Conceptual and nosological ambiguity has long shrouded pathological gambling. It seems that gambling addiction will at last find its rightful ‘home’ in the section on addictive disorders in DSM-5 (Reference PetryPetry 2010), rather than the section on impulse control disorders in which it currently resides. This is, finally, an acknowledgement that pathological gambling is conceptually akin to substance addictions, except that it is a behavioural addiction (Reference OrfordOrford 2001).
The British Gambling Prevalence Survey (Reference Wardle, Moody and SpenceWardle 2010) notes rates of problem gambling (a term preferred in the UK) to be around 0.9% of the general adult population (an increase from 0.6% in 2007) and those at risk of developing problem gambling in the future to be 7.3% of the adult population. Although precise estimates of gambling problems among those with mental health difficulties are lacking in the UK, international evidence suggests that comorbidity rates are high. Despite all of the above, gambling problems both in the general population and among psychiatric patients often go unrecognised and unaddressed. Reasons highlighted for this include gamblers' reluctance to seek help (enforced by issues of perceived stigma) and that many healthcare professionals are unaware of the problem. The negative consequences of unrecognised and untreated problem gambling are numerous: related harm adversely affects the individual (including psychiatric problems, comorbid addictions, physical ill health, financial problems, involvement in crime), family (e.g. impaired relationship with partner/spouse, domestic violence, detrimental effects on children) and society (e.g. crime, loss of employment). For a review of what the non-specialist needs to know about gambling addiction, read Reference George and HuangGeorge & Huang (2011a) and for an overview in this journal of the assessment and treatment of pathological gambling, read Reference George and MuraliGeorge & Murali (2005).
Despite all of the above, current treatment provision for gamblers in the UK is at best patchy and at worst nonexistent, as previously reported in Advances (Reference George and CopelloGeorge 2011b). Gambling treatment is provided almost exclusively through the third (voluntary/charity) sector and only one National Health Service (NHS) provider supplies such specialist services (the National Problem Gambling Clinic, London: www.cnwl.nhs.uk/gambling.html). Considering treatment, it is especially worth noting that despite some success with trials of selective serotonin reuptake inhibitors (SSRIs), mood stabilisers and opioid antagonists, there is no licensed drug in the UK for treating gambling addiction. Hence, it follows that psychological interventions are the mainstay for treating gamblers.
In this article, we present an overview of one of the most popular and widely available (and free) psychological interventions for gambling addiction – the Gamblers Anonymous fellowship.
The Gamblers Anonymous fellowship
What is Gamblers Anonymous?
Gamblers Anonymous (GA) describes itself as ‘a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from a gambling problem’ (Gamblers Anonymous 1984). It is important to note that GA states that ‘any betting or wagering, for self or others, whether for money or not, no matter how slight or insignificant, where the outcome is uncertain or depends upon chance or “skill” constitutes gambling’.
Origins of Gamblers Anonymous
The fellowship of GA was founded by Jim W in 1957 in Los Angeles, USA. He was a drinker and a gambler. He joined Alcoholics Anonymous (AA) in 1946 and, seeing its benefits, applied similar principles to help himself with his gambling addiction. A few years later, with three fellow drinkers/gamblers, Jim set up the forerunner of GA – the Algamus Society. This survived just two meetings and Jim too relapsed into gambling. However, through sheer perseverance and support from his wife, whom he had met through AA, Jim organised the first-ever meeting of GA, with one fellow addict, at his apartment in 1956.
Gamblers Anonymous in the UK
After starting up in the USA, GA soon took off in several other countries and now has chapters in the UK, other European administrations, Australia, New Zealand, Brazil, Israel, Africa (e.g. Kenya and Uganda) and Asia (including Korea, Japan and India). It appears to have arrived in the UK in 1964 and there are now meetings around the country on most nights of the week. Box 1 lists key guiding principles of GA, and further information about the organisation is available at www.gamblersanonymous.org.uk.
