You bet! A brief overview of our recent papers on youth gambling

Following my recent blogs where I outlined some of the papers that my colleagues and I have published on mindfulness, Internet addiction, and gaming addiction, here is a round-up of recent papers that my colleagues and I have published on adolescent gambling.

Calado, F., Alexandre, J. & Griffiths, M.D. (2014). Mom, Dad it’s only a game! Perceived gambling and gaming behaviors among adolescents and young adults: An exploratory study. International Journal of Mental Health and Addiction, 12, 772-794.

• Gambling and gaming are increasingly popular activities among adolescents. Although gambling is illegal in Portugal for youth under the age of 18 years, gambling opportunities are growing, mainly due to similarity between gambling and other technology-based games. Given the relationship between gambling and gaming, the paucity of research on gambling and gaming behaviors in Portugal, and the potential negative consequences these activities may have in the lives of young people, the goal of this study was to explore and compare the perceptions of these two behaviors between Portuguese adolescents and young adults. Results from six focus groups (comprising 37 participants aged between 13 and 26 years) indicated different perceptions for the two age groups. For adolescents, gaming was associated with addiction whereas for young adults it was perceived as a tool for increasing personal and social skills. With regard to gambling, adolescents associated it with luck and financial rewards, whereas young adults perceived it as an activity with more risks than benefits. These results suggest developmental differences that have implications for intervention programs and future research.

Delfabbro, P.H., King, D.L. & Griffiths, M.D. (2014). From adolescent to adult gambling: An analysis of longitudinal gambling patterns in South Australia. Journal of Gambling Studies, 30, 547-563.

• Although there are many cross-sectional studies of adolescent gambling, very few longitudinal investigations have been undertaken. As a result, little is known about the individual stability of gambling behaviour and the extent to which behaviour measured during adolescence is related to adult behaviour. In this paper, we report the results of a 4-wave longitudinal investigation of gambling behaviour in a probability sample of 256 young people (50 % male, 50% female) who were interviewed in 2005 at the age of 16–18 years and then followed through to the age of 20–21 years. The results indicated that young people showed little stability in their gambling. Relatively few reported gambling on the same individual activities consistently over time. Gambling participation rates increased rapidly as young people made the transition from adolescence to adulthood and then were generally more stable. Gambling at 15–16 years was generally not associated with gambling at age 20–21 years. These results highlight the importance of individual-level analyses when examining gambling patterns over time.

Canale, N., Vieno, A., Griffiths, M.D., Rubaltelli, E., Santinello, M. (2015). Trait urgency and gambling problems in young people: the role of decision-making processes. Addictive Behaviors, 46, 39-44.

• Although the personality trait of urgency has been linked to problem gambling, less is known about psychological mechanisms that mediate the relationship between urgency and problem gambling. One individual variable of potential relevance to impulsivity and addictive disorders is age. The aims of this study were to examine: (i) a theoretical model associating urgency and gambling problems, (ii) the mediating effects of decision-making processes (operationalized as preference for small/immediate rewards and lower levels of deliberative decision-making); and (iii) age differences in these relationships. Participants comprised 986 students (64% male; mean age = 19.51 years; SD = 2.30) divided into three groups: 16–17 years, 18–21 years, and 22–25 years. All participants completed measures of urgency, problem gambling, and a delay-discounting questionnaire involving choices between a smaller amount of money received immediately and a larger amount of money received later. Participants were also asked to reflect on their decision-making process. Compared to those aged 16–17 years and 22–25 years, participants aged 18–21 years had a higher level of gambling problems and decreased scores on lower levels of deliberative decision-making. Higher levels of urgency were associated with higher levels of gambling problems. The association was mediated by a lower level of deliberative decision-making and preference for an immediate/small reward. A distinct pathway was observed for lower levels of deliberative decision-making. Young people who tend to act rashly in response to extreme moods, had lower levels of deliberative decision-making, that in turn were positively related to gambling problems. This study highlights unique decision-making pathways through which urgency trait may operate, suggesting that those developing prevention and/or treatment strategies may want to consider the model’s variables, including urgency, delay discounting, and deliberative decision-making.

Carran, M. & Griffiths, M.D. (2015). Gambling and social gambling: An exploratory study of young people’s perceptions and behavior. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 33(1), 101-113.

• Background and aims: Gambling-type games that do not involve the spending of money (e.g., social and ‘demo’ [demonstration] gambling games, gambling-like activities within video games) have been accused in both the legal and psychological literature of increasing minors’ propensity towards prohibited forms of gambling thus prompting calls for gambling regulation to capture address such games and subject them to age restrictions. However, there is still a shortage of empirical data that considers how young people experience monetary and non-monetary gambling, and whether they are sufficiently aware of the differences. Methods: Data was collected from 23 qualitative focus groups carried out with 200 young people aged between 14 and 19 years old in schools based in London and Kent. As the study was exploratory in nature, thematic analysis was adopted in order to capture how pupils categorise, construct, and react to gambling-like activities in comparison to monetary forms of gambling without the constrains of a predetermined theoretical framework. Results: Despite many similarities, substantial differences between monetary and non-monetary forms of gambling were revealed in terms of pupils’ engagement, motivating factors, strengths, intensity, and associated emotions. Pupils made clear differentiation between non-monetary and monetary forms of gambling and no inherent transition of interest from one to the other was observed among participants. Only limited evidence emerged of ‘demo’ games being used as a practice ground for future gambling. Conclusion: For the present sample, non-monetary forms of gambling presented a different proposition to the real-money gambling with no inherent overlap between the two. For some the ‘softer’ form minimised the temptation to try other forms of gambling that they were not legally allowed to engage in, but ‘demo’ games may attract those who already want to gamble. Policy implications: Regulators must recognise and balance these two conflicting aspects.

Griffiths, M.D. (2015). Adolescent gambling and gambling-type games on social networking sites: Issues, concerns, and recommendations. Aloma: Revista de Psicologia, Ciències de l’Educació i de l’Esport, 33(2), 31-37.

