TREATMENT DEVELOPMENT IN PROBLEM AND PATHOLOGICAL GAMBLING by MIRANDA BULWER submitted in accordance with the requirements for the degree of DOCTOR OF PHILOSOPHY in the subject PSYCHOLOGY at the UNIVERSITY OF SOUTH AFRICA PROMOTER: PROF J M NIEUWOUDT NOVEMBER 2006 ii Student Number: 620-609-3 I declare that “TREATMENT DEVELOPMENT IN PROBLEM AND PATHOLOGICAL GAMBLING” is my own work and that all the sources that I have used or quoted have been indicated and acknowledged by means of complete reference. ------------------------- ------------------------- MRS M BULWER DATE iii ACKNOWLEDGEMENTS My thanks go to the people who have inspired, encouraged and assisted me to write this doctoral thesis. Thank you, Prof Johan Nieuwoudt, at Unisa for your help and guidance throughout this intricate journey. You were always so kind and generous with your assistance and insight. Thank you, not just for all your academic support, but for your emotional support and words of encouragement at all times. Thank you, Jonathan, my husband, for all your patience, support and love. Without you I would not have been able to do this study. To those who kindly shared their experiences of gambling I say: You had a great deal of courage to confess. Let the truth of your lives be the light for the rest. Let your stories be a warning to thousands of others who still believe ….... Miranda Bulwer iv v TREATMENT DEVELOPMENT IN PROBLEM AND PATHOLOGICAL GAMBLING KEY TERMS Gambling addiction; pathological gambling; problem gambling; comorbidity; auto-ethnographic inquiry; individual case studies; personal disposition; biopsychosocial vulnerability; codependency; situational and structural determinants; psycho-structural interaction model; cycle of problem gambling; gambling disposition profile; treatment development; components of treatment; long term treatment considerations; treatment matching; therapeutic approach. SUMMARY This study is an exploration, through ethnographic and auto-ethnographic inquiry, of the personal world, gambling experiences and underlying biopsychosocial vulnerabilities of three individual case studies – one male and two females - each representing a different sub-type of pathological gambler. It comprises the integration and implementation of a psycho-structural stage matching model to explore comorbidity and identify certain biopsychosocial manifestations in the respective stages of pathological gambling. Long term treatment strategies were identified and patient treatment matching was explored. Further, it comprises my personal relationship and therapeutic treatment of these sub-types of gamblers over a period of one year and longer. In this study it is hypothesized that formulating appropriate matching long term treatment strategies should be based on the stage of change, the phase in the psycho-structural model, as well as the gambler’s underlying vulnerability. From this a comprehensive gambling disposition profile can be completed with proper intervention matching approaches. A number of other hypotheses emerged from this study that could provide valuable information and serve as a guideline to those working with pathological gamblers. vi vii CONTENTS Page CHAPTER ONE INTRODUCTION 1 1.1 BACKGROUND 1 1.1.1 