Transcript Document 7144225

Self-Medication
Today’s agenda
•House Keeping
•Self-Medication, Trauma, and the Female Gambler
1
Self-Medication
Drugs push aside suffering
•
How should we be able to forget those ancient myths... about dragons that at the last minute turn into
princesses who are only waiting to see us once and beautiful and brave?... [P]erhaps everything terrible
is in its deepest being something helpless that wants help.
•
Rainer Maria Rilke
Comfortably: Numb
Pink Floyd
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decompressor
are needed to see this picture.
Nicotine’s the World’s
Antidepressant
5 million premature deaths associated with tobacco
use in 2000
It is estimated that between 2025 to 2050 there will be
300 million tobacco deaths
Why do we use it? Is it self-medication?
Effects on the brain
Dopamine, GABA,
MAO
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decompressor
are needed to see this picture.
DiFranza (2008)
suggests that it may
only take a month to
become hooked
Nicotine and Canadians
•
45,000 Canadians die
each year from smoking
related deaths each year
•
For long-time smokers, the
chance of dying from a
smoking-related cause is
50%
•
Smoking is the single most
preventable cause of cancer
(Lung Cancer Canada,
2008)
•
Check this out
Gender Differences in Alcohol Use
Men have higher lifetimes rates of alcohol disorders
However, women appear to surpass men in alcohol related
problems, such as
Deaths from suicide
Alcohol related accidents
Heart disease and stroke
Cirrhosis of the liver
Biological Differences
Women metabolize alcohol more
slowly, thus they experience
higher blood alcohol
concentrations with similar drinking
amounts
According to the *NIAAA (2005)
drinking > 7 drinks per week
increases a women’s chance of
becoming dependent
> than 7 per week, but more than 4
or any given day more likely to
develop a problem
*National Institute on Alcohol Abuse and Addiction
Post-traumatic Stress Disorder
& Self-Medication
Early research centred trauma and PTSD as an effect of war, civil war “soldiers heart”; world wars - shell shock
Today in the aftermath of 911 and closer to home residential school
aftermath, trauma and PTSD is becoming more recognized
We have now beginning to challenge the etiological diagnosis where
the traumatic event is thought to be “outside” the normal range of
experience - to realize that rape, battery, sexual and domestic abuse,
are so common that they can “hardly be outside” the range of normal
experience
The Heart of PTSD and
Trauma
According to Herman (1997) - Intense emotional reaction to an event - panic,
terror, grief or disgust
According to National Center for PTSD (2007) those most likely to develop
PSTD
DIRECTLY EXPOSED
SERIOUSLY INJURED IN THE EVENT
LONG LASTING AND SEVERE
BELIEVED LIFE IN DANGER
BELIEVED FAMILY MEMBER WAS IN DANGER
SEVERE REACTION DURING EVENT
FELT HELPLESS FOR ONESELF OR FAMILY MEMBER
HAD EARLIER LIFE THREATENING EVENT
DRANK ALCOHOL IN EXCESS
RECENT UNEXPECTED LOSS
PTSD SYMPTOMS
PTSD begins can begin intensely and can wane, and
wax, and wane.
Psychological symptoms include
Re-experiencing
(flashbacks, nightmares, intrusive memories)
Emotional Numbing
Avoidance
(feeling detached, lack of emotions, loss of interests
(activities, people, or places that are reminders of trauma)
Increase arousal (difficulty sleeping, irritability, hyper-vigilance,
exaggerated startle response)
Psychological outcomes can
include the following:
Depression, major or
pervasive
Anxiety disorders, phobias,
panic, and social anxiety
Conduct disorders
Dissociation
Eating disorders
Psychosocial
manifestations
Alcohol and substance abuse
Suicide attempts
Risky sexual behaviours
Self-injury
Interpersonal problems
PTSD and Substance
Abuse
Kimmerling et al. (2004) report that approximately 30% to 50%
of men and 25% to 30% of women with lifetime PTSD are also
substance abusers
Those with SUD and PTSD have poorer substance abuse
outcomes (Brown, 2000)
Meanwhile those with PTSD relaspe more quickly, drink more
on days when they drink, have greater % of heave drinking days
and more consequences due to non-PTSD substance abusers
(Brown, 2000)
Women are more likely to develop addictions after
exposure to traumatic event and symptoms of PTSD,
with approximately 65% to 84% of women
experiencing PTSD before developing addictive
dependencies (Milkman & Sunderwirth, 2008)
Meanwhile, men appear to develop PTSD
symptomology during their addictive careers
(Kimmerling et al. 2004)
Trauma, its Role and Trajectory in the
Development of Female Pathological Gambling
An Interpretative Phenomenological Analysis
It takes two to speak the truth. One to speak, and another to hear - Thoreau
Setting the Context
There is a paucity of research that addresses the connection between
trauma and female pathological gambling (Boughton & Brewster, 2002).
