Gambling is prevalent across most cultures of the world. Gambling refers to betting something of value (usually money) on an event whose outcome is unpredictable or is determined by chance. It is merely a leisure activity with no resultant harm for most people but for some it can become problematic. Problem gambling refers to gambling that disrupts or damages personal, family or recreational pursuits [1]. Gambling disorder, previously called gambling addiction or pathological gambling, refers to a condition related to excessive gambling and defined by criteria set forth in the Diagnostic and Statistical Manual of Mental Disorder [2]. These are very similar to the diagnostic criteria for substance addictions such as need to gamble with increasing amounts of money in order to achieve the desired excitement, becoming restless or irritable when attempting to cut down or stop gambling, making repeated unsuccessful efforts to control, cut back, or stop gambling, being preoccupied with gambling, etc. Similar to substance addictions, gambling addiction exists on a spectrum or continuum of escalating severity and can have multiple adverse consequences [3].

Problem gambling is an important public health issue because of its prevalence, increased risk to certain vulnerable groups and its numerous adverse consequences to the gambler, his/her family and the wider society [4]. The prevalence of gambling disorder or gambling addiction in most countries is in the region of 1%; more precise estimates are difficult in view of differing terminologies used to define problematic gambling and the different scales used to measure it. In a UK-wide study it was found that 0.7% of adults were problem gamblers and 7.3% of adults were ‘at risk’ gamblers (people who “may potentially experience varying degrees of adverse consequences from gambling” but who do not meet the criteria for ‘problem gambling’) [5]. Higher rates of problem gambling were found in respondents who were aged 16-35; Asian and Black; single, separated or divorced; and unemployed.

Furthermore, problem gambling is associated with a range of health and social harms and adversely affects the individual, the family and society. It can negatively impact the gambler’s physical health: gamblers tend to have high rates of various psychosomatic symptoms (cardiovascular, musculoskeletal, gastrointestinal and other non-specific psychosomatic symptoms) [6] and mental health problems such as depression, anxiety, substance misuse and personality disorders [7]. Problem gambling, more often than not negatively impacts on the individual’s financial situation, often resulting in large debts, poverty and even bankruptcy. It can also be associated with criminal activities, ranging from theft and prostitution to violent crime, with obvious legal consequences. Problem gambling can also adversely affect the gambler’s interpersonal relationships [8] and can result in relationship problems, neglect of the family, domestic violence [9] and child abuse. Finally, the costs of gambling borne by society include the cost of the crimes committed by gamblers and the various health and social care costs [10]

In terms of treatment of gambling disorder, no pharmacological agent is licensed for use although drugs such as mood stabilizers (Lithium, valpraote, etc.), SSRIs and opioid blockers such as naltrexone have been tried with some success. Psychological interventions are the mainstay for treatment of gambling disorder: Gamblers Anonymous is one such peer support group offering intervention, which is free and easily available across the world. In this editorial, we present an overview of the Gamblers Anonymous fellowship

WHAT IS GAMBLERS ANONYMOUS?

Gamblers Anonymous (GA) is ‘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’ [11]. GA adopts a very broad definition of gambling - ‘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’.

GA had its origins in the US in 1957 when Jim W, a drinker and gambler, organized the first meeting. He had earlier been to Alcoholics Anonymous (AA) and applied similar principles to the first GA meeting. Since then, GA has been set up in various countries across the globe – the UK, other European countries, Australia, New Zealand, Brazil, Israel, and some African countries (e.g., Kenya and Uganda) and Asia (including Korea, Japan, and India).

GUIDING PRINCIPLES OF GAMBLERS ANONYMOUS

The key guiding principles of GA are given in Box 1 below. Further information about the organization is available at www.gamblersanonymous.org.uk.

BOX 1: Basic guiding principles of Gamblers Anonymous Gamblers

Anonymous:

• is a fellowship program
• uses a disease model for compulsive gambling
• believes that no cure, only recovery/control, is possible
• recommends total abstinence, not controlled gambling
• is not religious but spiritual
• considers belief in a higher power to be essential
• is a lifelong endeavor
• maintains that anonymity is key
• encourages personal and spiritual growth
• focuses on repeatedly working through the twelve steps
• has no fees for membership
• has no sociopolitical or religious affiliation
• is a way of life

THE TWELVE STEPS OF GA: THE GA RECOVERY PROGRAM

The twelve steps of recovery are central to the GA recovery program [11] and are the foundation on which the fellowship of GA is built. See Box 2 for the twelve steps.

BOX 2: The twelve steps of GA

1. We admitted we were powerless over gambling – that our lives had become unmanageable.
2. Came to believe that a power greater than ourselves could restore us to a normal way of thinking and living.
3. Made a decision to turn our will and our lives over to the care of this Power of our own understanding.
4. Made a searching and fearless moral and financial inventory of ourselves.
5. Admitted to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have these defects of character removed.
7. Humbly asked God (of our understanding) to remove our shortcomings.
8. Made a list of all persons we had harmed and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
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.
12. Having made an effort to practice these principles in all our affairs, we tried to carry this message to other compulsive gamblers.

The twelve steps named above are very similar to the twelve steps of AA. Working through these twelve steps is integral to the gambler's recovery. Although the initial attempt is to get the gambler to attend 90 meetings in 90 days, it is a life-long commitment and GA meetings should be an integral part of the gambler’s life for the rest of his/her life.