Basic guiding principles of Gamblers Anonymous
Gamblers Anonymous:
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• is a fellowship programme
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• uses a disease model for compulsive gambling
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• believes that no cure, only recovery/control, is possible
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• recommends total abstinence, not controlled gambling
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• is not religious but spiritual
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• considers belief in a higher power to be essential
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• is a lifelong endeavour
-
• maintains that anonymity is key
-
• encourages personal and spiritual growth
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• focuses on repeatedly working through the twelve steps
-
• has no fees for membership
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• has no sociopolitical or religious affiliation
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• is a way of life.
The Gamblers Anonymous recovery programme
The GA recovery programme, in essence, consists of the twelve steps of recovery (Gamblers Anonymous 1984), which is the foundation on which the fellowship of GA is built. Hence, we first present the twelve steps (Box 2) and then discuss the structure and nature of GA's group meetings, which are the operational core of the fellowship.
The twelve steps
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1 We admitted we were powerless over gambling – that our lives had become unmanageable.
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2 Came to believe that a power greater than ourselves could restore us to a normal way of thinking and living.
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3 Made a decision to turn our will and our lives over to the care of this Power of our own understanding.
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4 Made a searching and fearless moral and financial inventory of ourselves.
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5 Admitted to ourselves and to another human being the exact nature of our wrongs.
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6 Were entirely ready to have these defects of character removed.
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7 Humbly asked God (of our understanding) to remove our shortcomings.
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8 Made a list of all persons we had harmed and became willing to make amends to them all.
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9 Made direct amends to such people wherever possible, except when to do so would injure them or others.
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10 Continued to take personal inventory and when we were wrong promptly admitted it.
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11 Sought through prayer and meditation to improve our conscious contact with God (as we understand him) praying only for knowledge of His will for us and the power to carry that out.
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12 Having made an effort to practise these principles in all our affairs, we tried to carry this message to other compulsive gamblers.
(Gamblers Anonymous 1984, with permission)
As it is hoped that the steps in Box 2 are self-explanatory, no further discussion is provided here. However, it is worth re-emphasising that GA had its origins in Alcoholics Anonymous and so is very much modelled on the same twelve-step approach. Working through these twelve steps is integral to the gambler's recovery. Although the emphasis, at least initially, is very much on getting the gambler to attend 90 meetings in 90 days, the first 90 days are merely the start of their recovery journey. For further reading, refer to the ‘The Blue Book’ (Gamblers Anonymous 1984).
The group meeting
It is through group meetings that the fellowship's principles are translated into action. Meetings are usually held weekly and may vary in length from 1 to 2 hours. Most meetings are held in venues such as churches or hospitals and although individual groups have some flexibility in how their meetings are run, the essential workings of groups are similar across the world. Most group meetings are open only to GA members, although with prior permission ‘observers’ can attend some meetings. After each meeting, coffee is provided and this gives an opportunity for more informal interactions.
Every group meeting has a chair, taken in turn by members each week. A typical meeting comprises:
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• introduction of new members;
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• members giving ‘therapy’;
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• reading from the Combo Book (Box 3), often referred to in the UK as ‘The Orange book’ or ‘The GA Bible’;
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• other fellowship-related announcements and business;
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• collections (optional) from the members.
Summary of the Combo Book
The Combo Book (Gamblers Anonymous 1999) is a series of questions and answers about compulsive gambling, along with elements of the GA recovery programme, condensed into a pocket-sized booklet. It comprises the following:
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• The GA 20 questions
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• A brief history of GA
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• Questions and answers (such as: What is compulsive gambling? Can a compulsive gambler ever gamble normally again? Why can't a compulsive gambler simply use his willpower to stop gambling?)
