Gambling within the Biopsychosocial framework

1. Gambling within the Biopsychosocial framework

2. Addiction and Gambling • Addiction occurs when an: • Individual ‘feels’ a constant desire to use a specific substance or engage in certain activities. • Despite the potentially negative consequences. This can cause: • Physical dependence: Evident by withdrawals or cravings when activity is withdrawn or unavailable. • Psychological dependence: The mental desire to experience the effects produced by the substance.

3. Addiction and Gambling • Addiction is now used more broadly to refer to a condition in which an individual feels a recurring urge to use a specific type of substance or engage in a certain activity despite potential harmful consequences.

4. Characteristics of Addictions • Griffiths (2005) proposed that all addictions have seven distinctive characteristics: • Salience: This activity has a high level of importance in a persons life. Typically it dominates their thinking. • Mood modification: Change in subjective experiences that people with an addiction report. As a result of the activity they may feel a ‘high or buzz’. • Tolerance: Decreased sensitivity to activity over time, leading to an increase in the amount of the activity to achieve the same buzz. Eg. as betting larger amounts over time to get same feeling.

5. Symptoms of Addictions 4. Withdrawal: Unpleasant psychological and/or physical reactions when activity is reduced such as sadness or nausea. 5. Conflict: Clashes that arise due to addiction that may be intrapersonal (within themselves) or interpersonal (with others) conflicts. 6. Relapse:After a period of control the recurrence of earlier patterns of behaviour occur. 7. Impaired self control: Lack the ability to suppress urges. http://www.youtube.com/watch?v=L7UVO5_zXj0

6. Gambling • Gambling is any activity in which money (or anything of value) is put at risk on an event of uncertain outcome that relies, in part or entirely, on chance. • It can be divided into two categories: • Continuous- those in which the time between betting and knowing the outcome is short- which permits instant gratification. • Non-continuous- those in which the time between wagering and knowing the outcome is long thereby delaying gratification.

7. Gambling as an addiction • For most people, gambling is a source of recreation and a pleasurable social activity. • It can be an escape from the pressures of work, boredom, for fun, excitement, a chance to win money or to meet people and socialise. • For a number of people, gambling stops being pleasurable and becomes a serious problem that causes harm to themselves and those around them. • When gambling consumes more than the person can afford it can affect both their psychological and physical health.

8. When is Gambling considered a Problem? • Problem gambling is when an individual has difficulties in limiting money and/or time spent on gambling, which leads to adverse consequences for the gambler, for others or for the community. • There is no clear point however, at which a recreational gambler becomes a problem gambler. • According to the DSM, a pathological gambling disorder is characterised by continuous gambling behaviour that disrupts personal, family and/or work related activities.

9. Problem gambling • It is estimated that about 125 000 Australians are problem gamblers and that about 290 000 gamblers are at moderate risk of developing a disorder. • 61.2% are of problem gamblers are male with the age range between 35-64 being most prevalent. • Currently in the DSM and ICD there is no category for an ‘addictive disorder’. Gambling comes under a type of impulse control disorder in the DSM-IV-TR. • Impulse control is the psychological effort made to resist an urge, inner drive or temptation to do something that is potentially harmful to oneself or others.

10. Impulse Control Disorder • In the DSM-IV-TR there are six different types of impulse control disorders such as pyromania and trichollomania (pulling one’s hair out for pleasure). • In the new DSM-V it has been proposed that ‘pathological gambling disorder’ will be replaced with the term ‘disordered gambling’ in a new category called addiction and related disorders within the subcategory behavioural addictions.

11. How can you be diagnosed with a pathological gambling disorder? • According to the DSM-IV-TR a person must experience at least five of the following ten symptoms to be diagnosed as a pathological gambler: • Preoccupation with gambling (salience): At least two weeks or more thinking about gambling, planning future gambling episodes, or thinking of ways to get money to gamble. • Tolerance: Increasing size of bets or time spent gambling to achieve and experience the desired excitement or rush that was originally experienced. • Loss of control: Individual has tried several unsuccessful attempts to stop gambling but cannot control themselves.

