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In the present investigation we were able to recruit both active and recovered problem gamblers through media announcements. The general demographic characteristics of these gamblers were similar to the problem gamblers identified in the Alberta prevalence survey (Wynne, Smith & Volberg, 1994). Moreover, they were individuals with substantial gambling problems as indicated both by high SOGS scores (mean = 12) and by DSM-IV criteria (94% of the sample met criteria).
The participants reported a variety of types of gambling problems, although the largest group had experienced problems with video lottery terminals (VLTs), which is a type of gambling that has caused significant public concern in Alberta since its introduction in 1993. Because VLTs have only recently been available we were unable to require a minimum 2-year period of resolution as an inclusion criteria for the study, although this time-frame has been adopted in other recent recovery studies (e.g. Sobell et al., 1993b). If we had adopted a 2-year minimum period of resolution, our active gambling group would have had a different type of gambling exposure and involvement than our recovered group could possibly have had. As a result of not having a minimum recovery time-frame, a proportion of the resolved respondents may not have had stable recoveries and may have subsequently relapsed. At present little is known about the course of recovery from problem gambling. None the less, gamblers' self-reports of their status when interviewed were confirmed with collateral interviews.
The data are self-reported and retrospective describing the attributions for recovery offered by the participants. People need to "make sense" of their lives and their behaviors (Heatherton & Nichols, 1994; Hodgins, el-Guebaly & Armstrong, 1995). Assessing life events systematically in the active group provided a type of control for this bias but prospective studies of these factors are crucial. We also attempted to collect data concerning the reasons for resolution and maintenance factors using two methods. First, respondents were asked in an open-ended interview to describe their experience and subsequently they completed a checklist adapted from previous research. A comparison of responses showed substantial overlap in the type of reasons and factors reported. However, the open-ended method consistently elicited fewer reasons per person than did the checklist despite probing of responses. A further investigation of the relative validity of these methods is important.
Almost all the active gamblers were "ready to quit", reporting that they were planning to quit within the next month. Participating in the research project may have been a way to ease themselves into examining their problem. A follow-up study of these individuals is planned to determine the subsequent course of their disorder.
Most of the resolved gamblers indicated that their goal was to quit gambling as opposed to cutting back or controlling their gambling and that this was a conscious decision. They gave a variety of reasons for quitting, mostly related to emotional and financial factors. Specific life events did not appear to precipitate the change. Emotional reactions to a range of events, however, were viewed as pivotal. It may be helpful to clinicians to recognize that typically individuals reported that a number of factors were involved in their decisions to change and that they did not necessarily "hit bottom" in advance of quitting. Active gamblers were experiencing as many negative life events as were those who resolved their gambling problem.
About a quarter of participants reported that they changed because their gambling was incompatible with their self-image and they did not like to see themselves as having a gambling problem. Struggling with a new identity has been suggested as a critical element in general behavior change (Heatherton & Nichols, 1994) and in quitting drinking (Ungar, Hodgins & Ungar, 1998).
Resolved gamblers were generally similar to alcohol and other drug treatment-seekers (Cunningham et al., 1994, 1995) in terms of the proportion endorsing each reason for resolution. Two exceptions to this general trend are noteworthy. First, fewer gamblers reported engaging in an evaluation of the pros and cons of their behavior when making their decision. This difference is significant because of emphasis placed on cognitive reappraisal in efforts to foster self-change in alcohol abusers (e.g. Sobell & Sobell, 1993). Such a strategy may be effective with a smaller proportion of problem gamblers compared with alcohol abusers. Fewer gamblers than drinkers also reported that a life-style change was significant in resolving their problem. This type of precipitant did not, in fact, emerge in the content analysis as a separate category. This difference may reflect that regular drinking is more socially imbedded and tied to general lifestyles than is regular gambling.
