Self-Medication

1. Self-Medication • Today’s agenda • House Keeping • Self-Medication, Trauma, and the Female Gambler 1

2. Self-Medication • Drugs push aside suffering • How should we be able to forget those ancient myths... about dragons that at the last minute turn into princesses who are only waiting to see us once and beautiful and brave?... [P]erhaps everything terrible is in its deepest being something helpless that wants help. • Rainer Maria Rilke

3. Hurt: Cash Covering Nine inch Nails...

4. Nicotine’s the World’s Antidepressant • 5 million premature deaths associated with tobacco use in 2000 • It is estimated that between 2025 to 2050 there will be 300 million tobacco deaths • Why do we use it? Is it self-medication?

5. Effects on the brain • Dopamine, GABA, MAO • DiFranza (2008) suggests that it may only take a month to become hooked

6. Nicotine and Canadians • 45,000 Canadians die each year from smoking related deaths each year • For long-time smokers, the chance of dying from a smoking-related cause is 50% • Smoking is the single most preventable cause of cancer (Lung Cancer Canada, 2008) • Check this out

7. Gender Differences in Alcohol Use • Men have higher lifetimes rates of alcohol disorders • However, women appear to surpass men in alcohol related problems, such as • Deaths from suicide • Alcohol related accidents • Heart disease and stroke • Cirrhosis of liver

9. Post-traumatic Stress Disorder & Self-Medication • Early research centred trauma and PTSD as an effect of war, civil war - “soldiers heart”; world wars - shell shock • Today in the aftermath of 911 and closer to home residential school aftermath, trauma and PTSD is becoming more recognized • We have now beginning to challenge the etiological diagnosis where the traumatic event is thought to be “outside” the normal range of experience - to realize that rape, battery, sexual and domestic abuse, are so common that they can “hardly be outside” the range of normal experience

10. The Heart of PTSD and Trauma • According to Herman (1997) - Intense emotional reaction to an event - panic, terror, grief or disgust • According to National Center for PTSD (2007) those most likely to develop PSTD • DIRECTLY EXPOSED • SERIOUSLY INJURED IN THE EVENT • LONG LASTING AND SEVERE • BELIEVED LIFE IN DANGER • BELIEVED FAMILY MEMBER WAS IN DANGER • SEVERE REACTION DURING EVENT • FELT HELPLESS FOR ONESELF OR FAMILY MEMBER • HAD EARLIER LIFE THREATENING EVENT • DRANK ALCOHOL IN EXCESS • RECENT UNEXPECTED LOSS

11. Reign over Me: A Trauma Example

12. PTSD SYMPTOMS • PTSD begins can begin intensely and can wane, and wax, and wane. • Psychological symptoms include • Re-experiencing(flashbacks, nightmares, intrusive memories) • Emotional Numbing(feeling detached, lack of emotions, loss of interests • Avoidance(activities, people, or places that are reminders of trauma) • Increase arousal(difficulty sleeping, irritability, hyper-vigilance, exaggerated startle response)

13. Psychological outcomes can include the following: • Depression, major or pervasive • Anxiety disorders, phobias, panic, and social anxiety • Conduct disorders • Dissociation • Eating disorders

14. Psychosocial manifestations • Alcohol and substance abuse • Suicide attempts • Risky sexual behaviours • Self-injury • Interpersonal problems

15. PTSD and Substance Abuse • Kimmerling et al. (2004) report that approximately 30% to 50% of men and 25% to 30% of women with lifetime PTSD are also substance abusers • Those with SUD and PTSD have poorer substance abuse outcomes (Brown, 2000) • Meanwhile those with PTSD relaspe more quickly, drink more on days when they drink, have greater % of heave drinking days and more consequences due to non-PTSD substance abusers (Brown, 2000) • Women are more likely to develop addictions after exposure to traumatic event and symptoms of PTSD, with approximately 65% to 84% of women experiencing PTSD before developing addictive dependencies (Milkman & Sunderwirth, 2008) • Meanwhile, men appear to develop PTSD symptomology during their addictive careers (Kimmerling et al. 2004)

16. Trauma, its Role and Trajectory in the Development of Female Pathological Gambling An Interpretative Phenomenological Analysis • It takes two to speak the truth. One to speak, and another to hear - Thoreau

17. Setting the Context • There is a paucity of research that addresses the connection between trauma and female pathological gambling (Boughton & Brewster, 2002). • However, research has revealed that a large percentage of individuals with mental health problems report having experienced a traumatic event (Larkin & Morrison, 2006). • Women in particular, are at a greater risk of being exposed to trauma that sometimes occurs in close relationships (Wolfe & Kimerling, 1997) (i.e., incest, marital and date rape, and intimate partner violence). • Then again, it is not known whether pathological gambling development and its progression can be related to the latter kinds of traumas.

