|
|
| Psychology Today: A winning bet: treatment for compulsive gambling |
Richard Pitts" came to our hospital with little hope that anything short of suicide could end his psychological pain. What had begun as a modest habit of racetrack betting at age 15 had become a nightmare of debt and desperation by age 27. Pitts had lost $1,400 borrowed from a finance company, could not pay his monthly living expenses and was falling short of repayments for his existing $12,000 gambling debt. He felt compelled to gamble daily (a fact he had tried to keep from his wife) and did so recklessly because he was also drinking heavily. He had been torn between "borrowing" money from petty cash at his office, which of course he would return, and killing himself.
Fortunately for Pitts, his wife intervened and convinced him to go for treatment. One week in our inpatient program allowed him to gain far greater control over his gambling and his life. He still may backslide occasionally, but he's out of the quagmire and likely to stay out.
Compulsive gambling can be controlled. For many of those who seek help, several types of effective treatment are available; most are variants of psychotherapy. Drug treatment is not commonly used for the gambling behavior itself, although it may help to reduce accompanying mental prolems such as depression or anxiety.
Determining which treatments work--and how effectively--requires rigorous research, and only some treatments have been studied systematically. Among these, psychoanalytic psychotherapy, although widely used with compulsive gamblers, has received relatively little study. In fact, only one psychoanalytic outcome study has been conducted on a large sample of compulsive gamblers. In 1958, New York psychiatrist Edmund Bergler selected 80 gamblers out of 200 referred and treated 60. Of these, 15 dropped out after six weeks, while the remainder stayed in treatment for 12 to 18 months. At the end of treatment, 30 were reported cured, for a success rate of 50 percent. However, Bergler's findings suffer from clinical bias and inconsistent criteria in selecting patients and from poor follow-up.
During the last decade, various behavioral and other psychotherapeutic techniques have been used. However, most studies of these therapies report on single cases, lack controlled comparison of one treatment with another or with placebos or combine several techniqes concurrently so that the active ingredient cannot be identified.
One relatively well-studied form of behavior therapy, and the one most frequently used in the United Kingdom and Australia for compulsive gambling, is aversive therapy. This treatment is based on the premise that since gambling is part of a learned pattern of behavior, it can be unlearned through classical conditioning. Thus, mild electric shocks to the fingers may be given as the gambler plays the slot machine or reads the racing-form guide. Aversive therapy, which in the United Kingdom and Australia has an overall success rate of about 30 percent abstinence and 60 to 70 percent improvement, has been criticized as being dehumanizing and causing unnecessary emotional distress. For this reason, alternate forms of therapy have been sought.
In the experience of our own program, one particularly promising alternative is "imaginal desensitization." My colleague pyschiatrist Nathaniel McConaghy has hypothesized that compulsive types of behavior are driven by increased arousal and tension produced by neurophysiological "behavior-completion mechanisms," which come into play when the compulsive behavior is stimulated but not actually completed. This led him to suggest that by teaching patients to relax as they imagine the experience (and discomfort) of giving up gambling, we could help them withdraw and could lower their general tension levels. He expected that the more benign approach would be as effective as aversive therapy.
To investigate this, psychiatrists McConaghy, Michael Armstrong and Clive Allcock and I conducted a comparative treatment study of 20 gamblers who sought treatment at our hospital. Ten received aversive therapy and 10 received imaginal desensitization. Desensitization consisted of giving gamblers a brief, individual five-minute relaxation training period followed by guided imagery in which they visualized themselves being stimulated to gamble, approaching a gambling situation but not actually gambling and leaving the scene. In each phase of the imagined sequence, the patients were requested to continue relaxing.
Both groups received 14 treatment sessions during a one-week period as inpatients. At one month and again at one year after treatment they were given a battery of psychological tests and were assessed by a psychiatrist who did not know which treatment they had received. At one year, 30 percent of the aversive-therapy group showed controlled or markedly reduced gambling compared with 70 percent of the imaginal-desensitization group. Further, as predicted, among the desensitization group, anxiety levels were far lower after treatment than before.
One of the study participants was Pitts. He had been somewhat skeptical early in his treatment, wondering how such a simple procedure could overcome his strong urge to gamble and his preoccupation with it. By the eighth session, however, imagined gambling scenes no longer produced any excitement. Indeed, he found it hard to concentrate on them.