However, research has revealed that a large percentage of individuals
with mental health problems report having experienced a traumatic event
(Larkin & Morrison, 2006).
Women in particular, are at a greater risk of being exposed to trauma that
sometimes occurs in close relationships (Wolfe & Kimerling, 1997) (i.e.,
incest, marital and date rape, and intimate partner violence).
Then again, it is not known whether pathological gambling development
and its progression can be related to the latter kinds of traumas.
Previous Research
Based on a Canadian study involving both males and females living in 22 families, Grant
Kalischuk and Cardwell (2004) developed a grounded theory that situated trauma as being
a factor implicated in problem gambling for both males and females.
Afifi, Brownridge, MacMillan & Sareen (2010) sought to understand the relationship
between problematic gambling and family violence. Results from their study suggested
problem gambling may be directly associated with dating violence, marital violence and
child abuse.
In a sample of 111 pathological gamblers, Kausch, Rugle, and Rowland (2006) identified a
relationship between gambling and trauma, however the role that trauma played in
development of these 111 pathological gamblers was not determined. With respect to
gender, the sample was comprised of only 9 female participants and yet all 9 reported
emotional, physical or sexual abuse or multiple abuses.
Previous Research
(contd)
In a more representative sample, Petry and Steinberg (2005) studied childhood
maltreatment in male and female treatment-seeking pathological gamblers,
recruiting participants from seven treatment sites (N= 149; 77 females and 72
males).
The authors found that gender was specific to the intensity and types of childhood
maltreatment experienced. It was revealed that female gamblers had higher scores
related to sexual/emotional abuse and physical neglect.
An important consideration pointed out by the authors was that the study “did not
address whether childhood maltreatment leads to pathological gambling” (Petry &
Steinberg, 2005, p. 228).
What we know about
Trauma and Gender!
Among survivors of abuse, research has
consistently documented increased rates of
psychiatric disorders (Kessler, Sonnega,
Bromet, Hughes & Nelson, 1995).
According to Strachan and Custer (1989) and
Lesieur and Blume (1991) as well as others,
gambling has been categorized as a means for
dealing with trauma and trauma-related abuse
(via escape), especially among females.
Half of Canadian women (51%) have
experienced at least one incident of physical
or sexual violence since the age of 16
(Statistics Canada, 2006). Moreover, the
World Health Organization (WHO, 2006)
have recognized that gender is a well known
determinant in a variety of health-related
problems and that differences exist between
male and female treatment utilization,
substance use, and mental health-related
symptoms and diagnoses.
Linking Trauma to
Women Gamblers
Interestingly, among 365 females gamblers from across the province
in Ontario, Boughton and Brewster (2002) found that 46% of
women reported experiencing physical abuse as adults and 28%
reported experiencing sexual abuse as an adult, while another 30%
of married participants reported current physical abuse in their
relationships.
However, despite determining that gambling was a means by which
the individual was able to escape from life stressors, the mechanism
by which trauma played a role in the development of problem
gambling continues to remain under-investigated (Boughton &
Brewster, 2002).
Sample Frame
This presentation will
focus on essences
drawn from a
phenomenological
interpretative
investigation of 6
women (taken from a
larger grounded theory
study of 40 women)
(Kalischuk, Nixon,
Hagen, & Solowoniuk,
in press) who selfreported having a
traumatic history and
whose scores on the
NORC DSM-IV gambling
screen indicated a severe
problem with gambling.
Method: Interpretative
Phenomenology (IPA)
IPA endeavours to provide a descriptive account of a participant’s world that
is both critical and conceptual leading to a life text that supports participant
claims and feelings about a lived experience (Smith, 1996).
