Cover

Table of Contents

Cover

Endorsements

Title page

Copyright page

Dedication

Preface

WHAT IS PATHOLOGICAL GAMBLING?

SELF-DIRECTED RECOVERY FROM GAMBLING

Acknowledgments

Introduction: How to Use This Book

THERE ARE NO RULES

HOW THIS BOOK IS ORGANIZED

WHERE TO START

WHERE DO YOU GO FROM HERE?

Part 1: How to Begin

1 Assessing Your Problems

WHAT DOES IT MEAN TO BE ADDICTED TO GAMBLING?

THE STAGES OF ADDICTION

ARE YOU STRUGGLING WITH GAMBLING ADDICTION?

WHAT OTHER PROBLEMS ARE YOU EXPERIENCING?

WHERE DO YOU GO FROM HERE?

2 Connecting the Dots

THE NINE DOT PROBLEM

WHAT YOU CAN LEARN FROM THE NINE DOT PROBLEM

WHERE DO YOU GO FROM HERE?

3 Setting Goals to Help You Change

WHAT YOU NEED TO KNOW ABOUT GOAL SETTING

GOAL SETTING, STEP-BY-STEP

SUMMING UP GOAL SETTING

WHERE DO YOU GO FROM HERE?

Part 2: How to Change

4 Getting Your Gambling Under Control

WHAT IS PROBLEM GAMBLING?

MODERATION VERSUS ABSTINENCE

MAKING CHANGES

WHERE DO YOU GO FROM HERE?

5 Anxiety and Gambling

TYPES OF ANXIETY

THE ANXIETY-GAMBLING CONNECTION

MAKING CHANGES

WHERE DO YOU GO FROM HERE?

6 Mood Disorders and Gambling

TYPES OF MOOD PROBLEMS

GAMBLING AND MOOD

MAKING CHANGES

WHERE DO YOU GO FROM HERE?

7 Impulse Control and Gambling

DIFFERENT FORMS OF IMPULSE CONTROL PROBLEMS

MAKING CHANGES

WHERE DO YOU GO FROM HERE?

8 Substance Abuse and Gambling

SUBSTANCE ABUSE

SUBSTANCE DEPENDENCE

GAMBLING AND SUBSTANCE ABUSE

MAKING CHANGES

WHERE DO YOU GO FROM HERE?

Part 3: How to Stay the Course

9 Preventing Relapses

UNDERSTANDING TRIGGERS

WHAT ARE YOUR TRIGGERS?

UNDERSTANDING SLIPUPS

DEALING WITH A SLIPUP

WHERE DO YOU GO FROM HERE?

Resources and Further Reading

References

About the Authors

About Harvard Medical School

Index

More Praise for Change Your Gambling, Change Your Life

“From recognizing the problem to changing your daily patterns to living a life beyond the dream of hitting it big, this book will transform your thinking about gambling and put you on the path to real change and long-term recovery.”—Christopher Kennedy Lawford, author, Symptoms of Withdrawal and Moments of Clarity



“This is a well-written and easily accessible book that provides the tools for individuals to take control of their gambling problem. In an era where professional addiction treatments are common and yet frequently unsuccessful, it is exciting to see a comprehensive, self-directed approach to addiction recovery.”—Jon E. Grant, MD, JD, MPH, professor of psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota; coauthor, Pathological Gambling



“The self-directed approach to addiction recovery is getting the attention it deserves with this must-read book for people who want to work through a gambling problem on their own. Kudos to Dr. Shaffer and his coauthors for meaningfully advancing the problem gambling treatment field with this book.”—Ken C. Winters, professor, Department of Psychiatry, University of Minnesota Medical School



“The topics of gambling and gambling problems often lead to politically and emotionally charged discussions that ignore the needs of the small percentage of people who need help. Dr. Shaffer and his colleagues have removed the value judgments and provided a thoughtful, authoritative manual for those in need.”—Frank J. Fahrenkopf, Jr., president and CEO, American Gaming Association



“At the Dunes, our clients have seen profound results from using the exercises in the chapters on anxiety and relapse prevention. Dr. Shaffer and his colleagues have come up with a practical way to combat addiction, one thought at a time. Valuable for clients, clinicians, and anyone with an addiction problem.”—Madeleine Narvilas, Esq., LMSW, executive director, The Dunes East Hampton



