Austin J Clin Case Rep. 2016; 3(4): 1101.
Góz G* and Sapiro M
Departnt of Medical Psychology, Clinical Hospital “Dr. Manuel Quintela”, Uruguay
*Corresponding author: Gracy Góz, Departnt of Medical Psychology, Prografor Prevention and Treatnt of Pathological Gambling, Clinical Hospital “Dr. Manuel Quintela”, Avenida Italia 2870, Montevideo, C.P: 11.600, Uruguay
Received: July 10, 2016; Accepted: September 13, 2016; Published: October 10, 2016
Conceived as a social or psychological addiction, pathological gambling, is worldwide a health workers concern. Its high prevalence and increang incidence, along with the growing offer of ga posbilities, portrays a not very easy future. In Uruguay, attending to these risk factors was established in 2009, under an agreent between Medicine School (UdelaR) and National Canos Managent, a free prografor the “Prevention and Treatnt of Pathological Gambling”, currently, coordinated by the Departnt of Medical Psychology. The progracarries out its asstance activities at the Univerty Hospital “Dr. Manuel Quintela”. The aiof the prograis that patients with gambling problems achieve continuous abstinence during two years. To achieve this goal, patients should have reached an adequate level of self-control against the harmful behavior exhibited when entered to the progra. It involves the patient solving so issues that go beyond the gambling proble, and linked with history of life. It is based on a psychotherapeutic group approach, on weekly frequency, and with co-therapy, two psychotherapists (Psychologists). Intervention strategies are part of an integrative approach in psychotherapy. It also pursues a didactic purpose. It provides the patients with tools through which they could restructure their lives, in order to find new anings for their lives. The working group is complented by psychiatrist consultation, selfexcluon request (resource that restricts soone to going into a gambling roo) and bi-monthly etings with family or referents.
Keywords: Pathological gambling; Social addiction; Psychotherapy; Cotherapy; Integrative approach
Susana Martinez is a 71-year-old woman. Divorced, she has two sons aged 48 and 44 and two grandsons aged 16 and 6. She lives alone and she works as an administrative clerk at a Health Center Laboratory. She is a high school graduate. The patient requested the “Prevention and Treatnt of Pathological Gambling” progra(Dr. Manuel Quintela Univerty Hospital, Montevideo, Uruguay), through a 0800 phone number, being registered on the waiting list as a candidate to participate in a group therapy device. In the anwhile a psychiatrist of the prograheld occaonal etings with her.
The patient exhibits such symptoms as anxiety and depreson.
See Table 1.
15 years old
Suicide Attempt with Psychotropic Drugs.
26 years old
33 years old
Major Depressive Episode (she has had multiple episodes / no internment)
From 15 years ago
Medicated with antidepressant and hypnotic.
The patient expresses: “got another $ 400 credit. Now have an $800 debt. think they will leave in the “Clearing” (Official list of no-payers, people who are in this list do not receive credit frothe banks).
“asked my youngest son for help. He took away all my credit cards”.
See Table 2.
Birth. Very dysfunctional family. Alcoholic father. Domestic Violence.
1953 (9 years)
Menarche. Left school. From then until 13 years old, she was sexually abused by her father.
Suicide attempt with Psychotropic Drugs.
Took school examinations to go to high school.
Met the father of her children.
She got married.
1967 (23 years old)
Her first son was born.
1970 (26 years old)
Her second son was born. Puerperal Depression.
1977(33 years old)
Major Depressive Episode. She found out that her husband is unfaithful and she decides to separate.
2010 (66 years old)
Went gambling for the first time
Her mom died
Began to attend Anonymous Gamblers.
The psychiatrist kept spaced interviews until the patient is admitted into a psychotherapy group.
The patient attends three interviews. The psychotherapist collects information about the patient’s gambling history, assesses her capacity to benefit froa therapeutic group work and froan educational perspective and observes the kind of bond established between the.
The patient is selected because of:
- Her voluntarily attendance.
- Her level of commitnt (high level of self-demand).
- Her real posbilities to attend the Health Center (she lives nearby).
- Her very good capacity for self-reflection.
- She reached the “contemplation stage”  regarding it’s problematic.
In 2010, she went gambling for the first ti with two couns who gambled in a controlled manner (social gamblers). She won. The second ti she went alone.