What makes IPA unique from other qualitative methods is its position on
constructing an interpretation derived from investigated experiences (Larkin,
Watts, & Clifton, 2006).
Tappan (1997) asserts that “an interpreter understands by constant reference
to her own perspective, which shapes her understanding of the world based
on her expectations, preconceptions, biases, and assumptions that rest
fundamentally on her lifestyle, life experiences, culture, and tradition.
Thus, IPA is collaborative research approach that requires the researcher to
share meanings and understandings with one’s participants toward generating
an “insider’s perspective” (Larkin, Watts, & Clifton, 2006).
IPA (contd).
Ultimately, the father of IPA
(Heidegger, 1962; 1982) asserts that
phenomenology is the study of
being....“Being” here refers to our
existence as human beings and it
implies that we are in it, that is, a
state of being.
Thus, we best represent ours world(s)
and our interpretations of reality
through words and language.
This means that the words of a
written text, which in this case are a
set of interviews, can be used for the
purpose of understanding and
examining lived experiences.
PARTICIPANT PROFILES
Name
Age
Ethnicity
Gambling Gambling
Onset
Type
Kathy
65
Caucasian
58
Barb
58
Caucasian
50
Liz
Martha
Matty
Eve
48
60
42
58
Caucasian
First Nations
First Nations
Asian
Trauma Experience
EGM
Childhood Sexual Abuse
Childhood Bereavement
Raised in Alcoholic Home
EGM
Childhood Sexual Abuse
Childhood Physical Abuse
Adult Physical Abuse
Breavement (violent death)
Raised in Alcoholic Home
46
EGM /
Cards
38
Residential School Abuse
Bingo/EGM Racial Discrimination
Adult Physical Abuse
22
Childhood Sexual Abuse
Childhood Physical Abuse
Racial Discrimination
Adult Bereavement
45
EGM
EGM
Childhood Physical Abuse
Childhood Multiple
Bereavement
Interview Procedure
The interview procedure began by restating and answering participants questions related
to the purpose and goals for the study. Afterwards empathic listening and paraphrasing
were employed by the interviewer to help participants feel safe and comfortable in
sharing intimate stories of how trauma and experiences of a traumatic nature associate
with the development of a gambling problem.
While the interview process was unstructured, the interviewer probed and prompted his
participants to sit inside their experiences of gambling and trauma (Solowoniuk &
Nixon, 2009).
This appeared to help amplify interpretations of experiencing and together the
interviewer and interviewee expanded their understanding of how trauma affects
personhood and how this then influenced the origin, progression, and complete loss of
control of one’s gambling behaviours.
Theme Construction
Theme construction involved five
processes (van Kaam, 1966; Solowoniuk,
2009).
1. Hypothetical grouping
2. Condensation
3. Elimination
4. Reconstructing
5. Final deconstruction
Terms and Terminology
Using Object-Relations theory to define the Ego, the authors refer to theorist
Frank Summers (2002), who states that ego is, “the part of the psyche charged
with the responsibility of mastering competing pressures while maintaining the
functional capacity of our organism” (p. 235). Object-relations theory states
that human beings experience essentially two births; a physical and a
psychological (Almaas, 1988; Mahler, Pine, & Bergman, 1975).
The implication here is that there is no inherent, separate sense of self from
birth, it is constructed through, in part, by our early experiences with our
caregivers; fashioning a blue print for relationships later on in life.
Thus, if a child does not have a nurturing environment that is essentially, “good
enough,” the ego does not develop normally; and in turn psychological
pathology can result (Summers, 2002). The latter point here is important to
keep in mind as all of our participants grew up in conditions that seem to have
impinged ego development through early childhood trauma.
Interpretative
Analysis
Theme 1: Early Life Trauma and the Not
Good Enough Self
Effect of trauma in earlychildhood created a visceral state of being.
Predominated by feeling of anxiousness, loneliness and emptiness, or “loss
of being”.
The developing sense of self (ego) appeared to be bitterly cut off from its
own ground of being (Almaas, 1988, 1997).
Dampening of affect.