One month after treatment ended, Pitts reported that he did not gamble at all and his gambling urge was far less powerful. He could walk past a betting office and not have to gamble, and he could quickly think of other matters. He had revealed the full extent of his gambling and financial problems to his wife, Fay, and, with her support, set up a budget to repay all loans.
One year after treatment he admitted to having had one gambling episode, precipitated by an argument with his boss, but did not enjoy it. "It was a flat feeling, I got nothing out of gambling." He felt no urge to chase his losses and could talk openly about his gambling. Moreover, the relaxation effect had spread to many other areas of his life, and stressors caused far less upset than they once did.
Another approach, used alone or in combination with other treatments, is participation in Gamblers Anonymous (GA), the mutual-help organization formed in 1957 and modeled on the principles and format of Alcoholics Anonymous. In GA, compulsive gambling is regarded as a progressive illness that can be arrested but not cured. Thus, a lifelong commitment is recommended. The program emphasizes sharing common experiences, mutual support and personality development.
Psychiatrist Robert Custer, now with the Veterans Administration (VA) in Washington, D.C., surveyed 150 GA members attending the organization's first international conference, in 1978. This group, acknowledged as not representing all GA members, had and average attendance of seven years and three months. Forty-two percent reported no gambling since attending, 32 percent one episode, 10 percent two and 16 percent more than two, giving an overall success rate of 74 percent. About half had spouses attending Gamanon, which is GA's companion organization.
This very high success rate for people who stay in GA masks the fact that some attend briefly and drop out. While at least one study suggests that even these individuals may receive some benefits, it is usually assumed that dropouts were not helped. Psychologist Iain Brown of the University of Glasgow examined attendance records for several GA chapters and found that 58 percent of members dropped out after 5 sessions and 70 percent after 10. Using a strict criterion of abstinence from gambling for two years, he found a success rate of 7.3 percent for all who attended. Though this rate seems disappointing, in another study Brown found that of those people who dropped out, 13 percent had substantially improved, so with less stringent criteria the success rate of GA could be raised to more than 20 percent.
Continued from page 1.
The treatments described above (including the one provided to inpatients at our hospital) are usually given on an outpatient basis. The first hospital inpatient program for compulsive gamblers was established in 1972 by psychiatrist Custer at the Cleveland Veterans Administration Center in Brecksville, Ohio. His one-month program, which has become a model for many other inpatient treatment programs, is designed to encourage abstinence, reduce to encourage abstinence, reduce the urge to gamble and restore social functioning. Gamblers who join the program, which is carried out in the context of an alcoholism unit, participate in unstructured group-psychotherapy sessions as well as in addiction- and health-education classes, and are advised to attend three of four GA meetings weekly. For those who need it, training in assertiveness, family living skills or coping with stress may also be provided. The patients' discharge plan focuses on combining financial recovery, continued attendance at GA and professional follow-up.
In an outcome study conducted in 1980 through 1981, researcher Angel Russo and her colleagues at the Cleveland VA Center surveyed 124 patients one year after their discharge from the program. Of those who responded to the surfvey, 55 percent were abstaining completely and 36 percent were gambling much less. Seven percent had increased their gambling. Those who reduced their gambling reported that their relationships with other people and their financial status had improved, while their depression was less. They were continuing to attend GA and maintain contact with mental-health professionals.
Russo and her colleagues acknowledge that their study has some limitations, such as the unrepresentativeness of the sample and the lack of a control group or any pretreatment assessment. They also concede that since there is no research on the effects of group therapy on gamblers, they do not know whether intensive group therapy was essential to teh program's effectiveness.
McConaghy argues that no group-comparison studies have shown combined-therapy approaches, such as the VA model, to be more effective than single-therapy approaches, such as our own; indeed, some research suggests that combined-therapy approaches may be less effective. These therapies are also costly in time and money, and may not be readily available for all gamblers wishing treatment. In contrast, single-therapy approaches such as imaginal desentization can be used by psychologists without extensive training, and offered to outpatients at community centers, where resources may be scarce.
Do all compulsive gamblers need treatment to kick or control their habit? Clearly, some do, but we do not yet know exactly which ones, in part because we lack research on how compulsive gamblers fare when untreated. We do know that, like alcoholics and smokers, some compulsive gamblers can stop on their own, yet others seem uncontrollable despite the best of today's treatments. As our understanding of compulsive gambling increases, we may develop new treatments for people not now helped, and we should be more able to match the needs of individuals patients.
