A study in gambling - Karl and Stella from Corrie
Karl Munro and his partner Stella arrived in Coronation Street a year ago. She is the bar manager of the ‘Rovers Return’ and he is taken on as a taxi driver for ‘Street Cars’. Karl’s gambling was revealed in early episodes but, in the first few weeks of April 2012 as his debts have mounted, he has been lying to his employer and it has got out of his control. In his desperation he staged a mock burglary and stole money from the pub safe.
However, this desperate act is not enough and his lies begin to unravel and news of his addiction spreads as the bailiffs arrive to recover property to cover his debts.
Stella confronts him and Karl says:
‘What can I say, I messed up big time, things got out of hand… I lost control. It started off with a little flutter here, a bet there and before you know it you’re chasing your losses and this is where you end up’.
Stella yells back ‘…so is this it, should I expect any more surprises?’
Karl says ‘I should never have let it get this bad, but for a while it was working and I did it for you’.
Stella is incredulous ‘You did it for me?’
Karl pleads ‘...so we could buy the pub and live the dream.’
Stella spells it out: ‘Karl, you have gambled thousands and thousands.’
Still in the grip of the addiction he says: ‘…one big win and I could have paid it all off.’
It is not clear yet how Karl and Stella will work this out and what Karl will do about his gambling addiction. Will he accept that he has a problem, will he ‘really’ want to change and will he seek treatment? Stella is the driving force in the relationship and has been left sorting out the £20,000 debt Karl has accumulated. If they stay together, she may insist that Karl gets treatment. If so, would she be right to insist on something more than a Person-Centred Therapy Approach?
Before we discuss his treatment options, it may be helpful to understand a bit more about Karl, what sort of gambler he is and why he gambles in the first place. This seems significant, although Gamblers Anonymous (GA) would suggest otherwise.
The Questions and Answers on their website read:
‘Is knowing why we gambled important?'
'Not as a rule. Of the many GA members who have had extended psychiatric treatment, none have found a knowledge of why they gambled to be of value insofar as stopping gambling.’
Definitions of Gambling
Some definitions refer to problem gambling in relation to symptoms such as time spent gambling and frequency of episodes. Most definitions of compulsive or pathological gambling refer to situations where gambling behaviour has given rise to ‘harm’ of the individual, his or her family or community. It is also described as a problem if the individual appears to have an impaired sense of control, often defined by repeated, unsuccessful attempts to resist the urge to gamble in the context of a genuine desire to stop. This is reflected in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria listed in the attachment.
More broadly, and considering addictive behaviour in general, Griffen and Tyrrell (2005) argue that anyone who engages in compulsive activity, like gambling, is probably doing so because they are not getting important needs met in their life. People who gamble are doing it to satisfy something within them. This appears to be true of Karl Munro who is portrayed as having unmet needs around status and power because, compared to Stella, he feels inferior, inadequate and unimportant and recently he has felt rejected because he has discovered that there were some significant issues in her life she has not shared with him.
This has probably left him feeling unfulfilled and useless and the ‘high’ he gets from gambling may help him to cope with the disappointments in his life. The ‘lows’, he may feel, are a legitimate form of ‘punishment’ for something – exactly what that is not clear.
Learning theory helps us to understand how the ‘buzz’ from gambling and the gambling environment creates states of arousal. Conditioning reinforces the behaviour and a persistent habitual pattern is formed: ‘If I do this, I feel that’. There are also the distorted cognitive processes resulting in faulty beliefs related to personal skill, control over the outcome and the probability of winning - Karl says ‘…one big win and I could have paid it all off.’ However, this does not explain why only some gamblers appear to lose control and why only some social gamblers become pathological gamblers.
There is a strong correlation between addiction and depression and, according to Blaszczynski and Nower (2001) three-quarters of problem gamblers also manifest symptoms of depression. Some use gambling to induce dissociation or to escape states of chronic depression or boredom. Of course, depression may also be a consequence rather than a cause of excessive gambling because of ‘losing streaks’, a financial crisis, the break-up of a relationship, loss of security and so on. There may also be a higher risk of suicide in gamblers than in the general population but, although this seems likely, the evidence according to Littman-Sharp (2004) is inconclusive.
Rosenthal and Lesieur (1992) refer to some gamblers as ‘action seekers’. These gamblers are characterised by needing stimulating competitive situations where there are big pay-offs and opportunities to impress. This could be found in casinos or ‘at the races’, whereas the depressed profile gamblers would more typically be attracted to slot machines, the internet and more socially isolating repetitive activities.