• Research indicates that compared to the general population, teenagers and students make the most use of social networking sites (SNSs). Although SNSs were originally developed to foster online communication between individuals, they now have the capability for other types of behaviour to be engaged in such as gambling and gaming. The present paper focuses on gambling and the playing of gambling-type games via SNSs and comprises a selective narrative overview of some of the main concerns and issues that have been voiced concerning gambling and gambling-type games played via social network sites. Overall, there is little empirical evidence relating to the psychosocial impact of adolescents engaging in gambling and gambling-type activities on SNSs, and the evidence that does exist does not allow definitive conclusions to be made. However, it is recommended that stricter age verification measures should be adopted for social games via SNSs particularly where children and adolescents are permitted to engage in gambling-related content, even where real money is not involved.

Canale, N., Vieno, A., Griffiths, M.D., Marino, C., Chieco, F., Disperati, F., Andriolo, S., Santinello, M. (2016). The efficacy of a web-based gambling intervention program for high school students: A preliminary randomized study. Computers in Human Behavior, 55, 946-954.

• Early onset in adolescent gambling involvement can be a precipitator of later gambling problems. The aim of the present study was to test the preliminary efficacy of a web-based gambling intervention program for students within a high school-based setting. Students attending a high school in Italy (N= 168) participated in the present study (58% male – age, M = 15.01; SD = 0.60). Twelve classes were randomly assigned to one of two conditions: intervention (N = 6; 95 students) and control group (N = 6; 73 students). Both groups received personalized feedback and then the intervention group received online training (interactive activities) for three weeks. At a two-month follow-up, students in the intervention group reported a reduction in gambling problems relative to those in the control group. However, there were no differences in gambling frequency, gambling expenditure, and attitudes toward the profitability of gambling between the two groups. In addition, frequent gamblers (i.e., those that gambled at least once a week at baseline) showed reductions in gambling problems and gambling frequency post-intervention. Frequent gamblers that only received personalized feedback showed significantly less realistic attitudes toward the profitability of gambling post-intervention. The present study is the first controlled study to test the preliminary efficacy of a web-based gambling intervention program for students within a high school-based setting. The results indicate that a brief web-based intervention delivered in the school setting may be a potentially promising strategy for a low-threshold, low-cost, preventive tool for at-risk gambling high school students.

Canale, N., Griffiths, M.D., Vieno, A., Siciliano, V. & Molinaro, S. (2016). Impact of internet gambling on problem gambling among adolescents in Italy: Findings from a large-scale nationally representative survey. Computers in Human Behavior, 57, 99-106.

• Aims: The primary aim of the present study was to understand the impact of online gambling on gambling problems in a large-scale nationally representative sample of Italian youth, and to identify and then further examine a subgroup of online gamblers who reported higher rates of gambling problems. Design: Data from the ESPAD^®Italia2013 (European School Survey Project on Alcohol and Other Drugs) Study were used for analyses of adolescent Internet gambling. Setting: Self-administered questionnaires were completed by a representative sample of high school students, aged 15–19 years. Participants: A total of 14,778 adolescent students. Measurements: Respondents’ problem gambling severity; gambling behavior (participation in eight different gambling activities, the number of gambling occasions and the number of online gambling occasions, monthly gambling expenditure); Socio-demographics (e.g., family structure and financial status); and control variables were measured individually (i.e., use of the Internet for leisure activities and playing video games). Findings: Rates of problem gambling were five times higher among online gamblers than non-online gamblers. In addition, factors that increased the risk of becoming a problem online gambler included living with non-birth parents, having a higher perception of financial family status, being more involved with gambling, and the medium preferences of remote gamblers (e.g., Internet cafes, digital television, and video game console). Conclusions: The online gambling environment may pose significantly greater risk to vulnerable players. Family characteristics and contextual elements concerning youth Internet gambling (e.g., remote mediums) may play a key role in explaining problem online gambling among adolescents.

Pallesen, S., Hanss, D., Molde, H., Griffiths, M.D. & Mentzoni, R.A. (2016). A longitudinal study of factors explaining attitude change towards gambling among adolescents. Journal of Behavioral Addictions, 5, 59–67

• Background and aims: No previous study has investigated changes in attitudes toward gambling from under legal gambling age to legal gambling age. The aim of the present study was therefore to investigate attitudinal changes during this transition and to identify predictors of corresponding attitude change. Methods: In all 1239 adolescents from a national representative sample participated in two survey waves (Wave 1; 17.5 years; Wave 2; 18.5 years). Results: From Wave 1 to Wave 2 the sample became more acceptant toward gambling. A regression analysis showed that when controlling for attitudes toward gambling at Wave 1 males developed more acceptant attitudes than females. Neuroticism was inversely related to development of acceptant attitudes toward gambling from Wave 1 to Wave 2, whereas approval of gambling by close others at Wave 1 was positively associated with development of more acceptant attitudes. Continuous or increased participation in gambling was related to development of more acceptant attitudes from Wave 1 to Wave 2. Conclusions: Attitudes toward gambling became more acceptant when reaching legal gambling age. Male gender, approval of gambling by close others and gambling participation predicted development of positive attitudes toward gambling whereas neuroticism was inversely related to development of positive attitudes toward gambling over time.

Ciccarelli, M., Griffiths, M.D., Nigro, G., & Cosenza, M. (2016). Decision-making, cognitive distortions and alcohol use in adolescent problem and non-problem gamblers: An experimental study. Journal of Gambling Studies, in press.

• In the psychological literature, many studies have investigated the neuropsychological and behavioral changes that occur developmentally during adolescence. These studies have consistently observed a deficit in the decision-making ability of children and adolescents. This deficit has been ascribed to incomplete brain development. The same deficit has also been observed in adult problem and pathological gamblers. However, to date, no study has examined decision-making in adolescents with and without gambling problems. Furthermore, no study has ever examined associations between problem gambling, decision-making, cognitive distortions and alcohol use in youth. To address these issues, 104 male adolescents participated in this study. They were equally divided in two groups, problem gamblers and non-problem gamblers, based on South Oaks Gambling Screen Revised for Adolescents scores. All participants performed the Iowa gambling task and completed the Gambling Related Cognitions Scale and the alcohol use disorders identification test. Adolescent problem gamblers displayed impaired decision-making, reported high cognitive distortions, and had more problematic alcohol use compared to non-problem gamblers. Strong correlations between problem gambling, alcohol use, and cognitive distortions were observed. Decision-making correlated with interpretative bias. This study demonstrated that adolescent problem gamblers appear to have the same psychological profile as adult problem gamblers and that gambling involvement can negatively impact on decision-making ability that, in adolescence, is still developing. The correlations between interpretative bias and decision-making suggested that the beliefs in the ability to influence gambling outcomes may facilitate decision-making impairment.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (1995). Adolescent Gambling. London: Routledge.

