CENTRAL AND EASTERN EUROPEAN CONFERENCE ON GAMBLING
21-23 SEPTEMBER 2000 WARSAW, POLAND
TREATMENT OF PROBLEM GAMBLING
JUST SITTING AND TALKING IS NOT ENOUGH
or
A WHOLISTIC APPROACH TO ADDICTION TREATMENT
THE CURRENT SITUATION IN SLOVENIA

Among other “benefits” of transition Slovenia experiences an enormous rise in gambling facilities as well. About a decade ago gambling didn’t seem to be a problem of ours. It was strongly prohibited for our citizens, playing cards for money in public places wasn’t allowed and there was an awareness among people that gambling was an addiction. The few pathological gamblers who played poker for money served more as a token than as role models and were considered “morally defective” to have caused so much trouble to their empoverished families. But the greed for money that the transition brought with it swept away the values that we used to think were untouchable. First they opened the casinos at the border regions to Italy and hundreds of Italian tourists as well as some pathological gamblers overflooded the cities near Italian-Slovene borders. They brought with them the glamour and promise of prosperity along with the despair and misery that accompany addictions. But as long as there were Italian wives and children who came crying in the middle of the night, trying to convince their fathers to stop gambling and go home, nobody seemed to care. Everybody wanted their piece of the cake. Ten years later, everything has changed. The rich have become much richer, and the poverty of the poor is on the increase. Unemployment, insecurity, loss of moral values, and addictions go hand in hand in creating masses of people who will never, no matter how hard they try, be able to grasp even ever so little of the glamorous world of their soap-opera dream models. Is there any wonder that they desperately try to catch up with the world that is reflecting their distorted image, pointing out that they are not good enough? “If only....”
Gambling is fun for some people and a problem for others, but according to various authors, 1% up to 5% of players develop an addiction. Not only casinos, but games and money chains and other money games thrive on the greed of small people trying to forget the misery and littleness of their lives and escape into the promised world. We do not know the extent of the problem in Slovenia yet. But on Saturdays there are rows in front of places that sell lotto tickets, almost every other advertisement on the TV offers a special prize if you buy their product, and gambling is now no longer considered a crime.
According to my correspondence with the therapists, we estimate that about 30 clients were seeking professional help for pathological gambling in Slovenia recently, 24 of them in the region near the Italian border where it all began, the majority of them being employees of casinos. I am afraid it is just the tip of the iceberg.

THE TREATMENT OF NON-CHEMICAL ADDICTIONS
While the number of people who loose control gambling and of their spouses is rapidly increasing, there is no governmental program for the treatment of gambling and other non-chemical addictions in Slovenia. Gamblers who seek help can find it in programmes for treating chemical addictions, that is mostly for alcohol addiction. There they usually do well for some time, as the best therapy for gambling resembles the therapy for other addictions. There are differences as well, and it is left to the experiences of the therapists to deal with them. Therapists with less experience usually underestimate the degree of denial and manipulation that the gambler can come up with and do not really understand that the client cannot control his gambling. Some of them try to preserve the gambler’s marriage by pressuring his spouse to “give him another chance”. In the case of gambling this is sometimes dangerous and costly to the family. The therapist must not collude with the gambler in making his family members feel too safe, but should rather teach them to take legal steps to protect the family’s financial assets. Usually the spouse will have to take over the financial management of the family, as money is the substance of abuse for a pathological gambler
The conditions that are relevant for abstinence have to be negotiated at the beginning of the treatment (Fig. 4), which begins with the recognition of the problem. It is often associated with denial, allowing the person to believe there is no problem. Most people enter treatment under pressure from others, mostly family members, rather than accepting the need for treatment voluntarily. Abstinence principles that apply to other types of addiction, such as substance abuse and alcohol dependence, are relevant.
A personal plan for treatment has to be elaborated then, considering reorganising debts, reestablishing family relationships, developing coping techniques, participating in group meetings, adressing other possible addictions and preventing relapse. The treatment involves education and development of a therapeutic relationship with the therapist and the therapeutic group. It ranges from individual to group psychotherapy and socio-therapy. It is a great advantage to be accompanied by a spouse or a parent in treatment. According to the two therapists that I interviewed and to my own experience a majority of pathological gamblers can control their addiction for a couple of months or even years, but eventually most of them return to gambling. Group therapy with recovering compulsive gamblers (or other addicts and their family members when there are not enough candidates to form a group) provides support and encouragement, and helps to reduce the use of defence mechanisms. People who “have been there” can see through a person’s denial and help confront a problem. Some pathological gamblers consider themselves to be too “fancy” to be treated among “junkies and alcoholics”, and in such a case it is a good idea to organise a “peer support and control group” for gamblers to help them stay away from gambling. While all compulsive gamblers can stop gambling for a while, most of them need professional help to stop for life. Only the addict himself is in charge of abstinence, all the other helpers, professional or lay, can only be of help - if he lets them help him. But abstinence alone does not mean that the gambler has been cured for life. We know of gamblers who “go clean” for months, even years, and relapse after a critical situation. The first few months are said to be the hardest, and there is always a threat that a personal crisis may start a series of events that can bring a recovering addict back to the old pathological tracks. The period of abstinence preconditios the deeper psychological changes that must occur within the addicts psyche, and in his relationships with the people he loves and depends upon. Trust, responsibility, honesty and the ability to love, and care for other people are the goals, and they are not easy to achieve, especially if you consider the denial, exploitation, contempt, anger and lying that such families have been going through.