The description of gambling offered by GA and the one they say is favoured by most of their members is: ‘an illness, progressive in nature, which can never be cured, but can be arrested.’ Given this definition, it is logical that they would recommend total abstinence as the only approach. This behavioural approach appears to work for some, but the psychological aspects may also need to be understood and attended to or the client may simply substitute one addictive behaviour for another, or will continue to stop and then lapse, or get stuck in the ‘maintenance phase’ of the ‘cycle of change’ (see below).
The Person-Centred Therapy Approach
The Person-Centred approach, formulated by Carl Rogers, proposed that when two people are in a therapeutic relationship and the core conditions are present, constructive personality change would occur. The core conditions are: contact, empathy, unconditional positive regard, congruence and perception (that is, that the client ‘perceives’ the acceptance, authenticity and empathy on the part of the counsellor). The approach regards the relationships that counsellors have with their clients, and the attitude that they hold within that relationship, to be key factors.
As Bryant-Jefferies explains: ‘From the theoretical perspective we can argue that the person-centred counsellor’s role is essentially facilitative. Creating the therapeutic climate of empathic understanding, unconditional positive regard and authenticity creates a relational climate which encourages the client to move into a more fluid state with openness to their own experience and the discovery of a capacity towards a fuller actualising of their potential.’ (2005 p 14).
The person-centred therapist trusts the ‘actualising tendency’ of the client and believes that, given the core conditions, the client will seek to resolve their difficulties and move to a position which will allow them to realise their full potential. In the safety of a therapeutic environment the client begins to explore and understand their own processes and needs. After this, constructive change can begin, which Embleton Tudor et al describe as ‘a movement from fixity to fluidity, from closed to open, from tight to loose, and from afraid to accepting’. (2004 p 47)
So, in the case of Karl Munro, and in Rogerian terms, he may have grown up believing that his ‘worth’ is ‘conditional’ on him being the strong provider in the relationship. For him to have ‘worth’ he must impress and prove himself to Stella and provide her with the means to realise her ambition of owning the pub and ‘living the dream’. Stella has never said that this is what she wants from him (and actually it isn’t) but it is likely that the values of others, maybe of his parents, have become a feature of Karl’s structure of ‘self’ and what he believes is the condition of him having ‘worth’ in the relationship and in the adult world. Whilst he has yet to prove himself worthy, his gambling habit provides an escape and at the same time continues to give him hope that the role of the strong provider is just one bet away.
If Karl experiences person-centred therapy, his state of being and patterns of conditioning will be challenged by the therapist offering him unconditional positive regard and a non-judgemental warm acceptance. This may enable him to liberate himself from the patterns of conditioning and make a shift away from what he believes are the conditions of this own worth. This may take time, and certainly may not be quick enough for Stella, but the therapy provides an opportunity for the individual to explore and unravel a sense of self that may have been developed, sustained and reinforced over many decades and allow the space for the client to re-define their manner of experiencing and relating to themselves in the world.
If it is perceived that there are limitations to the Person-Centred approach they are that, instead of challenging the client, the therapist’s role is to offer warm acceptance and ensure that the client is being heard. The counsellor’s role is to listen and maintain unconditional positive regard whatever the client says, even if the client decides to continue gambling and does not see it as a problem. If the Person-Centred therapist were to challenge their clients, Bryant-Jefferies argues this could: ‘disrupt their structure of self before the internal processes within that structure have brought the structure to the point at which it naturally has to change under pressure from the working of the actualising tendency.’ (2005 p 107)
Some may argue that the Person-Centred counsellor, in offering warm acceptance, is too passive and is simply colluding with an unreal perspective. However, the Counsellor would defend the process by saying that the unreality is being taken from the Counsellor’s frame of reference and not from the clients. The urge to change may be present along with an urge not to change. It is important that the client reaches their own sense of needing to change and how to make that change. Being warmly accepted helps the client to develop their thinking, minimising the urge to maintain the status quo and strengthening that part of them that is focussing on the urge to change. If the Counsellor attempted to point out the need to change to the client who is not ready, the client is likely to deny or block the possibility. In addition, a change in behaviour that is made to please others, or just to comply, is unlikely to be sustained.