12. How can you be diagnosed with a pathological gambling disorder? 4. Withdrawal: Unpleasant psychological and/or physical reactions when activity is reduced such as irritability or insomnia. 5. Escape: Some psychologists propose that all gamblers do so for escape from the hassles that daily life creates. When the gambler is addicted, gambling then becomes an escape from the problems associated with it creating a ‘vicious cycle’. • Chasing: A pathological gambler will chase their loses and not walk away.

13. How can you be diagnosed with a pathological gambling disorder? • Lying: To conceal the extent of gambling. There are two types: • Reactive lying-being dishonest in response to questions that may expose one’s gambling. b) Deceptive lying: dishonesty planned in advance. 8. Illegal activity: The person commits illegal acts like forgery. 9. Risked relationships: the person has jeopardised or lost a significant relationship or job. Eg. Gambling instead of being at the birth of a child. 10. Bailout: Receive money from family or friends to bail them out. http://www.youtube.com/watch?v=7aQgpcxVtu0

14. The Biopsychosocial Model

15. Biological Perspective:The dopamine reward system • The effects of dopamine on gambling addiction have become of interest to researchers due to Parkinson’s disease suffers who reported gambling addiction soon after treatment for the disease with dopamine. • Many sufferers of Parkinson’s disease however have not reported gambling addictions despite taking dopamine. • Research has indicated however that dopamine although found in a few areas of the brain has a role in the development and maintenance of addictive gambling.

16. The dopamine reward system • Dopamine is a neurotransmitter that is involved in pleasure, reward, motivation and emotional arousal. • The release of dopamine also contributes to planning and complex motor movements. • Researchers have identified a pathway in the brain where dopamine is concentrated producing a distinct sense of pleasure. • This pathway is known as the ‘dopamine reward system’.

17. The dopamine reward system • Is located in the medial forebrain bundle.

18. The dopamine reward system • Research by Gray 2007 has shown that dopamine is also released in anticipation of receiving a reward. • Research done on animals with the use of classical conditioning and schedules of reinforcement showed that dopamine was released at the presence of light without the UCS (food). • This creates an interaction between psychological and biological perspectives as it is conditioning and schedules of reinforcement that establishes the dopamine reward system.

19. The dopamine reward system • In relation to gambling fMRI imaging has shown that chance monetary rewards activate the brain’s dopamine reward system. • As the reward is never predictable the gambler receives a burst of dopamine into the brain every time they play. • This is also reinforced by socialenvironmental cues resulting in the development and maintenance of a strong response that is very resistant to extinction.

20. Summary • Dopamine is released both for survival when a person is involved in activities that are not crucial for survival. • This may be pathological gambling, the use of alcohol or other illicit substances. • The release of dopamine arouses the brains pleasure centers and this makes the experiences more enjoyable for the person hence the addiction forms. • This means the person becomes so used to this pleasure that when the activity is withdrawn they begin to crave the feeling. • Brain imaging techniques show that pathological gambling taps into the same neural circuits as cocaine addiction.

21. The dopamine reward system • http://www.youtube.com/watch?v=DwNPTP40yy8 • http://www.youtube.com/watch?v=xHm-my2wNGE

22. Gambling addiction and Genetics • Researchers from the University of Missouri and the Queensland Institute of Medical Research in 2007 used an Australian population to show evidence of a link between genetics and gambling. • In this study 2,889 pairs of twins investigated the role of genetic and environmental factors in the development of gambling addiction. • The study found that identical twins who were gamblers were more likely to have a twin who was also a gambler than non-identical twins. The researchers suggest that this association was more to do with a genetic link than environmental factors.

