Chapter 15: Addictive Disorder: Gambling

1. Chapter 15: Addictive Disorder: Gambling Unit 4 – AOS 2 Mental Health Pages 731-773

2. Study Design Content • application of a biopsychosocial framework to understanding ONE of the following types of mental disorder and its management: Addictive disorder: gambling – biological contributing factors: role of the dopamine reward system and as a target for treatment – psychological contributing factors: social learning theory and schedules of reinforcement; the use of psychotherapies in treatment including cognitive behavioural and psychodynamic therapies – socio-cultural contributing factors: social permission of gambling opportunities; management including social network and recovery groups – the interaction between biological, psychological and socio-cultural factors which contribute to an understanding of the disorder and its management

3. Addiction • Addiction is commonly used to refer to any condition in which an individual feels a recurring urge to use a specific type of substance or engage in a specific activity, despite potentially harmful consequences • Addiction is commonly associated with impaired self-control and mental preoccupation

4. Characteristics of Addiction • Griffiths (2006) has proposed that all addictions have six distinctive characteristics in addition to impaired self-control • Salience refers to the high level of importance of the activity in a persons life – typically the activity dominates the persons thinking, feelings and behaviour • Mood modification refers to the change in subjective experiences that people with an addiction report as a consequence of engaging in that activity • Tolerance refers to decreased sensitivity to the activity over time, whereby increased amounts of the particular activity are required to achieve the original desired effects

5. Characteristics of Addiction • Withdrawal refers to the unpleasant psychological and/or physical reactions that occur when the particular activity is reduced or removed • Conflict refers to disagreements, clashes and other problems experienced by the person with the addiction that arise as a consequence of the addiction\ • Relapse refers to the recurrence of earlier patterns of the activity after a period of abstinence or control

6. Gambling • Gambling is any activity where money or something of value, is put at risk on an event where the outcome is uncertain that relies, in part or entirely, on chance • The activity may be legal or illegal but the outcome is unknown and the gambler is usually risking something of value • Continuous forms of gambling are those in which the time between betting and knowing the outcome is short – this permits instant gratification • Pokie machines, horse racing, casino betting • Non-continuous forms of gambling are those where the time between wagering and the outcome is long – with delayed gratification • Tattslotto, Powerball

7. Gambling as an Addiction • For many Australians, most forms of gambling are a source of recreation and pleasurable social activity– participation in gambling can provide time away from the pressures of work, a temporary escape of boredom, fun, excitement, a chance to win money etc. • For a number of people though, gambling stops being pleasurable and becomes a serious problem that causes harm to themselves and/or to those around you such as friends or family • When gambling starts to consume more money and time than the person can afford, it can affect many part’s of the individuals life

8. Problem Gambling • Problem gambling is classified by difficulties in limiting money and/or time spent gambling, which leads to adverse consequences for the gambler, for others, or for the community – this is the preferred definition in Australia • The description ‘difficulties in limiting money and/or time spent gambling’ suggests a continuum of gambling behaviours by individuals who have no difficulty gambling to those who have extreme difficulty

10. Problem Gambling

11. Problem Gambling • The term pathological gambling disorder is used to describe problem gambling as a diagnosable mental disorder • According to the DSM, a pathological gambling disorder is characterised by persistent and recurrent gambling behaviour that disrupts personal, family and/or work-related relationships and activities • Gamblers Anonymous in Australia considers problem or pathological gambling to be an addiction • When considering treatment and management plans for an addictive gambling disorder, it is important to take into account the fact that many people who perceive their gambling as an addiction and seek help tend to prefer support that assists them to achieve abstinence while others may be more interested in controlling their gambling

12. Problem Gambling • Currently the DSM classifies pathological gambling disorder as a type of impulse control disorder • Impulse control is the psychological effort made to resist an urge, inner drive or temptation to do something that is potentially harmful to oneself or others

13. Pathological Gambling Disorder • In order to be diagnosed with pathological gambling disorder, according to the DSM-IV-TR, a person must experience at least 5 of the following ten symptoms • Preoccupation with gambling • Tolerance • Loss of control • Withdrawal • Escape • Chasing • Lying • Illegal activity • Risked relationships • Bailout