Aaron Beck et al (1979) developed Cognitive Behavioural Therapy as a new type of psychotherapy that differed from traditional Psychoanalytic or Person-Centred therapy in that the therapist is constantly active and deliberately interacting with the client. Whilst Beck and his colleagues continued to regard the therapeutic relationship to be key, they also found that a more structured approach, over a shorter time period, focussing on the clients internal thinking processes in the ‘here and now’, to be successful in some circumstances. The cognitive therapist actively collaborates with the client setting up schedules of activity and agreeing homework assignments. Beck said that, in his experience, the more passive therapy approaches involving only minimal activity on the part of the therapist could adversely affect depressed clients allowing them to ‘sink further into the morass of …negative preoccupations.’ (p. 7)
The cycle of change
The ‘cycle of change’ model, derived in the early 1980s by two American psychologists Prochaska and DiClemete describes the process and stages people pass through when undergoing change. The cycle of change can be used with person-centred counselling but the counsellor does not direct the client or ‘get ahead’ of the client. The model is used to inform the process and the counselling should proceed at the pace set by the client.
Not interested in changing a ‘risky’ lifestyle
Lapse or relapse
Stable ‘safer’ lifestyle
Thinking about change
Preparing to change
- Pre-contemplation – the client will not be thinking about change and this may because they simply do not see their gambling is a problem. Or, it could be that they recognise that it has become an issue, but find the idea of change too difficult or uncomfortable to consider and they have pushed the idea aside, choosing to ignore it and carry on as they have been. This might be described as denial and it may mean that the client is in a state of incongruence which is one of the necessary conditions for change. With a supportive therapeutic climate the client may, or may not, become ready to contemplate change.
- Contemplation – the client is recognising their discomfort about gambling and is beginning to think about change – exploring it and weighing it up. This can be a lengthy process. At this stage the client may be keeping a diary about their gambling to understand the quantity, pattern and type and their triggers for gambling. The gambling experience can mean many things to different people, for example, the lone gambler on the internet or the individual gambling on the horses as part of a social group. During this stage the client may decide, for whatever reasons, not to pursue change. The reasons and decisions must be warmly and genuinely accepted by the person-centred counsellor.
- Preparing for change – at this point the client will have recognised that, on balance, they want to make changes and they will begin to plan their strategy. This will require realistic goals and timeframes. Some clients will aim for abstinence, others for a more ‘controlled gambling’ regime. The risks of lapse or relapse should be discussed at this stage along with ways of minimising them or of responding to them so that the change is not abandoned.
- Action – the plan is put into action and monitored by the client and discussed in therapy. Support systems will be in place and the client may be introducing other areas of interest and social experience into their life and breaking up existing patterns.
- Maintenance – it may be sometime before the client feels that they no longer have to make themselves avoid gambling or maintain control. This will vary from client to client. The individual has to pass through a psychological process of accepting themselves as a person who does not gamble, or gambles in a particular way, or to a certain level. At this point they will leave the cycle having created a ‘stable’ safer lifestyle.
- Lapse or relapse – the reason for the slip or lapse may be something that was foreseen, but for which planning was not adequate, or something unexpected. The task at this stage will be to ensure that the lapse does not become a relapse.
There are exit points from the cycle either in contemplation or preparation, if the client feels that the time is not right for change, or they are just not able to sustain the motivation. They can exit from maintenance having achieved their goal, whether this is a change in the nature of the gambling habit, or in the amount gambled. Finally, they may exit from lapse or relapse, going back into their previous pattern of gambling as a result of which they may choose not to try to change, or they may return to pre-contemplation to assess and learn from their process so far.
The Pathways Model
There may be some common characteristics round addiction and the process of ‘recovery’. However, gamblers also have very different backgrounds, needs and personalities and this may suggest that they require different approaches to treatment. Blaszczynski and Nower (2002) have developed a model of three distinct subgroups of pathological gamblers that they describe as a ‘pathways model’ suggesting that there are three different routes into gambling and three different treatment routes out again the model demonstrates that individuals will require differential treatment interventions based on their particular etiology.