Our capacity to treat compulsive gambling effectively follows from a growing ability to understand its origins. These developments are historically quite new. Compulsive gambling has been devastating people's lives since at least 5000 B.C., but not until the early part of this century did people try to understand--and treat--the compulsive gambler.
Psychoanalysts were the first to provide a psychological formulation of pathological gambling, which they viewed as a neurosis. While not the first psychoanalyst to theorize on gambling, Freud was probably the most influential. In his 1928 case analysis of Dostoyevsky, the Russian writer (and pathological gambler), he stressed the role of unresolved Oedipal conflicts and masturbatory complexes. Freud may not have meant to apply his formulation to all gamblers, or even all compulsive ones, but it nonetheless formed the foundation for subsequent analytic descriptions.
Despite their historic importance in attempting to fathom compulsive gambling, psychoanalytic models fail to explain why people gamble in the first place or how controlled gambling becomes uncontrolled. They have been based on highly selected, unrepresentative samples, and their hypotheses are untestable.
A more recent and more readily tested model is that of Skinnerian behaviorism, which proposes that people persist at gambling because their behavior is reinforced (rewarded) by the money they sometimes win. Psychologist Mark Dickerson of the Australian National University explains that people receive two types of rewards from gambling: the intermittent and very powerfully reinforcing reward of occasionally winning money as well as the l more reliable one of subjective excitement associated with placing bets and with the gambling environment itself. This theory suggests that virtually everybody is at risk for pathological gambling. However, it does not explain why only some individuals become pathological gamblers or account for relapse after abstinence.
More recently, psychologist Brown of the University of Glasgow, working with George Anderson, suggested a three-stage theory of compulsive gambling. Two of the eight critical factors are: a person with a special pattern of physiological arousal and the opportunity to be reinforced irregularly, as happens when people gamble.
This theory incorporates the notion of "optimal levels of arousal," proposed by psychologist Marvin Zuckerman of the University of Delaware, to explain why some people gamble more than othes. According to Zuckerman, all people unconsciously try to maintain an optimal level of physiological arousal or stimulation. Overaroused, anxious people may try to reduce excessive arousal, while underaroused people may try to increase it.
The reinforcement provided by occasional wins gives people at both ends of the arousal spectrum a way to achieve an optimal arousal level and may lead to compulsive gambling. Anderson and Brown, as well as Kathryn Leary and Dickerson of the Australian National University, have shown experimentally that gambling can alter arousal levels, as measured by changes in heart rate.
Following in the behavioral tradition, I have also proposed a model of how compulsive gambling develops and is maintained. It is based on Brown's model as well as on the theories of psychiatrist McConaghy, who heads the behavioral treatment program at my hospital.
For most people, gambling is a healthy, exciting, recreational activity that can be kept under control. Indeed, I believe that noncompulsive gambling promotes self-worth and reduces the alienation and unrest produced by often boring work.
I believe that for some people, however, a number of factors interact to create and sutain an almost inescapable trap of ruinous behavior. It starts with the circumstances that establish a gambling habit: early exposure through informal and formal gambling with family members or friends (beginning at 12 to 15 years of age on average); initial large wins; and availability of gambling outlets. Psychologist Robert Ladouceur and colleagues at Universite Laval, Quebec, Canada, have shown that exposure to gambling can increase risk-taking and possibly the need to seek more and more action.
A person with a gambling habit will not necessarily become a compulsive gambler. Several other factors seem to be in volved as well. Among them, for some compulsive gamblers, may be a deficiency in brain systems that use the natural opiates known as endorphins. In a preliminary study, for example, my colleagues and I found that the natural opiate B-endorphin may be involved in some people's compulsive gambling (see "Brain chemicals and the gambler's high," Psychology Today, May 1985). People deficient in endorphins, which appear to be responsible for many kinds of natural "highs," may be more likely than others to respond rapidly and positively to arousal-producing activities such as gambling. This could explain why, for some, the addictive process is almost immediate.