15. Biological Contributing Factors • The growth of the gambling industry has been accompanied by a large number of researchers seeking to explain biological factors that may underlie and contribute to a gambling addiction • Of particular interest to psychologists have been reports of people treated with dopamine medication for Parkinson’s disease who apparently developed a gambling addiction soon after treatment

16. Dopamine Reward System • The neurotransmitter dopamine is found in relatively few areas of the brain but appears to have a role in the development and maintenance of addictive gambling • Dopamine is a neurotransmitter that is believed to be involved in pleasure, motivation, emotional arousal and the control of voluntary movements • Higher levels of dopamine are usually associated with positive emotions and may therefore be involved in the experience of pleasure that accompanies positive reinforcement

17. Dopamine Reward System • Researchers have identified a pathway in the brain where dopamine is concentrated and which is involved in the experience of a distinct sense of pleasure • This neural pathway, called the dopamine reward system, may therefore be an underlying brain mechanism in learning processes and behaviours involving positive reinforcement through pleasurable or satisfying consequences • This system is located in the medial forebrain bundle which is a neural pathway that ascends from the midbrain through the hypothalamus into the nucleus accumbens

18. Dopamine Reward System • Studies in animals show that dopamine is released in the medial forebrain bundle when reward or pleasure is received, as well as in anticipation of receiving a reward • In addition to problem gambling, fMRI studies have shown that games of chance with monetary rewards are powerful activators of the dopamine reward system • Because the reward is never predictable, every instance of payoff results in a new burst of dopamine into the brain

19. Dopamine Reward System • Research evidence suggests that problem gambling may be partially attributed to excessive dopamine activity • Some of this evidence comes from research with individuals with Parkinson’s disease which is associated with a deficiency in dopamine in the brain • Treatment therefore aims to increase dopamine levels in the brain using medication known as dopamine agonists which stimulate the release of dopamine or mimic dopamine to produce its effects

20. Dopamine Reward System • One of the most common dopamine agonists used to treat Parkinson’s disease is known as L-dopa • Studies have been done where individuals with Parkinson’s disease who are taking dopamine agonists as treatment have developed a gambling addiction as well as addictions and urges to other things such as eating, drinking and spending money

21. Dopamine Reward System – Target for Treatment • Increasing evidence suggests that some medications can decrease the frequency of gambling behaviour – one medication that has been studied is naltrexone • Naltrexone has traditionally being used to treat alcohol dependence and addiction to heroin or other opioid drugs – it does not cause physical dependency and it can be stopped at any time without withdrawal symptoms • An antagonist such as naltrexone will inhibit activity of dopamine at the synapse which can result in decreased subjective feelings of pleasure

22. Dopamine Reward System – Target for Treatment • A study by Kim and Grant (2001) looked at the effectiveness of naltrexone in the treatment of participants with a gambling addiction • Of the 14 participants who participated in the study, all had effectiveness for the treatment of gambling disorders – the medication however is limited by its side effects such as nausea

23. Psychological Contributing Factors • Numerous psychological factors have been proposed as contributing to the development and maintenance of a gambling addiction • Two main types of explanations are based on learning theories and cognitive processes

24. Social Learning Theory • The social learning theory/observational learning is a combination of learning and cognitive processes used to explain the onset and/or maintenance of addictive gambling • Bandura had four condition for social learning to take place attention, retention, reproduction and motivation to perform the behaviour • A key variable that influences motivation to perform gambling is whether gambling behaviour is observed as being reinforced or punished • Researchers have demonstrated that the media portrays gambling by using vicarious reinforcement rather then vicarious punishment

25. Social Learning Theory • Real life models • These are people with whom we have contact with such as friends, family, teachers etc • Some parents expose children to gambling from an early age by ‘family days’ at horse-racing carnivals or children amusement facilities at some gaming establishments. • This creates the impression to children that gambling is a socially acceptable family activity • There is considerable research that shows if children are first exposed to gambling by their parents and it is seen to be socially acceptable this can lead to the development of problem gambling later in life

26. Social Learning Theory • Symbolic models • These types of models are presented to us in the media such as TV, movies and books • Research indicate the higher the status of the model the more the observer will imitate the behaviour. • Gambling providers spent large sums of money to encourage symbolic models to display their company. • Such as Shane Warne and ‘888.com’ or the AFL Brownlow Medal awards being held at Crown Casino. • There is clear interaction between social factors (being exposed to gambling) creating erroneous cognitive psychological thoughts about it. • Box.15.6 The influence of social learning on gambling behaviour, pg. 753