Lizzy Stated:
•
I started hanging out with older guys in the pool hall, and kind of wanting
attention all the time and my Dad had a real reaction to that. He thought
I should be a good girl, instead of a bad girl… So I guess that’s why he
only beat me... Only me... And then their was, well my Mom and Dad
didn’t like each other either... My mom was a nasty drunk... I always
looked for a time when they were happy together, you kind of seek that, I
mean when you know your parents have some kind of harmony or
connection. I mean what other reference point do you have when you’re a
kid.
Mirroring from parents is natural, but not receiving it was a predominant
experience shared by our participants (we then seek is elsewhere).
By the age of 12, Lizzy tried to pacify herself through substance use and years
later by binge gambling.
Matty speaks about:
Emptiness
I don’t think it ever goes away honestly, to tell you the truth.
The emptiness.
It’s like, you’re dying – it’s like a
continuation of that over and over and over again… Because
you’re on that train and you’re going so fast that if you jump
you’re gonna die anyway. Well, you don’t really want to die.
You just want those parts of your life to stop. It’s like
somebody standing there with the light flickering on and off.
So what do you do? You end up going to a corner; you learn
how to block it out, right?
Corner and space is >>> Gaming Venue.
It appeared that emptiness could be blocked out or denied, but not forever.
Emptiness was altered somewhat effectively by moments of psychic inflation
(charge of energy) that fills up the holes in one’s being via a win and
admiration during gambling.
Theme 2:
Not So Innocent Beginning’s
The experience of trauma – whether in childhood or later in life – for all of
the participants seems to have left them in-the-world already searching for
something to soothe trauma’s numbing effects on the psyche/self.
Left raw and empty from past trauma, it may interpreted that all participants
were already primed for an addiction.
Thus, no matter how innocent the beginnings may seem, it appeared that our
participants compulsions lay dormant.
Some participants experienced addictions and behavioural
compulsions years before the development of pathological gambling.
Eve’s First Time in
•
…I got introduced to Vegas.
And of course my interest was
not in Vegas, because my
brother had a time share thing
there. It was pure innocence
because his son couldn’t make
it – oh yeah I’ll join you!
Well that was my first
exposure. When I got there it
was like, glitz! And I thought,
is this me?
I’m looking
around, sweating it out there.
Looking at the strip. And of
course you throw in a few
coins and of course, ding,
ding, ding and outcome the
quarters...I enjoyed it, I had
fun…nothing happened, it was
okay.
Sum of Not So
Innocent Beginning’s
Beginner’s luck, winning and enticement
Downplaying “effect of affect”
Begin to learn how gambling can be an
escape
Theme 3: Seduction and
Intoxication
[My family] would drop me off at one of the casino’s and go
shopping and not come for five or six hours. It was
fascinating…cause when you did win, it would come out, and
you put it right back as well. And the first day we were down
there and they dropped me off about four o-clock and they
didn’t pick me up until midnight. And I just had pots and pots of
money but I didn’t want to cash them in, I wanted to take them
back to the hotel (Barb).
“The high or rush
associated with the
game and the gambler
is well documented
across all cultures
throughout
history.
Lady Luck with her
spinning wheel of
fortune
beckons
(Currie, 2007, p.
17).”
The Archetype is
loosely defined as a
representation
of
powerful
psychic
energy
organized
around basic forms
and pathways that are
enacted
through
human behaviour that
appear to have been
ever present in various
forms in all cultures
(Jung, 1971).
Seduction
Summation
Seductive nature of gambling and its phenomenal affects both
sooth (sense of emptiness) while heightening gambling
experience(s).
For some participants accumulation of stressors added to the drive
to gamble more.
There is a progression financially and psychologically.
I found something that “feels right”.... “I feel right”
Theme 4: Opening the Doorway
to Oblivion
• Oblivion - “A state of forgetting”?
Participant’s existence could be said to be tied up in an eternity of forgetting
about the past and future...
Paradox here...
•
Yet there would appear to be a very cognizant pursuit to get the stuff to continue
to gamble or
•
Secure “time” necessary to gamble wantonly... Thus is it really about escape!
Oblivious Accounts
Liz reported... “It’s all about changing the way you feel, it’s all about not wanting
to deal with things that are painful. I think to me, that has been my experience.”