National Responsible Gambling Programme (NRGP) 5 1.2 PERSONAL BACKGROUND 7 1.3 RESEARCH FINDINGS 8 1.3.1 Summary/description of all treatment seekers 9 1.3.2 Gender differences in treatment seekers 12 1.3.3 Summary of treatment effectiveness 14 1.4 UNDERSTANDING PROBLEM GAMBLING 15 1.5 OBJECTIVES OF THIS STUDY 19 1.6 CONCLUSION 21 CHAPTER TWO RESEARCH METHODOLOGY 23 2.1 RESEARCH METHODS 23 2.1.1 Quantitative methods 23 2.1.2 Qualitative methods 28 2.2 METHODOLOGICAL UNFOLDING OF THE STUDY 32 2.2.1 The nature of ethnography 32 2.2.2 Determining a focus for inquiry 33 2.2.3 Determining where and from whom data will be collected 34 2.2.4 Data collection 38 2.2.5 Determining instrumentation 38 2.2.6 Data recording procedures 39 2.2.7 Data analysis 40 viii Page 2.3 AUTO-ETHNOGRAPHY 42 2.4 CONCLUSION 46 CHAPTER THREE PERSONAL DISPOSITION IN PROBLEM AND PATHOLOGICAL GAMBLING 47 3.1 PROBLEM GAMBLING AS A MULTIFACETED BEHAVIOUR 47 3.2 TYPE I – THE BIOLOGICAL VULNERABLE GAMBLER 49 3.2.1 Biochemical vulnerability 51 3.2.2 Neuropsychological vulnerability 53 3.3 TYPE II – THE EMOTIONAL VULNERABLE GAMBLER 55 3.3.1 Personal vulnerability and experiential factors 57 3.4 TYPE III – THE CODEPENDENT VULNERABLE GAMBLER 63 3.4.1 The missing link? 65 3.4.2 The meaning of codependency in a historical context 67 3.4.3 Defining codependency 69 3.4.4 Recognizing codependency 71 3.4.5 How does codependency start? 74 3.4.5.1 The aggressive codependent 83 3.4.5.2 The passive codependent 86 3.4.6 The “interpersonal” link between codependency and problem gambling 90 3.5 TYPE IV – THE PSYCHOSOCIAL VULNERABLE GAMBLER 95 3.5.1 Psychosocial vulnerability and gambling 97 3.6 CONCLUSION 100 CHAPTER FOUR SITUATIONAL AND STRUCTURAL DETERMINANTS OF GAMBLING 103 4.1 SITUATIONAL DETERMINANTS OF GAMBLING 103 4.2 STRUCTURAL DETERMINANTS OF GAMBLING 109 ix Page 4.2.1 House advantage 112 4.2.2 Game preference 115 4.3 PSYCHO-STRUCTURAL INTERACTION IN GAMBLING 122 4.3.1 The impact of technology on gambling: Salient factors 124 4.3.2 Sub-types of gamblers 126 4.4 CONCLUSION 130 CHAPTER FIVE THE CYCLE OF PROBLEM GAMBLING 133 5.1 THE CYCLE OF PROBLEM GAMBLING 133 5.2 THE WINNING/INTRODUCTORY PHASE (apparent/impaired control) 135 5.2.1 Beginner’s luck: The “early win” hypothesis 137 5.2.2 Reinforcement theory 138 5.3 THE LOSING PHASE (poor control – problem gambling developing) 142 5.3.1 Poor coping skills 143 5.3.2 Denial patterns 144 5.4 THE CHASING PHASE (loss of control – gambling problem developed) 147 5.4.1 The role of cognition 151 5.4.2 Chasing – It’s not just about money 162 5.5 THE ADDICTIVE PHASE (absence of control (compulsion) – pathological gambling) 164 5.5.1 Diagnostic criteria for pathological gambling 167 5.5.2 Theory of addiction 168 5.5.3 Defense patterns 172 5.6 DISTORTED SENSE OF SELF 175 5.7 THE ESCAPE PHASE 178 x Page 5.8 THE DEVELOPMENT OF A DISTORTED REALITY WITH CHARACTER AND COPING DEFECTS 181 5.8.1 Character defects 184 5.9 CONCLUSION 187 CHAPTER SIX TREATMENT CONSIDERATIONS 189 6.1 INTRODUCTION 189 6.2 BIOPSYCHOSOCIAL ASSESSMENT IN TREATMENT 189 6.3 STAGE-CHANGE MATCHING IN THE TREATMENT OF GAMBLING ADDICTION 193 6.4 COMPONENTS OF TREATMENT IN PROBLEM AND PATHALOGICAL GAMBLING 194 6.4.1 Pharmacotherapy 195 6.4.2 