Many differing treatment models exist to explain problem
gambling and guide clinicians in their delivery of care. Some models
borrow from our understanding of the treatment of other addictive disorders;
others are unique conceptualizations, which build on newly emerging understanding
of the diverse needs of problem gamblers. Communicating the value of
treatment and the hope for recovery is essential to enhance greater use
of the treatment system.
This case study provides an opportunity to compare and
contrast how the understanding and treatment of clients varies depending
on the theoretical filter applied by the therapist. Most clients who
seek professional care do not know the differences between cognitive
therapy, psychotherapy, narrative therapy and the role of psychopharmacology
in getting well. They only know things feel out of control. Successful
treatment requires a "good fit" with the therapist and a shared belief
in the efficacy of treatment, the treatment process and how it will help.
We invite clinicians to participate in this case study,
to make transparent the therapeutic model that you would select based
on your conceptualization of Mary's situation. Clinicians are also challenged
to include a brief explanation of the therapeutic process in language
that Mary and her family could understand to engage them in a therapeutic
contract. Please consider your priorities of care, the therapist's role
in family therapy and any additional information or assessments that
would be advantageous to understand Mary's situation. Also consider what
additional community supports and resources could or should be brought
into play to aid her recovery and why.
Recent research is beginning to document the correlation
between the availability of gambling opportunities, the various modalities
of play and the rise in problem gambling prevalence rates. With the active
involvement of government in both the proliferation and management of
gambling activities, this presents some interesting ethical issues that
challenge the traditional client-centered focus of clinical care. Mary's
gambling decisions may also provoke your consideration of what role,
if any, therapists have in personal and systemic advocacy with the gaming
industry and government. Mary clearly blames herself for her gambling
problems, but are there issues to consider beyond personal responsibility?
If so, how should these issues be handled within the therapeutic alliance
and within the community?
Case study
The Ontario Problem Gambling Help-Line referred Mary
to therapy. She made the initial appointment from the parking lot of
the casino following what she reports as "another brutal beating at the
slots." Her presenting complaint was:
"I can't control my gambling anymore, it's invading my
life. I hate what has happened to me and what gambling is doing to my
family and my life. Everything is a lie. I want control of my life back!"
Presentation
Mary is 46-year-old female of Anglo-Irish decent.
She presented as an attractive middle-aged woman. She arrived on time
and was neatly dressed and well groomed. Her thoughts were normal in
form and flow. She displayed a wide range of affect throughout the
assessment interview appropriate to content of conversation.
Mary reported episodes of forgetfulness and distraction.
She complained of decreased appetite, of weight loss and nighttime
waking, with an inability to return to sleep. She complained of increasing
feelings of irritability and dread, and a loss of interest in normal
activities. Although she has no active plan, she reports increasing
preoccupation with thoughts of suicide: "I would never do anything
but I wish that my life would just end."
Mary reported long-standing difficulty with anxiety
dating back to her teens, which is currently treated by her family
physician with medication. He is unaware of the presence of a gambling
problem and has provided increasing doses of an anti-anxiety medication
to help her "cope with my fathers' death." Mary reports a growing dependency
on the medication and admits to taking more than the prescribed amount.
She expressed feeling ashamed of her deception.
Mary feels that gambling has "stolen my self-esteem." Mary
described the development of a gambling problem as a "complete shock
I
am an intelligent, responsible person
I can't believe that I've
lost control
it is a nightmare
I have to accept that I
have become a compulsive gambler." Mary has always prided herself on
her ability to competently manage the household finances, over which
she has control. She expressed pride in her ability to save significant
amounts of money in RRSPs (registered retirement savings plans) through
careful money management. Fortunately, these were placed in her husband's
name to take advantage of tax savings. In retrospect, she sees this
as a "saving grace," for she is certain that she would have used the
money to try to win back her losses.
Gambling history
The family has a combined annual income of approximately
$32,000. Mary reported being over $6,500 in debt, accumulated by credit
card use, bank overdrafts and borrowing from family and friends. At
this point, she reports having trouble meeting even the minimum charges
on her debt and is behind in paying household bills. Creditors call
frequently and are increasingly aggressive in their demands.
Mary reluctantly admits that if she had money she
would probably be at the casino "trying to make things right." She
is angry with herself that she can't control her gambling. Mary's husband
is unaware of the extent of her problem with gambling or the amount
of debt incurred. She is fearful of him finding out; this makes her "a
nervous wreck." Mary reports feeling tired of maintaining the deception
that everything is fine when she feels totally overwhelmed and out
of control. Although her husband, Steve, is conscious that things are
not quite right, he ascribes Mary's sadness and anxiety to her father's
death.
In an effort to stop gambling, Mary registered herself
with the self-exclusion program at the local casino. It did not take
long for Mary to "test the system" and return to play. Although she
is frustrated that the staff have never asked her to leave, she feels
her losses are her own fault and a sign of her weakness of character.
