The perspective of pathological gambling as an addiction is a relatively accepted paradigm, despite it being categorised in DSM as an impulse disorder. Non-chemical dependence appears to be an uncomfortable concept, and so pathological gambling has, since its inclusion in DSM-III (1980), remained described as an impulse that has not been restrained.

In New Zealand, however, problem gambling (inclusive of pathological gambling, its most extreme expression on the gambling-problem gambling continuum) has been largely accepted as an addiction, and presentations have been regularly delivered at Cutting Edge conferences over the past decade or so. In the last year addressing the issues of problem gambling passed another important milestone with the enactment of the Gambling Act in September 2003. From that date the Ministry of Health assumed responsibility for the minimisation of harm that may rise from problem gambling, for the first time bringing problem gambling under the direction of mainstream health provision.

An important question now to be answered is, how should problem gambling treatment be delivered most effectively? The placing of problem gambling treatment under the umbrella of other mental health services not only legitimises the field formerly funded directly by the gambling industry, but also raises the potential of treatment delivery through other allied addiction therapy providers. There is evidence of varying levels of persuasion that problem gambling, as it becomes more intense, will co-exist with a number of additional negative conditions, some of which will be addictions. Substance abuse, particularly alcohol, is common with findings of between 25% and 63% of pathological gamblers meeting the criteria of substance use disorder in their lives (Shaffer & Korn 2002). In New Zealand, research with alcohol treatment providers has identified 11% of clients to meet the criteria of pathological gambling (Mackinnon & Paton-Simpson 1999).

Problem gambling appears to constantly co-exist with a range of other conditions, such as (in varying degrees), depression (up to 78%), anxiety disorders including Post-traumatic Stress, GAD and Panic Disorder, is commonly associated with alcohol abuse, personality disorders including Borderline PD and the previously inconsistent Antisocial PD, and so the list goes on (Unwin et al 2000; Shaffer & Korn 2002). Some researchers have queried whether problem gambling is not better defined with these symptoms rather than describe them as separate co-existing conditions (Shaffer et al 1997).

This perception has a considerable impact upon the future development of the field of problem gambling. Questions that arise may rightly be:

• How do these co-existing conditions impact upon the effectiveness of problem gambling focussed therapy (whether the co-existing condition existed before the gambling problem or not)
• In any event, if these ‘additional’ conditions common co-exist, shouldn’t they be addressed in any treatment plan of ‘problem gambling’?
• Does the current problem gambling workforce have the skills to identify and address these ‘additional’ symptoms?

All of these questions require consideration if the signalled importance placed upon addressing problem gambling sent by the mainstreaming effect of the Gambling Act is to be realised in the treatment sector. The WHO in a recent seminal paper in the chemical addiction field noted:

‘There is significant comorbidity of substance dependence with various other mental illnesses; assessment, treatment and research would be most effective if an integrated approach were adopted…..Attention to comorbidity of substance use disorders and other mental disorders is thus required as an element of good practice in treating or intervening in either mental illness or substance dependence’
p248, WHO (2004)

This view appears to be even more appropriate to problem gambling addiction. The high degree of comorbidity, and the poor history of problem gamblers to complete referrals raises the need for a ‘one stop shop’. Pathological gambling is defined as a ‘persistent and recurrent’ behaviour in DSM-IV and it may well be that a major influence on relapsing is failure to address these comorbidities as an integral part of the gambling behaviour.

Some amongst us may note that few therapists in addictions have skills in treating anxiety, depression and particularly personality disorders. The catchcry ‘a little knowledge is a dangerous thing’ is likely to be voiced strongly, and that referral to experts in these fields is the best practice. In addition, raising the skills of the existing problem gambling workforce to an expert standard in a number of additional fields may seem unlikely.

Others, however, may counter-argue that a level of expert is not required and would be ‘gilding the lily’. Training to recognise the various categories of anxiety disorders, depression and drug misuse, could be supported by brief, effective screens. Brief interventions may reduce the negative effects of these symptoms that may impact upon recovery from problem gambling. Almost certainly not addressing these symptoms will contribute to relapse, while recognising when, as a therapist, you are getting out of your depth would be part of the necessary training to ensure safety. In addition, both training and limits to interventions are determined not only by clinical considerations, but also by funding requirements. The often heard ‘we are not funded to do that’ can conflict with clinical sensibility.

Perhaps the welcoming of problem gambling into the mainstream health field can be a catalyst for skills enhancement for all addiction therapists. Problem gambling therapists may also be interventionists for substance misuse and anxiety/depression, while AOD therapists become problem gambling interventionists and anxiety/depression.

The future of problem gambling therapy delivery now appears to be wide open with the possibility of several new ‘starters in the field’. The skills appropriate to best practice in this field may require further training, and rather than viewed from the perspective of a barrier, perhaps the better view would be that outcomes may improve while improving the quality and skills of the field as a whole. A parallel approach would be upskilling other addiction therapists to address problem gambling amongst their own clients. The integration of problem gambling treatment into mainstream health provision may be an opportunity to start with a clean slate and model a new approach for all addiction treatment delivery. It could really be a winner!

References

American Psychiatric Association (1980) Diagnostic and statistical manual of mental disorders, third edition. Washington DC: Author

American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, revision of third edition. Washington DC: Author

American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, fourth edition. Washington DC: Author

Mackinnon S & Paton-Simpson G (1999) Rates of problem gamblers presenting to alcohol and drug services. Paper presented at the Problem Gambling and Mental Health in NZ: National Conference on Gambling in Auckland.

Shaffer H, Hall M & Vander Bilt J (1997) Estimating the prevalence of disordered gambling behavior in the United States and Canada: A Meta-analysis. Boston MA: Harvard Medical School Division of Addictions.

Shaffer H & Korn D (2002) Gambling and related mental disorders: a public health analysis. Annu. Rev. Public Health 23:171-212.

Unwin B, Davis M & De Leeuw J (2000) Pathologic gambling. American Family Physician. Feb 1.

WHO (2004) Neuroscience of psychoactive substance use and dependence. Geneva: Author