18. Previous Research • Based on a Canadian study involvingboth males and females living in 22 families, Grant Kalischuk and Cardwell (2004) developed a grounded theory that situated trauma as being a factor implicated in problem gambling for both males and females. • Afifi, Brownridge, MacMillan & Sareen (2010) sought to understand the relationship between problematic gambling and family violence. Results from their study suggested problem gambling may be directly associated with dating violence, marital violence and child abuse. • In a sample of 111 pathological gamblers, Kausch, Rugle, and Rowland (2006) identified a relationship between gambling and trauma, however the role that trauma played in development of these 111 pathological gamblers was not determined. With respect to gender, the sample was comprised of only 9 female participants and yet all 9 reported emotional, physical or sexual abuse or multiple abuses.

19. Previous Research (contd) • In a more representative sample, Petry and Steinberg (2005) studied childhood maltreatment in male and female treatment-seeking pathological gamblers, recruiting participants from seven treatment sites (N= 149; 77 females and 72 males). • The authors found that gender was specific to the intensity and types of childhood maltreatment experienced. It was revealed that female gamblers had higher scores related to sexual/emotional abuse and physical neglect. • An important consideration pointed out by the authors was that the study “did not address whether childhood maltreatment leads to pathological gambling” (Petry & Steinberg, 2005, p. 228).

20. What we know about Trauma and Gender! • Among survivors of abuse, research has consistently documented increased rates of psychiatric disorders (Kessler, Sonnega, Bromet, Hughes & Nelson, 1995). • According to Strachan and Custer (1989) and Lesieur and Blume (1991) as well as others, gambling has been categorized as a means for dealing with trauma and trauma-related abuse (via escape), especially among females. • Half of Canadian women (51%) have experienced at least one incident of physical or sexual violence since the age of 16 (Statistics Canada, 2006). Moreover, the World Health Organization (WHO, 2006) have recognized that gender is a well known determinant in a variety of health-related problems and that differences exist between male and female treatment utilization, substance use, and mental health-related symptoms and diagnoses.

21. Linking Trauma to Women Gamblers • Interestingly, among 365 females gamblers from across the province in Ontario, Boughton and Brewster (2002) found that 46% of women reported experiencing physical abuse as adults and 28% reported experiencing sexual abuse as an adult, while another 30% of married participants reported current physical abuse in their relationships. • However, despite determining that gambling was a means by which the individual was able to escape from life stressors, the mechanism by which trauma played a role in the development of problem gambling continues to remain under-investigated (Boughton & Brewster, 2002).

22. Today’s Presentation • This presentation will focus on essences drawn from a phenomenological interpretative investigation of 6 women (taken from a larger grounded theory study of 40 women) (Kalischuk, Nixon, Hagen, & Solowoniuk, in press) who self-reported having a traumatic history and whose scores on the NORC DSM-IV gambling screen indicated a severe problem with gambling.

23. Method: Interpretative Phenomenology (IPA) • IPA endeavours to provide a descriptive account of a participant’s world that is both critical and conceptual leading to a life text that supports participant claims and feelings about a lived experience (Smith, 1996). • What makes IPA unique from other qualitative methods is its position on constructing an interpretation derived from investigated experiences (Larkin, Watts, & Clifton, 2006). • Tappan (1997) asserts that “an interpreter understands by constant reference to her own perspective, which shapes her understanding of the world based on her expectations, preconceptions, biases, and assumptions that rest fundamentally on her lifestyle, life experiences, culture, and tradition. • Thus, IPA is collaborative research approach that requires the researcher to share meanings and understandings with one’s participants toward generating an “insider’s perspective” (Larkin, Watts, & Clifton, 2006).