“The authors have devoted decades of time and energy to the study and treatment of people whose gambling has caused them problems. They have condensed and translated this wealth of experience into a book that is state-of-the-science and accessible to all people who want to change their patterns of gambling, whether on their own or with the aid of a professional or self-help group.”—Stephen A. Maisto, PhD, ABPP, editor, Psychology of Addictive Behaviors; Department of Psychology, Syracuse University



“Bravo! This groundbreaking self-help resource is a boon to millions of excessive gamblers who would do best as captain of their own ship. It is a prototype that will be replicated many times across the broad spectrum of addictive disorders. Change Your Gambling, Change Your Life reads like a good friend offering a helping hand, asking for nothing in return. It whets your appetite, then invites you to enjoy any or all of its sumptuous menu.” —Harvey B. Milkman, PhD, professor of psychology; director, Center for Interdisciplinary Studies, Metropolitan State College of Denver



“This book is an excellent resource for individuals who struggle with gambling regardless of the severity of their problem. Written clearly and with compassion, it offers various self-help tools to help people find their own pathway to change, always taking into account each person’s unique characteristics and preferences.”—Michael Levy, PhD, vice president clinical services, CAB Health and Recovery Services and Health and Education Services, Peabody, Massachusetts



“In the summer of 2011, the American Society of Addiction Medicine introduced a revolutionary new definition of addiction that, for the first time, includes the behavioral addictions. Finally, after more than thirty years of research, pathological gambling has come out of the closet! Dr. Shaffer and his colleagues eloquently discuss ‘intemperate gambling as a disorder of excess’ and provide an invaluable practical roadmap for clinicians, patients, and their loved ones on the road to recovery from gambling addiction.”—Petros Levounis, MD, MA, director, The Addiction Institute of New York; associate clinical professor of psychiatry, Columbia University College of Physicians and Surgeons



“If you are struggling with problem gambling, Dr. Shaffer’s approach to coping with addictive disorders is based on sound principles and workable solutions. This book will help you if you follow his course of action.”—Kitty S. Harris, PhD, LCDC, LMFT, director, Center for the Study of Addiction and Recovery, Texas Tech University

Title page

To Linda, who continues to teach me to do things on my own; in addition to her loving support, she sacrificed her time to afford me the opportunity to work on this project

—HJS

To my parents and my mentors

—RM

To my wife, Melissa, for her limitless love, patience, and support; to my mother for teaching me the value of service to others; and to those who seek to change, may you find your path

—JHK

To my wonderful husband, Jay, the love of my life

—LN

Preface

We wrote this book as a way to support anyone looking to take a self-help approach to recovery from gambling addiction. We also want to provide support for loved ones and clinicians encouraging such efforts. Our aim is to provide a variety of tried-and-true self-directed tools to help control problem gambling.

Unfortunately, most people with addiction receive a specific kind of help that’s primarily determined by the door they knock on to get help rather than by the problem they have. This is particularly common for an expression of addiction like pathological gambling. Even as there are many popular treatments with little or no empirical evidence to support their use, there are many effective and legitimate treatments that are overlooked. Influenced by the assortment of ideas that influence treatment, a help-seeking gambler can sometimes feel like a rudderless ship adrift on an ocean of indifference and misinformation.

We believe that self-directed change is one approach to addiction recovery that is underrated and underutilized. There seems to be a deeply rooted belief in this society, even among some clinicians, that people with addiction can make improvements only with profes­sional help.

In fact, people recover from addiction in many different ways. Some people are comfortable getting help; others prefer to work things out on their own. Across a wide variety of problems, there are more people who want to try to make changes without help compared to those who seek assistance. As the scientific evidence regarding addiction mounts, it’s more apparent than ever that behavior change can occur with or without treatment. In fact, the majority of indivi­duals recover via self-directed change.

WHAT IS PATHOLOGICAL GAMBLING?

The American Psychiatric Association (APA) defines pathological gambling as an urge to gamble despite harmful negative consequences or a desire to stop. We prefer to view intemperate gambling as a disorder of excess; that is, as an addiction. The APA’s introduction of pathological gambling as a diagnosis in 1980 sparked a new interest in its causes and treatments. Now, more than thirty years later, the study and treatment of gambling problems remains a nascent field with new ideas and approaches emerging all the time.

Although high-quality research is shedding light on gambling and gambling-related conduct all the time, strange beliefs still persist about why someone becomes a problem gambler. For example, some experts, and even some gamblers, tend to think that inanimate objects, such as slot machines, dice, and cards, are the cause of gambling disorders. If these were the necessary and sufficient catalysts for the problem, people wouldn’t develop gambling disorders without using them.

