“Ms. A” was a 51-year-old Haitian woman who immigrated to the United States with her family at age 25. She married soon after her arrival, settled in a large city on the East Coast, and had two daughters. At the time of treatment, Ms. A had been working for more than 20 years as a secretary in a business office.
Ms. A started gambling in Haiti at an early age, occasionally betting small amounts of money on domino games and local lotteries. Initially her gambling behavior did not have any immediate adverse consequences, although, paralleling the effects of early substance use, it may have predisposed her to pathological gambling in adulthood
(9) . At age 30, 5 years after her arrival in the United States, Ms. A began to gamble periodically in hopes of improving her financial situation. Over the next 10 years, she began to lose increasing amounts of money playing slot machines at casinos. By age 40, Ms. A would often spend the entire weekend sitting at the slot machines, without sleeping, and eating only snacks. After a few years of intense gambling activity, she was able to stop on her own without treatment. However, at age 45, she relapsed, a common experience among pathological gamblers
(10), into playing lottery tickets.
The relapse occurred after she had vivid dreams that she interpreted as depicting number combinations she should play in the lottery. Growing up in Haiti, she had learned to look for symbols in her dreams. In her culture, dreams were believed to convey important life messages that were often represented by numbers. When she was a teenager, books about dreams and numbers were very popular, and she read them fervently. She would also frequently gather with her family members to discuss her dreams and their meanings and to agree on the numbers the dreams suggested should be played in the lottery. These discussions about dreams and numbers among her family members continued to be an important topic in their almost daily conversations after they immigrated to the United States.
As a result of her gambling behavior, Ms. A began to have financial problems. One of Ms. A’s primary motivations to seek treatment was the constant arguments with her husband about the monetary constraints caused by her gambling activities. She also felt ashamed and guilty about the money spent on gambling over the years. Although she had financial difficulties as a result of the gambling behavior, Ms. A did not commit any illegal acts to finance her gambling activities, nor did she rely on others to bail her out of financial difficulties.
Ms. A reported that her gambling did not interfere with her work and household chores because it took her only a few minutes during the day to purchase tickets at convenience stores located close to her workplace and home. She never missed days at work, and she performed her work well. She noted only mild difficulties concentrating at work during the minutes prior to the lottery deadline. She did note an impact of gambling on her social activities, however. She reported being more socially withdrawn, spending less time with her daughters, and having increasing conflict with family members as a result of her overall irritability.
Treatment
At the initial treatment contact, Ms. A clearly stated that her main goals were to abstain from gambling and to improve her financial situation and her relationship problems. One of her main concerns was that although she had been able to abstain from gambling in the past, she found herself unable to do so after her last relapse. At the initial evaluation, Ms. A scored 20 on the Yale-Brown Obsessive Compulsive Scale adapted for pathological gambling (PG-YBOCS; range of possible scores=0–40), a valid and reliable measure of pathological gambling severity
(15) .
Early in treatment, Ms. A identified her dreams and visions as her main triggers for gambling. She described two types of dreams. In one type, either she actually “saw” numbers or one or more characters in the dream disclosed “winning” numbers. These dreams were very vivid and constituted very strong triggers to gamble. The other type of dream, which she referred to as visions, was more common and happened throughout the day. Those dreams contained images and actions of different individuals she knew, including family members, friends, coworkers, and neighbors. For these visions, Ms. A had predetermined number conventions derived from Haitian culture and conversations with her family. That is, the images and actions she saw conveyed number combinations. For example, she would describe a dream in which she saw an unknown little girl talking to her uncle. Ms. A said that dreaming about children meant the number 32, while dreaming about a male family member represented the number 5. She would thus create different sets of numbers with these three digits. In other dreams, the numbers were more obvious, such as in a dream in which she saw herself walking on a street and seeing a license plate with a certain number. Ms. A typically started attributing numbers to the images that appeared in her dreams and visions as soon as she woke up every day. She would write down the numbers and generate a list of different combinations to buy a series of lottery tickets that day. Depending on the results of the first drawings, she would generate a new series of combinations for the next drawing. Ms. A also reported other triggers for gambling
(16), including her wish to solve her financial problems, her family’s constant involvement in gambling activities, and the sight of gambling advertisements or convenience stores that sold lottery tickets.
Having identified a variety of triggers, Ms. A began to address them to minimize the possibility that they would result in gambling. For example, she started making a conscious effort to avoid recalling her dreams. This was difficult because of her long-standing habit of recalling them, but it was effective in controlling her gambling behavior. She also stopped carrying with her the list of numbers generated in the morning, and she later replaced generating the list with doing her weekly therapy homework assignments. During treatment, therapist and patient maintained a tracking graph on a grid of gambling and nongambling days. Graphing all gambling and nongambling days together on one sheet of paper, she was able to visualize her progress. After the third session, she found she was able to decrease the amount of money spent on gambling and to buy lottery tickets every other day rather than daily.
Ms. A also started to actively avoid some other gambling triggers. She avoided the convenience store close to work and stopped watching gambling television shows and advertisements, including the lottery results. She contacted the customer service departments at the casinos she used to visit, requesting that they stop sending her their invitations and publicity. She purposely kept busy during the hour before the lottery deadline, to avoid buying lottery tickets for the next drawing.