23. Biological Treatment for Gambling • There is no magic pill for problem gambling however one has shown that it can decrease the frequency of gambling behaviour. • Naltrexone has been used as an antagonist inhibiting the neurotransmitter dopamine at the synapse. • It does not cause physical dependence and can be stopped without withdrawal symptoms at any time. It is also used to treat alcohol dependency and addiction to heroin. • Its use can result in decreased feelings of pleasure which therefore limits the compulsion to seek reward from further gambling. • A study conducted by Kim and Grant (2001) showed naltrexone to be very effective in treating participants gambling addiction. • Limitation is side effects that naltrexone causes which is predominately nausea but also can have toxic effects on the liver.

24. Psychological contributing factors • There are two main explanations that demonstrate how psychological factors contribute to the development and maintenance of a gambling addiction: • Learning theories (modeling through observational learning and schedules of reinforcement) • Cognitive processes (distorted patterns of thinking about luck, odds and probabilities) • Social learning theory shows the role of social learning and reinforcement in the development of a gambling addiction.

25. Psychological contributing factors: Social learning theory • Social learning theory and observational learning are often used interchangeably. • It includes concepts like imitation and modeling as it was proposed by Albert Bandura. • Bandura proposed that we are exposed to and learn many different behaviours that we don’t necessarily have to experience ourselves (vicarious). • Social learning theory is a description and explanation of learning that combines operant conditioning and observational learning processes, taking account of the environment or social context in which they occur

26. Psychological Perspective: Social Learning Theory • The social learning theory/observational learning is a combination of learning and cognitive processes used to explain the onset and/or maintenance of addictive gambling. • Bandura had four conditions for social learning to take place attention, retention, reproduction and motivation to perform the behaviour. • A key variable that influences motivation to perform gambling is whether gambling behaviour is observed as being reinforced or punished. • We know these as vicarious reinforcement and vicarious punishment.

27. Social Learning Theory • Researchers have demonstrated that the media portrays gambling by using vicarious reinforcement rather then vicarious punishment. • It is common for younger people to be targeted by the gambling industry such as a ‘young members club’ providing free drinks and free gambling tokens. • Even in Tattslotto and school fetes the emphasis is on winning but never on losing. • This creates misconceptions and false beliefs about gambling. • http://www.crowncasino.com.au/

28. Social Learning Theory: Real-life models • Real life models are people with whom we have direct contact (parents, siblings, teachers). • Some parents expose children to gambling from an early age by ‘family days’ at horse-racing carnivals or children amusement facilities at some gaming establishments. • This creates the impression to children that gambling is a socially acceptable family activity. • There is considerable research that shows if children are first exposed to gambling by their parents and it is seen to be socially acceptable this can lead to the development of problem gambling later in life.

29. Social Learning Theory: Symbolic models • Research indicates the higher the status of the model the more the observer will imitate the behaviour. • Gambling providers spent large sums of money to encourage symbolic models to display their company. • Eg. Shane Warne and ‘888.com’ or the AFL Brownlow Medal awards being held at Crown Casino. • There is clear interaction between social factors (being exposed to gambling) creating flawed cognitive psychological thoughts about it. http://www.youtube.com/watch?v=ta0AIFaW0Z4 http://www.youtube.com/watch?v=ohBDEZLQA64

30. Psychological Perspective: Schedules of Reinforcement • Gamblers are often observed persisting with play through strings of consecutive losses with only a win here and there. • The wins maintain their behaviour but the losses lead to substantial financial repercussions. • In terms of schedules of reinforcement people become accustomed to a partial schedule of reinforcement under which gambling operates. • This means their behaviour becomes highly resistant to extinction and play can be maintained for long sessions without reward.

31. Psychological Perspective: Schedules of Reinforcement • Gambling and in particular poker machines are often described as using a variable ratio reinforcement schedule however they actually use a schedule known as random ratio. • In a variable ratio schedule reinforcement is given after an unpredictable (variable) number (ratio) of correct responses and there is a constant mean number of correct responses for giving reinforcement. • If you had a variable ratio of 20 that would mean that although it is unpredictable over a large number of correct responses, say 100, it would still equal 20 payouts overall. • This is not truly random as there is an upper limit on the maximum number of responses given before reinforcement occurs.

