A Case Study
Jonathan, a married 32-year-old Asian-American male, with an income of $70,000 annually reported symptoms of pathological gambling. As stated by his wife, Marigold, Jonathan has an uncontrollable urge to visit casinos and bet on slot machines. If he could not go out, he uses his credit cards to bet online. He rarely communicates with Marigold and their two children and prefers to lock himself in the room. According to Marigold, Jonathan started betting on casino slot machines with his workmates. They persuaded him by telling him that it was a lucrative activity with negligible losses. He began betting online. He won on his first try and felt a rush of excitement, believing that he could reap huge amounts of money for himself. His workmates told him to bet regularly or frequently so that his chances of winning would increase. They persuaded him that the more he bets, the greater his chances of getting rich.
Eventually, he began to neglect his family because all he could think about is gambling and ways to earn more money through this. He has to bet with higher amounts of money or invest more in gambling so as to satisfy his craving for excitement. He eventually lost his job because of frequent absences. Yet, even without a regular income, he kept on betting online. Sooner or later, through the help of his wife, he made persistent effort to control his gambling addiction, but, unfortunately, he also failed repeatedly. At present, he gambles to comfort himself and escape boredom and depression. He is currently paying his massive debts, which he incurred through gambling.
Presenting Problem
Jonathan is receiving the service due to the reported persistent disruptive symptoms he is experiencing. He reported the following symptoms: chronic thoughts of gambling, like going back to previous experiences or planning how to acquire money to gamble; an erratic urge to borrow cash because of losses in gambling; failed attempts to control, lessen, or give up gambling; disrupted relationship with family members and reduced motivation to go back to work or pursue a career; gambling to ease the feeling of loneliness, depression, or problems; and, feeling anxious, surly, or agitated when making an attempt to control or give up gambling. All these symptoms are indicative of pathological gambling, and the patient wants to regain his normal life and patch up his broken relationships, particularly with his wife and children. These sets of symptoms and the desire to recover from gambling addiction are the two primary reasons why the patient is receiving the service.
Goals
The goals of intervention are based on the following premises: pathological gambling is marked by continuous gambling in spite of detrimental effects on relationships, work, and self; unreasonable thoughts about chances and winning; obsession with gambling and cash by which to satisfy the desire to gamble; and, persistent or erratic uncontrollable urge to gamble. Therefore, the main goal of the intervention would be the recovery of the patient's health, not only physically, but, most importantly, emotionally and psychologically. Health is defined by the World Health Organization (WHO) as the capability of the person to adjust to his/her environment, to meet basic needs, and pursue ambitions (Grant & Potenza, 2008). For pathological gamblers, like Jonathan, such goal implies reducing, controlling, or quitting gambling.
The intervention has three key objectives: first, to cope successfully with adverse psychological conditions, such as loneliness, depression, and anxiety, by means of new approaches and methods that enhance or recover life competence; second, to reduce the adverse effects of gambling for the patient and his loved ones (e.g. family, relatives) and significant others (e.g. friends, workmates); and, third, to gratify cravings for excitement, social interactions, and diversion through healthier, more beneficial leisure or recreational options. Therefore, the overall model of treatment for pathological gambling can be characterized as dividing an enormous task into workable pieces, each must be perfectly fitted to the patient's needs. Because of the underlying complications of the problem and widespread effects, interventions should comprise numerous aspects. In order for the intervention to work, it must satisfy the diverse needs of the patient.
Relevant Theoretical Constructs
Psychoanalysts were one of the earliest scholars to identify pathological gambling. During the earlier times, this disorder was viewed as a moral wrong and was believed to be a marker of a fragile individual with weak character. Basically speaking, a pathological gambler was a person to be shamed, criticized, and reproached. Bergler (1943) opposed, claiming that “the [pathological] gambler is not a 'weak' person who wants to gain money by means of a short cut, taking the risk of failure and of moral reproach from his environment, but a neurotic with the unconscious wish to lose” (as cited in Dixon et al., 2006, 22). Alternatively, Simmel (1920) talked about one aspect that is broadly known until now as usual of those suffering from pathological gambling. He explains how the gambler becomes enmeshed in this unhealthy cycle of failures and winnings. Simmel (1920) provides a somewhat graphic explanation of the vicious cycle of gambling, comparing it to an erotic fantasy that seeks gratification.
