Inter-personal
•
Social Support
– Positive social support and social network is highly predictive of
long-term abstinence rates
– Meanwhile negative social support (interpersonal conflict, social
pressure to use, anti-personality traits / cue exposure) is an
increase risk for relapse
– Functional support (spouse sharing in goals) appears to predict
best outcomes following treatment at both 3months and 15
months
Craving
• According to Marlatt and Witkiewitz(2005)
coping is the most widely studied, but
misunderstood concept in the addictions field
• Craving is both the physical and psychological
and is has been married to the notion of loss of
control
• Research has disconfirmed loss of control
hypothesis
Craving (cont.)
• Research has also shown that there is a lack of strong
association between subjective reports of craving and
relaspe.
• However, the correlates and underlying mechanisms of
craving may still predict relaspe
• Thus Marlatt et al. 1999 distinguish between an urge to
use from that of a subjective desire to use (which is
closer to what they understand as craving)
Inter-personal
•
Social Support
– Positive social support and social network is highly predictive of
long-term abstinence rates
– Meanwhile negative social support (interpersonal conflict, social
pressure to use, anti-personality traits / cue exposure) is an
increase risk for relapse
– Functional support (spouse sharing in goals) appears to predict
best outcomes following treatment at both 3months and 15
months
Toward the Future: Linear to
Dynamic and Multidimensional
Models
• Need for greater understanding
What are we learning?
Witikiewitz and Marlatt, 2007
Richard Rosenthal – Staying in the Action
• Modern day psychoanalyst,
psychiatrist, has been treating
gamblers and substance abusers
for twenty-years.
• Greatly responsible for the DSM
criteria of the pathological
gambler.
• Although trained in
psychoanalysis, largely studies
the process by which gambling
and addiction continues and how
to go about treating it.
Rosenthal and the Gambler’s Defenses
•
For Rosenthal, treatment of the pathological
gambler lies in the understanding, of how these
five defense mechanisms:
1.
2.
3.
4.
5.
•
Omnipotence
Splitting
Idealization/devaluation
Projection, and
Denial
Interact and help the gambler control his/her inner
and outerworld(s), although eventually leading to
their demise.
Omnipotence:
• Refers to feeling of being all powerful, which is a
direct defense against feelings of helplessness.
• This is a quality found in a great deal of gamblers
and is exempflied in their wishful thinking.
• I will win because I have to win or I can will myself
to win (despite the house odds).
Splitting:
• Is a defense mechanism whereby the gambler thinks
himself/herself to be two separate people.
• One is all good: the “winner,” and the other, all bad:
the “loser.” Hence, the gambler oscillates between
these two personalities types.
• One hand, they can act all powerful whereby they
seek to try to control others, thus, repressing the
loser into the background.
Idealization and Devaluing
• Essentially, the idea of
controlling others is seen
in either, I idealize you,
or I devalue you.
– Thus, as much research
points out, we see why
gambler’s appear to have
problems with intimacy,
because the relationship is
based on. . .
Projection
• Process of casting your feelings, thoughts, judgments
onto somebody else.
• Hence, the gambler routinely goes about controlling
his inner world by devaluing/idealizing others.
• He or she can then deal with the division with
themselves (splitting, good or bad), but never really
perceiving that it is them who are bad and good.
DENIAL
• Or that people themselves can be bad or good, a
milestone that the self usually negotiates between
the age of 0 – 6.
Rosenthal and Treatment
• Ultimately, Rosenthal suggest that successful
therapy hinges on helping the client realize
that they are employing the latter defense
mechanisms.
• Not to mention how they are related to
current gambling binges, and possibly how
and why such defenses originated in the first
place.
Rosenthal and Treatment
•
The question maybe asked then,
“How does the therapist go about
bringing these defenses to the
clients awareness . . .
•
The answer is simple, the patient
will try to deceive the therapist,
idealize him or her, or devalue him/
her, thus projecting their good and
bad onto to him or her.
