that disrupts family, personal, or vocational pursuits. It also involves continuous or periodic loss of control, a preoccupation with obtaining money for gambling, irrational behaviour and continuation of this behaviour in spite of adverse consequences.
The high incidence of co-morbidity of pathological gambling and other behavioural and substance abuse addictions and psychiatric disorders are well documented. Pathological gambling addiction is highly co-morbid with substance use in particular alcohol abuse and cocaine abuse, mood, anxiety, depression with suicidal tendencies and personality disorders, suggesting that treatment for one condition should involve assessment and possible concomitant treatment for co-morbid conditions.
In addition, some pathological gamblers also develop simultaneous dependencies on certain activities of living such as sex addictions, food addictions, and religious addictions that can be just as life threatening as depression and just as socially and psychologically damaging as alcoholism.
All in all, pathological gambling addiction is a lifestyle disease. Failure to diagnose and treat other poly-behavioural addictions simultaneously as a lifestyle disease is one of the main reasons why pathological gambling is difficult to treat.
This systematic evidence-based under-diagnostic standard in the field of addictions could be due to both the lack of diagnostic tools as well as inadequate resources to resolve the complexity of assessing and treating patients with pathological gambling addiction.
Statistics estimated that 20 million Americans develop gambling problems wagering and eventually losing approximately $0.5 trillion dollars annually. Someone has to pay those 24-hour electric bills. Approximately 2 million Americans are pathological gamblers, 3 million adults can be considered problem gamblers and an additional 15 million are considered at-risk for problem gambling. But who are the real losers? One study reported that direct and indirect costs to American society from problem and pathological gambling (e.g., health care, bankruptcy, criminal costs, etc.) are approximately $5 billion per year. That means that the taxpayers are the real losers. The only “Winners,” are the Casino owners, stockholders, and other investors in the Gaming industry.
The Addictions Recovery Measurement System (ARMS) is proposed as a first step in fighting this global War on Pathological gambling addiction.
Screening for Pathological Gambling Addiction
Several screening tools are available to assist counsellors and therapists with diagnosing pathological gambling. One of the earlier tools is the South Oaks Gambling Screen by Lesieur & Blume, 1987. The LIE/BET questionnaire screening tool was created by Johnson in 1997. In 2005, Slobodzien introduced The Addictions Recovery Measurement System (ARMS).
Adapted ARMS
The following statements and interpretations are adapted from ARMS.
Instructions: Following are groups of statements that are numbered. Please read each group of statements carefully. Then pick out the one statement in each group that is most true for you, and circle the number beside the statement that you pick.
1. I have never gambled with more than $100.00 on any one- day, and it was purely for social entertainment. My gambling has never resulted in adverse consequences to others or myself.
2. Gambling is sometimes a part of my recreational activities, but I have never gambled with more than $1000.00 on any one-day. Periodically I have suffered from some negative consequences, but I have never lost control over this behaviour.
3. I have gambled with more than $1000.00 on any one-day and/ or I have a continuous or periodic loss of control over gambling behaviours; and/ or a preoccupation with gambling and obtaining money for gambling; and/ or a pattern of continuing to gamble in spite of adverse consequences.
Interpretation:
1 = (At-Risk-For Problem Gambling)
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2 = (Problem Gambling)
3 = (Pathological Gambling)
Poor Results
You have come to realize today more than any other time in history that the treatment of lifestyle diseases and addictions such as pathological gambling are often a difficult and frustrating task for all concerned. Poor results are seen with all sorts of addictions despite using the most effective treatment strategies. For example, Gorski in 2001 reported that 47% of patients treated in private treatment programs relapse within the first year following treatment. There are many reasons for this poor prognosis. Some would say that failures are due simply to a lack of self-motivation or will power. However, most would agree that lifestyle behavioural addictions could possibly be that patients with multiple addictions are being under diagnosed simply due to a lack of diagnostic tools and resources that are incapable of resolving the complexity of assessing and treating a patient with multiple addictions?
Diagnostic Delineation
Thus far, the DSM-IV-TR has not delineated a diagnosis for the complexity of multiple behavioural addictions such as pathological gambling, sex addiction and substance addictions. It has reserved the Poly-substance Dependence diagnosis for a person who is repeatedly using at least three groups of substances during the same 12-month period, but the criteria for this diagnosis do not involve any behavioural addiction symptoms. In the Psychological Factors Affecting Medical Condition’s section (DSM-IV-TR, 2000); maladaptive health behaviours such as pathological gambling, overeating, unsafe sexual practices, excessive alcohol and drug use may be listed on Axis I only if they are significantly affecting the course of treatment of a medical or mental condition.
Successful treatment outcomes in all addictions are dependent on thorough assessments, accurate diagnoses, and comprehensive treatment programs tailored to an individual gambler. However, major addiction centres throughout the world have limited capability in these three major areas. The DSM-IV-TR does not even include a diagnosis for multiple addictive behavioural disorders. Therefore, it is not surprising that repeated rehabilitation failures and low success rates are the norm instead of the exception in the addictions field. Treatment clinics need to have a treatment planning system and referral network that is equipped to thoroughly assess multiple addictive and mental health disorders and related treatment needs and comprehensively provide education, awareness, prevention, and specific addictions treatment services for gamblers diagnosed with multiple addictions. Written treatment goals and objectives should be specified for each separate addiction and dimension of the gamblers’ lifestyle, and the desired performance outcome should be measurable.