Simmel's (1920) description reflects the view of Freud on pathological gambling. According to Dixon and colleagues (2006), Freud claims that guilt is hastened through losses in gambling, gambling is never about being a winner, and gambling is pathology, and similar to all other pathologies, it is an expression of masturbation. Several scholars further explained this Freudian idea, stating that Freud thought that the apparent connection between gambling and masturbation is rooted in the guilt and actual movement of the hands (Aasved, 2002, 28) that comes with masturbation and gambling. Gambling and masturbation, as illustrated in the reinterpretation of Freud's ideas, are also tied to the usual unconscious illusion of being saved or redeemed by a mother figure (Aasved, 2002), also known as as the 'oedipal stage'.
Intervention Methods
Rosenthal and Rugle (1994) identified the different causes of an individual's tendency to gamble and afterward specify methods helpful in attaining the main treatment objective-- self-control. In the psychoanalytic perspective, prevention is a falsehood. Psychoanalytic interventions are rooted in the belief that all human behaviors have underlying significance and are useful. This idea implies that self-damaging behavioral patterns can work as a coping mechanism. This model claims that pathological gambling is a manifestation or indication of a hidden psychological disorder (Weitz, 2014). As explained by Rosenthal and Rugle (1994), this model adopts the idea that, even though certain individuals do not need to know or discover the cause(s) of their gambling addiction in order to recover, there are numerous others who are unsuccessful with abstinence, which only worsens their feeling of hopelessness.
Given these facts, it appears that Jonathan would benefit more from group psychotherapy alongside other therapies (e.g. cognitive-behavioral). This intervention would involve requisite or obligatory appearance to and participation in social skills exercises, relaxation activities, and group discussions to help deal with daily depressive or anxiety-inducing circumstances, and informative sessions about gambling. Here, Jonathan will be included in a circle of gamblers who narrate their own experiences with gambling addiction while others could remark and respond to the narrator's statements. The job of the psychotherapist is to monitor and supervise the activities instead of commanding it. The 'spoken autobiography', as explained by Adkins and colleagues (1985), is a vital part in Jonathan's long-term treatment. It is argued that the effectiveness of psychotherapy rests in group solidarity and individual determination and hope.
Apparently, the patient's individual needs must also be addressed. There are numerous features of Jonathan's life wherein he needs support and assistance. This can be clearly summed up by the term 'gambling', which means “gambling, alienation, marital problems, behavior problems, legal problems, indebtedness, needs, goalessness” (Spanier, 2006, 113). A regular psychotherapeutic session with the patient would help resolve these issues.
Cultural Considerations
Studies reveal that Asian-Americans could be more hesitant to ask for support or assistance from people outside their families, especially when it concerns problems like gambling addiction. In consequence, in numerous cases when Asian-American gamblers and their families consult a counselor or psychotherapist, they are already in a severe, hopeless condition (Liao, 2014). Such delaying would hinder the psychotherapist from competently helping the patient recover from the disorder. Activities intended to fulfill the needs of Asian-American pathological gamblers and their families should resolve the stigma of asking support and help from an outsider.
Therapy sessions can be structured to be more culturally sensitive. Furthermore, current facilities or organizations trusted by Asian Americans can help in winning the confidence, acceptance, and participation of the patient and the community. For psychotherapists who are somewhat inexperienced with the Asian-American community, collaborating with institutions that are respected and trusted in the community could be beneficial.
Use of Technology
Nowadays, technology is a highly useful tool for psychotherapy. A greater number of psychotherapists are making use of technology, such as audio-visual recording as a component of their psychotherapeutic sessions and programs. Computers can be used to record or document the patient's behavior and performance in the activities. So as to constantly be updated with Jonathan's progress, the psychotherapist could use the social media (e.g. Facebook, Twitter), instant messaging, and email communication. If the patient needs help from a long distance, the psychotherapist could encourage video conferencing or FaceTime to give assistance, instructions, or supervision (Meichenbaum, 2013). Moreover, the psychotherapist could consistently monitor the patient after every treatment session through Internet or online services.