However, the opposite is true. The vast majority of people who play slot machines, dice, or cards don’t develop a gambling problem, whereas many people who do develop gambling issues never touch any of these objects. For example, some people who struggle to limit their out-of-control bets on sporting events might never succumb to the flashing lights of the slot machines or the lure of a card game.

You might presume that exposure to gambling opportunities is sufficient to jump-start addictive behavior. Research tells us that this isn’t always the case either. People tend to adapt relatively quickly after exposure to gambling opportunities, and the prevalence of pathological activity increases only during the short term—as a novelty effect—after the introduction to new gambling opportunities. In other words, there seems to be something about the gambler—as opposed to particular games played or exposure to gambling—that is central to the development of gambling-related problems.

The idea of adaptation to changes in the social setting emerged from the work of Norman Zinberg, a highly influential addiction treatment specialist who recognized the importance of understand­ing the interactive biological (drug), psychological (set), and social (setting) influences that determine the subjective effects of intoxicant use. Over time, these factors interact to regulate substance use and to limit adverse consequences; simply put, given time, many people with addiction tend to improve even if they do nothing to control their addiction. Zinberg and one of the authors of this book, Howard Shaffer, were the first to generalize these theories about adaptation to gambling, even though most experts were predicting a spike in the rate of pathological gambling as legalized gambling expanded.

In reality, the prevalence of pathological gambling among adults has remained remarkably steady during the past thirty-five years despite an unprecedented increase in access to lotteries, casinos, Internet gambling, and other gambling opportunities. New research even shows a decline in the rate of gambling among young people in recent years. Gambling disorders are far from being relentlessly progressive; rather, research reveals that many individuals move in and out of gambling disorders.

If exposure to gambling opportunities doesn’t necessarily con­tribute to the development of gambling problems, what does? Co-occurring mental health disorders seem to have a significant impact. Research indicates that pathological gamblers are approximately seventeen times more likely than people without gambling problems to have mental disorders, substance use disorders, or both.

SELF-DIRECTED RECOVERY FROM GAMBLING

People with a gambling disorder are often hesitant to enter treatment, but research shows that they still can manage to improve their situation even without any sort of outside help. The National Epidemiologic Survey on Alcohol and Related Conditions and the National Gambling Impact Study Commission found that, among individuals who previously have experienced pathological gambling during their lifetime, 36 to 39 percent have not experienced any gambling-related problems in the past year, but only 5.5 percent of them received professional treatment for their gambling problems, and only 7.3 percent attended one of the popular self-help group meetings held by Gamblers Anonymous. None of the participants in the National Comorbidity Survey Replication with a pathological gambling diagnosis had received treatment for their problem, even though nearly half had received treatment for other mental disorders.

We recognize that there are many different factors that might make you hesitate to seek help: you may be ashamed of your circumstances; you may be unaware that help is available; you may not have insurance or the financial resources to enter treatment; or you may simply feel that you want to try working things out on your own. Whatever the reason, there should be nothing stopping you from trying to take control and to assume responsibility for your own recovery. We strongly believe that with a few life-threatening exceptions, people deserve the opportunity at least to try to recover on their own if they so choose.

We are not saying that all people with addiction under every circumstance can or should change without having some help. What we do want to emphasize is that the idea that you can’t recover and change addiction on your own defies current scientific evidence and magnifies our desire to bring the truth, through first-rate resources and sound advice, to as many people as we can who are suffering with addiction, as well as to their families and the clinicians who try to help them. We believe that simply knowing that you can change on your own permits and even creates new and different opportunities for change.

At the same time, we also want you to know that if you aren’t immediately ready to change your addiction, this doesn’t mean you won’t ever be ready. Similarly, if you do decide you need professional treatment of some kind, or decide you’d do best with a mix of self-help and professionally guided strategies, that’s OK too.

Our main premise is that self-directed change is preferable and often successful for many people in recovery from gambling problems. Someone struggling with unrelenting excessive gambling also might be experiencing other mental health problems, such as depression, anxiety, or drug abuse; for this reason, we’ve devoted a number of chapters to co-occurring problems that are typical for pathological gamblers. Our belief is that success can come from tackling more than one problem at once, or at least having the tools to tackle accompanying issues when you are ready to face them. No one is a helpless victim to excessive gambling.

The bottom line is that there is no “right” way to recover from addiction. We do hope that this book encourages you to accept self-directed change for your gambling problems. We also hope that we’ve provided more ways to recover than you might have realized were available before you picked up this book.