Behaviourally conditioned problem gamblers
These gamblers are essentially healthy before their problems begin but are described as falling victim to circumstances such as easy access to gambling, poor judgement and a misunderstanding of the odds. Their gambling will tend to fluctuate but can become excessive. They tend to respond quickly to fairly minimal treatment and are more likely to successfully reduce (rather than stop) their gambling, if this is their choice. Cognitive therapies may help with distorted thinking and irrational schemas whilst psychodynamic approaches may be of benefit in dealing with unresolved conflicts and issues arising from ‘conditions of worth’. In this group it is also possible that ‘natural recovery’ may take place without recourse to any formal treatment.
Emotionally vulnerable problem gamblers
These gamblers have a predisposition to a gambling problem through a disturbed family or personal history and/or precursors such as another addiction, trauma, depression, low self-esteem, rejection, or inadequacy. They gamble as an escape from negative moods and are affected by the same triggers as the first group – easy access and a misunderstanding of the odds. Given the vulnerability of this group, abstinence is generally the most realistic goal.
Antisocial, ‘impulsivist’ problem gamblers
This group includes individuals with the tendency to impulsive behaviour found in attention deficit/hyperactivity disorder (ADHD). This may exist concurrently with other problems such as substance use, chronic boredom, inadequate social skills, social instability, criminal offences, anxiety and poor school or work performance. There may be a vulnerability to weakened control and dysfunctional behaviour in other areas and this will tend to pre-date the gambling. These clients will tend to be inconsistent and unreliable and are also generally poor candidates for the goal of reduced gambling. Treatment may include intensive cognitive-behavioural interventions aimed at impulse control and/or medication to balance the neurochemistry. Blaszczynski et al also report on early evidence of correlation between a genetic variant and pathological gamblers and individuals with impulse control disorders. This may have implications in the future for pharmacological treatment.
The basis of the Person-Centred Therapy approach is that, given the core conditions, the self-actualising tendency will take the client to where he needs to be and this will be the case for all issues including an addiction to gambling. However, cognitive behavioural approaches are also likely to assist where there are faulty beliefs and tools like the ‘cycle of change’ may help with providing structure and a greater understanding of the process of change.
Beck, A. T. Rush, John. A. Shaw, Brian F and Emery, Gary (1979) Cognitive Therapy of Depression
Blaszczynski, Alex. and Nower, Lia. (2002) A pathways model of problem and pathological gambling in Society for Study of Addiction to Alcohol and Other Drugs
Bryant-Jefferies, Richard. (2005) Counselling for Problem Gambling Person-Centred Dialogues
DiClemente, C.C. and Prochaska, J.O. (1988) Towards a comprehensive, transtheoretical model of change: stages of change and addictive behaviours. In Miller, W. and Heather, N. (eds) Treating Addictive Behaviour
Embleton Tudor, L. Keema, K. Tudor, K. et al (2004) The Person-Centred Approach: A Contemporary Introduction.
Gamblers Anonymous: www.gamblersanonymous.org.uk
Griffen, Joe. Tyrrell, Ivan. Winn, Denise. (2005) Freedom from Addiction. The Secret behind successful addiction busting.
Littman-Sharp. Nina. (2004) Introduction to the Treatment of Problem Gambling. Alcohol & Drug Problems: A Practical Guide for Counsellors. Edited by Harrison, S and Carver, V. Problem Gambling Institute of Ontario, Centre for Addiction and Mental Health: http://www.problemgambling.ca/gambling-help/gambling-information/what-is-problem-gambling.aspx
Reilly, Christine. Shaffer, Howard J.(2009)Increasing the Odds: Roads to Recovery from Gambling Addiction. Volume 2 National Center for Responsible Gaming (NCRG)
Rosenthal, R and Lesieur, H (1992) Self-reported withdrawal symptoms and pathological gambling American Journal of Addictions
DSM - IVCriteria: Pathological Gambling
A. Persistent and recurrent maladaptive gambling behaviour as indicated by five (or more) of the following:
1. Is preoccupied with gambling (e.g. preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble).
2. Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
3. Has repeated unsuccessful efforts to control, cut back, or stop gambling.
4. Is restless or irritable when attempting to cut down or stop gambling.
5. Gambles as a way of escaping from problems or of relieving a dysphonic mood (e.g. feelings of helplessness, guilt, anxiety, depression).
6. After losing money gambling, often returns another day to get even (“chasing” one’s losses).
7. Lies to family members, therapist, or others to conceal the extent of involvement with gambling.
8. Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling.
9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
10. Relies on others to provide money to relieve a desperate financial situation caused by gambling.
B. The gambling behavior is not better accounted for by a Manic Episode.
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.
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