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Journal Information
Journal ID (publisher-id): jgi
ISSN: 1910-7595
Publisher: Centre for Addiction and Mental Health
Article Information
© 1999-2003 The Centre for Addiction and Mental Health
Publication date: May 2001
Publisher Id: jgi.2001.4.2
DOI: 10.4309/jgi.2001.4.2

Expert Responses
Durand F. Jacobs, PhD, ABPP Affiliation: Clinical Professor of Medicine (Psychiatry and Behavioral Sciences), Loma Linda University Medical Center, California, USA
Rina Gupta Affiliation: Youth Gambling Research and Treatment Clinic, McGill University, Montreal, Quebec, Canada
David Hodgins Affiliation: Coordinator, Program Development and Research, Foothills Medical Centre, Calgary, Alberta, Canada

Response to a Case of Gambling-Induced Analgesia

I will attempt to cast the case of Mr. S.M. within the context of the General Theory of Addictions (Jacobs, 1982; 1986), key elements of which are summarized in the Discussion section of Dr. Blaszczynski's paper. From this perspective, I view the most devastating immediate and continuing result of the patient's accident as the loss of the psychological, social and financial rewards that stemmed from the business that he had created, and in which he had become so involved that at one time it even threatened his marriage.

In effect, the accident robbed this man of the essential substance and quality of his life, and left him virtually adrift from his previously established moorings.

His chronic and episodically severe pain further restricted his former, physically active work and social life. This combination of physiological and psychological stressors set the stage for his later, enthusiastic “discovery” that high excitement while gambling actually provided an escape from all his stressors: from his preoccupation with feelings of low self-worth; from his worry about his failing business and attending money problems; as well as from his severe pain and its attending physical limitations. Moreover, he stated that he frequently experienced an altered, clearly dissociated, state of consciousness and identity while gambling. In this altered state, his mood and self-confidence were dramatically improved and he felt superior to others — invincible.

That his analgesic release from pain, while gambling, was only one component of the above dissociated experience is evidenced by the fact that his gambling “binges” continued long after the pain had become manageable. As Dr. Blaszczynski relates, the later gambling binges continued to be triggered by a range of situational stressors much like those I have described above.

The patient acknowledged that Dr. Blaszczynski's treatment of his erroneous perceptions and expectations regarding gambling had greatly reduced the frequency and amount spent per period of gambling. Yet, the patient also admitted that, despite his own and others' attempts to control his gambling, he still continued to rely on bouts of gambling to escape the build-up of intolerably frustrating stressors in his life that periodically peaked during the treatment period and continued one year after his treatment.

Fifteen months post-treatment, when last seen by Dr. Blaszczynski, the patient reported no binges during the previous three months but admitted that he had a “persistent, underlying urge to gamble,” which he claimed he was controlling.

From the perspective of the General Theory of Addictions (and my own clinical experience), I don't believe one can talk or reason anyone with pathological gambling problems (or any person with an addiction) out of his or her chosen pattern of addictive behavior, while it is serving that person's needs. After all, in the case of Mr. S.M., pathological gambling was not the patient's “problem.” For him, it was his best available solution to his long-standing underlying problems (Gupta & Derevensky, 1998) that were exposed by the physical and the functional disabilities caused by his accident. Until these underlying physiological (hypotensive) and psychological (self-worth) issues are ameliorated by whatever means, and until the patient acquires more effective coping skills for dealing with his daily stressors, I expect that his episodic gambling binges will continue.

I would like to offer a word about the differences between my view of dissociation and those expressed by Drs. Blaszczynski and Cardena. My clinical experience and research findings consistently support the position that the phenomenon of (self-induced) dissociation constitutes an unbroken continuum of behaviors. This extends from simple, everyday forms of reverie or concentration or distraction to a middle ground, wherein a commonly held and extensively verified set of dissociative reactions are reported by people with addictions, while they are indulging (Jacobs et al., 1985; Jacobs, 1988). Towards the far end of this continuum are ever more extreme dissociative reactions, such as those reported by patients showing post-traumatic stress disorders, functional fugue states and dissociative identity disorders (Jacobs, 1982).

Consequently, I cannot agree with Cardena's argument (1994) that the concept of dissociation should be restricted to the more clinically abnormal circumstances “where there is a qualitative disconnection from ordinary modes of experience.” He would thus relegate involvements with ordinary modes of experiences such as board games, computer play and reading to the (non-dissociative) realm of normal engrossments.