25. PARTICIPANT PROFILES

26. Interview Procedure • The interview procedure began by restating and answering participants questions related to the purpose and goals for the study. Afterwards empathic listening and paraphrasing were employed by the interviewer to help participants feel safe and comfortable in sharing intimate stories of how trauma and experiences of a traumatic nature associate with the development of a gambling problem. • While the interview process was unstructured, the interviewer probed and prompted his participants to sit inside their experiences of gambling and trauma (Solowoniuk & Nixon, 2009). • This appeared to help amplify interpretations of experiencing and together the interviewer and interviewee expanded their understanding of how trauma affects personhood and how this then influenced the origin, progression, and complete loss of control of one’s gambling behaviours.

27. Theme Construction • Theme construction involved five processes (van Kaam, 1966; Solowoniuk, 2009). • Hypothetical grouping • Condensation • Elimination • Reconstructing • Final deconstruction

28. Terms and Terminology • Using Object-Relations theory to define the Ego,the authors refer to theorist Frank Summers (2002), who states that ego is, “the part of the psyche charged with the responsibility of mastering competing pressures while maintaining the functional capacity of our organism” (p. 235). Object-relations theory states that human beings experience essentially two births; a physical and a psychological (Almaas, 1988; Mahler, Pine, & Bergman, 1975). • The implication here is that there is no inherent, separate sense of self from birth, it is constructed through, in part, by our early experiences with our caregivers; fashioning a blue print for relationships later on in life. • Thus, if a child does not have a nurturing environment that is essentially, “good enough,” the ego does not develop normally; and in turn psychological pathology can result (Summers, 2002). The latter point here is important to keep in mind as all of our participants grew up in conditions that seem to have impinged ego development through early childhood trauma.

29. Interpretative Analysis • Theme 1: Early Life Trauma and the Not Good Enough Self • Effect of trauma in earlychildhood created a visceral state of being. • Predominated by feeling of anxiousness, loneliness and emptiness, or “loss of being”. • The developing sense of self (ego) appeared to be bitterly cut off from its own ground of being (Almaas, 1988, 1997). • Dampening of affect.

30. Lizzy Stated: • I started hanging out with older guys in the pool hall, and kind of wanting attention all the time and my Dad had a real reaction to that. He thought I should be a good girl, instead of a bad girl… So I guess that’s why he only beat me... Only me... And then their was, well my Mom and Dad didn’t like each other either... My mom was a nasty drunk... I always looked for a time when they were happy together, you kind of seek that, I mean when you know your parents have some kind of harmony or connection. I mean what other reference point do you have when you’re a kid. • Mirroring from parents is natural, but not receiving it was a predominant experience shared by our participants (we then seek is elsewhere). • By the age of 12, Lizzy tried to pacify herself through substance use and years later by binge gambling.

31. Matty speaks about: Emptiness • I don’t think it ever goes away honestly, to tell you the truth. The emptiness. It’s like, you’re dying – it’s like a continuation of that over and over and over again… Because you’re on that train and you’re going so fast that if you jump you’re gonna die anyway. Well, you don’t really want to die. You just want those parts of your life to stop. It’s like somebody standing there with the light flickering on and off. So what do you do? You end up going to a corner; you learn how to block it out, right? • Corner and space is >>> Gaming Venue. • It appeared that emptiness could be blocked out or denied, but not forever. • Emptiness was altered somewhat effectively by moments of psychic inflation (charge of energy) that fills up the holes in one’s being via a win and admiration during gambling.

32. Theme 2: Not So Innocent Beginning’s • The experience of trauma – whether in childhood or later in life – for all of the participants seems to have left them in-the-world already searching for something to soothe trauma’s numbing effects on the psyche/self. • Left raw and empty from past trauma, it may interpreted that all participants were already primed for an addiction. • Thus, no matter how innocent the beginnings may seem, it appeared that our participants compulsions lay dormant. • Some participants experienced addictions and behavioural compulsions years before the development of pathological gambling.

33. Eve’s First Time in • …I got introduced to Vegas. And of course my interest was not in Vegas, because my brother had a time share thing there. It was pure innocence because his son couldn’t make it – oh yeah I’ll join you! Well that was my first exposure. When I got there it was like, glitz! And I thought, is this me? I’m looking around, sweating it out there. Looking at the strip. And of course you throw in a few coins and of course, ding, ding, ding and outcome the quarters...I enjoyed it, I had fun…nothing happened, it was okay.

