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Pathological Gambling: Diagnosis & Treatment
Gambling continuing education counselor CEUs

Section 12
Gambling: The ‘Hidden Addiction’

CEU Question 12 | CEU Answer Booklet | Table of Contents | Gambling
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

Statistically, barely one per cent of the British population suffers a severe gambling problem. According to the only nationwide study on the subject Gambling behavior in Britain British gambling prevalence survey,Homeless Pathological Gambling Diagnosis psychology continuing ed 2000, the total was 300,000 people. But, as Gamcare (the charity set up to help problem gamblers) points out, if you multiply that figure by 13, you start to have a sense of the full impact on partners, relatives, friends and colleagues.

'Gambling is the hidden addiction,' says Adrian Scarfe, Clinical Practice Manager at Gamcare in south London. 'Mostly the Department of Health defines addiction as substance addiction, so other addictions like gambling, shopping and eating disorders don't get the same recognition.' He argues that because of this and because, in his view, the general public judges gambling problems as self-inflicted, the area is under-resourced, despite the fact that 'pathological gambling' is listed as an impulse-control disorder in the DSM-IV. He believes that more Rinds are needed to nurture better understanding and offer solid training in the field.  Gamcare, which began eight years ago, runs what it believes is the only national telephone helpline offering information, advice and counseling to gamblers, their families and also to healthcare professionals in the field. In 2004, it received almost 22,000 calls. The demands on it are dearly growing, but Adrian Scarfe maintains that its phone counselors must be immediately accessible to callers as these clients may well not be willing to call back. Phone counselors either offer regular appointments themselves or refer callers on for face-to-face work at its London Bridge offices. Here, counselors see 75 clients a week for a basic 12-session contract. For those living outside London, Gamcare has a project called 'Break Even' through which it refers to a network of partner addiction agencies throughout Great Britain. However, there are gaps in its geographical reach and, with little expertise in this field available via GP surgeries or even the professional counseling and psychotherapy bodies, the only option for many is regular contact by phone.

What can be done?
For those working at Gamcare, the stated aims of counseling may include: 1. stopping or reducing the frequency of a person's problem gambling; 2. helping them develop ways of coping with their behavior; 3. looking at some of the underlying reasons why gambling has become a problem for them; and 4. addressing issues like financial and health problems that may have become linked to gambling.

Gamcare speaks of helping people 'move towards a gambling-free lifestyle; But in the wider political and social context, the organization is not against the gambling industry per se. In fact, Adrian Scarfe admits to enjoying the occasional flutter.  'Gambling, like most things, lies on a continuum,' he says. 'At one end is your social gambler, occasional gamblers we're unlikely to see here. Further along is the regular gambler who we're also unlikely to see unless it becomes a problem. Then there is the place where gambling starts to develop a hold on someone's life and they are developing problems linked to it At the far end of that continuum you have what's known as the pathological or compulsive gambler who would have been gambling for anything from five to 40 years, who probably has considerable debt impaired physical and psychological health and the breakdown or near breakdown of relationships. This is the main group we see here.'

Profiles of these clients range from those who are homeless or who have served time in prison to high-flying sporting and media personalities. Around a third are from ethnic minorities and most are men, though female gambling appears to be on the increase. According to Adrian Scarfe, who conceptualizes his work in terms of Kleinian theory, many come from an abusive and neglectful childhood in which they may have learned to think and act in a split manner. 'A typical gambler's mode of thinking is all or nothing, win or lose, elation or catastrophe. From an Object Relations model, gambling is basically an idealized object. It's entered into as a way of meeting unfulfilled needs and particularly as a way of offering instant gratification. This is the aspect that makes gambling different from other addictions. A gambler needs to have needs met instantly. And that has implications for the way they see life and gambling — but also for the way they see counseling. Many enter into the relationship in the hope of getting instant gratification and if it doesn't work, as in gambling, you move on.'

The DNAs can be dispiriting for counselors, but Adrian Scarfe claims impressive results. According to his statistics, more than 60 per cent of all clients who came to Gamcare for counseling in 2004 had stopped gambling by the end of their contract and 17 per cent had reduced their gambling. At three- and six-month follow-ups none of them had relapsed and only one had done so at 12 months. For him this work is professionally rewarding, but also personally compelling: 'My passion in this work is that gamblers throw up issues that I have in my own life, but not in the context of gambling,' he says. They are risk-takers, pushing boundaries and becoming self — destructive. That fascinates me. When I see someone who is competent, creative and charismatic who runs a successful business in the city with the world at their feet, destroying it through their gambling, I am intrigued to know what that self-destructiveness is about'

Counselors at Gamcare have a range of views on the subject. They come to the organization from a wide variety of backgrounds and experiences. Those recruited to the helpline aren't required to have any counseling qualification. They may have some counseling training or be former gamblers or related to a gambler. Gamcare offers training in gambling awareness and counseling skills related to helpline work. If they later gain formal counseling qualifications, they can transfer to face-to-face work. These counselors are qualified and work from different models, though they are all expected to use some form of integrative model in which they are open to consider in supervision transferential issues such as a client's alternate good and bad projections onto them.