Matty remarked... “Pawning… I lost every single one of my rings. It wasn’t 24 hours
but I mean, I’d go to work right? I mean, as soon as we got paid we wouldn’t even
go home after. It got to the point where we just went straight from work to the bank
to the bar and yeah [Laughter]. And I would be dipping into the rum and coke and
he’d be drinking his beer. And then we’d be like, okay! And at that point in time,
too, you gotta remember, those vlts – ummm – you had to wait for them. Because
everybody would be on them at that time. So we’d be bouncing all over the place. It
was almost like a panic if we didn’t get on a machine”.
Barb reiterates... “I started going for an hour after work, and then it got, then I
couldn’t get the work done fast enough to get back to the casino to gamble. I played
for twelve hours straight. Because by this time I had let bills go, and I was kind of
trying to gain the money, I hid the bills as they came in and when [my husband]
wasn’t around, and then he started ignoring me. [Feelings]?... Well, I didn’t care. I
just wanted to get back to the machines. It was like easy money”.
A Sanctuarious
Space
Fecundity of the case (Gadmer,
1975)
Arising from Oblivion....
We are not talking about the classic escape gambler!
We are talking about direct impingement upon the
psyche from a traumatic or traumatic events.
Sanctuarious
narratives...
It seemed the less absorbed you were with it [grieving], that your generally
up winning, I can’t remember trying to win. It always just seemed like it was
a place I could go and hide from the world, and I didn’t have to do anything
or talk to anybody.... It was a space for me to just be... (Kathy).
Kathy was able to contain psychic energies within herself and the pain she was
feeling...
A return to the wellspring of Being?
I could comprehend more and feel more of what was happening and accept
that fact that my husband wasn’t there and he wasn’t coming back
[Alzheimer’s disease] and he wasn’t getting better and people kept on telling
me you have to go on with your life and you have to stay healthy for him, and
it just automatically starts to heal. I don’t know what the hell I would have
done to fill those hours; I don’t know if I would have gotten really mentally
ill.
Theme 5: Trauma and Ties
that Bind Us
Exposure to trauma and its effects are unique to each individual and its
repercussions can be felt in all areas of life, i.e. (emotionally, mentally,
physically, socially, and spiritually) (Levine, 2005).
Trauma arising from childhood and adulthood (especially within families)
echoed from the past thru to our participants relationships in the present.
When support was needed during gambling addiction - their was a difficulty
in our participants asking for help or in trusting oneself or others.
Frozen in time - both the body of trauma and the (personal) relationships that
are connected to them (Levine, 2005).
Trauma Bonds and Unfinished
Business
Martha provides an illumination of this phenomenon: “When I...do win,
especially big...and people are coming to me, trying to borrow and all that...I
felt big. And I thought, well at least I’m somebody today because I’ve got
money.”
Chase ideals, both socially via relationship and financially; both of
which are not born from our own being.
Matty sadly remarked: …Through the abuse that I’ve gone through, I would
say that yeah, I have a very addictive personality. I can cling onto things
pretty quick…and… the really good people that I run into, I throw them as
far away as I possibly can; because I’m going to end up being the one
hurting them. They’re not going to hurt me or maybe I subconsciously think
that they will hurt me; because their lives are too perfect – and I’m kinda not
in that category of perfect.
Resurfacing
I went to my pastor and we went through six sessions with him, and he told me that the
only way that I would get that out of my system [sexual abuse] is to forgive. You know
it went on for five years. I’d try to block it out and then it would come back, I would
block it out and it would come back. Then a lot of times when my Dad was still alive
him and my Mom would come to visit it just about drove me drinking…And I hated my
Dad, but I mean I done it for my mom. My mother is still in denial that my father
abused me and my sister and we just put that behind us (Barb).
Traumatic memories or associations appeared to resurface for our participants
And once gambling becomes a learned panacea... It makes is easy to want to regulate feelings of not
being okay
Resurfacing coincided with relaspe(s) and gambling binges
Barb concludes Ties that Bind Us, stating:
“Well I hated him and I think it was there for a long, long time and I had to get
away from that hate. Because it was a bad feeling. And it wasn’t right to hate my
dad. It wasn’t right for me.”