My clinical and research experience suggests that people who become compulsive gamblers bring to their gambling habit two kinds of motivation: Some gamble to escape stresses and some to overcome depression, boredom or loneliness. But in both types, the disorder often develops in a similar way: After an average of nine years of controlled gambling, some people may begin to gamble pathologically when they become anxious or depressed in extremely stressful situations.
Continued from page 2.
For anxious and stressed people, gambling heps to narrow attention and provides the reward of emotional escape: "I become totally absorbed by playing the slot machine. Nothing else in the world worries me." For depressed people, gambling provides a "buzz": "It's like having a 'high.'" I have found that the former group usually selects low-skill activities such as slot machines or roulette, while the latter usually chooses high-skill action such as horse racing or cards.
Gambling may relieve anxiety and depression, but it provides only temporary relief at best, and at worst, it compounds the very problems it is intended to solve. Gambling-induced financial losses, combined with guilt, remorse and fear of detection, make matters worse emotionally, thus fueling the drive for continued gambling. Gamblers then increase their bet sizes to increase diminishing excitement and to "chase" losses, as described by sociologist Henry Lesieur of St. John's University in New York.
At this point, compulsive gamblers begin the rapid descent into the "desperation phase," outlined by VA psychiatrist Custer (see "Against All Odds," this issue). They can't stop gambling even when they want to. Indeed, trying to stop can even tighten the habit's grip. As noted earlier, McConaghy argues that once the behavior pattern is set, compulsive gamblers who are not allowed to indulge in their habit become extremely distressed and preoccupied with an urge to continue gambling. Eventually their discomfort drives them back to the racetrack or slot machines.
Compulsive gamblers may delude themselves into thinking that they can make up their losses only through large wins. Walter Miller, a psychiatric social worker at the Connecticut Compulsive Gambling Treatment Program, in Bridgeport, observes that pressure for continued gambling is maintained by impatience for rapid restitution and by feelings of great loss or being left in a void.
As we learn more about how gamblers become compulsive gamblers, we are beginning to change our ways of thinking about this problem. Compulsive gambling, although still formally defined as an impulse-control disorder, is increasingly being viewed as an addictive disorder. Indeed, many of its features also occur in alcohol- and drug-abuse disorders (including dependence, tolerance and withdrawal symptoms of disturbed mood and/or behavior), and cross-addictions are frequently seen. For example, Lesieur and psychiatrists Sheila Blume and Richard Zoppa of South Oaks Hospital in Long Island, New York, found that 8.7 percent of alcohol and drug patients were pathological gamblers, and another 10.3 percent showed signs of some gambling problems. Our own studies indicate that 30 percent of gamblers abuse alcohol, with 40 percent having a family history of alcoholism.
In addition, my colleagues and I have found that pathological gamblers have a personality profile similar to that of addicts. We administered a 32-item Addiction Scale derived from the Eysenck Personality Questionnaire to 60 pathological gamblers, 51 heroin addicts and 52 normal volunteers. Pathological gamblers, like addicts, had highly elevated Addiction Scale scores. However, many of the items on that scale deal with anxiety and depression, and major depression may occur among as many as three-quarters of compulsive gamblers. Thus, the similarities we see may stem from gamblers' emotional problems rather than from a personality type common to gamblers and addicts.
If arousal, mediated by brain systems using endorphins, plays an integral part in starting or maintaining pathological gambling, this mechanism may suggest new drug treatments. Opiate antagonists or other drugs that interfere with gambling-induced arousal may be given before people gamble to lessen their urge.
I am very encouraged by the trend to view pathological gambling as similar to the substance-abuse disorders. It allows researchers to develop testable hypotheses and models. We will have a firm foundation for rejecting this view and developing alternative explanations if it proves incorrect. But if, as I believe, it's a solid lead, we may find more effective ways to keep gambling a recreation and not a form of self-destruction.
Despite the long and persistent history of compulsive gambling, we have just begun to understand and treat it. Yet we have already found ways to help thousands of people to escape its disastrous grip, and I expect even more powerful techniques to emerge in years to come. If we can combine effective treatment with the social controls needed to prevent new cases from developing (see "Preventing Compulsive Gambling" box), we may be on our way, at last, to overcoming one of our way, at last, to overcoming one of mankind's oldest psychological and social problems.
COPYRIGHT 1985 Sussex Publishers, Inc.
COPYRIGHT 2004 Gale Group
|
|