A WHOLISTIC APPROACH VERSUS »SITTING AND TALKING«
In recent years there are more and more attempts to transcend the classic medico-psychological models of treatment. People are much more than just bodies and a psyche is much more than the consciousness. We are physical and psychological, as well as social and spiritual beings, and the latter dimensions of our existence are by large underestimated in modern world. Addictions are all encompassing and it does not seem to be enough to try to manage them using intellectual efforts only. Once the urge gets in, there goes the sanity! “Sitting and talking”, namely individual and group psychotherapy are important tools in addiction treatment, but they leave out the physical and spiritual dimensions of a person. Another disadvantage of the “sitting and talking” model is that it cannot help as a coping technique in crisis, because there is no schedule for crisis. What can an addict do, when he is alone in the middle of the night, fighting with his urge to gamble? Call a friend, possibly a recovering gambler, and talk to him until the danger is over. What can he do to relieve the tension that is becoming ever greater? He should go jogging for at least one hour, and if this is not enough, for another hour. In 1970’s, a Slovene psychiatrist dr.Rugelj has devised a unique method for treating chemical, as well as non-chemical addictions (Fig.6), and has used it ever since with good results. In addition to group psychotherapy it utilises various socio-therapeutic measures as techniques for activation, among which: running, marathon, biblio-therapy (the use of books in therapy), regular morning exercise and (Fig.7). The clients write reminiscences or a personal diary to the therapist, reporting on their feelings and their inner processes, thereby making the hidden dynamics of addiction visible. The therapeutic group is conducted by an autocratic leader. Originally the method was devised for the treatment of alcohol addiction, but it has proved to be useful in the treatment of non-chemical addictions such as bulimia, anorexia nervosa, sexual and relationship addiction and codependency.

SOCIO-ANDRAGOGIC METHOD: THERAPEUTIC MEANS
The method we use combines individual and group psychotherapy with a variety of »psychotherapeutic means« that are designed to have effects in various dimensons of a client’s life. The main objective of the programme is the creation of the conditions for the self-realisation of every member. Individual and group therapy, as well as biblio-therapy, journal and biography writing, help a person to understand intellectually and feel emotionally, to grieve one’s losses and to develop better coping mechanisms in crisis. These therapeutic means promote changes mostly on psychological. levels. The physical dimension of a person, their body and health, are improved by regular morning exercising, jogging, marathon running and mountaineering.The social dimension of a person, the relationships, are developed and improved by group psychotherapy, group mountaineering and excursions, group celebrations and other events, and by being a mentor to a newcomer to the programme. The spiritual dimension, one’s beliefs and faith, attitude toward oneself, to Powers Greater than Oneself and to all living beings, are affirmed and developed by regular practice of meditation and in selected cases by therapeutic fasting. Let me describe the use of the therapeutic means further:

1.RUNNING (JOGGING): . A graded regimen of increased psycho-physiological activity reduces the adrenaline level and acts as a kind of tranquiliser, alleviating the withdrawal symptoms and increasing overall energy and the ability to cope. Clients learn to postpone immediate pleasure for the benefit of long term values. Running also demands a healthy lifestyle. Performance: individually, preferably each day or at least 3 times a week for 1 hour, in nature. One needs no special equipment or place to run, all you have to do is get out and start and in 6 months of regular practise dramatic changes will take place. Physical capacity and self-confidence grow parallel.
2. MARATHON: Addicts crave extatic experiences and expect that something outside themselves, a drug, a gambler’s fortune, sex or adrenaline will provide extasy. Here is one legitimate extatic experience that you can achieve if you work out very hard for a very long time. It is something you never forget and you can derive feelings of self worth from the fact that you have made it. You cannot cheat at marathon.
3. MOUNTANEERING: The aim is to be with people, to feel the beauty of Nature, to start to feel that there are forces greater that human will that control the Universe, to spend time and have fun with other people,and to strengthen the group and family ties. Performance: therapeutic excursions of the group and of family members, following by analysis of conflicts and relationships on group sessions.
4. AEROBIC EXERCISE: At least 30 minutes every morning. It is useful as anti stress therapy as well as a good test of motivation: the addicts that are about to quit the programme stop exercising before! It is important for training discipline as well as muscles!
5. MEDITATION: Meditation can be performed in a group or individually. Guided imagery or techniques that work on even deeper subconscious levels such as working with symbols are important methods for »reprogramming« the unconscious mind. Regular meditation heals deeply by working on symbolic levels, and helps transformation of hidden complexes into consciousness. On a deeper lever it brings “conscious contact with God, as we understand it” (Alcoholics Anonnymus). Sometimes it evokes a memory - a »film of past trauma«. Caution is recommended with schisophrenic patients.
6. BIBLIOTHERAPY: Books are used in therapy for education, reflection on one’s position and crisis behaviour, and understanding that you are not alone in your struggles with addiction. It teaches empathy, sympathy and identification with positive role models. There are some very useful self-help books available.
7. JOURNAL WRITING: This is a very useful for the therapist to get insight into everyday life and understand the individual dynamics of the addict’s life (trigger points, crisis behaviour, conflicts). On the other hand it helps the client be aware of both sides of his personality at once, as he is usually not able to remember what he thought when he was “high” once he gets sober. It makes a client reflect deeply upon his life, analyse it and look for better solutions.
8. BIOGRAPHY: The client writes extensive biography with emphasis on childhood traumas, current difficulties and “standpoints and prejudices” at the beginning of treatment. What one remembers is important, but perhaps what one cannot remember is even more interesting. It is useful to have a questionnaire to guide the client through the story of his life to make him aware of the »blind spots«. Amnesia, signs of posttraumatic stress disorder and sexual difficulties are late symptoms that suggest possible sexual abuse in childhood. Our own experience shows that more than 40% of clients of the therapeutic group were sexually abused in childhood.
9.PERSONAL PRESENTATION: A personal presentation is a self-experienced analysis of one’s own life and relationships, shared with the group. When the therapist believes that the client is ready, he invites him to speak up. The group offers support and empathy. Group members write reminiscences to the client, but it is not acceptable for them to give advice or criticise. They should rather stay focused on their emotional experience at the time of presentation or reflect on similar events in their own life. Shared feelings and memories enhance the feelings of closeness and empathy of the group. Being able to share is a cathartic experience, which brings to the person presented a deep emotional release.
10. ESSAY and REMINISCENCE WRITING: written feed back to the therapist on everything important that happens in one’s life or on group sessions. Our therapeutic groups are rather large and the time to express one’s opinions in sessions is limited. Written feed-back to the therapist makes up for this inadequacy and provides him with excellent study material to be analysed for the purpose of preparation or correction of his interventions. Writing bridges the gap between two group sessions which is too long for people in crisis, ensuring continuous communication. Some people cannot speak up about their problems, but find it easier to write about them.
11. GROUP: Group sessions are scheduled every 2 weeks and last for 3 hours. It is possible for a client in crisis to attend sessions once every week, combining the attendance of two therapeutic groups. Group sessions are conducted by the therapist who in his work combines various approaches to group psychotherapy (analytic, transactional analysis, some Gestalt elements).
12. CELEBRATIONS: Our group celebrates New Year’s Eve and some other festivals together. Family members are invited and get to know the positive dynamics of the group, which encourage them to join the programme. The addicted are often very lonely people and awareness of their social isolation can be very painful in times of family holidays such as Christmas. They also have to learn how to celebrate without alcohol and other mood altering substances. A pleasant reunion enhances feelings of closeness and empathy within the group.
13. FASTING: Not eating for a period up to 21 days demands discipline (but not self-denial!), the daily routine is changed, the body is “cleansed”. It is helpful at the start of a nicotine abstinence or periodically once a year. When done appropriately, it reduces cravings and enhances spiritual growth, bringing a profound introspection and awareness that we are not just bodies! This method is not suitable for everybody, we do not recommend it to clients who have ever had anorexia or bulimia for fear of triggering a relapse!
14. MENTORSHIP: Experienced group members are available to newcomers to help them become part of the group, to explain the details and schedules and to contact them in times of crisis. When doing this, they once again consider their own development stages and become increasingly aware of the process of recovery. The method helps developing a sensitivity to others and promotes empathy rather than attempts to »rescue« other people. This is a valuable tradition of Alcoholics Anonymus.