32. Psychological Perspective: Schedules of Reinforcement • A random ratio schedule occurs when the reinforcer is given after a random number of responses and each response has an equal chance of reinforcement. • In a random ratio schedule there is no predetermined upper limit before reinforcement is given. • Each spin is completely independent of the next and it may take 100 0r 1 000 000 responses before the reward is achieved. • On this schedule there is no way to predict when there will be a payout nor is there any way to change the outcome.

33. Psychological Perspective: Schedules of Reinforcement • Unfortunately many gamblers believe that each time they don’t receive a pay out they are getting closer to winning. When a random ratio schedule is used this is a false belief as each event is mutually exclusive.

34. Psychological Treatment for Gambling • Usually a person with a gambling problem will not seek help until they have hit rock bottom. • Psychological treatment for problem gambling can take many forms two of which are: • Cognitive behaviour therapy (focused on thought processes and behaviour) • Psychodynamic psychotherapy (focused on underlying conflicts within the individual.

35. Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) • CBT treatment aims to assist the individual to examine their thought processes and examine other alternatives when looking at their situation. • People experiencing problem gambling typically have irrational thoughts and beliefs about gambling which are referred to as cognitive distortions. • These maintain their gambling behaviour. • Many gambling addicts have cognitive distortions with two of the most common being illusions of control and gambler’s fallacy.

36. Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) • Illusions of control occur when the gambler thinks they can beat the odds using their knowledge or skills. • An illusion of control refers to the mistaken belief that the outcomes of random, unpredictable events can be influenced by one’s thoughts or actions. • The gambler would attribute wins due to their personal actions and losses to factors outside their control. • By using this thought process the gambler will be able to maintain their false belief that their gambling strategies are effective. • This may be things like ‘willing’ a win, talking to and touching a poker machine, having a preferred machine, any sort of ritual when gambling.

37. Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) • The Gambler’s fallacy refers to the belief that in a series of independent chance events, future events can be predicted from past ones. • This is evident in coin tosses (after ten throws of heads there is a more likely chance that the coin will land tails). • At a roulette table certain numbers are ‘due’ because they haven’t come up for a while. • Most people with gambling problems are unaware that they have cognitive distortions.

38. Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) • The first step of the cognitive component when using CBT is to help the person identify and correct distorted thoughts, beliefs and attitudes about playing and winning games of chance (identifying their cognitive distortions). • The next step involves educating the person to develop an awareness of concepts such as probability, random and chance events (that there is no predictability). • An important aspect of CBT is to encourage the individual to directly challenge and correct their distorted thoughts and provide problem solving strategies to gain control over their impulses.

39. Psychological Treatment for Gambling: Cognitive behavioural therapy (CBT) • The behavioural component of CBT assists the individual to manage the arousal, anxiety or tension that is associated with the urges to gamble. • A common method of achieving this is using imaginal desensitisation. • Imaginal desensitisation exposes the individual to mental images of gambling opportunities while they are in a state of relaxation, so that over time they associate feelings of relaxation with gambling rather than tension and arousal. • Imaginal desensitisation is a three step process designed in the same way as systematic desensitisation. http://www.youtube.com/watch?v=JSO6iAFekPw http://www.youtube.com/watch?v=5g2-qzYhwgY&feature=related

40. Psychological Treatment for Gambling: Psychodynamic psychotherapy • Based on Freud’s theory that all mental disorders are caused by unresolved psychological conflicts that occur in the unconscious with their origins being in early childhood. • The aim of this treatment is to help people to understand the cause of the emotional distress which for problem gambling revolves around the Oedipal complex. • When using the psychodynamic approach the therapist will try to achieve abstinence (voluntary restraint from the activity) from gambling which can be a lengthy process thus it is important that the client is an active participant.

41. Psychological Treatment for Gambling: Psychodynamic psychotherapy • When treating problem gambling therapists use a range of techniques such as free association, dream interpretation, identification of defence mechanisms and displays of transference. • Free association is when the client is encouraged to say whatever comes to their minds in order to identify the themes involved in their gambling. The themes may be power, overconfidence, helplessness or emptiness. • Dream interpretation involves clients sharing their dreams as the psychodynamic perspective has the belief that dreams symbolically represent information stored in the unconscious mind.