Griffiths, M.D. (2002). Gambling and Gaming Addictions in Adolescence. Leicester: British Psychological Society/Blackwells.

Griffiths, M.D. (2003). Adolescent gambling: Risk factors and implications for prevention, intervention, and treatment. In D. Romer (Ed.), Reducing Adolescent Risk: Toward An Integrated Approach (pp. 223-238). London: Sage.

Griffiths, M.D. (2010). Asian national adolescent gambling surveys: Methodological issues, protocols, and advice. Asian Journal of Gambling Issues and Public Health, 1, 4-18.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D. (2013). Adolescent gambling via social networking sites: A brief overview. Education and Health, 31, 84-87.

Griffiths, M.D. & Linsey, A. (2006). Adolescent gambling: Still a cause for concern? Education and Health, 24, 9-11.

Griffiths, M.D. & Parke, J. (2010). Adolescent gambling on the Internet: A review. International Journal of Adolescent Medicine and Health, 22, 59-75.

Hayer, T. & Griffiths, M.D. (2015). The prevention and treatment of problem gambling in adolescence. In T.P. Gullotta & G. Adams (Eds). Handbook of Adolescent Behavioral Problems: Evidence-based Approaches to Prevention and Treatment (Second Edition) (pp. 539-558). New York: Kluwer.

Tech’s appeal: Another look at Internet addiction

Generally speaking, Internet addiction (IA) has been characterized by excessive or poorly controlled preoccupation, urges, and/or behaviours regarding Internet use that lead to impairment or distress in several life domains. However, according to Dr. Kimberly Young, IA is a problematic behaviour akin to pathological gambling that can be operationally defined as an impulse-control disorder not involving the ingestion of psychoactive intoxicants.

Following the conceptual framework developed by Young and her colleagues to understand IA, five specific types of distinct online addictive behaviours were identified: (i) ‘cyber-sexual addiction’, (ii) ‘cyber-relationship addiction’, (iii) ‘net compulsions (i.e., obsessive online gambling, shopping, or trading), (iv) ‘information overload’, and (v) ‘computer addiction’ (i.e., obsessive computer game playing).

However, I have argued in many of my papers over the last 15 years that the Internet may simply be the means or ‘place’ where the most commonly reported addictive behaviours occur. In short, the Internet may be just a medium to fuel other addictions. Interestingly, new evidence pointing towards the need to make this distinction has been provided from the online gaming field where new studies (including some I have carried out with my Hungarian colleagues) have demonstrated that IA is not the same as other more specific addictive behaviours carried out online (i.e., gaming addiction), further magnifying the meaningfulness to differentiate between what may be called ‘generalized’ and ‘specific’ forms of online addictive behaviours, and also between IA and gaming addiction as these behaviours are conceptually different.

Additionally, the lack of formal diagnostic criteria to assess IA holds another methodological problem since researchers are systematically adopting modified criteria from other addictions to investigate IA. Although IA may share some commonalities with other substance-based addictions, it is unclear to what extent such criteria are useful and suitable to evaluate IA. Notwithstanding the existing difficulties in understanding and comparing IA with behaviours such as pathological gambling, recent research provided useful insights on this topic.

A recent study by Dr. Federico Tonioni (published in a 2014 issue of the journal Addictive Behaviors) involving two clinical (i.e., 31 IA patients and 11 pathological gamblers) and a control group (i.e., 38 healthy individuals) investigated whether IA patients presented different psychological symptoms, temperamental traits, coping strategies, and relational patterns in comparison to pathological gamblers, concluded that Internet-addicts presented higher mental and behavioural disengagement associated with significant more interpersonal impairment. Moreover, temperamental patterns, coping strategies, and social impairments appeared to be different across both disorders. Nonetheless, the similarities between IA and pathological gambling were essentially in terms of psychopathological symptoms such as depression, anxiety, and global functioning. Although, individuals with IA and pathological gambling appear to share similar psychological profiles, previous research has found little overlap between these two populations, therefore, both phenomena are separate disorders.

Despite the fact that initial conceptualizations of IA helped advance the current knowledge and understanding of IA in different aspects and contexts, it has become evident that the field has greatly evolved since then in several ways. As a result of these ongoing changes, behavioural addictions (more specifically Gambling Disorder and Internet Gaming Disorder) have now recently received official recognition in the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Moreover, IA can also be characterized as a form of technological addiction, which I have operationally defined as a non-chemical (behavioural) addiction involving excessive human-machine interaction. In this theoretical framework, technological addictions such as IA represent a subset of behavioural addictions featuring six core components: (i) salience, (ii) mood modification, (iii) tolerance, (iv) withdrawal, (v) conflict, and (vi) relapse. The components model of addiction appears to be a more updated framework for understanding IA as a behavioural addiction not only conceptually but also empirically. Moreover, this theoretical framework has recently received empirical support from several studies, further evidencing its suitability and applicability to the understanding of IA.

For many in the IA field, problematic Internet use is considered to be a serious issue – albeit not yet officially recognised as a disorder – and has been described across the literature as being associated with a wide range of co-occurring psychiatric comorbidities alongside an array of dysfunctional behavioural patterns. For instance, IA has been recently associated with low life satisfaction, low academic performance, less motivation to study, poorer physical health, social anxiety, attention deficit/hyperactivity disorder and depression, poorer emotional wellbeing and substance use, higher impulsivity, cognitive distortion, deficient self-regulation, poorer family environment, higher mental distress, loneliness, among other negative psychological, biological, and neuronal aspects.

In a recent systematic literature review conducted by Dr. Wen Li and colleagues (and published in the journal Computers and Human Behavior), the authors reviewed a total of 42 empirical studies that assessed the family correlates of IA in adolescents and young adults. According to the authors, virtually all studies reported greater family dysfunction amongst IA families in comparison to non-IA families. More specifically, individuals with IA exhibited more often (i) greater global dissatisfaction with their families, (ii) less organized, cohesive, and adaptable families, (iii) greater inter-parental and parent-child conflict, and (iv) perceptions of their parents as more punitive, less supportive, warm, and involved. Furthermore, families were significantly more likely to have divorced parents or to be a single parent family.