Mary reported that gambling has always been a part
of her life. She recalls going to the community bingo hall with her
mom and a time when the family bought a weekly lottery ticket. Fantasizing
about winning a million dollars in the lottery was a frequent game
with her family. Mary's problem with gambling began with the introduction
of the casino into her community three years ago. Mary and her friends
and neighbours all saw it as an exciting opportunity to create needed
jobs and bring tourist dollars into their community. Mary occasionally
visited the casino with her girlfriends as part of a "girls' night
out." The bright lights and excitement dazzled her. Initially she set
a spending limit and had no difficult keeping to it, but things rapidly
changed following the death of her father. At the same time, her husband
began a job as a long-distance trucker and was away from home more
often.
Mary reports that she plays approximately $25 each
week in break-open lottery tickets and experiences an average loss
of $250 per visit to the casino to play the slots. At first, Mary went
once a month with friends, but lately she has gone two or three times
a week on her own. She says that while playing on the machines her
mind completely empties and she feels vaguely soothed by the rhythmic
quality of play. "When I sit down at a video lottery terminal, I don't
see anything else around me. I feel nothing
nothing matters but
playing the game." But Mary notes that when play stops and she appreciates
the reality of her losses "
life crashes down upon me
I
go to bed and pull up the covers, hoping that when I wake up, it will
all just be a bad dream. But it's not, and even though I don't want
to, I go back to the casino and try again."
Mary reported playing 18 hours straight at the same
slot machine without interruption. Her son Terry was concerned when
she failed to return home that night. The next day, Mary broke down
in tears, told him about her gambling and swore him to secrecy about
her problem. Mary recognizes that this is causing increased tension
within the family and weighs heavily on her son. Mary has noticed that
Terry is becoming more withdrawn and sullen and she fears this is related
to her gambling problem. She reports this fear as a major motivator
for her seeking help. Mary's friends are unaware of the degree of her
gambling problem and this secret leaves her feeling isolated from both
family and friends.
Mary described with great enthusiasm a "big win early
on in her play. Playing her "lucky machine" she won over $10,000, which
she spent on a family holiday and shared amongst her family and friends.
Mary enjoyed the attention she received and loved being able to treat
her family to a "luxurious vacation with all the trimmings."
Approximately two years ago, Mary's father developed
lung cancer. She cut down her hours working as a cashier to help her
mom care for him at home. Although he was drinking less by then, he
was still a difficult man to care for. When he died, Mary described
an overwhelming sense of relief.
Personal history
Mary reports being happily married to Steve for the
past 26 years. They live together in their own three-bedroom home in
the same small town where they were born. Mary and Steve started dating
in high school and married two years after graduation. They have three
grown children, ages 25, 23 and 18. Their youngest son lives with them
while he completes school. Her two daughters moved away before their
grandfather became ill. Both appear to be happy and well adjusted.
Mary is the eldest and only daughter of four children.
She described her father as a "hard drinking, hardworking man" who
was prone to aggressive flare-ups when drunk. Although violent with
her brothers, Mary reports her dad never hit her or her mom. Her mother
was a stay-at-home mom, with whom Mary reports having a close, loving
relationship. Although her mother was never treated for depression,
Mary suspects that there were periods of illness throughout her life.
At times her mother became irritable and withdrawn and would take to
her bed for what seemed to Mary like months on end. Her periods of
depression were never discussed inside or outside the home. When her
mom was well they would go out together to the local bingo hall. At
these times, her mom was friendly and outgoing, and appeared to be
well liked in the community.
Mary expressed pride in her ability to support the
family when her mother "was not herself." As a teenager, she cooked
meals and cared for her younger brothers. She wanted to make things
seem as "normal as possible" and keep her brothers out of "the line
of fire." During this time, she took a job as a cashier at the local
grocery store. Again, Mary expressed pride at her ability to responsibly
hold a job, care for her family and save money.
During high school, Mary described periods where she
felt highly anxious "but nobody would ever know." Mary was a good student,
worked hard and achieved good grades. She participated in school activities
and had a number of friends but never felt she could trust anyone enough
to let them know what was going on at home. It was at this time she
started to date Steve who was her one and only boyfriend. Mary was
attracted to Steve because he was "steady, hardworking, and had a friendly,
kind nature."
Mary reports that two of her brothers have adjusted
well; they are working and married, with families of their own. They
do not live in the same town and Mary sees them only on special occasions.
She reports that one brother is a heavy drinker, unable to hold a steady
job and has had two "failed" marriages.
Mary describes herself as a sociable and outgoing
person with a number of female friends. But Mary reports that she currently
has no interest in seeing her friends because of her "shameful problem." Being
with others feels like a chore. Mary does not participate in any of
her previous interests.
For the first time in her marriage, Mary feels cut
off from her husband. Probing revealed a deep-seated fear that her
husband would leave her if he knew the extent of her problem. He has
always spoken contemptuously of people, like her brother, who were "too
weak to stop drinking" and believes they should "just pull up their
socks" to overcome their problems. From his perspective, discipline,
hard work and family are all that a person needs to live a good life.
Without Steve, Mary feels there would be no purpose in living. Her
shame at being "weak" and her fear of Steve leaving her have contributed
to both the secrecy of her addiction and (unsuccessful) attempts to "win
back" her losses.
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