THE GROUP MEETING

Group meetings aid translate the fellowship's principles into action. The frequency and duration of individual meetings can vary: most meetings are weekly, and each lasts anywhere from 60 to 90 minutes. Meetings are often held in venues such as churches or hospitals. The core structure and format of GA meetings are the same, whichever part of the world it is held in. After the formal meeting, during coffee time, there is more informal interaction.

Every group meeting has a chair, taken in turn by members each week and a typical meeting comprises the following:

• introduction of new members;
• members giving ‘therapy’;
• reading from the Combo Book;
• other fellowship-related announcements and business;
• Collections (optional) from the members.

In the meeting, each attendee is encouraged to talk about their gambling past, their attendance at GA, how they are dealing with life and so on - this is called ‘therapy’. It not only helps the individual but also gives others an opportunity to listen, share and learn. 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.

BEYOND 90 DAYS

Once a gambler has been attending meetings regularly and after he/she has been abstinent from gambling for 90 days, he/she is requested to offer some services to the fellowship, two of which will be discussed briefly here – the twelfth step call and sponsorship.

TWELFTH STEP CALL

After 90 days of attending the programme, those who are doing well are encouraged to make the twelfth step call – i.e., to call, in person rather than on the phone, those who are still addicted to gambling. The purpose of this meeting is to encourage them to attend GA meetings by explaining the benefits. 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 extends beyond making the twelfth step call and is a life-long commitment to helping another compulsive gambler. A sponsor should encourage attendance at meetings, ensuring that the sponsored member understands what the program is about, and should be empathetic and available in times of crises. A sponsor must be aware of his/her own role, strengths and limitations: always remembering that it is the fellowship that aids recovery and not their individual attributes. Although sponsorship primarily helps the person being sponsored, it also helps the sponsor in his recovery journey.

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 program for children of compulsive gamblers.

EVIDENCE BASE FOR GAMBLERS ANONYMOUS

GA hasn’t been subjected to robust research and hence the evidence base for its effectiveness is limited. The reasons for this include the fact that GA is anonymous, so no notes/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[12].

A BRIEF SUMMARY OF RECENT RESEARCHES

A 2004 review of all the available GA literature[13] identified several gaps in knowledge and suggested that the following areas be researched further: 'an examination of GA’s effectiveness with larger and varied samples, better accounting of GA beliefs and practices, assessing the performance of GA with formal treatment regimens as well as attendance at other mutual aid organizations, an assessment of who may be best and least suited to GA, and an understanding of how GA can help in the process of recovery’.

A more recent review [14] that looked for studies which evaluated the evidence base in the area of GA research identified only seventeen studies and they were categorized as: ‘(1) randomized controlled trials that evaluated the effectiveness of GA either as a control condition or as an adjunct treatment to medication or psychotherapy, (2) quantitative non-randomized studies that (a) described characteristics of individuals who attend GA or (b) examined the association between attending GA and various outcome measures, and (3) qualitative and mixed methods studies that explored GA practices’.

Desai et al.[15] carried out a 12-week study, where 36 participants were randomly allocated to one of four treatment groups: Bupropion and Harm Reduction, Bupropion and GA, Placebo and Harm Reduction, or Placebo and GA. This study found no significant differences between the groups on measures of gambling frequency and intensity, treatment compliance, global functioning, disability, and treatment motivation. But of the 36 participants, 77% showed reductions in the amount of money spent on gambling, and 60 % showed reductions in the amount of time spent gambling.

Some other quantitative non-randomized studies have described characteristics of individuals who attend GA, and some have examined the association between attending GA and various outcome measures.

Oei et al. [16] studied 75 GA attendees and looked at the role of seven variables in predicting abstinence or relapse; the variables were: meeting attendance and participation; social support; belief in God; belief in a higher power; working through the twelve steps of recovery; gambling urges; and erroneous cognitions. Authors concluded that meeting attendance and participation and social support increased the chances of abstinence; greater gambling urges and erroneous cognitions increased the chances of relapse.

Traditionally, GA attendees have mostly been men and the organization were criticized for being ‘unfriendly’ to women. However, this is changing as Ferentzy et al. [17] showed that GA was becoming more female-friendly and that nearly 20% of attendees in Canada were women.

CONCLUSION

Although GA is based on the same 12 steps as AA, it has certain unique and different features when compared with AA. Unlike AA, GA places more emphasis on patience (delaying instant gratification and trying not to solve problems quickly) in working through the 12 steps. In terms of the 12 steps themselves, in GA they don’t have to be followed in strict order from 1 to 12. For example, steps 4 and 9, which deal with financial matters may be dealt with first. Step 4, dealing with financial issues, is unique to GA (Gamblers Anonymous International Service Office (GAISO) 1999) [18]. GA, more than other fellowships, encourages a “socially based conception of recovery” - it relies on family members, including significant others, for social support. Many GA attendees prefer to have their wives as their sponsors [19]. GA is a free and easy to access psychological intervention, with benefits for those addicted to gambling. It is compatible to be offered with other one-to-one and family-based psychological interventions. We call for clinicians to be more familiar with this intervention and to help offer it more widely.

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Dr. Sunju George
Associate Editor
Email: sanjugeorge531@gmail.com