New Proposed Diagnosis
To assist in resolving the limited DSM-IV-TRs’ diagnostic capability, a multidimensional diagnosis of “Poly-behavioural Addiction,” is proposed for more accurate diagnosis leading to more effective treatment planning. This diagnosis encompasses the broadest category of addictive disorders that would include an individual manifesting a combination of substance abuse addictions, and other obsessively-compulsive behavioural addictive behavioural patterns which include pathological gambling, religion, sex and pornography. Behavioural addictions such as pathological gambling are just as damaging psychologically and socially as alcohol and drug abuse.
They are comparative to other life-style diseases such as diabetes, hypertension, and heart disease in their behavioural manifestations, their aetiologies, and their resistance to treatments. They are progressive disorders that involve obsessive thinking and compulsive behaviours. They are also characterized by a preoccupation with a continuous or periodic loss of control, and continuous irrational behaviour in spite of adverse consequences.
Poly-behavioural addiction would be described as a state of periodic or chronic physical, mental, emotional, cultural, sexual, spiritual and religious intoxication. These various types of intoxication are produced by repeated obsessive thoughts and compulsive practices involved in pathological relationships to any mood-altering substance, person, organization, belief system, and activity. The individual has an overpowering desire, need or compulsion with the presence of a tendency to intensify their adherence to these practices, and evidence of phenomena of tolerance, abstinence and withdrawal, in which there is always physical and psychic dependence on the effects of this pathological relationship. In essence, Poly-behavioural addiction is the synergistically integrated chronic dependence on multiple physiologically addictive substances and behaviours. Some examples include abusing substances such as nicotine, alcohol, & drugs, or acting obsessively and compulsively in regards to gambling, food binging, sex, and religion.
New Proposed Theory
The Addictions Recovery Measurement System’s (ARMS) theory is a nonlinear, dynamical, non-hierarchical model that focuses on interactions between multiple risk factors and situational determinants similar to catastrophe and chaos theories in predicting and explaining addictive behaviours and relapse. Multiple influences trigger and operate within high-risk situations and influence the global multidimensional functioning of an individual.
There are four variables that determines the outcome of addiction therapy.
1. background factors (e.g., family history, social support, years of possible dependence, and co-morbid psychopathology).
2. physiological states (e.g., physical withdrawal).
3. cognitive processes (e.g., self-efficacy, cravings, motivation, the abstinence violation effect, outcome expectancies).
4. coping skills
In other words, small changes in gambler’s behaviour can result in large quantum changes at the gambler’s social-economic outcome and patterns at the social-economic level of the gambler’s lifestyle portfolio emerge solely from numerous little interactions.
Partnerships and coordination among service providers, government departments, and community organizations in providing treatment programs are a necessity in addressing the multi-task solution to poly-behavioural addiction. The (ARMS) resources can be used to fight the War on pathological gambling disorders within poly-behavioural addiction.
According to therapists and other professionals in the field, pathological gambling is a difficult disorder to treat. Treatment for pathological gambling is a costly, time-consuming effort, often without quick results and with a high degree of re-occurrence. Given the lack of information about the root causes of the disorder and the relatively new awareness of the phenomenon, at least on a large scale, no single treatment approach has been devised. Instead, a variety of different approaches are employed, with mixed results. The ARMS approach to treat pathological gambling within the polybehavioural disorder appear to the most promising.
PROBLEM GAMBLING
Do not confuse treatment for pathological gambling with treatment for problem gambling.
Unlike pathological gambling where treatment must include all four variables mentioned earlier, treatment for problem gambling is much simpler. This is because problem gambling has been recognized as a more cognitively based disorder. Most researchers have concluded that excessive gamblers characteristically demonstrate core cognitive distortions in their belief systems about their ability to win at gambling. These beliefs can persist even when the gambler continues to lose at gambling. It is essential to assess the gambler’s beliefs about his or her ability to win. Some gamblers also have cognitive distortions not only about their ability to win, but also their need for excitement, and a correlating distorted belief that they will not be able to function without the excitement that they derive from gambling.
COGNITIVE BEHAVIOUR THERAPY
Cognitive therapy is required to identify, challenge and modify cognitive distortions, or relapse to gambling is likely because the gambler believes that he or she is going to win if he or she gambles. Other interventions may be appropriate and effective, for example behavioural therapy, family therapy, impulse control training, and so on, but cognitive assessment and therapy will be a cornerstone of the treatment plan.
Cognitive behaviour therapy per se is sufficient to treat problem gambling. However, for pathological gambling, cognitive behaviour therapy forms only one part of treatment. The therapists also need to address the background factors, physiological states and coping skills of the pathological gamblers.
KEY POINTS
1. Do not confuse problem gamblers with pathological gamblers.
2. Do not confuse treatment for pathological gamblers with treatment for problem gamblers.
3. Professional gambling is an unqualified and unstable profession.
4. Cognitive behaviour therapy is effective to treat problem gamblers.
5. ARMS resources which include cognitive behaviour therapy are promising therapeutic tools to treat pathological gamblers.