Cognitive and behavioural treatment approaches 198 6.4.3 Solution-focused therapy 205 6.4.4 Motivational interviewing approach 207 6.4.5 Gamblers Anonymous 12-step programme 208 6.4.6 Self-exclusion (banning) 211 6.4.7 Medical/disease model approach 212 6.4.8 Codependency treatment approach 215 6.5 CONCLUSION 218 CHAPTER SEVEN HENRY: A BIOLOGICAL VULNERABLE GAMBLER 221 7.1 INTRODUCTION 221 7.2 HENRY’S STORY 221 7.3 ASSESSING HENRY’S GAMBLING PROBLEM 228 7.4 ANALYSIS OF HENRY’S GAMBLING PROBLEM 229 xi Page 7.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS 238 7.5.1 Initial phase of treatment 239 7.5.2 Middle phases of treatment 241 7.5.2.1 Addressing Henry’s deviant sexual behaviour 245 7.5.3 Middle to end phases 247 7.6 MY RELATIONSHIP WITH HENRY AND ROLE AS HIS THERAPIST 250 7.7 CONCLUSION 252 CHAPTER EIGHT TINA: A PSYCHOLOGICALLY VULNERABLE GAMBLER 255 8.1 INTRODUCTION 255 8.2 TINA’S STORY 256 8.3 ASSESSING TINA’S GAMBLING PROBLEM 262 8.4 ANALYSIS OF TINA’S GAMBLING ADDICTION 262 8.4.1 Tina’s syndrome of codependency 265 8.4.2 Tina’s motivation for gambling 267 8.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS 269 8.5.1 Initial phase of treatment 271 8.5.2 Middle phases of treatment 274 8.6 TINA’S OTHER COMPULSIONS 277 8.7 TINA’S GAMBLING ADDICTION AS SUBSTANTIAL AND COMPELLING CIRCUMSTANCES IN HER COURT CASE 278 8.8 MY RELATIONSHIP WITH TINA 281 8.9 CONCLUSION 282 xii Page CHAPTER NINE SANTJIE: A PSYCHOSOCIAL VULNERABLE GAMBLER 285 9.1 INTRODUCTION 285 9.2 SANTJIE’S STORY 286 9.3 ASSESSING SANTJIE’S GAMBLING PROBLEM 291 9.4 ANALYSIS OF SANTJIES GAMBLING ADDICTION 291 9.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS 295 9.5.1 Initial phase of treatment 296 9.5.2 Middle to end phases of treatment 299 9.6 MY RELATIONSHIP WITH SANTJIE AND ROLE AS HER THERAPIST 304 9.7 CONCLUSION 306 CHAPTER TEN CONCLUSION AND IMPLICATIONS 309 10.1 GENERAL DISCUSSION OF THE STUDY 309 10.2 EMERGING HYPOTHESES 310 10.3 STRENGHTS OF THE STUDY 336 10.4 LIMITATIONS OF THIS STUDY 338 10.5 CONCLUSION AND IMPLICATIONS FOR BEST PRACTICE 340 REFERENCES 343 ANNEXURES Annexure 1 : DSM-IV Diagnostic Criteria for Pathological Gambling 358 Annexure 2 : Gamblers Anonymous 20 Questions 359 Annexure 3 : Spann-Fischer Codependency Scale 360 xiii Page Annexure 4 : Personal Gambling Disposition Profile 361 Annexure 5 : Personal Gambling Disposition Profile: Henry 363 Annexure 6 : Personal Gambling Disposition Profile: Tina 366 Annexure 7 : Personal Gambling Disposition Profile: Santjie 369 FIGURES Figure 3.1 : The biological gambler 50 Figure 3.2 : The emotional vulnerable gambler 56 Figure 3.3 : The codependent vulnerable gambler 64 Figure 3.4 : The psychosocial vulnerable gambler 96 Figure 3.5 : An integrated biopsychosocial vulnerability model of problem gambling 101 Figure 5.1 : A psycho-structural model of the cycle of problem gambling 136 Figure 5.2 : Schematic illustration of the gambler’s fallacy 160 TABLES Table 2.1 : Demographic and gambling-related characteristics 37 of the three participants at the time of interview 1 CHAPTER ONE INTRODUCTION 1.1 BACKGROUND With the election of a new democratic government in South Africa in 1994, gambling laws were liberalized and the government granted 40 casino licenses.