Acknowledgments

This book was a long time in the making. As a result, a number of people participated in various aspects of manuscript preparation. We acknowledge our colleagues who made central contributions to the development of this book. Sara Kaplan, Ingrid Maurice, Leslie Bosworth, and Erica Marshall were instrumental research assistants who helped organize and prepare early manuscript versions. We appreciate the many gifts they brought to this project and are very proud of their accomplishments since they left the Division on Addiction for greener pastures. We also recognize our colleagues at the Division on Addiction. Tasha Chandler, Debi LaPlante, Sarah Nelson, Richard LaBrie, and Christine Thurmond provided encouragement, support, curiosity, and assistance as we developed this project. For these gifts, we extend our special thanks. We also thank Julie Silver and Linda Konner for their guidance and encouragement as we prepared and revised this book. We thank the late Thomas Cummings for collaborating with Dr. Shaffer for so many years; he enlightened us all about the nature of gambling addiction and how people recover from it. We extend special thanks to Kathy Scanlan and Marlene Warner for their support and collaboration as we worked together to learn from, teach, and treat people struggling with gambling-related problems. Finally, we thank the many gamblers and their families who shared the most intimate details of their lives as they were coping with their gambling-related problems. They taught us well, and for this we are forever grateful.

Introduction: How to Use This Book

There are two major ways to change behavior: change the world around you or change the way you see it. Without our making any assumptions about you, the information in this book is aimed at helping you change both.

The purpose of this book is to help you gain control of your gambling and understand it within the context of the many other issues in your life. Although we want to make sure you understand that changing behavior is difficult, it is not impossible—and you are certainly capable of making tangible, important changes in your life. Yes, gambling may be causing problems for you. You may have tried to get these problems under control many times, or perhaps this is your first time making an attempt. Whatever the circumstances, when you are ready, you will be able to achieve your goals.

Changing your relationship with gambling means sorting out many aspects of your life, gaining some perspective, and acquiring new skills. In many ways, you are taking a journey. This Introduction provides an overview of the book’s design and features that will help you on this journey.

As you probably have realized already through your own experience, excessive gambling is born of—and begets—other problems. We have structured this book to help you recognize and cope with your gambling issues as well as your other problems because we believe you’ll have the greatest chance of recovery if you make improvements in multiple areas of your life.

THERE ARE NO RULES

Although we’ve titled this Introduction “How to Use This Book,” we have no intention of giving you a list of rules. In fact, you don’t have to read the chapters in any special order; you don’t even have to read all the chapters. You’ll probably determine fairly quickly which information applies to you and which doesn’t.

For example, most people with a gambling problem have what psychiatrists call “co-occurring disorders.” This is simply a fancy label for the problems you have in your life. Many problem gamblers are plagued with anxiety. Others suffer from depression. Some struggle with substance abuse. Some experience all of these prob­lems. But you may not have any of those challenges; if that’s the case, there’s no reason to dwell on the chapters that cover those topics, though you might find a quick review of the information in them useful.

You might want to start with a chapter you think is easiest for you to tackle. If you feel confident in your ability to set goals, then the chapter focused on goal setting could be the right place for you to start. Or you might feel the need to tackle a specific problem right away, such as worry about your job or problems at home, or mood swings from day to day. If so, then the chapter focused on solving that particular problem would be a good place for you to start.

The main goal of this book is to guide you toward an approach and solutions to your gambling problems that work for you. There is no right way or wrong way to get your gambling under control—only a way that is best for you. You may decide to take a completely self-directed journey; in other words, you can try to conquer your gambling problems and all of the accompanying baggage on your own. However, after you begin reading, you may feel that you need the help of a counselor, therapist, psychologist, or psychiatrist; a self-help or professionally run group; a family member; or a few close friends. Or you may decide on a strategy that combines working on your own with some support from others. Any of these strategies can work in different situations, and this book can be of help.

Although you’re certainly capable of facing recovery on your own, there’s nothing wrong with reaching out for a helping hand. We certainly encourage you to consider asking for help, especially if you feel overwhelmed with the task of confronting your addiction. Your primary care physician is often a good resource. Similarly, social workers, psychologists, other types of counselors, and various organizations, which we describe in the Resources and Further Reading section, can also provide a wealth of information, help, and resources.

HOW THIS BOOK IS ORGANIZED

The chapters are laid out in three parts: How to Begin, How to Change, and How to Stay the Course.

Part One, How to Begin, is a series of chapters designed to prepare you for what lies ahead. This part of the book will help you evaluate your starting point and how ready you are to make changes.