42. Psychological Treatment for Gambling: Psychodynamic psychotherapy • Identification of defence mechanisms is essential for treatment to work as it prevents the unconscious conflicts from being explored and resolved. Denial (refusal to believe whatever it is that may be causing one’s anxiety or emotional conflict) and omnipotence (the feeling of being all powerful and defence against feelings of inadequacy and helplessness) are two common defence mechanisms that gamblers use. • Transference provides a valuable source of information by the client unconsciously responding to the therapist as though they are a significant person in their life. • Limitation of this approach is it is hard to scientifically examine the unconscious and obtain empirical data. http://www.youtube.com/watch?v=oS_L8efaJ-E&feature=related

43. Socio-cultural contributing factors • Important contributory factors to gambling addiction are: • Transmission of information that gambling is acceptable • That gambling is legal and there are so many points of access to gambling venues • The potential for significant harm from some types of gambling is what distinguishes gambling from most other enjoyable recreational activities.

44. Socio-cultural Perspective: Social permission to Gamble • Many psychologists believe that an important factor for problem gambling is that it is considered as acceptable within a socio-cultural context. • Gambling is regarded by many Australians as part of their cultural heritage. Around three in four Australians gamble at some time in the year. • There is the Melbourne Cup, two-up during Anzac day and constant advertising that provides and reinforces a positive image of gambling in our society. • Research indicates that when there is a perception that gambling is socially acceptable younger people are more likely to try gambling and less likely to associate negative consequences with it.

45. Socio-cultural Perspective: Social permission to Gamble • There is also research to indicate that the number of people in a community that undertake gambling is related to promotion, accessibility and availability of gambling outlets. • Some other social factors that can contribute to gambling problems include: boredom, unemployment and relationship issues.

46. Social Treatment for Gambling: Social networks • The term social network refers to various individuals or groups who maintain a relationship with an individual in different aspects of their lives. • The main benefit of a social network is social support in the form of appraisal, information and emotional support as well as tangible assistance. • One limitation with social networks for gamblers is that it usually involves other problem gamblers which makes it very difficult for abstinence to occur.

47. Social Treatment for Gambling: Recovery groups • A recovery group is typically a non profit organisation facilitated by and for people who interact on the basis of common interests or experiences to support one another. • The assumption of all support groups is that recovery is possible and that by drawing on the groups experiences this will be achieved using a step by step process. • These can be open groups where individuals can join at any time or closed groups that have no additional admittance to the sessions once started.

48. Social Treatment for Gambling: Recovery groups • Typically a psychologist, social worker or someone who has recovered from pathological gambling is invited to the session. • Gamblers anonymous (GA)- one of the best known recovery groups was established in 1957 in California. • Sessions run for 90 minutes, there are no fees with the only requirement for membership being a desire to stop gambling. • The initial process in recovery for the problem gambler is admitting they are powerless in controlling their gambling and surrendering to a ‘higher power’.

49. Social Treatment for Gambling: Recovery groups • Another key feature of GA is having a sponsor who is a former problem gambler who has remained abstinent and can provide support and guidance through the recovery process. • GA although social in its structure does use some psychological theories such as: • Positive reinforcement when the gambler is given rewards from not gambling for a period of time. • Behavioural techniques that provide different social activities other then gambling.

50. Social Treatment for Gambling: Recovery groups 3. Cognitive approaches encourage problem gamblers to take one day at a time thus decisions are more likely to be rational and self-controlling (Grant, 2007). • Some of the limitations of GA is that: 1. It believes that abstinence is the only solution for problem gambling. There has been empirical research to show a reduced and responsible gambling behaviour for some people can be a realistic goal. 2. GA is more likely to be effective when used in combination with psychological therapy. http://www.youtube.com/watch?v=M7Ddmf8VNDQ