There are now Apps that could help the psychotherapist monitor and observe the everyday changes in the patient's behavior, attitude, and mood. Text messages can also be used to give directions or advices on how to effectively deal with anxiety-inducing situations or stressors. A perfect case in point is the Dialectical Behavior Therapy (DBT) assistance, which can be used to track emotional levels and extent of urges to gamble (Meichenbaum, 2013). The psychotherapist could afterward make use of an interactive system to assist the patient in positively responding to these cravings more successfully. Mobile devices are also useful tools because it can provide actual, real-time interaction and discussion between the psychotherapist and his/her patient. Through the Electronic Outcome Questionnaire, which generates a comparison of the patient's outcomes to recovery criteria, the psychotherapist can monitor the vital changes in Jonathan and find out if he is prone to relapse or deteriorate. The Questionnaire produces patient outcomes relating to quality of life, social skills, interpersonal difficulties, and psychological problems (Meichenbaum, 2013; Goss & Anthony, 2003). These data can be transmitted directly to the psychotherapist so as to develop or modify intervention approaches.
Without a doubt, these technologies can be highly useful to the attainment of treatment goals. However, there are also disadvantages. For instance, any technologically generated assessments could be in breach of the Ethics Code standards. A situation may arise wherein the patient could not give his consent through the phone, email, or instant messaging. The use of technology in psychotherapy can also be ethically questionable because of technological glitches, general effectiveness, problems in keeping confidentiality and security, and failure to ensure the credibility and integrity of the psychotherapist. The security of the patient's confidential, private information might be threatened if the database or computer unit where these records are stored breaks down.
Conclusions
Pathological gambling is a continuously growing problem today. Because gambling becomes increasingly accessible, both offline and online, an increasing number of individuals are diagnosed with gambling addiction. As demonstrated in the analysis, pathological gambling manifests an underlying mental health problem. Pathological gamblers endure negative symptoms, like chronic thoughts of gambling, depression, delusion, and anxiety, to name a few. However, there are numerous ways that can be done in order to help them. Through psychotherapy, pathological gamblers can recover from their addiction and regain their normal lives. Technology can definitely help hasten the recovery process, yet are disadvantages as well, such as the potential breach of confidentiality and security.
References
Aasved, M. (2002). The psychodynamics and psychology of gambling: the gambler's mind. New York: Charles C. Thomas Publisher.
Adkins, B.J., Taber, J.I., & Russo, A.M. (1985) The spoken autobiography: a powerful tool in group psychotherapy. Social Work, 435-438.
Dixon, M. et al. (2006). Gambling: behavior theory, research, and application. Gear Street, Reno, NV: New Harbinger Publications.
Grant, J. & Potenza, M. (2008). Pathological gambling: a clinical guide to treatment. New York: American Psychiatric Publisher
Goss, S. & Anthony, K. (2003) Technology in Counselling and Psychotherapy: A Practitioner's Guide. New York: Palgrave Macmillan.
Liao, M. (2014). Asian Americans and problem gambling. NAPAFASA. Retrieved from http://www.napafasa.org/resources/PGP.Asian%20Americans%20and%20Problem %20Gambling%20Rev.11.0321.pdf.
Meichenbaum, D. (2013). A look into the future of psychotherapy: the possible role of computer technology. Retrieved from http://melissainstitute.org/documents/Meichenbaum_A_LOOK_INTO_THE_FUTURE_OF_PSYCHOTHERAPY.pdf
Rosenthal, R. & Rugle, L. (1994). A psychodynamic approach to the treatment of pathological gambling: achieving abstinence. Journal of Gambling Studies, 10(21), 21-42.
Simmel, E. (1920). Psycho-analysis of the gambler. The International Journal of Psycho-analysis, 1, 352-353.
Spanier, D. (2006). Easy money: inside the gambler's mind. New York: High Stakes.
Weitz, P. (2014). Psychotherapy 2.0: where psychotherapy and technology meet. London: Karnac Books.