Another recent systematic literature review conducted by Dr. Lawrence Lam published in the journal Current Psychiatry Reports examined the possible links between IA and sleep problems. After reviewing seven studies (that met strict inclusion criteria), it was concluded that on the whole, IA was associated with sleep problems that encompassed subjective insomnia, short sleep duration, and poor sleep quality. The findings also suggested that participants with insomnia were 1.5 times more likely to be addicted to the Internet in comparison to those without sleep problems. Despite the strong evidence found supporting the links between IA and sleep problems, the author noted that due to the cross-sectional nature of most studies reviewed, the generalizability of the findings was somewhat limited.

IA is a relatively recent phenomenon that clearly warrants further investigation, and empirical studies suggest it needs to be taken seriously by psychologists, psychiatrists, and neuroscientists. Although uncertainties still remain regarding its diagnostic and clinical characterization, it is likely that these extant difficulties will eventually be tackled and the field will evolve to a point where IA may merit full recognition as a behavioural addiction from official medical bodies (ie, American Psychiatric Association) similar to other more established behavioural addictions such as ‘Gambling Disorder’ and ‘Internet Gaming Disorder’. However, in order to achieve official status, researchers will have to adopt a more commonly agreed upon definition as to what IA is, and how it can be conceptualized and operationalized both qualitatively and quantitatively (as well as in clinically diagnostic terms).

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Please note: This article was co-written with Halley Pontes and Daria Kuss.

Further reading

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M.D. (2010). Internet abuse and internet addiction in the workplace. Journal of Workplace Learning, 7, 463-472.

Griffiths, M.D., Kuss, D.J., Billieux J. & Pontes, H.M. (2016). The evolution of internet addiction: A global perspective. Addictive Behaviors, 53, 193–195.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

Király, O., Griffiths, M.D., Urbán, R., Farkas, J., Kökönyei, G. Elekes, Z., Domokos Tamás, D. & Demetrovics, Z. (2014). Problematic internet use and problematic online gaming are not the same: Findings from a large nationally representative adolescent sample. Cyberpsychology, Behavior and Social Networking, 17, 749-754.

Kuss, D.J. & Griffiths, M.D. (2015). Internet Addiction in Psychotherapy. Basingstoke: Palgrave Macmillan.

Kuss, D.J., Griffiths, M.D. & Binder, J. (2013). Internet addiction in students: Prevalence and risk factors. Computers in Human Behavior, 29, 959-966.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014). Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Kuss, D.J., Shorter, G.W., van Rooij, A.J., Griffiths, M.D., & Schoenmakers, T.M. (2014). Assessing Internet addiction using the parsimonious Internet addiction components model – A preliminary study. International Journal of Mental Health and Addiction, 12, 351-366.

Kuss, D.J., van Rooij, A.J., Shorter, G.W., Griffiths, M.D. & van de Mheen, D. (2013). Internet addiction in adolescents: Prevalence and risk factors. Computers in Human Behavior, 29, 1987-1996.

Lam, L.T. (2014). Internet Gaming Addiction, Problematic use of the Internet, and sleep problems: A systematic review. Current Psychiatry Reports, 16(4), 1-9.

Li, W., Garland, E.L., & Howard, M.O. (2014). Family factors in Internet addiction among Chinese youth: A review of English-and Chinese-language studies. Computers in Human. Behavior, 31, 393-411.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H.M., Kuss, D.J. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

Pontes, H.M., Szabo, A. & Griffiths, M.D. (2015). The impact of Internet-based specific activities on the perceptions of Internet Addiction, Quality of Life, and excessive usage: A cross-sectional study. Addictive Behaviors Reports, 1, 19-25.

Tonioni, F., Mazza, M., Autullo, G., Cappelluti, R., Catalano, V., Marano, G., … & Lai, C. (2014). Is Internet addiction a psychopathological condition distinct from pathological gambling?. Addictive Behaviors, 39(6), 1052-1056.

Widyanto, L. & Griffiths, M.D. (2006). Internet addiction: A critical review. International Journal of Mental Health and Addiction, 4, 31-51.

Young, K. (1998). Caught in the net. New York: John Wiley

Young K. (1999). Internet addiction: Evaluation and treatment. Student British Medical Journal, 7, 351-352.

Term warfare: Internet Gaming Disorder and Internet Addiction Disorder are not the same

Over the last 15 years, research into various online addictions has greatly increased. Alongside this, there have been scholarly debates about whether internet addiction really exists. Some may argue that because internet use does not involve the ingestion of a psychoactive substance, then it should not be considered a genuine addictive behaviour. However, the latest (fifth) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) re-classified ‘Gambling Disorder’ as a behavioural addiction rather than as a disorder of impulse control. The implications of this reclassification are potentially far-reaching. The most significant implication is that if an activity that does not involve the consumption of drugs (i.e., gambling) can be a genuine addiction accepted by the psychiatric and medical community, there is no theoretical reason why other problematic and habitual behaviours (e.g., shopping, work, exercise, sex, video gaming, etc.) cannot be classed as a bone fide addiction.

There have also been debates among scholars that consider excessive problematic internet use to be a genuine addiction as to whether the those in the field should study generalized internet addiction (the totality of all online activities) and/or specific addictions on the internet such as internet gambling, internet gaming and internet sex. Since the late 1990s, I have constantly argued that there is a fundamental difference between addictions on the internet, and addictions to the internet. I argued that the overwhelming majority of individuals that were allegedly addicted to the internet were not internet addicts but were individuals that used the medium of the internet as a vehicle for other addictions. More specifically, I argued that internet gambling addicts and internet gaming addicts were not internet addicts but were gambling and gaming addicts using the convenience and ubiquity of the internet to gamble or play video games.

