Author: Jane Elizabeth Oakes
Oakes, Jane Elizabeth, 2014 Relapse in Electronic Gaming Machine Gambling, Flinders University, School of Medicine
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Despite pervasive negative impacts, the research into problem gambling is limited with relatively little understanding of the factors that lead to the development of gambling problems and relapse. In addition, there is limited understanding about the relapse process itself and the existence of risk factors, their strength and importance, and their mechanisms of action and interaction. This thesis reports on the findings of research that investigated relapse in Electronic Gaming Machine (EGM) gambling, which is the most prevalent form of problem gambling in Australia. This qualitative research study used a combination of focus group methodology and face-to-face in-depth interviews to provide knowledge about the predictors, protective factors, and processes involved in episodes of relapse. This knowledge was acquired from problem gamblers (PGs), significant others, and workers with direct experience of gambling relapse. The study describes the processes involved in relapse and concludes by providing a framework for conceptualising this complex social behaviour. In-depth interviews were used to examine and complement the focus group findings and to test the framework derived from the initial focus group exploratory study with individual PGs, to further examine if the process identified by the focus group participants actually reflected the experiences of these individuals. In this research, relapse is defined, from the perspective of PGs. They see relapse occurring when gambling causes harm that is recognised by them and when realise that they have lost control each time they gamble. This research provides new knowledge regarding the risk factors and processes involved in relapse. It provides a framework for conceptualising relapse described as the 'push' towards relapse and the 'pull' away from relapse. The research established that each relapse episode comprised a sequence of mental and behavioural events, which evolved over time and were modified by factors that 'push' this sequence towards relapse. In this process, participants identified two separate categories of erroneous cognitions leading to an urge to gamble and subsequent relapse. The first have been well recognised in the literature where exciting erroneous cognitions about the outcomes of gambling added to the risk of relapse. However, little importance has been given in the literature to the second category, that of facilitatory erroneous cognitions. Participants referred to this phenomenon as 'gambling sense', which acted upon critical thought and the capacity for self-observation, resulting in impairment of cognition such that the capacity for moral judgement became distorted. 'Gambling sense' facilitated erroneous logic by permission-giving, reality-denying, memory-defying, and excuse provision for gambling losses. This then acted as a means of reducing the PGs'capacity for vigilance in order to allow 'free reign' as it were, for the exciting erroneous cognitions to dominate decision-making. Once these two categories of erroneous cognition were acting in unison, they completely counteracted the 'pull' away from relapse. This then enabled the urge to emerge fully, without any personal sanction or scrutiny for this gambling behaviour being possible, because their memories about previous harm were no longer consciously available to be taken into consideration during their gambling behaviour and decision-making. The PGs described this as being 'in the zone'. All PGs developed this altered state of consciousness during relapse, which enabled and prolonged the relapse episode. The 'zone'appeared to be a dissociative phenomenon precipitated by the EGMs, which may well only be found in EGM gambling. When in the 'zone', it was found that the PGs' capacity to reflect on the harms of their gambling was absent. This inability to self-observe appeared to limit the PGs' ability to learn from these harms resulting in repeated relapse. When the relapse episode ended, as the money had been exhausted, all participants experienced intense negative affect filled with grief, shame, anxiety, and guilt, with much self-recrimination. This state of despair, when all the available money had been spent and the 'zone' had ended, often acted as a trigger; planning the next gambling episode (or relapse) became an immediate solution for the PG. This immediate solution enabled the PG to get away from these negative feelings and the reality of their desperate lifestyle. In this desperate situation, all that the PGs could do to make themselves feel better would be to fantasise about and plan the next episode of gambling. This coping strategy could be seen as 'relapsing in fantasy', which had the effect not only of making them feel better, but also of preventing the PG from experiencing distress from the harms of their behaviour. Learning from these consequences was not possible at this time. However, some PGs were able to maintain awareness about what they had done. They began to experience the pain and disappointment with themselves and the harm they had done to those who were dependent on them, or to whom they owed a duty of care. Learning how to stop gambling could therefore occur under such circumstances. For these PGs, their vigilance and motivation to commit to change could be strengthened. This was much enhanced when the PG had positive social support, and people or groups available to them to assist with developing cognitive and behavioural strategies to enable them to manage the urge to gamble, and to 'pull' away from the temptation and the urge to succumb by relapsing. For others, urge extinction became the key factor that protected against relapse, indicating that an apparent 'cure' was possible for EGM gambling for these PGs. This process of reappraisal of personal gambling behaviour pulled the PG away from relapse, which resulted in an increasing commitment to change. This was a very prolonged process for many. It developed over time and was affected by, but was independent of, each episode of relapse. These findings provide insight into therapeutic approaches for PGs and, on face value, may have medico-legal and public health implications for the EGM industry. This altered state of awareness ('the zone') may affect the PG's capacity to execute the valid financial transaction that is required in the act of gambling when in such a state of impaired cognitive functioning.
Keywords: relapse,problem gambling,qualitaitve,focus groups,indepth interviews
Subject: Medicine thesis
Thesis type: Doctor of Philosophy
School: School of Medicine
Supervisor: Dr Rene Pols