OUR OWN EXPERIENCE
In 1995 I have modified the socio-andragogical method to suit my personality (less authocratic leadership) and I have used it for six years to lead a non-governmental program for treating non-chemical addictions. The activity is organised in the form of the Association for Help for the Addicted and People in Distress. The number of clients varies around 60 (2 therapeutic groups of 30 clients). So far, more than 150 clients have entered the program and followed it for 2 to 3 years in average. The participation is based on voluntary acceptance of the program, and the co-operation of family members is encouraged. The two groups form a strongly cohesive therapeutic community that offers support and understanding to its members and that has quite a lot of successfully recovered cases in it’s “group memory”, thus giving grounds for hope for everyone. Out of the 56 clients now in the programme, 54 joined the programme because of serious problems in a primary relationship that we refer to as relationship addiction or codependency. 40 of them are adult children of alcoholics. 24 of them were sexually abused in childhood, most of them by a close relative or a person they trusted. 10 of them abuse food or starving in an addictive way and 14 of them consider themselves sexually addicted. At the moment we have one man who joined to overcome his addiction to playing a video game - his problems look similar to those of gamblers, only he is not playing for money (yet?) but for scores. But he has lost two important relationships and jeopardised career opportunities due to playing, is preoccupied with playing and planning, derives great pleasure and self-approval from “winning the Machine”, the signs that bear resemblance to compulsive gambling.

Our experience shows that it is a great advantage to be able to offer the clients more than “just sitting and talking” and that it is well worth the effort. The therapist himself must teach a healthy lifestyle by example, not by power. He should lead a self-realised life, free of all known chemical or non-chemical addictions. His authority is based on the fact that he adheres to the programme himself and not just sit in an office and give advice. Only if one is running, mountaineering, exercising daily, meditating and practising a responsible and spiritual way of life,one has grounds to expect the same from the clients. This may be the reason why the traditional therapists are reluctant to use this method and prefer the traditional ways.