The counselor’s view
Len Kleanthous comes from a person-centered model, though he says his counseling at Gamcare is now integrative. 'I believe the client knows what's right for them, so if what they want is problem-solving, I may use a cognitive-behavioral therapy approach; if it's to understand their family dynamics, I will draw on transactional analysis.' He is also willing to work with the Twelve Step approach — albeit his own modified version in which he encourages a client who comes believing that he or she has a 'disease' to consider it more as an 'allergy", something they can take care to prevent recurring. 'I want to encourage a client to take responsibility for themselves and their life,' he says. 'When someone says for the first time that they didn't understand what they were doing to themselves and others by gambling, I can accept that, but they can't use that excuse again because from then on they are aware.' In his thinking about his work, Len sees gambling as a potential block to the natural processes of development, particularly if someone has started gambling young. This will affect the way the person presents in counseling and the transference that gets set up. In TA terms, he says he often sees clients approach counseling in a child ego state, relating to him as a parent and that, from working with this, one of his goals during the contract, will be to move towards an adult-adult meeting. Transparency about the way he works is important and, once a person has set out what they want to achieve, he will talk to them about identifying their triggers for gambling, examining their coping skills and ways of getting support, as well as looking at the relationship between their history and the present — how they got to where they are now.

Once a person has moved away from gambling, he will then focus on the grieving for its loss, dealing with the emptiness it leaves. There will also be work on self-esteem, exploring alternative activities that offer highs in life and create rewards — perhaps using the newly spare money. The work is very challenging for these clients and, he says, often requires more than the basic 12 sessions offered by Gamcare. In this case, the counselor is usually allowed to extend the contract, working perhaps for up to a year. Len himself has been responsible for setting up Gamcare's first support group for clients finishing therapy — currently a circle of 10 people who meet weekly. The work is demanding. Len points out that many of these clients attend counseling initially at the suggestion of someone close to them and may still be in considerable denial about the extent of their problem. At this point, the work may be along the lines of motivational interviewing, looking at the evidence of what's happened in a client's life and evaluating the impact of it before any real counseling can start. They may also present in a relationship which is enabling, perhaps feeding the gambling habit, one in which the partner may also be playing parent to the client's child and which may need to be explored in order for counseling to be effective. However, most frustrating for the counselor are the common DNAs in this work. In Len's view, there is great ambivalence, fear and reluctance to change in this client group because what's known — the losing in the gambling, the coping strategies, the lies, deceit and denial of 'Go on, it's your lucky day' — is felt to be safe. The counseling is what is unknown.

So what makes it worthwhile for a counselor in this field? According to Len, the work can be frustrating, stop-start, even painful where the client's work brings up in the counselor who is also an exgambler their own experience. But it can also be highly effective, hugely rewarding and, in his case, one of the best things he ever did: 'I love watching my clients change and grow. Hearing them come back and say therapy has been the greatest thing is fantastic I believe that there is a solution to the problem of gambling. And what we're doing is carrying that hope for the client who arrives here hopeless until they are ready to pick it up for themselves. A gambler needs to have needs met instantly. And that has implications for the way they see life and gambling — but also for the way they see counseling. Many enter into the relationship in the hope of getting instant gratification and if it doesn't work, as in gambling, you move on. The Department of Health defines addiction as substance addiction, so other addictions like gambling, shopping and eating disorders don't get the same recognition'

- Pointon, Clare; When the casino calls: can counseling help? CPJ: Counseling & Psychotherapy Journal, Jul2005, Vol. 16, Issue 6
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #5
The preceding section contained information regarding gambling as a hidden addiction.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 12
For what two reasons does Scarfe consider gambling to be a ‘hidden addiction'? Record the letter of the correct answer the CEU Answer Booklet

 
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CEU Answer Booklet for this course | Gambling
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People who gamble frequently may experience brain changes that make it extremely difficult for them to give up the habit.

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