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• The GA twelve-step recovery programme
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• The GA Unity programme
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• ‘Just for today’ – simple tips for coping a day at a time
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• My daily moral inventory
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• Advice to new members
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• The serenity prayer
‘Therapy’ is where each attendee is encouraged to talk about their gambling past, their attendance at GA, how they are dealing with life and so on. Therapy not only helps the individual but also gives others an opportunity to listen, share and learn. If newcomers are present, they may be asked GA's 20 Questions (Box 4), a diagnostic tool for gambling addiction. The questionnaire consists of 20 dichotomous questions (yes/no), developed by GA to self-assess gambling problems. An affirmative/positive response to seven or more questions is considered to identify a gambling problem. Reference Ursua and UribelarreaUrsua & Uribelarrea (1998) evaluated the psychometric properties of the questionnaire on 269 gamblers in Spain (127 problem gamblers and 142 social gamblers) and found it to be a robust screening instrument with high reliability (Cronbach's α = 0.94), good convergent validity (r = 0.94), good factorial validity and high discriminative power (diagnostic efficacy = 98.88%).
Gamblers Anonymous 20 questions
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1 Did you ever lose time from work or school due to gambling?
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2 Has gambling ever made your home life unhappy?
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3 Did gambling affect your reputation?
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4 Have you ever felt remorse after gambling?
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5 Did you ever gamble to get money with which to pay debts or otherwise solve financial difficulties?
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6 Did gambling cause a decrease in your ambition or efficiency?
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7 After losing did you feel you must return as soon as possible and win back your losses?
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8 After a win did you have a strong urge to return and win more?
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9 Did you often gamble until your last dollar was gone?
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10 Did you ever borrow to finance your gambling?
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11 Have you ever sold anything to finance gambling?
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12 Were you reluctant to use ‘gambling money’ for normal expenditures?
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13 Did gambling make you careless of the welfare of yourself and your family?
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14 Did you ever gamble longer than you had planned?
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15 Have you ever gambled to escape worry or trouble?
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16 Have you ever committed, or considered committing, an illegal act to finance your gambling?
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17 Did gambling cause you to have difficulty in sleeping?
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18 Do arguments, disappointments or frustrations create within you an urge to gamble?
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19 Did you ever have an urge to celebrate any good fortune by a few hours of gambling?
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20 Have you ever considered self destruction or suicide as a result of your gambling?
(Gamblers Anonymous 1999, with permission)
Finally, each meeting concludes with the serenity prayer:
‘God grant me the serenity to accept The things I cannot change Courage to change the things I can And the wisdom to know the difference.’
Gamblers Anonymous as a way of life
It goes without saying that committing to the GA programme entails much more than attending meetings. The fellowship is considered a way of life where the individual himself grows personally and spiritually. It helps others to do the same, fosters friendships and bonds built on empathy and shared understanding, and is an opportunity to socialise – some even consider the group their ‘family’.
90 days and beyond
After a gambler has been abstinent from gambling for 90 days and has been attending GA meetings regularly, he/she is requested to offer some services to the fellowship, two of which will be discussed briefly here – the twelfth step and sponsorship.
The 90-day plateau
Ninety days of commitment to the fellowship, including regular attendance and abstinence from gambling, is often seen as a ‘plateau’ – a stage at which a member has reached some degree of stability in his life. In these 3 months, the member will have benefited personally and gained sufficient understanding about the programme to help others still addicted to gambling (i.e. to give back to the fellowship in any way possible). This may include chairing meetings, helping with public relations, doing twelfth-step work and being a sponsor.
Twelfth-step work
Twelfth-step work is about reaching out to those who are still addicted to gambling and encouraging them to attend GA meetings by explaining the benefits. This is often referred to as making the ‘twelfth-step call’ – preferably made in person rather than by post or by phone. Those making the call are reminded that their purpose is merely to explain what GA is about and to share their experiences rather than to ‘sell’ the programme. Such calls can be made to both prospective and current GA members. The fellowship also urges that, wherever possible, these twelfth-step conversations are one to one and are kept simple, rather than overloading the gambler with information.
Sponsorship
Sponsorship goes beyond making the twelfth-step call and is a longer-term commitment to helping a compulsive gambler. It entails helping the sponsored person to adhere to the programme and to attain recovery. Sponsors must be aware of their own roles, strengths and limitations, always remembering that it is the fellowship that aids recovery and not their individual attributes. Being a sponsor may include encouraging attendance at meetings, ensuring that the sponsored member understands what the programme is about, being empathetic and being available in times of crises. To be a sponsor, one needs a great deal of maturity and commitment and although sponsorship primarily helps the person being sponsored, it also helps the sponsor in his recovery journey.