Prior to the publication of the latest DSM-5, there had also been debates as to whether ‘internet addiction’ should be introduced into the text as a separate disorder. Following these debates, the Substance Use Disorder Work Group (SUDWG) recommended that the DSM-5 include a sub-type of problematic internet use (i.e., internet gaming disorder [IGD]) in Section 3 (‘Emerging Measures and Models’) as an area that needed future research before being included in future editions of the DSM. However, far from clarifying the debates surrounding generalized versus specific internet use disorders, the section of the DSM-5 discussing IGD noted that:

“There are no well-researched subtypes for Internet gaming disorder to date. Internet gaming disorder most often involves specific Internet games, but it could involve non-Internet computerized games as well, although these have been less researched. It is likely that preferred games will vary over time as new games are developed and popularized, and it is unclear if behaviors and consequence associated with Internet gaming disorder vary by game type…Internet gaming disorder has significant public health importance, and additional research may eventually lead to evidence that Internet gaming disorder (also commonly referred to as Internet use disorder, Internet addiction, or gaming addiction) has merit as an independent disorder” (p.796).

In light of what has been already highlighted in previous research, two immediate problematic issues arise from these assertions. Firstly, IGD is clearly seen as synonymous with internet addiction as the text claims that internet addiction and internet use disorder are simply other names for IGD. Secondly – and somewhat confusingly – it is asserted that IGD (which is by definition internet-based) can also include offline gaming disorders.

With regards to the first assertion, internet addiction and online gaming addiction are not the same. A number of recent studies (including ones I’ve co-authored) clearly shows that to be the case. The second assertion that IGD can include offline video gaming is both baffling and confusing. Some researchers consider video games as the starting point for examining the characteristics of gaming disorder, while others consider the internet as the main platform that unites different addictive internet activities, including online games. For instance, I have argued that although all addictions have particular and idiosyncratic characteristics, they share more commonalities than differences (i.e., salience, mood modification, tolerance, withdrawal symptoms, conflict, and relapse), and likely reflects a common etiology of addictive behaviour. For me, IGD is clearly a sub-type of video game addiction. For people like Dr. Kimberley Young, ‘cyber-relationship addictions’, ‘cyber-sexual addictions’, ‘net compulsions’ (gambling, day trading) and ‘information overload’ are all internet addictions. However, many would argue that these – if they are addictions – are addictions on the internet, not to it. The internet is a medium and it is a situational characteristic. The fact that the medium might enhance addictiveness or problematic behaviour does not necessarily make it a sub-type of internet addiction.

However, recent studies have made an effort to integrate both approaches. For instance, some researchers claim that neither the first nor the second approach adequately captures the unique features of Massively Multiplayer Online Role-Playing Games (MMORPGs), and argue an integrated approach is a necessity. A common observation is that “Internet users are no more addicted to the Internet than alcoholics are addicted to bottles”. The internet is just a channel through which individuals may access whatever content they want (e.g., gambling, shopping, chatting, sex). On the other hand, online games differ from traditional standalone games, such as offline video games, in important aspects such as the social dimension or the role-playing dimension that allow interaction with other real players. Consequently, it could be argued that IGD can either be viewed as a specific type of video game addiction, or as a variant of internet addiction, or as an independent diagnosis. However, the idea that IGD can include offline gaming disorders does little for clarity or conceptualization.

Finally, it is also worth mentioning that there are some problematic online behaviours that could be called internet addictions as they can only take place online. The most obvious activity that fulfills this criterion is social networking as it is a ‘pure’ online activity and does not and cannot take place offline. Other activities such as gambling, gaming, and shopping can still be engaged in offline (as gamblers can go to a gambling venue, gamers can play a standalone console game, shoppers can go to a retail outlet). However, those engaged in social networking would not (if unable to access the internet) walk into a big room of people and start chatting to them all. However, even if social networking addiction is a genuine internet addiction, social networking itself is still a specific online application and could still be considered an addiction on the internet, rather than to it.

Based on recent empirical evidence, IGD (or any of the alternate names used to describe problematic gaming) is not the same as Internet Addiction Disorder. The gaming studies field needs conceptual clarity but as demonstrated, the DSM-5 itself is both misleading and misguided when it comes to the issue of IGD.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Demetrovics, Z., Urbán, R., Nagygyörgy, K., Farkas, J., Griffiths, M. D., Pápay, O., . . . Oláh, A. (2012). The development of the Problematic Online Gaming Questionnaire (POGQ). PLoS ONE, 7(5), e36417.

Griffiths, M.D. (2000). Internet addiction – Time to be taken seriously? Addiction Research, 8, 413-418.

Griffiths, M. D. (2005). A ‘components’ model of addiction within a biopsychosocial framework. Journal of Substance Use, 10(4), 191-197.

Griffiths, M.D., King, D.L. & Demetrovics, Z. (2014). DSM-5 Internet Gaming Disorder needs a unified approach to assessment. Neuropsychiatry, under review.

Griffiths, M.D., Kuss, D.J. & King, D.L. (2012). Video game addiction: Past, present and future. Current Psychiatry Reviews, 8, 308-318.

Griffiths, M.D. & Pontes, H.M. (2014). Internet addiction disorder and internet gaming disorder are not the same. Journal of Addiction Research and Therapy, 5: e124. doi:10.4172/2155-6105.1000e124.

Kim, M. G., & Kim, J. (2010). Cross-validation of reliability, convergent and discriminant validity for the problematic online game use scale. Computers in Human Behavior, 26(3), 389-398.

King, D. L., Delfabbro, P. H., Griffiths, M. D., & Gradisar, M. (2011). Assessing clinical trials of Internet addiction treatment: A systematic review and CONSORT evaluation. Clinical Psychology Review, 31, 1110-1116.

King, D. L., Delfabbro, P. H., & Griffiths, M. D. (2012). Cognitive-behavioral approaches to outpatient treatment of Internet addiction in children and adolescents. Journal of Clinical Psychology, 68, 1185-1195.

King, D.L., Haagsma, M.C., Delfabbro, P.H., Gradisar, M.S.^, Griffiths, M.D. (2013). Toward a consensus definition of pathological video-gaming: A systematic review of psychometric assessment tools. Clinical Psychology Review, 33, 331-342.

Koronczai, B., Urban, R., Kokonyei, G., Paksi, B., Papp, K., Kun, B., . . . Demetrovics, Z. (2011). Confirmation of the three-factor model of problematic internet use on off-line adolescent and adult samples. Cyberpsychology, Behavior and Social Networking, 14, 657–664.

Kuss, D.J. & Griffiths, M.D. (2012). Internet and gaming addiction: A systematic literature review of neuroimaging studies. Brain Sciences, 2, 347-374.

