Kansas Nurse: Compulsive gambling: A Women's health risk

Women, and older women in particular, can find themselves at risk for developing problems associated with gambling. Despite the male stereotype, a 1995 Yankelovich poll revealed that women make up 55% of all gamblers. Several factors contribute to vulnerability to this type of addiction. Some are uniquely related, like needing more money, the fantasy of winning enough to live a dream life and attempting to win back money already lost. Others are loneliness, boredom, and personality and cognitive styles that harmonize with gambling behavior. These same conditions can challenge the elderly, and it is therefore not surprising that increasing numbers of women are drawn to gambling as a compelling but ineffective coping mechanism. The elderly as a group are disproportionately female and as Baby Boomers mature, the number of older women with Compulsive Gambling addiction will increase.

Gambling is defined here as betting money on the outcome of a future event that will be determined by chance or "skill." It need not involve large sums of money or money at all, according to some. Buying lottery tickets; playing slot machines and bingo; and buying a ticket to a quilt raffle are all gambling activities. In themselves they are benign pastimes. It is when gambling creates increasingly severe problems that escalate to crisis proportions that diagnosis and intervention are required. Compulsive gambling is a syndrome occurring along a continuum similar to other addictions that ranges from Problem Gambling (mild) to Pathologic Gambling (severe). Problem Gambling is any gambling behavior that results in serious disruption in a major life area, for example personal relationships, financial integrity, vocational status or psychological equilibrium. Betting does not need to occur daily to be a problem since gambling binges, separated by periods of irritability and psychic discomfort, are also a common pattern. Compulsive Gambling as a "progressive addiction characterized by increasing preoccupation with gambling, a need to bet more money more frequently, restlessness or irritability when attempting to stop" and "loss of control manifested by continuation of the gambling behavior in spite of mounting, serious negative consequences," (National Council on Pathological Gambling [NCPG] Website, 2000). Pathological Gambling, where seriously maladaptive gambling behavior causes a cluster of specific symptoms and is not caused by mania, is a psychiatric illness described in the DSM-IV (American Psychiatric Association, 1994).

A pattern of specific stages has been identified in the development of Compulsive or Pathological Gambling; Winning, Losing and Desperation. Gamblers are optimistic in the Winning stage, betting increasing amounts more often. They frequently experience a big win, one comparable to their annual salary. Women gamblers, however, may not truly experience this beginning stage because their level of betting usually does not yield an extremely large win. The Losing stage features continuing losses, often because gamblers have become overconfident, reckless and impulsive. This can last for years, often prolonged by borrowing, deception and even illegal behaviors like forgery and fraud. The Desperation stage often begins with a big "buy out" loan that rescues the gambler from debt. With the easing of her anxiety, the gambler can start to feel lucky again and wager until she "hits bottom." Suicide attempts often follow the disintegration of the gambler's life.

Depression and alcoholism are common co-morbid conditions. Gamblers experience both major episodes of depression and periodic depressive states more frequently than do non-addicted women. Antisocial and manipulative tendencies can be observed in the behavior of compulsive gamblers, often serving to hide gambling involvement. As with other patterns of addiction, the use of denial as a defense mechanism is deeply entwined in the effort to gratify the compulsion to wager without interference. Gamers deny that there is a problem at all, and often develop elaborate strategies to avoid discovery, postpone inevitable consequences and continue wagering.

The repetitive nature of some forms of gambling, e.g., slot machines, may serve emotional defense purposes. Gamblers describe becoming completely preoccupied with depositing coins and making the tumblers role. As a defense against anxiety, this type of gambling is obviously effective in supporting the gamers' compulsive defenses. The casino environment itself is reassuring to many people: It is (superficially) a safe place and everyone wants to be there. Mundane worries and concerns fade into the background and the bright lights and happy music no doubt help the gambler leave her problems at the door. In contrast to men who tend to be thrill seekers, women tend to gamble to escape from their problems (NCPG, 2000). Further, gaming activities provide structure and fill time, so how could anyone be bored? There are no clocks, so a sense of timelessness prevails. The elder is never late, never early, and best of all she can forget that she has nowhere else to go.