Other relevant Gamblers Anonymous literature
Another key text for GA attendees is what is often called the Little Blue Book (Gamblers Anonymous 1976). This pocket-sized book contains readings for each day of the year. Each reading comprises three sections:
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• ‘Reflection for the day’ - self-reflection (about one's past and present);
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• ‘Today I pray’ – a short prayer (in line with the ethos of the twelve-step approach); and
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• ‘Today I will remember’ – a note to self (realistically optimistic) for the day.
Box 5 contains an extract from this book as an illustrative example.
An extract from the Little Blue Book
June 29. Reflection for the day
Once we surrendered and came to the Gamblers Anonymous program, many of us wondered what we would do with all that time on our hands. All the hours we'd previously spent planning, hiding, alibing, losing our shirts, borrowing, juggling accounts – and all the rest – threatened to turn into empty chunks of time that somehow had to be filled. We needed new ways to use the energy previously absorbed by our addiction. We soon realised that substituting a new and different activity is far easier than just stopping the old activity and putting nothing in its place.
Am I redirecting my mind and energy?
Today I pray
I pray that, once free of the encumbrance of my addiction, I may turn to my Higher Power to discover for me how to fill my time constructively and creatively. May that same Power that makes human paths cross and links certain people to specific situations, lead me along good new roads into good new places.
Today I will remember
Happenstance may be more than chance.
(Gamblers Anonymous 1976, with permission)
A first-person account
Having discussed the basic tenets and workings of GA, we now present, with the individual's permission, a gambler's experiences of the fellowship.
Learning to deal with addiction
Take a group of people, be they black, white, purple or green; it is impossible to tell a compulsive gambler from just the outside appearance. For me, gambling was something that came naturally and I couldn't control it, or rather it controlled me. I just didn't care for anyone except myself. I found that I couldn't, wouldn't stop until all avenues of getting money had been exhausted. There were no depths to which I wouldn't go to feed the habit. Being declared bankrupt, losing my credit rating, nothing would convince me that I had a problem. I couldn't stop when I was winning and I couldn't stop when I was losing. Well, not until I joined the GA fellowship.
Let me say up front that as far as GA is concerned, it has nothing against gambling. GA exists to help the compulsive gambler back to a normal way of thinking and living. I remember my first meeting; it was my wife who dragged me there. And that's when the light dawned on me. A man described what gambling had done to him and that was scary. I heard things I thought were just not possible. I had got suited and booted and frankly thought I was too good for those scoundrels and scallywags, but in 10 minutes I realised I was one of them. Someone said at that first meeting, which is so very true, that it makes no difference how long the period off, the itch, if you will allow, is always there. What one is able to do after a period of not gambling is recognise the potential itchiness and deal with it. For me that means attending as many meetings and as often as I can. Not that that alone will stop the compulsive gambler – equally important is making GA your way of life. Even after all these years of not having gambled, I know I'm not cured and that I shouldn't go looking for temptations or try to test myself. Attending GA gives me that sense of humility and strength, and also immense satisfaction from helping other compulsive gamblers. Also, I know that if need be I can rely on the fellowship for help. I think it's worth saying, especially to those who are not familiar with GA, that GA is not a religious organisation. Because I know this is a common misperception that puts some people off. Even to those who think the group style of GA would not suit them, I say, give it a go – attend at least one meeting. Because it could change your life, as it did for me, and my near and dear ones will vouch for that.
It is not a secret; it is simple. I can now have anything I want materially and financially, and most importantly, I have peace of mind – all by simply not gambling. I have GA to thank for that. It sounds simple but it is not easy for a compulsive gambler to stop gambling. But GA makes it possible.