For Ms. A, the most effective strategy to abstain from gambling was to conduct functional analyses every time she experienced an urge to gamble. Describing her gambling activities, she talked about the anxiety she experienced before buying lottery tickets and the frustration, shame, and guilt she felt once the results were published and she was confronted with the amount of money lost that day. Conducting functional analyses allowed her to see how despite a few wins, the overall result was always monetary loss and greater debt. The patient gradually started to feel less excited about thoughts of winning. Eventually, even winning became an anxiety-provoking situation.
The patient experienced intense frustration on one particular occasion when she had a dream about the winning number but did not feel the dream with enough strength. She hedged her bets, rather than put all her money on the winning number. This experience filled her with doubt about her abilities. She started to experience her ability to foresee the future in visions and dreams as an unpleasant responsibility. In the past, stressful familial events had also appeared in her dreams before they happened, but she had been unable to influence those events—a very painful experience. She realized now that, similarly, “knowing” the correct number did not lead her to win, and hence her gambling activities were making her financial situation worse. At that time, around the midpoint of the treatment, Ms. A’s PG-YBOCS score had decreased to 11. Tracking the number of gambling days revealed that she was now gambling once or twice a week.
The therapist conceptualized the knowledge Ms. A acquired through her dreams as a special type of erroneous belief. Erroneous beliefs are commonly found in gamblers and often manifest as beliefs in “lucky days” and “lucky streaks.” They can also include ignorance of the true probabilities of winning and failure to understand the independence of events (“I lost three times on this slot machine, so I should win soon”).
In CBT, at least an entire session is generally devoted to understanding and challenging erroneous beliefs. The purpose is to help the patient identify his or her thinking errors regarding the odds of winning. However, in this case, given the strong family and cultural support for the patient’s cognitions, the therapist’s approach was to subtly question Ms. A’s beliefs, without confronting them directly. The therapist focused on having the patient recognize that the dreams and visions did not consistently provide her with winning numbers, rather than challenging the irrationality of the belief. This approach, and the patient’s progressive perception of her dreams and visions as a burden, strengthened the patient’s decision to ignore her dreams and visions related to gambling. In so doing, a main trigger of her gambling was removed.
During subsequent sessions, the therapist coached Ms. A on assertiveness and gambling refusal skills. It was difficult for Ms. A to control her urges to buy lottery tickets after participating in “number conversations” with her family members or coworkers. She decided during one of these sessions to tell her mother and sisters about her wish to abstain from gambling. However, after 2 weeks of abstinence, Ms. A lapsed one day. She bought a lottery ticket after one of her sisters told her of a vivid dream about what she believed to be the winning number for the next drawing. Using the gambling tracking chart, the patient was able to see that weekends, when she spent longer hours with her family members, represented a risk.
This lapse led Ms. A to identify family members and conversations about numbers as additional triggers to gamble. Ms. A had to reiterate to her family members that she wanted them to avoid discussing numbers, dreams, or visions when she was present. This was difficult initially, as her family would pressure her to continue gambling, given its importance in family life and beliefs. However, Ms. A eventually prevailed and found it helpful to avoid these conversations. Having the strength to voice her opinions and wishes also raised her self-esteem and self-efficacy. Around that time, she learned that one of her brothers had a gambling problem when they were living in Haiti. This knowledge increased her motivation to remain abstinent, as she remembered the financial struggle her brother experienced before immigrating to the United States.
The last two sessions served to solidify Ms. A’s gains and refine her skills. The patient had already achieved abstinence and felt strong and confident. Her urges were mild. She spent more time in pleasant alternative activities, such as physical exercise, going out with friends or to church, helping organize holiday festivities, and participating in other community activities. She also spent more time with her husband and daughters during the weekdays and attended social gatherings with them.
Although Ms. A had initially reported that her gambling activities never affected her work, toward the end of treatment she noticed an improvement in her ability to concentrate and complete tasks more efficiently. Her abstinence helped improve her relationship with her husband, with whom she now argued less. She was also excited about being able to buy more things for her home as a result of not spending money on gambling. At the end of the tenth session, her PG-YBOCS score had decreased to 2, within the normal range. The gambling tracking chart was now a straight line, since she had not gambled for an entire month. The process of tracking nongambling days increased Ms. A’s perception of control of her gambling behavior, and she reported that it became a strong motivation to remain abstinent.
After completing the 10 weekly sessions, Ms. A continued to come to therapy for monthly follow-up sessions. At follow-up, 10 months later, Ms. A continued to abstain from gambling. During these sessions, therapist and patient continued working on strengthening the skills learned during the acute treatment and brainstorming alternatives to gambling. The patient was also referred to a therapy group for women who want to remain abstinent from gambling, which Ms. A found helpful. It is likely that Ms. A will require continuous treatment and follow-up for pathological gambling. If her preferences or situation change, other therapeutic alternatives, such as medication for other psychiatric symptoms, motivational interviewing, or Gamblers Anonymous, could also be considered.