I believe it is far more parsimonious to view dissociation as the unbroken continuum described above. Within this conceptual framework, increases in the frequency and types of dissociative reactions reported would indicate the extent to which the person chooses to progressively separate himself or herself (via self-induced changes in thought, emotion, identity, time and/or memory) from ordinary, mildly challenging to highly aversive reality situations. For example, tables 1 and 2 reveal the progressively increasing use of five different dissociative reactions as direct correlates to the increasing extent of self-reported problems with gambling (Jacobs, 2000).

As one knowledgeable about pain management strategies, I find it unacceptable to propose “distractions” as a freestanding entity arbitrarily and without supportive evidence. Distraction, via reading or meditation, is firmly included within the range of simple to more complex dissociation techniques (e.g., self-hypnosis) regularly taught to hospitalized patients reporting chronic, intractable pain (Jacobs, 1980; 1987).

This is a final comment about the respective motives for gambling, which Dr. Blaszczynski attributes to social and pathological gamblers. Overwhelmingly, both groups enjoy the excitement and opportunity to win money. What separates them is that social gamblers typically set and hold to time and loss limits for a given playing session. When they win larger amounts, social gamblers tend to pocket their winnings and leave. Gamblers with pathological-level problems, like Mr. S.M., find it very difficult when stressed to set or maintain time or loss limits. They rarely pocket the money and leave even when they win very significant amounts. Their overriding motivation is to use winnings and other sources of money to keep playing. Their primary objective is to maintain and enjoy the dissociated, altered state of consciousness that results from gambling. In the words of one person with pathological gambling problems: “The next best thing to winning is losing – just so I stay in action!”

Submitted: November 6, 2000


“In our work with young gamblers…”

It was a real pleasure reading the article “Gambling-Induced Analgesia: A Single Case Report,” as it echoes what we see and experience in our treatment of adolescent gamblers.

The single case report describes a man in his late forties who turned to gambling as a way of escaping the pain of a back injury incurred from a serious car accident. Gambling, for him, resulted in analgesic properties allowing him to escape physical pain for brief periods of time. The article also reported that he experienced depression as a result of his pain, and that he would also engage in binge drinking as a means of escape. One must wonder if he was also intentionally escaping feelings of depression with his gambling and use of alcohol.

What is particularly interesting about this individual is that he continued his gambling despite an improvement in his physical condition, and he was aware of gambling for reasons other than its analgesic effects; that is, primarily for the excitement. He continued to gamble beyond the limits he set for himself and recognized that the reasons causing him to begin gambling in a problematic fashion were not the same as those maintaining his gambling involvement.

In our work with young gamblers, we often encounter adolescents whose motivations underlying their gambling change over time. However, we are more likely to see youth who start gambling primarily for reasons of socialization and excitement, and then realize over time, the “escape” that gambling provides. Those who feel they benefit from the escape are more likely to continue gambling for this property and less for the excitement and socialization advantages that attracted them in the first place.

Our research efforts have consistently indicated a strong linear relationship between degree of gambling and reported degrees of dissociation experiences by youth while gambling. They report that gambling is a “whole different world” where “problems do not exist,” where they “feel good.” It is not uncommon for us to work with youth who are either mildly or seriously depressed, and they explain that only when gambling do they feel “not depressed” and “alive.”

More likely than not, youth who experience gambling problems lack adequate problem-solving, coping and social skills. They often find themselves having friendships that lack depth and closeness, feeling as though they “don't belong” and as though they are incapable of successfully facing the challenges of adolescence. Most of our adolescents in treatment can reflect back on previous years and honestly admit to feeling dysfunctional in many ways — in terms of interpersonal relationships with friends and family, and often, with respect to their academic performance. More often than not, these youth are struggling with identity issues and issues of belonging.

Many of these youth are anxious or fidgety, and may only feel comfortable when engaged in highly stimulating activities. It is no wonder they quickly come to recognize gambling as a solution to their unhappy states of being; to recognize gambling as their new “best friend.” This best friend keeps them busy, does not judge or criticize them, satisfies their need for high arousal and stimulation and allows them to forget that they are not functioning well in the outside world.

