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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
Received Day: 21 Month: February Year: 2002
Accepted Day: 17 Month: March Year: 2002
Publication date: May 2003
Publisher Id: jgi.2003.8.1
DOI: 10.4309/jgi.2003.8.1

Counselling Mary about her gambling problems: A self-reliant person
[This Introduction prints out to about six pages.]
This Introduction to the Case study conference was peer-reviewed.

Introduction

This is a case review with a slight difference. Mary M. is not a real person. She represents a composite of the “average” woman with gambling problems based on research conducted by Roberta Boughton, Problem Gambling Services, Centre for Addiction and Mental Health, (Toronto, Canada).

Like many people with a gambling problem, Mary brings a complex interplay of family genetics, personal history, precipitating life events and environmental influences to therapy. This challenges the clinician to carefully consider which element of the individual's narrative to respond to and when.

Through anecdotal data and epidemiological studies we know that problem gamblers are reluctant to seek help. A recent Ontario study found that of the estimated 318,000 people in the province with gambling problems, only 1,425 had sought help from the formal treatment system. Of those, only 975 were problem gamblers — the rest were family members (Rush, Shaw Moxam & Urbanoski, 2002). We also know that problem gamblers often approach treatment after all other avenues have been exhausted, yet we do not really understand why. It may be the stigma associated with getting help for a mental health problem, lack of knowledge that help is available, denial of the extent of the problem, or uncertainty about what happens during the therapeutic process.

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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