Many compulsive gamblers display classic symptoms of a narcissistic personality organization, including an attitude of superiority and feelings of entitlement. The perks casinos provide like free drinks and lodging are gratifying reinforcements for these attitudes. A stronger than normal propensity for risk-taking has been noted as a personality characteristic of many problem gamblers. Research demonstrates a tendency toward emotional thinking, in contrast with realistic thinking (Pacini & Epstein, 1999). This is consistent with data that indicates problem gamblers often have an unrealistic beliefs about their ability to influence future events, for example which number will be called next in bingo. They feel exempt from universal mathematical laws, wagering even while acknowledging that the odds are in the casinos' favor (Cusack & DePry, 1993). Another type of unrealistic cognition is superstitious, magical thinking concerning "lucky" behaviors, tokens, and rituals. One study of elderly women found that, while women can be found wagering at all of the available games, they do tend to gravitate toward bingo, slot and video poker machines and lottery gambling. These jackpot games are more anonymous and emphasize luck over skill (Cusack & DePry, 1993). Whatever the compulsive gambling activity, many describe feeling a temporary "high" when wagering, and state that gambling is their only way to achieve such a wonderful sense of euphoria.

Addictive behaviors are under-recognized in older age groups, and problems with gambling are especially likely to be hidden. (Glazer, 1998). Elders often use easily found, socially encouraged betting activities like scratching lottery tickets and numbers sweepstakes. In addition, gambling may appear to be a social outlet such as when buses are sent to bring groups of retirement home residents to casinos. The social benefits are illusory since the main activity is sitting in a large room and confronting a slot machine: There are other people there, but there is minimal interpersonal interaction. Some gamblers who cannot engage other people in relationships may appreciate this, and seek relief from their loneliness by simply being around others.

In addition to boredom and loneliness, financial coaerns are common for older women. While the amount of their monthly pension stays the same, the prices of food, rent and medicine keep climbing. State lotteries and casinos have professional marketing campaigns that implicitly promise a "big win" to those who play. It is understandable when elders embrace the hope that, if they buy one more scratch-off ticket, they will win the jackpot and all their worries will be over. Of course it is more likely that the elder will lose that bet: Compounding the disappointment, her financial situation is that much worse. A compulsive gambler is convinced the only option is to bet again, a symptomatic behavior called "chasing a loss" (Cusack & DePry, 1993).

Financial ruin can result from attempting to "hit the jackpot," and then trying to win back money lost. After a binge, a woman may have nothing left to live on. Older gamblers often hide losses from their families and so are hesitant to ask fir help even for subsistence expenses. Women feel they should take care of their children, and not the other way around. Compulsive Gambling can lead to neglecting important family and work obligations. Gamblers have been known to spend the family's life savings, secretly obtain mortgages, usurious loans, and to jeopardize retirement funds. As devastating as gambling debt can be, the embarrassment, shame and shattered self-esteem are often worse consequences. Even though Compulsive Gambling with its uncontrolled wagering seems like a financial problem, it is in fact an emotional problem.

Recognizing Gambling Addiction

Nurses are often the first health care providers encountered by clients troubled by problem gambling (Ebert, 1999). Nurses can make use of the various surveys available to help identify clients with gambling problems. Questionnaire items include "Have you ever gambled to escape worry and trouble?" and/or "Have you had the urge to celebrate good fortune with a few hours of gambling?" (See Table 1) The South Oaks Gambling Screen is useful for more thorough evaluations (Unwin, Davis & DeLeeuw, 2000). When people demonstrate the factors described earlier, especially in combination and when denial is present, a structured assessment of their gambling patterns is indicated.

Intervention

Gambler's Anonymous (GA) often helps motivate people to stop wagering. It offers a 12-step program modeled closely on other addiction treatment models and can be started on an inpatient or outpatient basis. Compulsive gambling and its destructive effects can lead to depression and suicidal tendencies severe enough to require hospitalization. Most insist that abstinence, i.e., no gambling, is required for a return to maximum well being, but there is some disagreement with this GA principle. All recognize that clients must,see gambling as a serious problem and be disposed to gain complete control over it and other associated activities. Intervention can be successful, but clients' denial and continued wagering despite abstinence contracts make the therapeutic work challenging. The thrill of gambling may be stronger than their motivation to avoid its consequences. The local telephone number for GA is 1.816.346.9230.