Kuss, D.J., Griffiths, M.D., Karila, L. & Billieux, J. (2014).  Internet addiction: A systematic review of epidemiological research for the last decade. Current Pharmaceutical Design, 20, 4026-4052.

Pápay, O., Nagygyörgy, K., Griffiths, M.D. & Demetrovics, Z. (2014). Problematic online gaming. In K. Rosenberg & L. Feder (Eds.), Behavioral Addictions: Criteria, Evidence and Treatment. New York: Elsevier.

Petry, N.M., & O’Brien, C.P. (2013). Internet gaming disorder and the DSM-5. Addiction, 108, 1186–1187.

Pontes, H. & Griffiths, M.D. (2014). The assessment of internet gaming disorder in clinical research. Clinical Research and Regulatory Affairs, 31(2-4), 35-48.

Pontes, H. & Griffiths, M.D. (2015). Measuring DSM-5 Internet Gaming Disorder: Development and validation of a short psychometric scale. Computers in Human Behavior, 45, 137-143.

Pontes, H., Király, O. Demetrovics, Z. & Griffiths, M.D. (2014). The conceptualisation and measurement of DSM-5 Internet Gaming Disorder: The development of the IGD-20 Test. PLoS ONE, 9(10): e110137. doi:10.1371/journal.pone.0110137.

Pontes, H., Kuss, D. & Griffiths, M.D. (2015). The clinical psychology of Internet addiction: A review of its conceptualization, prevalence, neuronal processes, and implications for treatment. Neuroscience and Neuroeconomics, 4, 11-23.

Porter, G., Starcevic, V., Berle, D., & Fenech, P. (2010). Recognizing problem video game use. The Australian and New Zealand Journal of Psychiatry, 44, 120-128.

Young, K. S. (1998). Internet addiction: The emergence of a new clinical disorder. Cyberpsychology and Behavior, 1, 237-244.

Sell division: Responsible marketing and advertising by the gambling industry

Over the last few years there has been a great deal of speculation over the role of advertising as a possible stimulus to increased gambling, and as a contributor to problem gambling (including underage gambling). Various lobby groups (e.g., anti-gambling coalitions, religious groups, etc.) claim advertising has played a role in the widespread cultural acceptance of gambling. These groups also claim casino advertising tends to use glamorous images and beautiful people to sell gambling, while other advertisements for lottery tickets and slot machines depict ordinary people winning loads of money or millions from a single coin in the slot.

Around the world, various lobby groups claim that advertisements used by the gambling industry often border on misrepresentations and distortion. There are further claims that adverts are seductive, appealing to people’s greed and desperation for money. Real examples include: ‘Winning is easy’, ‘Win a truckload of cash’, ‘Win a million, the fewer numbers you choose, the easier it is to win’, ‘It’s easy to win’ and ‘$600,000 giveaway simply by inserting card into the poker machine’. Lobby groups further claim that in amongst the thousands of words and images of encouragement, there is rarely anything about the odds of winning – let alone the odds of losing. It has also been claimed that many gambling adverts feature get-rich-quick slogans that sometimes denigrate the values of hard work, initiative, responsibility, perseverance, optimism, investing for the future, and even education.

Those promoting gambling products typically respond in a number of ways. The most popular arguments used to defend such marketing and advertising is that: (i) the gaming industry is in the business of selling fantasies and dreams, (ii) consumers knows the claims are excessive, (iii) big claims are made to catch people’s attention, (iv) people don’t really believe these advertisements, and (v) business advertising is not there to emphasise ‘negative’ aspects of products.   While some of these industry responses have some merit, a much fairer balance is needed.

Statements such as ‘winning is easy’ are most likely (in a legal sense) be considered to be ‘puffery’. Puffery involves making exaggerated statements of opinion (not fact) to attract attention. Various jurisdictions deem it is not misleading or deceptive to engage in puffery. Whether a statement is puffery will depend on the circumstances. A claim is less likely to be puffery if its accuracy can be assessed. The use of a claim such as ‘winning is easy’ is likely to be considered puffery because it is subjective and cannot be assessed for accuracy. However, a statement like ‘five chances to win a million’ may not be puffery as it likely to be measurable.

Most of us who work in the field of responsible gambling agree that all relevant governmental gambling regulatory agencies should ban aggressive advertising strategies, especially those that target people in impoverished individuals or youth. It is also worth pointing out that there are many examples of good practice. Responsible marketing and advertising needs to think about the content and tone of gambling advertising, including the use of minors in ads, and the inclusion of game information. There has to be a strong commitment to socially responsible behaviour that applies across all product sectors, including sensitive areas like gambling. Socially responsible advertising should form one of the elements of protection afforded to ordinary customers and be reflected in the codes of practice. Children and problem gamblers deserve additional shielding from exposure to gambling products and premises, and their advertising. Many codes that regulate gambling marketing and advertising across the world now typically include special provisions on the protection of such groups.

Gambling advertising also plays an important role in ‘normalizing’ gambling. Content analyses of gambling adverts have reported that gambling is portrayed as a normal, enjoyable form of entertainment involving fun and excitement. Furthermore, they are often centred on friends and social events. The likelihood of large financial gain is often central theme, with gambling also viewed as a way to escape day-to-day pressures (one gaming company’s advertising even had the strapline “Bet to forget”). Research has found that there is a large public awareness of gambling advertising, and that problem gamblers often mention advertising as a trigger to gambling.

An example of good practice is that of Canadian gaming operator Loto-Quebec. They did a thorough review of its advertising code and some of the key aspects in terms of responsible marketing and advertising of gambling included:

• A marketing policy that (i) prohibits any advertising that is overly aggressive, (ii) rejects concepts liable to incite the interest of children, and (iii) prohibits the use of spokespeople who are popular among youth, and (iv) prohibits placement of advertisements within media programs viewed mainly by minors.
• The odds of winning are highlighted. This is being done in response to the suggestions expressed so frequently by various groups interested in knowing their chances of winning.
• Television commercials for new products devote 20% of their airtime to promoting the gambling help line and to presenting warnings about problem gambling.
• A policy that prohibits the targeting of any particular group or community for the purposes of promoting its products. For example, one of their instant lotteries used a Chinese theme to stimulate interest. However, the Chinese community did not agree with making references to its customs in order to promote the game. Out of respect for this community, the game was immediately suspended.