TABLES

WHAT IS COMPULSIVE GAMBLING ?

AMERICAN PSYCHIATRIC ASSOCIATION - the criteria for pathological gambling

1. being preoccupied with gambling (or planning to get the money back)
2. needing to gamble with increasing amount of money to achieve the desired excitement
3. repeated unsuccessful efforts to cut back or stop gambling
4. being restless or irritable when attempting to cut down or stop gambling
5. gambling as a way of escaping problems or of relieving a dysphoric mood (feelings of helplessness, guilt, anxiety, depression
6. “chasing one’s losses”, returning the next day to get the money back
7. lying to family members, therapist or others to conceal the extent of involvement with gambling
8. having committed illegal acts such as forgery, fraud, theft or embesselment to finance gambling
9. having jeopardised or lost a significant relationship, job or educational or career opportunity because of gambling
10. relying on others to provide money to relieve a desperate financial situation caused by gambling
- the result is positive when more than five criteria apply!

THE CONDITIONS THAT HAVE TO BE MET AT THE BEGINNING OF THE TREATMENT (Rozman, 1998):

1. Public word of honour never to lye to the therapist or to the group (this is a prerequisite to the development of trust).
2. A family member who would guarantee that the gambler respects the therapeutic agreement and report of his adherence to the agreement.
3. A reasonable plan to cover or reprogram the debts, made with the consent of creditors who must be aware of the reality of the situation.
4. A promise to avoid people or places that trigger the urge. (What about casino employees?)
5. Abstinence of all mood altering chemicals, including alcohol and smoking!

NON-CHEMICAL ADDICTIONS:

1. Compulsive gambling, compulsive gaming
2. Addictions to food and dieting:

-bulimia nevrosa (»binge and purge« syndrome)
-anorexia nevrosa (dieting to starvation and sometimes purging)
-compulsive overeating (bingeing without purging)
-addiction to sugar and chocolate (new, partly chemical)
-addiction to excessive jogging and fitness

3. Sexual addiction and sexual codependency, sometimes sexual anorexia
4. Compulsive overworking (very often combined to spending or gambling)
5. Compulsive spending and debting
6. Codependency and relationship addiction
7. Other: people can become addicted to almost anything that reduces tension and anxiety and can be used regularly for that purpose: daydreaming, shoplifting, danger (bungie-jumping, speed driving), soap-operas and cheap literature, television, computer games and, of course, internet.

THE THERAPEUTIC GROUP FOR TREATING NON-CHEMICAL ADDICTIONS

relationship addiction or co-dependency 54
adult children of alcoholics 40
sexually abused in childhood 24
addicted to overeating or starving 10
sexually addicted 14
addicted to gambling or computer games 1
all 56

WHAT IS WHOLISTIC HEALTH?

Declaration of Alma Ata:
... HEALTH, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right ...
People are spiritual beings, living in physical bodies, thinking, feeling and having meaningful relationships with everybody and everything we are aware of.
Physical dimension: Our body and physical health
Psychological or mental dimension : What we think and feel
Social dimension: Our relationships
Spiritual dimension : Our beliefs and faith, attitude towards oneself, to Powers Greater than Oneself and to all living beings

THE THERAPEUTIC MEANS APPLIED TO BODY, MIND, RELATIONSHIPS AND SPIRIT

PSYCHOLOGICAL DIMENSION : What we think and feel

- individual and group psychotherapy
- reminiscences
- bibliotherapy
- journal writing
- biography writing

PHYSICAL DIMENSION: Our body and physical health

- regular morning exercising,
- jogging,
- marathon running
- mountaineering.

SOCIAL DIMENSION: Our relationships

- group psychotherapy
- group mountaineering and excursions
- group celebrations and other events
- mentorship.

SPIRITUAL DIMENSION:

Our beliefs and faith, attitude towards oneself, to Powers Greater than Oneself and to all living beings

- meditation
- therapeutic fasting
- mentorship (help to someone in need)