It is important address the issues that contribute to elder women's vulnerability to gambling problems: It is not enough to insist they wagering. Arranging regular social outlets for small groups helps conteract loneliness. Providing a clear, easily accomplished focus like manageable exercises, volunteer sorting, mailing and crafts helps make the gourps accepable to socially challenged elders whho nonetheless need human contact. Reminiscence activities are helpful for a variety of reasons, including the mastery of developmental tasks. Group dining like congregate meals, read-to and movie groups are other options.

Another advantage of scheduled outlets is that social contact can help prevent boredom and add some purpose to an otherwise unstructured day. Elders often complain of a lack of purpose in life or of not being needed. Volunteer activities are well suited to the needs of many, espcially since women have traditionally been comfortable in a caretaker/giver role. Performing even simple tasks for another offers rewards far beyond the work involved. Some shared projects like canning and quilting provide social interaction with a tangible reward. If the client seems to favor compulsive defenses as coping strategies, then building in detailed or repetitive actions can make outlets optimally beneficial. An ideal combination is an activity that takes enough concentration to be truly distracting but that does not overwhelm the elder. It may take a little effort to find a compatible group and activity, but the benefits to self-esteem and daily emotional functioning are well worth it.

While the choice of Compulsive Gambling as a coping strategy mainly results from unfulfilled emotional needs, practical attention should also be paid to the financial component. Programs may be available that could ease their financial burdens. Heartland Shares, for example, makes food available on a monthly basis, and people receive much more for the low fee than they could purchase in a store. Another option is the Schick Program that helps reduce the amount spent for certain medications. Communities have various services that could help substantially, for example harvest-- sharing systems and donated maintenance and yardwork programs. Women whose needs are partially met by gaming are at risk for Compulsive Gambling, especially when more adaptive coping is preempted by gambling behavior. People tend to react more judgmental toward women with gambling problems, whereas they tend to dismiss men's gambling as a minor "boys will be boys" lapse. Gam-Anon, an organization modeled after Al-Anon, can be helpful to family and friends of people affected by problem gambling; their telephone number is 1.213.386.8789.

Problem gambling can pose a significant risk to women's health. Kansas casinos took in $85-$175 million dollars profit in 1998, highlighting how much people lose when gambling (The Associated Press, 2000). By recognizing predisposing factors and onset of addicted behavior, and intervening to meet needs in a more realistic way, nurses can help female clients maintain healthy coping and a sense of well-being.

References

American Psychiatric Association. (1994). Diagnostic and

Statistical Manual of Mental Disorders, (4th Ed.) (DSM IV. Washington, D.C.:Author.

Cusack,J.R. & DePry, D.L. (1993). Insights about pathological Gamblers. Postgraduate Medicine, 93(5).169-177.

Eber, G. (1999). When gambling becomes a losing battle. American Journal of Nursing, 99(5).22.

Glazer, A (1998). Pathologic gambling. The Nurse Practitioner. 23 (9) 74-82.

Meintz, S. & Larson, C. (1994). Can you spot this kind of addiction? RN,57(7).42-44.

National Council on Problem Gambling, Inc. (2000). (2000, Aug. 30).

National Council on Problem Gambling, Inc. (2000). Women and their gambling: A problem gamblers helpline publication. Washington, D.C.: Author.

Pacini, R. and Epstein, S, (1999). The relation of rational and experiential information processing styles to personality, basic beliefs, and the ration-bias phenomenon. Journal of Personality and Social Psychology 76(6). 972-987.

The Associated Press. (2000). (2000,Aug.30).

Unwin, B.K, Davis, M.K. and DeLeeuw, J.B. (2000). Pathologic gambling. American Family Physician, 61(3). 7411-748.

About the Author

Annette Millius, MA, ARNP, is an Instructor of gerontology and research with Baker University School of Nursing. She won the 1987 AJN/KSNA Writing Award for the article "Nursing Care of the PMS Client." She is a member of District 1.