Resolved gamblers reported engaging in a variety of helpful actions in reaching their goal of resolving their gambling problem. The predominant change strategies they employed were behavioral and cognitive-motivational. Behavioral strategies included stimulus control (e.g. staying away from gambling situations) and engaging in new non-gambling activities (e.g. starting new hobbies or projects). These strategies were almost universally endorsed. Common cognitive-motivational actions included recalling past problems with gambling and anticipating future problems and, for the non-treated in particular, using "will power". It may be true that successful change requires cognitive and behavioral change and that clinicians can use this information in helping gamblers increase their repertoire of change strategies. The results are also consistent with the notion that people are likely to attribute "success" to intrinsic factors and "failure" to external factors (Heatherton & Nichols, 1994; Hodgins et al., 1997). Of note, few participants reported that limiting access to finances, an external constraint, was important in achieving success. This finding is intriguing because one of the common thrusts of counseling problem gamblers is to help them control their access to money. We did not ask participants directly if they limited their access to money--perhaps they did but did not perceive it as beneficial.
Consistent with Tucker et al (1994), whereas life events did not play a central role in precipitating recovery, a reduction in negative life events, and in health and financial events in particular, and an increase in positive life events appeared important in maintaining resolutions. Participants also reported that engaging in new activities, remembering negative consequences and general support were important in maintaining their changes.
A significant proportion of the recovered gamblers was naturally recovered, having had no involvement with self-help or formal treatment interventions. As has been found with other types of addictions (Weisner, 1993; Humphreys, Moos & Cohen, 1997), gamblers with less severe problems (as indicated by the number of DSM-IV criteria met) were more likely to resolve without treatment and those with more severe problems were more likely to report moderate or greater treatment involvement. Other factors such as demographics and co-morbid disorders did not predict treatment involvement. These findings support the notion that there is a continuum of severity of gambling problems that require a continuum of responses. At the lower end of problem severity, individuals are more likely to initiate and achieve change in their gambling behavior without the use of formal treatment or self-help groups. These individuals realistically believe that they can stop without intervention. Over 80% of the non-treated participants reported that they did not seek treatment because they wanted to "do it on their own". At the more severe end of the spectrum, gamblers report having sought treatment or participated in Gamblers Anonymous and reported that this involvement was helpful in overcoming their problem. Clearly, the need for an organized and accessible treatment system is supported. In addition, it may also be possible to promote individuals to engaging in self-change or "natural recovery". This promotion may be possible through providing general public information and education or through secondary interventions that make information easily available to problem gamblers in a way that protects their privacy. We have an ongoing study examining this possibility in which self-help materials promoting change are provided to problem gamblers through the mail.
The finding that the major reason for not seeking treatment was the desire to handle the problem without help has consistently been reported in studies of people with serious alcohol and other drug problems who have not accessed treatment (Cunningham et al., 1993; Grant, 1997). A common interpretation is that this attitude is in part related to stigmatization of addiction problems. In our sample, like samples of alcohol and other drug problems, about half of those not accessing treatment directly identified this factor. About half also reported embarrassment/pride as important factors. Clearly, public campaigns aimed at shifting attitudes towards treatment-seeking for gambling problems are crucial.
Rates of co-morbid mood, alcohol and other drug disorders were high. Over 50% of the gamblers reported life-time alcohol problems, about 50% reported life-time mood disorders and a third reported other drug problems. These findings are consistent with the results from other studies and with clinical impressions (Crockford & el-Guebaly, 1998) although solid epidemiological studies are not available. Routine clinical screening for these co-morbidities is warranted with appropriate intervention as necessary. It is interesting that co-morbid problems did not appear to increase the likelihood of treatment-seeking. We did not ask participants about their involvement in treatment for these co-morbid problems. However, it may be helpful to provide gambling treatment services that are integrated into or coordinated with general mental health and addiction services. Certainly cross-training of service providers is important.
In conclusion, this project provides an exploratory portrait of the recovery process in problem gambling. The results provide some suggestions for future clinical and research directions that will hopefully be of benefit in combating this growing challenge.
- Hodgins, David C., El-Guebaly, Nady; Natural and treatment-assisted recovery from gambling problems: a comparison of resolved and active gamblers; Addiction, May2000, Vol. 95, Issue 5
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