34. Sum of Not So Innocent Beginning’s • Beginner’s luck, winning and enticement • Downplaying “effect of affect” • Begin to learn how gambling can be an escape

35. Seduction & IntoxicationTheme 3: Seduction and Intoxication [My family] would drop me off at one of the casino’s and go shopping and not come for five or six hours. It was fascinating…cause when you did win, it would come out, and you put it right back as well. And the first day we were down there and they dropped me off about four o-clock and they didn’t pick me up until midnight. And I just had pots and pots of money but I didn’t want to cash them in, I wanted to take them back to the hotel (Barb). • “The high or rush associated with the game and the gambler is well documented across all cultures throughout history. Lady Luck with her spinning wheel of fortune beckons (Currie, 2007, p. 17).” • The Archetype is loosely defined as a representation of powerful psychic energy organized around basic forms and pathways that are enacted through human behaviour that appear to have been ever present in various forms in all cultures (Jung, 1971).

36. Seduction Summation • Seductive nature of gambling and its phenomenal affects both sooth (sense of emptiness) while heightening gambling experience(s). • For some participants accumulation of stressors added to the drive to gamble more. • There is a progression financially and psychologically. • I found something that “feels right”.... “I feel right”

37. Theme 4: Opening the Doorway to Oblivion • Oblivion - “A state of forgetting”? • Participant’s existence could be said to be tied up in an eternity of forgetting about the past and future... • Paradox here... • Yet there would appear to be a very cognizant pursuit to get the stuff to continue to gamble or • Secure “time” necessary to gamble wantonly... Thus is it really about escape!

38. Oblivious Accounts • Liz reported... “It’s all about changing the way you feel, it’s all about not wanting to deal with things that are painful. I think to me, that has been my experience.” • Matty remarked... “Pawning… I lost every single one of my rings. It wasn’t 24 hours but I mean, I’d go to work right? I mean, as soon as we got paid we wouldn’t even go home after. It got to the point where we just went straight from work to the bank to the bar and yeah [Laughter]. And I would be dipping into the rum and coke and he’d be drinking his beer. And then we’d be like, okay! And at that point in time, too, you gotta remember, those vlts – ummm – you had to wait for them. Because everybody would be on them at that time. So we’d be bouncing all over the place. It was almost like a panic if we didn’t get on a machine”. • Barb reiterates... “I started going for an hour after work, and then it got, then I couldn’t get the work done fast enough to get back to the casino to gamble. I played for twelve hours straight. Because by this time I had let bills go, and I was kind of trying to gain the money, I hid the bills as they came in and when [my husband] wasn’t around, and then he started ignoring me. [Feelings]?... Well, I didn’t care. I just wanted to get back to the machines. It was like easy money”.

39. A Sanctuarious Space • Fecundity of the case (Gadmer, 1975) • Arising from Oblivion.... • We are not talking about the classic escape gambler! • We are talking about direct impingement upon the psyche from a traumatic or traumatic events.

40. Sanctuarious narratives... • It seemed the less absorbed you were with it [grieving], that your generally up winning, I can’t remember trying to win. It always just seemed like it was a place I could go and hide from the world, and I didn’t have to do anything or talk to anybody.... It was a space for me to just be... (Kathy). • Kathy was able to contain psychic energies within herself and the pain she was feeling... • A return to the wellspring of Being? • I could comprehend more and feel more of what was happening and accept that fact that my husband wasn’t there and he wasn’t coming back [Alzheimer’s disease] and he wasn’t getting better and people kept on telling me you have to go on with your life and you have to stay healthy for him, and it just automatically starts to heal. I don’t know what the hell I would have done to fill those hours; I don’t know if I would have gotten really mentally ill.

41. Theme 5: Trauma and Ties that Bind Us • Exposure to trauma and its effects are unique to each individual and its repercussions can be felt in all areas of life, i.e. (emotionally, mentally, physically, socially, and spiritually) (Levine, 2005). • Trauma arising from childhood and adulthood (especially within families) echoed from the past thru to our participants relationships in the present. • When support was needed during gambling addiction - their was a difficulty in our participants asking for help or in trusting oneself or others. • Frozen in time - both the body of trauma and the (personal) relationships that are connected to them (Levine, 2005).