As various national and international advertising regulation bodies have advocated, socially responsible advertising should form one of the elements of protection afforded to ordinary customers and be reflected in the codes of practice. Personally, I believe that gambling advertising should focus on buying entertainment rather than winning money. Gambling problems often occur when an individual’s primary reason to gamble is to win money.

Many countries have strict codes for gambling advertisements, and good codes (like those in the UK) recommend that gambling advertisements must not: (i) exploit cultural beliefs or traditions about gambling or luck, (ii) condone or encourage criminal or anti-social behaviour, (iii) condone or feature gambling in a working environment (with the exception for licensed gambling premises), (iv) exploit the susceptibilities, aspirations, credulity, inexperience or lack of knowledge of under-18s or other vulnerable persons, (v) be likely to be of particular appeal to under-18s, especially by reflecting or being associated with youth culture, and (vi) feature anyone who is, or seems to be, under 25 years old gambling or playing a significant role.

Quite clearly it is appropriate and necessary for the gaming industry to advertise, market, and promote its facilities and products. However, I believe that all advertising and marketing should be carried out in a socially responsible manner as it is good for long-term repeat business.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Adams, P. (2004). Minimising the impact of gambling in the subtle degradation of democratic systems, Journal of Gambling Issues, 11. Available at: http://www.camh.net/egambling/issue11/jgi_11_adams.html.

Binde, P. (2007). Selling dreams – causing nightmares? On gambling advertising and problem gambling. Journal of Gambling Issues, 20, 167-191.

Griffiths, M.D. (2005). Does advertising of gambling increase gambling addiction? International Journal of Mental Health and Addiction, 3(2), 15-25.

Griffiths, M.D. (2007). Brand psychology: Social acceptability and familiarity that breeds trust and loyalty. Casino and Gaming International, 3(3), 69-72.

Griffiths, M.D. (2010). Online ads and the promotion of responsible gambling. World Online Gambling Law Report, 9(6), 14.

Griffiths, M.D. & Wood, R.T.A. (2008). Responsible gaming and best practice: How can academics help? Casino and Gaming International, 4(1), 107-112.

Hanss, D., Mentzoni, R.A., Griffiths, M.D., & Pallesen, S. (2015). The impact of gambling advertising: Problem gamblers report stronger impacts on involvement, knowledge, and awareness than recreational gamblers. Psychology of Addictive Behaviors, in press.

Korn, D, Hurson, T. & Reynolds, J. (2004). Commercial Gambling Advertising: Possible Impact on Youth Knowledge, Attitudes, Beliefs and Behavioural Intentions. Report submitted to the Ontario Gambling Research Centre.

Place your bets: Has problem gambling in Great Britain decreased?

In the summer of 2014 I was commissioned to review problem gambling in Great Britain (the fall out of which I wrote about in detail in a previous blog). Earlier last year, a detailed report by Heather Wardle and her colleagues examined gambling behaviour in England and Scotland by combining the 2012 data from the Health Survey for England (HSE; n=8,291 aged 16 years and over) and the 2012 Scottish Health Survey (SHeS; n=4,815). To be included in the final data analysis, participants had to have completed at least one of the gambling participation questions. This resulted in a total sample of 11,774 participants. So what did the research find? Here is a brief summary of the main results:

• Two-thirds of the sample (65%) had gambled in the past year, with men (68%) gambling more than women (62%). As with the British Gambling Prevalence Survey (BGPS), past year participation was greatly influenced by the playing of the bi-weekly National Lottery (lotto) game. Removal of those individuals that only played the National Lottery meant that 43% had gambled during the past year (46% males and 40% females).

• Gambling was more likely to be carried out by younger people (50% among those aged 16-24 years and 52% among those aged 25-34 years).

• The findings were similar to the previous BGPS reports and showed that the most popular forms of gambling were playing the National Lottery (52%; 56% males and 49% females), scratchcards (19%; 19% males and 20% females), other lottery games (14%; 14% both males and females), horse race betting (10%; 12% males and 8% females), machines in a bookmaker (3%; 5% males and 1% females), slot machines (7%; 10% males and 4% females), online betting with a bookmaker (5%; 8% males and 2% females), offline sports betting (5%; 8% males and 1% females), private betting (5%; 8% males and 2% females), casino table games (3%; 5% males and 1% females), offline dog race betting (3%; 4% males and 2% females), online casino, slots and/or bing (3%; 4% males and 2% females), betting exchanges (1%; males 2% and females 0%), poker in pubs and clubs (1%; 2% males and 0% females), spread betting (1%; 1% males and 0% females).

• The only form of gambling (excluding lottery games) where females were more likely to gamble was playing bingo (5%; 7% females and 3% males).

• Most participants gambled on one or two different activities a year (1.7 mean average across the total sample).

• Problem gambling assessed using the Problem Gambling Severity (PGSI) criteria was reported to be 0.4%, with males (0.7%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 180,200 British adults aged 16 years and over.

• Problem gambling assessed using the criteria of the fourth Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was reported to be 0.5%, with males (0.8%) being significantly more likely to be problem gamblers than females (0.1%). This equates to approximately 224,100 British adults aged 16 years and over.

• Using the PGSI screen, problem gambling rates were highest among young men aged 16-24 years (1.7%) and lowest among men aged 65-74 years (0.4%). Using the DSM-IV screen, problem gambling rates were highest among young men aged 16-24 years (2.1%) and lowest among men aged over 74 years (0.4%).

• Problem gambling rates were also examined by type of gambling activity. Results showed that among past year gamblers, problem gambling was highest among spread betting (20.9%), played poker in pubs or clubs (13.2%), bet on other events with a bookmaker (12.9%), bet with a betting exchange (10.6%) and played machines in bookmakers (7.2%).

• The activities with the lowest rates of problem gambling were playing the National Lottery (0.9%) and scratchcards (1.7%).

• Problem gambling rates were highest among individuals that had participated in seven or more activities in the past year (8.6%) and lowest among those that had participated in a single activity (0.1%).

The authors also carried out a latent class analysis and identified seven different types of gambler among both males and females. The male groups comprised:

• Cluster A: non-gamblers (33%)
• Cluster B: National Lottery only gamblers (22%)
• Cluster C: National Lottery and scratchcard gamblers only (20%)
• Cluster D: Minimal, no National Lottery [gambling on 1-2 activities] (9%)
• Cluster E: Moderate [gambling on 3-6 activities] (12%)
• Cluster F: Multiple [gambling on 6-10 activities] (3%)
• Cluster G: multiple, high [gambling on at least 11 activities] (1%).