Gam-Anon and Gam-A-Teen
Gam-Anon is a fellowship for family members (usually spouses) and friends of compulsive gamblers and Gam-A-Teen is a similar programme for children of compulsive gamblers. For purpose of brevity, these ‘sister’ fellowships of GA will not be discussed in detail. For further information, please see www.gamanon.org.uk.
Evidence base for Gamblers Anonymous
A frequently cited criticism of GA is the lack of a robust evidence base for its effectiveness. Despite its 50-odd-year history, there is little published research on the effectiveness of GA. Difficulties in conducting outcome studies include: GA by definition is anonymous so no records are kept; information collected is exclusively based on self-reports and hence is entirely subjective; self-selection bias of GA attendees; constantly fluctuating membership of GA groups; and a lack of universally accepted outcome measures and definitions of success (Reference Stewart and BrownStewart 1988).
In this article, we do not comprehensively review all of the studies in this field but instead give the reader a flavour of the types of research done and some key findings.
One of the earliest attempts to profile GA attendees was made by Custer & Custer in the USA. In a widely cited but unpublished study (Reference Custer and CusterCuster 1978), they surveyed 150 gamblers who had been in recovery for more than 7 years and noted the following: 96% were male; most were married, well educated and employed; 58% had experienced one or more relapses; 40% had consulted a mental health professional before attendance at GA; the majority gave 18 (on average) ‘yes’ responses to the GA 20 questions; the mean age of initiation of gambling was 17 years; the mean age of first GA attendance was 39.7 years; 18% had attempted suicide; and a large proportion had experienced parental deprivation in childhood.
Patterns of success
Some studies have also followed up GA attendees for drop-outs and predictive variables. Using a combined retrospective and prospective study design, Reference Stewart and BrownStewart & Brown (1988) studied 232 GA attendees in Scotland and noted abstinence rates of 8% at 1 year and 7% at 2 years. Disappointingly, they also found high rates of drop-outs after the first meeting: between 22 and 41%. In another study in Scotland, Reference BrownBrown (1987) specifically studied GA drop-outs and identified characteristics/features that differentiated them from regular attendees. He found that those who dropped out early saw their own gambling as less problematic, believed they could control it (and hence did not see the need to totally abstain), had underlying feelings of inferiority and said the group was unsympathetic when they reported ‘slips’. Based on the above, Brown concluded that GA was better suited to those with severe gambling problems than those with less severe problems and that it worked better for those with few or no relapses than those with several relapses.
Oei & Gordon (2008) looked at the role of seven variables among 75 GA attendees in Australia, in predicting abstinence or relapse:
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• meeting attendance and participation;
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• social support;
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• belief in God;
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• belief in a higher power;
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• working the twelve steps of recovery;
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• gambling urges; and
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• erroneous cognitions.
They found that meeting attendance and participation and social support increased the chances of abstinence; greater gambling urges and erroneous cognitions increased the chances of relapse.
Patients seeking professional treatment for gambling problems may or may not have attended GA. More often than not, gamblers seeking professional treatment have a prior and/or ongoing history of GA attendance. This raises two vital, clinically pertinent questions: does it affect treatment outcomes and is GA attendance compatible with other treatments? A US study by Reference PetryPetry (2003) looked at 342 such pathological gamblers presenting to treatment and looked at their patterns and correlates of GA attendance. Of the sample, 53.8% had attended one or more GA meetings before seeking professional help. These GA attendees were older, had had gambling problems for longer, had more severe gambling problems and had accrued larger debts. They also had fewer concurrent drug problems but more severe family/social/psychiatric problems. Finally, prior GA attendees were also more likely to re-engage with GA in the 2 months after treatment, more likely to better engage in professional treatment and, importantly, more likely to be abstinent from gambling 2 months into treatment. Petry concluded that ‘those gamblers entering professional treatment with a history of GA attendance differ from those who do not, and these differences may impact treatment recommendations and outcomes’.