•
Hence, learning to hold such
projections, while equally learning
when to help the client peel away
their defenses, is key to assessing
the role that gambling plays in the
client’s life, and why there is a
need to feel omnipotent in the first
place.
Rosenthal and Further Insights: Staying in
the Action
• Most recently, Rosenthal has brought attention to the issue of
dry drunk syndrome and this operates in the gambler; a terms
he calls “staying in the action.”
• While it is know that most substance abusers have to remain
abstinent, it is a near impossibility for gambler’s to not indulge
in the use of money, similar to eating disorders.
• Thus, this poses a risk for the gambler as they are somewhat
still involved in the action (at least when it comes to money).
Staying in the Action: I’m Not Talking
about Money.
•
And yet, using money is not the only way in which the gambler stays
in the action.
•
As Rosenthal’s clinical research makes clear, and suggests, that
there are many ways for the gambler to take risks, or remain in a
gambling mind-set, without making a bet.
•
Examples of staying in the action
1.
2.
3.
4.
5.
6.
Mind Bets
Success
Playing with Reality
Covert gambling
Lying, cheating and stealing, and;
Switching addictions
Staying in the Action: Through the Guise of
Switching to another Addiction.
• The concept of dual
addiction is not new, but
Rosenthal suggests that
a dual addiction for the
gambler might not be
the case.
• Essentially, their
supposed co-addiction,
may actually represent
gambling phenomena or
an unconscious or covert
way of staying in the
action.
Switching Addictions: One gambler stated,
•
After a period of individual therapy and regular attendance at Gamblers
Anonymous, Mr. A appeared to have turned his life around. He
abstained from gambling, which no longer seemed attractive, and his
old debts were being paid off. He had remarried (his first wife divorced
him because of his gambling), and claimed he and his wife were
happy. His career had gone in a new direction and he was doing even
better than before. He worked hard, but got satisfaction from his work.
His employer and clients praised his accomplishments, and he was
rewarded with frequent bonuses. By all accounts he would be
considered successful.
• What was wrong? With a great deal of embarrassment, he
confided that he had begun frequenting prostitutes. He
attempted to rationalize his behavior by telling the therapist that
his sex drive was stronger than his wife's, and that she had
been less available for him recently because of their different
work schedules, and because of her involvement with her ailing
mother. His turning to prostitutes, he said, was "quick and
easy."
•
As he continued talking, the self-deception became obvious. If all he
wanted was sexual gratification, he knew a number of women willing
to accommodate him. He was a good looking, rather charming and
outwardly confident young man, and women were sometimes quite
forward in indicating interest. They did not even seem to mind that he
was married. However, he rejected any and all such opportunities,
preferring instead to seek out prostitutes on the street.
•
Such assignations were anything but "quick and easy." He experienced
enormous anxiety that the prostitute would give him AIDS or some
other disease which he would then pass on to his wife, or that the
prostitute would turn out to be a policewoman and he would be
arrested. In addition, he was certain that if his behavior became
known, his wife would leave him and his career would be ruined. It
dawned on him that he was gambling, and that the more he engaged
in this behavior, the more certain he was to lose.
– Why, he then asked, when he found a prostitute who appeared "safe,"
would he not go back to her, but would insist on trying someone different
each time?
• Obviously he either wanted to lose, or was excited by the risk of
jeopardizing everything and escaping unharmed.
• Mr. A then recognized that the feelings he had while looking for
prostitutes were identical to the feelings previously experienced
gambling. He not only had the same "rush," but the compulsive
aspects were the same. He would find himself preoccupied by it
while at work, inventing excuses for driving home through
neighborhoods where there were streetwalkers. The
anticipation, and the guilt afterwards, and the need to lie about
where he spent his time and money, all reminded him of his
previous gambling.
Opinions Please?
• What do
folks think
about this
case?
• Is it
gambling or
is it a sex
addiction?
Switching Addiction and Treatment
• For Rosenthal, gambling and his sexual compulsion
can be fused, which is not an uncommon occurrence.