42. Trauma Bonds and Unfinished Business • Martha provides an illumination of this phenomenon: “When I...do win, especially big...and people are coming to me, trying to borrow and all that...I felt big. And I thought, well at least I’m somebody today because I’ve got money.” • Chase ideals, both socially via relationship and financially; both of which are not born from our own being. • Matty sadly remarked: …Through the abuse that I’ve gone through, I would say that yeah, I have a very addictive personality. I can cling onto things pretty quick…and… the really good people that I run into, I throw them as far away as I possibly can; because I’m going to end up being the one hurting them. They’re not going to hurt me or maybe I subconsciously think that they will hurt me; because their lives are too perfect – and I’m kinda not in that category of perfect.

43. Resurfacing • I went to my pastor and we went through six sessions with him, and he told me that the only way that I would get that out of my system [sexual abuse] is to forgive. You know it went on for five years. I’d try to block it out and then it would come back, I would block it out and it would come back. Then a lot of times when my Dad was still alive him and my Mom would come to visit it just about drove me drinking…And I hated my Dad, but I mean I done it for my mom. My mother is still in denial that my father abused me and my sister and we just put that behind us (Barb). • Traumatic memories or associations appeared to resurface for our participants • And once gambling becomes a learned panacea... It makes is easy to want to regulate feelings of not being okay • Resurfacing coincided with relaspe(s) and gambling binges • Barb concludes Ties that Bind Us, stating: • “Well I hated him and I think it was there for a long, long time and I had to get away from that hate. Because it was a bad feeling. And it wasn’t right to hate my dad. It wasn’t right for me.”

44. Theme 6: What Trauma Does: Introspection into Access • Participants report that trauma freezes their capacity to “feel” and it appeared that it also arrested ego development • Creates feelings of inadequacy • Overt need for mirroring • Push into the unconscious (I acknowledge / I don’t ) • Shame bonding • Trauma and gambling become intertwined Loss of Being

45. Trauma and its link to Gambling • Deep down I think I do [equate early childhood losses to gambling]; because they didn’t see me go through all my tribulations and the graduation, all the highlights that would have been in my life. Yeah, they died too young [parents]. In a way, even though they were really strict and that, you still have a loss of being… And then something triggers it [her gambling]…I kind of try to figure it out myself, too, because I’ve gone to a psychologist. I’ve gone to the mental health – they said, geez, you seem to be pretty even-keeled. You’re outgoing, you’re this and that. But I said, but there’s something underlying it. You know, there’s something deeper. And I haven’t got to that deep part (Eve). • For participants, first their was trauma and then gambling acted, “Like a camouflage. It wasn’t really...an answer. Yeah, it wasn’t an answer but yet I still went to it. Because it didn’t talk back. It was one on one.” • But Eve’s mind would come back to gambling again and again trying to find one. • Such a phenomena was first delineated by Freud (1938) - the classic corrective emotional experience.

46. Gambling, Trauma, and the Need To Be Seen. • Wounding in childhood or wounds in adulthood compounded the feeling of “not okay-ness”. • Hence, as stated previous, participants reported feeling not good enough, frozen, and emotionally cut-off, it is no wonder then that winning and receiving admiration fuels a continued desire to play. • My other part of our life was rejected, because I couldn’t, I didn’t feel like a wife anymore it was. When you win at the machine and everybody comes around and you are very special and everybody’s looking at you and saying hey, you won! Good for you!

47. Theme 7: Gambling Becomes Trauma • The gambler becomes like Sisyphus rolling the boulder up the hill... (were our participants happy playing again and again). • Jungian analyst and author Linda Schierese Leonard (1989) parallels mythic literature and provokes a deep question about the experience of addiction: • Is addiction, then, the act of giving oneself over to something as one’s master – be it a substance, object, person, or activity – so totally that one’s entire being becomes possessed by it?

49. Conclusions: Trauma and Gambling • Trauma in early childhood impinges ego development • Creating deep rooted feeling of “not good enough” (visceral) • Creates hunger and drive need to be seen • Cuts us off from essence / vitality (emotional body) • Prone to periods of emptiness throughout life • Trauma lies in wait • Gambling • I can feel or I learn how to escape (mood regulator) • I can be seen / or disappear • I can be important • Cycle of gambling trigger’s and reinforces old feelings of not good enough • Gambling becomes traumatic Primer for Addiction

50. Recovery From Trauma • According to Herman (1997) recovery from traumatic events unfold in three : • Establishing Safety • Remembrance and mourning • Reconnection with ordinary life