Theme 6: What Trauma
Does: Introspection into
Access
Participants report that trauma freezes their capacity to “feel” and
it appeared that it also arrested ego development
Creates feelings of inadequacy
Overt need for mirroring
Push into the unconscious (I acknowledge / I don’t )
Shame bonding
Trauma and gambling become intertwined
Loss of
Being
Trauma and its link to
Gambling
Deep down I think I do [equate early childhood losses to gambling]; because they
didn’t see me go through all my tribulations and the graduation, all the highlights
that would have been in my life. Yeah, they died too young [parents]. In a way, even
though they were really strict and that, you still have a loss of being… And then
something triggers it [her gambling]…I kind of try to figure it out myself, too,
because I’ve gone to a psychologist. I’ve gone to the mental health – they said, geez,
you seem to be pretty even-keeled. You’re outgoing, you’re this and that. But I
said, but there’s something underlying it. You know, there’s something
deeper. And I haven’t got to that deep part (Eve).
For participants, first their was trauma and then gambling acted, “Like a camouflage.
It wasn’t really...an answer. Yeah, it wasn’t an answer but yet I still went to it.
Because it didn’t talk back. It was one on one.”
But Eve’s mind would come back to gambling again and again trying to find one.
Such a phenomena was first delineated by Freud (1938) - the classic
corrective emotional experience.
Gambling, Trauma, and
the Need To Be Seen.
Wounding in childhood or wounds in adulthood compounded the
feeling of “not okay-ness”.
Hence, as stated previous, participants reported feeling not good
enough, frozen, and emotionally cut-off, it is no wonder then that
winning and receiving admiration fuels a continued desire to play.
My other part of our life was rejected, because I
couldn’t, I didn’t feel like a wife anymore it was. When
you win at the machine and everybody comes around
and you are very special and everybody’s looking at you
and saying hey, you won! Good for you!
Theme 7: Gambling Becomes
Trauma
The gambler becomes like Sisyphus
rolling the boulder up the hill... (were
our participants happy playing again
and again).
Jungian analyst and author Linda
Schierese Leonard (1989) parallels
mythic literature and provokes a deep
question about the experience of
addiction:
•Is addiction, then, the act of giving
oneself over to something as one’s
master – be it a substance, object,
person, or activity – so totally that
one’s entire being becomes possessed
by it?
Gambling akin to Soul
Possession?
Barb reports, “Oh I knew I had
a problem; I wasn’t going to
deal with it, at any cost.” “It
started slipping to the point
where I didn’t care anymore. It
totally took control of your
life... I was too far in debt, I was
having problems with the
bank…I did let go of the wheel
and a semi was coming up. I
just thought you know why keep
going through this. I, [Let go of
the wheel] for five seconds, and
I said wake up, you won’t waste
your life cause of that.
Eve reports, The last 12, 13 years, I have lost quite a few
thousand. [75,000?] I’d say at least that. It’s in the back of my
mind all the time. Being a professional that I am [School
Teacher]. And I’ve said, it’s nothing to do with money, it’s
something to do with something else. Something more engrained.
Conclusions: Trauma and
Gambling Gambling
Trauma in early childhood
impinges ego development
1.
2.
Creating deep rooted
feeling of “not good
enough” (visceral)
Creates hunger and
drive need to be seen
3.
Cuts us off from essence
/ vitality (emotional body)
4.
Prone to periods of
emptiness throughout
life
5.
1. I can feel or I learn
how to escape (mood
regulator)
Trauma lies in wait
2. I can be seen / or
disappear
Primer for Addiction
3. I can be important
4. Cycle of gambling
trigger’s and
reinforces old feelings
of not good enough
5.
Gambling becomes traumatic
Recovery From
Trauma
According to Herman (1997)
recovery from traumatic events
unfold in three :
Establishing Safety
Remembrance and
mourning
Reconnection with
ordinary life
SAFETY
•
Establish Safety (regain
control)
•
Feeling safe in relation to
others
•
Support
•
Letting go of addictive
behaviours
•
Name the demon
•
Make connection with
abuse and symptoms and
behaviours
•
Trusting Therapeutic
Relationship
Remembrance and Mourning
Tell the whole story
Repeat until story is part of survivor’s experience rather than focus
Memory coherent linked to feeling
Grief and other symptoms retract / less intrusive
QuickTime™ and a
decompressor
are needed to see this picture.
Reconnection
Create new self / new future
“I know have myself” - basic trust
New relationship or old re-established
Understands damage becomes person she / he wants to be
Imagine, fantasy, desire, and initiative