The patient expresses:
At that mont of entering into the progra:
- She attended the gambling rooalmost daily.
- She would engage in gambling for 12 hours non-stop
- She had co to lose $400 in a day.
- Always returned ho to get more money to continue gambling.
- She resorted to money she had reserved to pay bills.
- She had requested loans froher family and she had not returned the money.
- She had hidden her gambling problefroher family and friends.
- She had tried to stop but she could not do it until she had lost everything in spite of feeling very guilty about gambling.
- months later, the patient went back gambling (January 1th, 2014)
The following stressful tuation is identified: his youngest son did not invite her to his birthday party.
- 5 months later, the patient went back to gambling (July 20th, 2014)
- 14 months later, the patient went back to gambling (November, 20th, 2015)
- Control techniques and response prevention.
- Relaxation and ditation techniques to connect with emotions and regulate anxiety and stress.
- Restructuring irrational beliefs and distortions of information procesng (statistical probability of winning)
- Social and communication skills training.
- Techniques of artistic expreson
- Psychodrama techniques
- The trigger event: what happened? (Recapitulation of the circumstances in which the act of gambling is presented).
- The emotional response to the event: what did you feel in that mont? (Identification of emotions).
- The interpretation of the event/adjustnt to reality: what did you think? (Irrational ideas/distortions in information procesng).
- The link with the patient life history: what does this tuation have to do with your personal story? (Traumatic tuations).
- Work stressful and traumatic life tuations.
- Improve personal, relational and economic aspects of her life.
- Strengthen the motivation to change stereotypic (harmful) behavior [27,28].
- Show new, creative (healthy) behavior .
The following stressful tuation is identified: his youngest son did not invite her to his birthday party.
Conflict in the relationship with her children. She feels rejected and guilty because her eldest son cannot “move on in life” (he is not working, he has a child but he is unable to take care of hi). The other son has problems with alcohol and he has been distant lately.
Therapists worked with the patient against the different tuations that ca up, favoring a more assertive behavior [2-4] (setting limits to the others, confront hypotheses, expresng what she thinks and feels, developing self-confidence). It shows up difficulties in their marriage (alcoholis, infidelity of her ex - husband) and the issue of sexual abuse by her father, fact that she had never told anyone.
Currently, her oldest son lives with her; he is working and has recovered healthy habits. Her youngest son was hiding her that his partner (mother of his child) had been unfaithful. He is separating.
The following stressful tuation is identified:
Fears about death and about her own death appear.
The following stressful tuation is identified: she found out that a friend who had abandoned her after knowing she had problems with gambling (fact that had hurt her a lot), was dying of cancer.
In therapy, the patient’s feelings and thoughts related to her
friends illness where explored. They could identify the presence of
The therapist works with the “A, B, C of Human Behavior”  and negative emotion managent, helping the patient to forgive her friend and forgive herself.
The patient “uses” gambling, as a way to handle stressful life tuations, unable to connect with negative emotions and escaping froloneliness [6-8]. We understand compulve gambling as a sympto, the “tip of the iceberg” of a life story that is often gned by abuse, dostic violence, unresolved grief, relationship problems, and financial problems. We work froan integrative  and trans-academic approach in psychotherapy, ung theoretical concepts and techniques frodifferent disciplines as cognitivis, psychoanalys, psychodrama, communication sciences, psycho-immuno-endocrinology. As well as a “toolbox” , that includes [11-24].
In this case, therapists worked on the several relapses the patient had, based on the principle of “A.B, C of Human Behavior”  and the History of Patient Life .
This principle allowed theanalyzing the behavior of gambling again (recurrences). Therapists sought to identify with the patient, the different elents involved:
The work done, let the patient “see and think by herself “. The developnt of self-observation and self-reflection  allowed the patient to:
Evaluation of the process by the own patient:
Therapist: What does having co to the group an to you?
Patient: A big change.
T: What changed?
T: Can you tell us what changed?
P. “Before ca to the group, when thought about , thought was a bad person”, “learned to connect with what feel”, “changed my appearance. My closet was full of clothes and did not use the. Now, care, go to the hairdresser and enjoy it”
“The mood. feel good. ’happy”.
“When asked where had heard the word “relience”  and we talked about what it was, realized everything had done alone. knew the aning of that word, but was unable to see it in myself. “learnt a lot here”.