Gamblers Anonymous and other interventions
In an interesting exploration of GA and cognitive-behavioural therapy (CBT) in treatment of gambling addiction, Reference ToneattoToneatto (2008) analysed each of the twelve steps of GA. In this Canadian study, he concluded that, despite the apparent linguistic differences between CBT and GA, the underlying concepts and strategies are comparable. He further added that the differences merely reflect different traditions rather than different underlying concepts and called for elements of GA and CBT to be combined. To substantiate this point, he highlighted the similarity between the first steps in GA and CBT:
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• Step one in GA: ‘We admitted we were powerless over gambling – that our lives had become unmanageable’
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• Step one in CBT: ‘We realised that our belief that we could control or predict gambling outcomes was illusory and that uncritical belief in this illusion had led to severe gambling-related problems in all of the important areas of our lives.’
Hence, it seems reasonable to infer that GA is very much an intervention that can be offered alongside or integrated with other psychological interventions. Furthermore, some studies (e.g. Reference Russo, Taber and RamirezRusso 1984; Reference Taber, McCormick and RussoTaber 1987; Reference Lesieur and BlumeLesieur 1991), albeit subject to numerous methodological limitations, even suggest that the effectiveness of GA can be improved by concurrent attendance at other professional treatment programmes, be it outpatient or in-patient.
Dispelling myths
Two of the criticisms that are often levelled at GA are that it exclusively caters to men and that it ignores the emotional lives of individuals, focusing almost exclusively on abstinence from gambling and practical issues, such as debt. In a qualitative ethnographic study comprising interviews with 23 GA members and observations of 42 GA meetings, Reference Ferentzy, Skinner and AntzeFerentzy and colleagues (2006) noted that 20% of attendees were women and that members are encouraged to discuss emotions and life issues. Although this study was limited to Canada, anecdotal reports from UK GA attendees also lend support to the observation that GA, these days, focus more on twelve steps and spirituality than on practical aspects, such as debt and legal problems.
Studies in this field are, however, riddled with methodological problems that limit the validity of their findings and GA is a long way from having a robust supporting evidence base. Further studies are warranted that evaluate the effectiveness of GA, profiling of gamblers who are likely to respond best to GA and the ingredients of GA that are essential for success.
Conclusions
The aims of this article are to raise clinicians' awareness of GA and to make them better equipped to offer it as a treatment option to patients who are addicted to gambling. Despite its detractors, GA can be an effective treatment for gambling addiction, which has no licensed pharmacological treatment in the UK. More importantly, GA is also compatible with other psychological interventions (such as CBT) for gambling addiction. However, more robust research is needed before GA can stake its claim as a truly evidence-based treatment approach.
MCQs
Select the single best option for each question stem
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1 Pathological gambling is best conceptualised as:
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a an addictive disorder
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b an impulse control disorder
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c an obsessive compulsive spectrum disorder
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d a personality disorder
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e a mood disorder.
-
-
2 Gamblers Anonymous (GA) is:
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a a religious organisation
-
b a group fellowship
-
c a quasi-political movement
-
d a Christian charity
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e a cult.
-
-
3 Regarding the underpinning principles of GA:
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a it is a time-limited endeavour
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b anonymity is optional
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c it is spiritual
-
d belief in a higher power is optional
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e it recommends controlled gambling.
-
-
4 The following is not true of the twelve steps:
-
a they need to be worked through again and again
-
b they are the cornerstone of the fellowship
-
c belief in a higher power is essential
-
d carrying the message of twelve steps to others is crucial
-
e it dissuades personal growth.
-
-
5 Research into GA has shown that:
-
a more men than women attend GA
-
b GA is more effective than cognitive–behavioural therapy (CBT)
-
c GA and CBT are incompatible
-
d 90% of GA attendees drop out after the first meeting
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e GA focuses less on spirituality than practical aspects like debt.
-
MCQ answers
| 1 | a | 2 | b | 3 | c | 4 | e | 5 | a |
Acknowledgements
Our thanks to M.P. for sharing his experiences of Gamblers Anonymous and to Jim Fearnley for his comments on an earlier version of this manuscript.
eLetters
No eLetters have been published for this article.