• However, when looking at addiction this way, the
therapist needs to be sure that the phenomena
he/she is hearing is actually what is happening.
• Thus, making treatment easier, despite the
complexity in treating an addiction switcher.
Switching Addiction and Treatment
• Essentially, at the core of the behavior was risktaking, and more pertinently, reliving / reenacting
former gambling behaviors.
• As such, these behaviors needed to be pointed out,
investigated, and brought to light, whereby staying in
the action is understood fully by both client and
therapist alike.
Lying, Cheating, Stealing
• A second way gamblers stay in the action is
through, lying, cheating, and stealing.
• For some pathological gambles, lying,
cheating, and stealing are the heart of their
addictive behavior.
• Even after maintaining abstinence, LCS, may
still frequent the gambler’s mindset.
Confronting Lying, Cheating, Stealing
• Hence, sometimes the slightest transgressions on part of the
client need to be investigated.
• Because part of the pathological gambler’s game is to have the
therapist collude with them.
• And in this collusion, the gambler wants them to accept their
dishonesty, as something that cannot be changed. (At least I
don’t gamble, right?)
• Rosenthal suggests, that by not confronting the gambler on
such matters, the client is unconsciously devaluing the therapist,
themselves, and the work they have done together.
Case of Magazine theft. . .
•
Mr. D took a magazine from the waiting room and brought it into the
session with him, and then, afterwards, while driving home, realized he
still had it with him. Actually he had wanted to finish reading an article,
so his forgetting, although not conscious, nevertheless served a purpose.
He had not thought of asking if he could borrow it, because the therapist
might say no, and besides it would have made him aware of his
dependency on another person, something he went to great lengths to
avoid. He did have a momentary thought that he should go back and
return the magazine, but "put it out of (his) mind.”
•
The following week he forgot to bring the magazine with him for his
appointment. He intended to mention it but started talking about
something else, and it was again forgotten. He was shocked when the
therapist brought it up halfway through the session, and referred to it as
a kind of stealing. Mr. D became very defensive, and argued that
everybody did things like that, but then realized that he had been feeling
particularly uncomfortable about coming for the session, and had not
known why.
• Nevertheless, he persisted in trying to trivialize the incident, and
could not accept the therapist's contention that it was
something for them to examine in the session. It was only later
that he could admit to other "omissions"—obligations that were
forgotten, bills he ignored, promises he failed to keep—a
pattern of lying and cheating that he had not consciously
recognized. By stealing the magazine, the patient was gambling
that he could get away with it.
• He was also protecting, and trying to keep out of the therapy, a
part of his personality that believed these kinds of activities
were all right. This included his secrecy and sense of
entitlement. Only when this was acknowledged and dealt with
was there any chance of recovery.
Primitive Avoidance and Case of the
Magazine Theft.
• According to Rosenthal, this example illustrates not only how
one little lie or omission can lead to another, but the kind of
"primitive avoidance" so common among pathological gamblers.
• Hence, uncomfortable realities can be just put out of mind, or
"shoved under the rug.” But, the therapist cannot let little
things like this go, because if they do, they actually are enabling
covert behaviors to continue possible leading to full blown
relapse.
• Thus, Rosenthal suggests that the pathological gambler must
develop, or reestablish, an internalized value system based on
honesty and integrity.
Guilt and Staying in the Action
• And the only way to help the gambler deal with their staying in
the action behaviors, is to have the gambler take responsibility
for their dishonesty.
• Hence, as evidenced in a great deal of psychodynamic theories
presented, the gambler needs to dispel their guilt.
• Which is done by not decreasing their discomfort over their
guilty actions and allowing them to get away with it, but to
actively challenge it and get to the bottom of why the guilt is
their in the first place.
Guilt and Staying in the Action
• One of the major
reasons for intractable or
unrelenting guilt is the
continuation of some
harmful behavior,
however covert, subtle,
or rationalized.
• The first step toward
self-forgiveness is an
acknowledgment of
change. In other words,
being able to say “I used
to do such-and-such. I
don't do that any more.”