27. Schedules of Reinforcement • It is commonly known that a variable schedule of reinforcement promotes a steady response rate over a longer period of time and is much more resistant to extinction in comparison to a fixed schedule • Gambling and in particular poker machines are often described as using a variable ratio reinforcement (VR) schedule however they actually use a schedule known as random ratio (RR) (Haw, 2008)

28. Schedules of Reinforcement • If you had a variable ratio of 20 (VR20) that would mean that although unpredictable over a large number of correct responses say 100 would equal 20 payouts • This is not truly random as there is an upper limit on the maximum number of responses given before reinforcement occurs • In contrast in a random ratio schedule there is no predetermined upper limit before reinforcement is given • Each spin is completely independent of the next and it may take 100 0r 1 000 000 responses before the RR20 is achieved

29. Schedules of Reinforcement • A RR schedule of reinforcement leads the gambler to respond at high rates for relatively little reinforcement, and to persist in long periods of responding even when no payout is forthcoming • This is because the gambler thinks that each response brings them closer to a response that will be reinforced however this is false belief when the RR schedule is used

30. Treatment of Problem Gambling • Only a small people experiencing problems with gambling seek professional help • Research evidence also indicates that the reasons people with gambling problems do not seek professional help include feelings of shame, guilt, embarrassment and denial; a concern of social stigma; and the belief that they can resolve their gambling problems without professional help • Psychological treatment of problem gambling can take many forms– two treatment methods are cognitive behavioural therapy (CBT) and psychodynamic psychotherapy

31. Cognitive Behavioural Therapy (CBT) • Cognitive behavioural therapy (CBT) is a type of therapy that combines cognitive and behavioural therapies to help people overcome psychological problems and mental disorders • CBT is based on the assumption that the way people feel and behave is largely a product of the way they think • Therefore according to the principles of CBT, anyone can change the way they feel and behave by thinking about a situation in a more balanced and helpful way

32. Cognitive Behavioural Therapy (CBT) • CBT treatment aims to assist the individual to examine their thought processes and examine other alternatives when looking at their situation • Many gambling addicts have cognitive distortions with two of the most common being illusions of control and gambler’s fallacy • Illusions of control occurs when the gambler thinks they can beat the odds using their knowledge or skills • The gambler would attribute wins due to their personal actions and losses to factors outside their control • By using this thought process the gambler will be able to maintain their false belief that their gambling strategies are effective

33. CBT • Gambler’s fallacy refers to the belief that future events can be predicted by past events in a series of independent chance events • This is evident in coin tosses or ‘hot streaks’ • Most people with gambling problems are unaware that they have cognitive distortions • The first step of the cognitive component when using CBT is to obtain information of the individuals gambling patterns and distortions. This may involve role plays, diaries or simulations

34. CBT • The next step involves educating the person to develop an awareness of concepts such as probability, random and chance events • An important aspect of the cognitive component of CBT is to encourage the individual to directly challenge and correct their distorted thoughts and provide problem solving strategies to gain control over their impulses • The behavioural component of CBT assists the individual to manage the arousal, anxiety or tension that is associated with the urges to gamble • A common method of achieving this is using imaginal desensitisation. In this technique the gambler is asked to imagine being in a typical gambling situation while in a state of relaxation • The goal being to extinguish the arousal and gambling and replace it with relaxation

35. CBT • Imaginal desensitisation is a three step process • 1. constructing a CD that includes brief instructions for a progressive muscle relaxation technique as well as a number of very detailed gambling scenes • 2. learning the progressive muscle relaxation technique • 3. listening to the CD and imagining the gambling scenes they have recorded while at the same time applying the progressive muscle relaxation process

36. Psychodynamic Psychotherapy • Psychodynamic psychotherapy is based on the theories proposed by Freud and was widely used in treating people with problem gambling prior to the development of CBT • It is a type of psychological treatment that aims to help people understand the roots of emotional distress by exploring unconscious conflicts, motives, needs and defences • Based on Freud’s theory that all mental disorders are caused by unresolved psychological conflicts that occur in the unconscious with their origins being in early childhood • The aim of this treatment is to help people to understand the cause of the emotional distress which for problem gambling revolves around the Oedipal complex (Freud, 1928) • When using the psychodynamic approach the therapist will try to achieve abstinence from gambling which can be a lengthy process thus it is important that the client is an active participant