The chapters in Part Two, How to Change, outline the different approaches to changing behavior. Over the course of more than thirty years of clinical research and patient practice, we have come to the conclusion that there are three main pathways you can consider to overcome a gambling addiction and the problems associated with it:

1. You can do nothing and wait for change to come.

2. You can try to change on your own, using self-help techniques like the ones outlined in this book.

3. You can change with support, including organizations, self-help groups, or a range of supportive and therapeutic professionals.

We refer to each of these choices as a pathway because each determines the road you travel to get where you need to go. Because both our research and practice have shown that other problems often accompany gambling and that these difficulties can exacerbate the gambling or get in the way of making change, we go beyond dealing with only the gambling behavior and ask you to work on any issues you might have with anxiety, mood, impulse control, and substance abuse as well.

These chapters also act as toolboxes packed with exercises, strategies, and approaches. Think of the pathways as the roads you travel toward recovery and of the toolboxes as the walking stick, GPS, and other equipment that help you reach your destination successfully. You’ll use the tools to stop, delay, or avoid gambling.

These tools fall into three general categories:

1. Managing situations

2. Controlling urges

3. Identifying triggers

Finally, the chapter in Part Three, How to Stay the Course, contains valuable resources for recovery and preventing relapses and slipups. This is a very important part of the book. Even if you complete the chapters appropriate to you and get your gambling under control, at some point in the future you might find yourself at risk for slipping into old ways. That’s why we’ve included information in the Resources and Further Reading section that specifically addressees how to prevent backslides and how to deal with the consequences if one occurs. In addition, we’ve also gathered a diverse list of resources that will help support your efforts now and going forward.

Because you’ll probably do some skipping around, we’ve structured each chapter as a self-contained entity that’s relatively uniform and simple. This should make it easy for you to use this book on your own, with a clinician, or with anyone else who is helping you with your recovery. It’s also structured so that you can adapt it to your needs and preferences in the ways that make you most comfortable, work best with your life, and ultimately lead to the best results.

It’s quite possible that you’ve already tried some of the suggestions and strategies discussed in this book. Feel free to skip the ones that haven’t worked; however, you might want to consider giving approaches that have failed in the past another try. This time could be the charm. Timing is everything, and sometimes a strategy that hasn’t helped you in the past will work under new and different circumstances—or simply because you’re in a different frame of mind and are truly ready to make the change.

WHERE TO START

Before undertaking such a major and important project as recovery, it’s important for you to understand how you feel and what underlying emotions have the potential to distract you from succeeding. You also need to assess your level of comfort with the decisions you are about to make.

Let’s begin by having you figure out how you feel right now by taking the following self-assessment. As we do for all the exercises in this book, we recommend that you keep your answers in a special notebook or journal so that all of your work is in one place for you to review and reflect on. If you’re using a support team or group, plan on sharing and discussing your responses with them too.

WHERE DO YOU GO FROM HERE?

Armed with your answers to the self-assessment questions and a sense of your current level of comfort, you can now choose to do one of three things:

If you decide you’re not ready for change, perhaps you just need to sort out your thoughts and feelings. Sometimes it’s best simply to acknowledge this and take some time to understand your decision. If you feel too nervous or anxious and think you might need some help to calm your feelings before continuing, please flip to Chapter Five for some practical relaxation techniques. Sometimes all it takes is a step back to gain a clearer sense of what you want to accomplish.

Self-Assessment

1. On this 10-point scale, where 1 represents the calmest or most relaxed you’ve ever felt and 10 represents the most nervous or tense you’ve ever felt, circle the number that represents how you feel right now.

            1      2      3      4      5      6      7      8      9      10

2. Are you being honest with yourself about having a problem with gambling?

3. How have you been feeling during the past month? If these feelings are relatively recent, why do you think you are having them now?

4. What has influenced you to decide to make a change in your life and get your gambling and other issues under control?

5. What happened to make you want to change now?

6. Is this your first effort at gaining control of your gambling?

7. What do you think has held you back from making changes in your life?

8. What influences your current gambling behavior?

9. What do you usually do about these influences?

10. What do you want the end result of using this book to be?

Think about the roles different people will play in your recovery: What role will you take? If you’re currently under treatment, what role will your provider play? What role will other people in your life play?

If you’ve decided you’re ready to make some changes in your life and you think this book can help you with the process, continue on to Chapter One. It offers a basic overview of what your underlying issues could be and explores the possible reasons for your troubles with gambling.