“acharging more than my salary. When ca here, did not have money to eat”
As a final concluon, today, nine months after the last recurrence, the patient has not gambled again. She is also very committed to achieve two years of abstinence. Therapists are confident that she can achieve her goal.
- Campiñez M. The TTM and motivational interview. Gaceta Gpcys. 2014.
- Castanyer Mayer-Spiess O. Assertiveness: expreson of healthy self-estee. Bilbao, Españ Desclée De Brouwer. 2013.
- Smith MJ. When say no, feel guilty. Barcelona, Españ Nuevas Ediciones De Bolllo. 2003.
- Navas-Robleto JJ. Behavioral modification and assertive discipline: a procedures manual for teachers, parents, profesonals. San Juan, Puerto Rico: Publicaciones Puertorriqueñas. 1998.
- Ellis A, Lega . How to apply so bac rules of scientific thod to change irrational ideas about self, others and life in general. Revista Pcología Conductual. 1993; 1: 101-110.
- Alonso Fernández F. New Addictions. Madrid: Tea. 2002.
- Echeburúa E. Pathological gambling: progress in the clinic and in treatnt. Pirámide. Madrid. 2010.
- Echeburúa E. Future challenges in the treatnt of pathological gambling. Adicciones. 2005; 17.
- Fernández Álvarez H. Fundantals of an integrative psychotherapy model. Buenos Aires: Paidos SAICF. 2005.
- Raffin M. The thought of Gilles Deleuze and Michel Foucault in question. Lecciones Y Ensayos. 2008; 17-44.
- Ibáñez Tarín C, Manzanera Escartí R. Cognitive-behavioral techniques easy to apply in primary care. Sergen. 2012; 38: 377-387.
- Lega L, Cabezas Pizarro H. empirical relationship between Rational Emotive Behavior Therapy (REBT) and Ellis cognitive therapy (CT) Beck in a Costa Rican sample. Educación. 2006; 30: 101-109.
- Morales Calatayud F. Chapter V: The Psychology in health atenciónprimaria in Introduction to the study of health psychology. Serviciosescolares address. Dirección de serviciosescolares. Unison. 1995.
- Valadez Ramírez A. Application of cognitive behavioral techniques in a case of family problems: cognitive restructuring, assertiveness and contingency managent. Revista de Pcología Iztacala. 2002; 5.
- Lehrer P, Barlow D, Woolfolk R, Wesley E. Principles and practice of stress managent. New York: Guilford. 2007.
- Univerty Of Wisconn-Madison. Compason ditation changes the brain. Science Daily. 2008; 27.
- Lamrimpa G. Calming the mind: Tibetan Buddhist teachings on the cultivation of ditative quiescence. U.S.A: Snow Lion. 1995.
- De La Llera Suárez E, Reyes W. Therapies with art: its use in primary health care. Rev Cubana Med Gen Integr. 2000; 16: 295-304.
- Moreno J. y psychodrama group psychotherapy. México: Fondo De Cultura Económica. 1975.
- Moreno J. The theater of spontaneity. Buenos Aires: Vancú. 1977.
- Bustos D, Noseda E. Manual psychodrama psychotherapy and education. Buenos Aires: R.V Ediciones. 2007.
- Van-Der Hofstadt C. Communication skills applied: a guide for improving personal communication skills. Valencia, Españ Promolibro. 1999.
- Watzlawick P, Beavin J, Jackson D. Theory of human communication: interactions, pathologies and paradoxes. Buenos Aires, Argentina: Tiempo Contemporáneo. 1971.
- García Martínez J. narrative techniques in psychotherapy. Madrid: Síntes. 2012.
- Mc Adams D. The life story interview. Chicago: North Western Univerty. 1995.
- Bandura A. Self-efficacy: how to face the changes of modern society. Bilbao: Desclée De Brouwer. 1999.
- Habermas J. Knowledge and Interest. Madrid: Taurus. 1981.
- Freud S. Beyond the Pleasure Principle in Complete Works of Sigmund Freud. Traducción José Luis Etcheverry. Buenos Aires & Madrid: Amorrortu Editores. 1920.
- Nietzsche F. The Gaya Science Madrid. Spain: Editorial Akal Colección Báca De Bolllo. 2001.
- Arican Psychological Association (A.P.A.). The road to relience. Centro de apoyo.