37. Psychodynamic Psychotherapy • When treating problem gambling therapists use a range of techniques such as free association, dream interpretation, identification of defence mechanisms and displays of transference • Free association is when the client is encouraged to say whatever comes to their minds in order to identify the themes involved in their gambling • Dream interpretation involves clients sharing their dreams as the psychodynamic perspective has the belief that dreams symbolically represent information stored in the unconscious mind

38. Psychodynamic Psychotherapy • Identification of defence mechanisms is essential for treatment to work as it prevents the unconscious conflicts from being explored and resolved. Denial and omnipotence are two common defence mechanisms that gamblers use • Denial is the refusal to believe whatever it is that may be causing ones anxiety or emotional conflict; omnipotence refers to the feeling of being ‘all powerful’ and is a direct defence against feelings of inadequacy and helplessness • Transference provides a valuable source of information by the client unconsciously responding to the therapist as though they significant person in their life • Limitation of this approach is it is hard to scientifically examine the unconscious and obtain empirical data

39. Socio-cultural Contributing Factors • Many psychologists believe that an important factor for problem gambling is that it is considered as acceptable within a socio-cultural context

40. Social Permissions of Gambling • Gambling is regarded by many Australians as part of their cultural heritage. Around in three in four Australians gamble at some time in the year • There is the Melbourne Cup, two-up during Anzac day and constant advertising that provides and reinforces a positive image of gambling in our society • Research indicates that when there is a perception that gambling is socially acceptable younger people are more likely to try gambling and less likely to associate negative consequences with it (Australian Psychological Society, 1997)

41. Support Factors • Support may be provided in other ways to assist people with a gambling disorder • Support can be provided through the individual’s social networks, as well as through recovery groups that may be accessed in the local and wider community

42. Social Networks • Social psychologists have define a social network in terms of the social structure that maps out the relationships between individuals • These relationships usually have some kind of significance or importance to the individual – immediate family, friends, colleagues • Another characteristic of the social network is that people within the network may also have some kind of connection with each other, as well as the individual

43. Social Networks • The main benefit of a social network is that it gives access to social support – help or assistance from other people during a recovery process, this can take different forms • Appraisal support – such as having access to someone with whom to talk and obtain feedback from • Tangible assistance – such as help with a bill payment or a meal • Information support – such as providing the website of a social network or a recovery group in the community • Emotional support – such as help in coping with problems experienced • A concern with social networks is that the network of someone with a gambling problem usually includes others with a gambling problem

44. Social Networks • This seems to be especially true for females who have gambling problems with pokie machines • This continued association with other problem gamblers may cause the cues that promote or initiate gambling to re-emerge • Gamblers are more likely to abstain from gambling when they associate with individuals who support their abstinence

45. Recovery Groups • A recovery group or support group is a not for profit group run by and for people who interact on the basis of common interests or experiences to support one another • One of the best known recovery groups for people experiencing problem gambling is Gamblers Anonymous (GA) • GA is based on the principles of peer support and the power of relating to people whose gambling has left them with feelings of emptiness, isolation, guilt and shame

46. Recovery Groups • GA sessions run for 90 minutes, there are no fees with the only requirement for membership being a desire to stop gambling • The initial process in recovery for the problem gambler is admitting they are powerless in controlling their gambling and surrendering to a ‘higher power’ • Another key feature of GA is having a sponsor who is a former problem gambler who has remained abstinent and can provide support and guidance through the recovery process

47. Recovery Groups • GA although social in its structure does use some psychological theories such as: • Positive reinforcement when the gambler is given rewards from not gambling for a period of time • Behavioural techniques that provide different social activities other then gambling • Cognitive approaches encourage problem gamblers to take one day at a time thus decisions are more likely to be rational and self-controlling (Grant, 2007) • Some of the limitations of GA is that: • It believes that abstinence is the only solution for problem gambling. There has been empirical research to show a reduced and responsible gambling behaviour for some people can be a realistic goal • GA is more likely to be effective when used in combination with psychological therapy. • Box 15.7 – Gamblers anonymous, pg. 767