These words from an 18-year-old girl sum up what we have come to understand about the motivations underlying gambling very well:

“ …It was a whole fantasy life and I felt happier than I ever did before. I didn't feel sad or bored, or as if I did not belong. I realized that I did not have any real friends, my whole life. I never really had a friend that I could confide in or cry with, or even really laugh with. Now, I felt satisfied and happy and I thought gambling was the best thing for me. …Now I can't stop. I need it to make me forget my problems at school and with my family, and the fact that I have no real friends.”

We have not yet treated any youth who were gambling for analgesic reasons, but we have frequently worked with youth who gambled to numb emotional pain resulting from the death or loss of a parent as well as other traumas. While gambling they can feel good and let go of the pain, resulting in a very powerful situation where gambling serves as a negative reinforcer. Most youth, due to a lack of previous gambling involvement, are unaware that gambling will help them escape pain and unhappiness, but they latch onto gambling for these reasons through repeated exposure and their primary motivations for gambling seem to fall into the background.

In sum, we must acknowledge the strong analgesic and escape properties inherent in gambling participation, as well as the fact that reasons for gambling participation can change over time. This awareness will serve to develop better prevention messages and allow for more successful treatment outcomes.

Submitted: October 24, 2000


Further Specifying Our Models of Problem Gambling

This 48-year-old German man living in Australia could easily be living in Calgary, Alberta, playing our infamous video lottery terminals, or he could be anywhere else in Canada or North America. I am struck by how the clinical presentation of gambling problems is so similar from country to country and continent to continent, despite the fact that our gambling venues, habits and traditions vary considerably. In many ways, people with gambling problems in different countries seem more similar than different. Frequently, the person with gambling problems describes the functional role of gambling as escape from dysphoria. Grief, depression, relationship difficulties, and pain are commonly cited causes of the dysphoria. Also very common is the report of a “big win” early in the course of the development of the problem.

Various models and theories attempt to account for these aspects of problem gambling phenomena. The author draws upon concepts such as arousal, dissociation, excitement, narrowing of attention and operant conditioning among others. Specific reference is made to Jacobs' general theory and the behavior completion mechanism model. The concept of dissociation in the general theory is accurately identified as particularly fuzzy. It is interesting, however, that all these concepts can be invoked in the conceptualization of this case. None, however, seems necessary or sufficient. Our models are ripe for further development and integration, particularly with clearly specified, parsimonious and testable tenets.

Self-reports and observations of people with gambling problems have been helpful in developing our models. These retrospective reports can, however, be misleading. The challenge to theorists and researchers is to specify these models in a way that allows testable hypotheses that do not depend upon the retrospective reports from problem gamblers. Years ago, we believed that the etiology of Down's syndrome, now recognized as a chromosomal disorder, was related to stressful life events during pregnancy. We based these beliefs on research using retrospective reports of mothers who were struggling to understand a very stressful situation compared with mothers of babies without Down's syndrome (Brown & Harris, 1978). It is not surprising that they were more likely to recall stressful events during their pregnancies. Similarly, various self-medication models of substance abuse, albeit intuitively attractive, have failed to yield strong empirical support when prospective designs are used. Likewise, in the gambling area, we need to move away from sole reliance on retrospective reports as the major dependent variables, and instead, use prospective designs and/or non–self-report variables in studying our models.

I have a number of clinical observations about Mr. S.M.'s treatment. Cognitive therapy designed to correct erroneous perceptions appears to have played a central role in this man's treatment. This approach is curious given that the conceptualization of the case does not focus on erroneous perceptions. Mr. S.M.'s gambling was conceptualized as offering “emotional escapism” through distraction, dissociation or some type of narrowed attention. A logical treatment thus would involve training in alternative distraction techniques generally, and cognitive pain management techniques specifically.

Would Mr. S.M.'s progress have been faster with a treatment more consistent with the conceptualization? Or was the conceptualization limited by the lack of integration of cognitive features? The author alludes to fantasies associated with winning and anticipations of the next outcome but does not appear to view them as central in either the development or maintenance of the problem. I am also curious about why this man developed a gambling problem versus an alcohol problem, or even a narcotic problem. He clearly used alcohol and antidepressant medications to cope with pain with at least some positive effect. Presumably these coping options were more accessible than gambling, but gambling became the “analgesic” that became generalized to coping with other aversive states. Why so? We have much to learn about this fascinating disorder.

Submitted: October 16, 2000



Tables
Table 1: 

Potential Effects of Gambling on Personality among Ontario Adolescents (N = 400)


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Table 2: 

Potential Effects of Gambling on Personality among Alberta Adolescents


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