The female groups comprised:

• Cluster A: non-gamblers (40%)
• Cluster B: National Lottery only gamblers (21%)
• Cluster C: National Lottery and scratchcard gamblers only (7%)
• Cluster D: Minimal, no National Lottery (8%)
• Cluster E: moderate, less varied [2-3 gambling activities, mainly lottery-related] (8%)
• Cluster F: moderate, more varied [2-3 gambling activities but wider range of activities] (6%)
• Cluster G: multiple [gambling on at least four activities] (6%)

Using these groupings, the prevalence of male problem gambling was highest among those in Cluster G: multiple high group (25.0%) followed by Cluster F: multiple group (3.3%) and Cluster E: moderate group (2.6%). The prevalence of problem gambling was lowest among those in the Cluster B; National Lottery Draw only group (0.1%) followed by Cluster C: minimal – lotteries and scratchcards group (0.7%). The prevalence of female problem gambling was highest among those in the Cluster G: multiple group (1.8%) followed by those in Cluster F: moderate – more varied group (0.6%). The number of female gamblers was too low to carry out any further analysis. The report also examined problem gambling (either DSM-IV or PGSI) by gambling activity type.

• The prevalence of problem gambling was highest among spread-bettors (20.9%), poker players in pubs or clubs (13.2%), bettors on events other than sports or horse/dog races (12.9%), betting exchange users (10.6%) and those that played machines in bookmakers (7.2%).

• The lowest problem gambling prevalence rates were among those that played the National Lottery (0.9%) and scratchcards (1.7%).

• These figures are very similar to those found in the 2010 BGPS study although problem gambling among those that played machines in bookmakers was lower (7.2%) than in the 2010 BGPS study (8.8%).

• As with the BGPS 2010 study, the prevalence of problem gambling was highest among those who had participated in seven or more activities in the past year (8.6%) and lowest among those who had taken part in just one activity (0.1%). Furthermore, problem gamblers participated in an average 6.6 activities in the past year.

Given that the same instruments were used to assess problem gambling, the results of the most recent surveys using data combined from the Health Survey for England (HSE) and Scottish Health Survey (SHeS) compared with the most recent British Gambling Prevalence Survey (BGPS) do seem to suggest that problem gambling in Great Britain has decreased over the last few years (from 0.9% to 0.5%). However, Seabury and Wardle again urged caution and noted:

“Comparisons of the combined HSE/SHeS data with the BGPS estimates should be made with caution. While the methods and questions used in each survey were the same, the survey vehicle was not. HSE and SHeS are general population health surveys, whereas the BGPS series was specifically designed to understand gambling behaviour and attitudes to gambling in greater detail. It is widely acknowledged that different survey vehicles can generate different estimates using the same measures because they can appeal to different types of people, with varying patterns of behaviour…Overall, problem gambling rates in Britain appear to be relatively stable, though we caution readers against viewing the combined health survey results as a continuation of the BGPS time series”.

There are other important caveats to take into account including the differences between the two screen tools used in the BGPS, HSE and SHeS studies. Although highly correlated, evidence from all the British surveys suggests that the PGSI and DSM-IV screens capture slightly different groups of problem gamblers. For instance, a 2010 study that I co-authored with Jim Orford, Heather Wardle, and others (in the journal International Gambling Studies) using data from the 2007 BGPS showed that the PGSI may under-estimate certain forms of gambling-related harm (particularly by women) that are more likely to be picked up by some of the DSM-IV items. Our analysis also suggested that the DSM-IV appears to measure two different factors (i.e., gambling-related harm and gambling dependence) rather than a single one. Another important distinction is that the two screens were developed for very different purposes (even though they are attempting to assess the same construct). The PGSI was specifically developed for use in population surveys whereas the DSM-IV was developed with clinical populations in mind. Given these differences, it is therefore unsurprising that national surveys that utilize the screens end up with slightly different results comprising slightly different groups of people.

It also needs stressing (as noted by the authors of most of the national gambling surveys in Great Britain) that the absolute number of problem gamblers identified in any of the surveys published to date has equated to approximately 60 people. To detect any significant differences statistically between any of the studies carried out to date requires very large sample sizes. Given the very low numbers of problem gamblers and the tiny number of pathological gamblers, it is hard to assess with complete accuracy whether there have been any significant changes in problem and pathological gambling between all the published studies over time. Wardle and her colleagues concluded that:

“Overall, based on this evidence, it appears that problem gambling rates in England and Scotland are broadly stable. Whilst problem gambling rates according to either the DSM-IV or the PGSI were higher in 2010, the estimate between 2007 and the health surveys data were similar. Likewise, problem gambling rates according to the DSM-IV and the PGSI individually did not vary statistically between surveys, meaning that they were relatively similar” (p.130).

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2014). Problem gambling in Great Britain: A brief review. London: Association of British Bookmakers.

Orford, J., Wardle, H., Griffiths, M.D., Sproston, K. & Erens, B. (2010). PGSI and DSM-IV in the 2007 British Gambling Prevalence Survey: Reliability, item response, factor structure and inter-scale agreement. International Gambling Studies, 10, 31-44.

Seabury, C. & Wardle, H. (2014). Gambling behaviour in England and Scotland. Birmingham: Gambling Commission.

Wardle, H. (2013). Gambling Behaviour. In Rutherford, L., Hinchliffe S., Sharp, C. (Eds.), The Scottish Health Survey: Vol 1: Main report. Edinburgh.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., & Seabury, C. (2013). Gambling Behaviour. In Craig, R., Mindell, J. (Eds.) Health Survey for England 2012 [Vol 1]. Health, social care and lifestyles. Leeds: Health and Social Care Information Centre.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.

Wardle, H., Sutton, R., Philo, D., Hussey, D. & Nass, L. (2013). Examining Machine Gambling in the British Gambling Prevalence Survey. Report by NatCen to the Gambling Commission, Birmingham.

Back to the ‘why’ fronts: A brief look at gambling motivation

In the three decades that I have been studying gambling, the question that I am most asked is ‘Why do people gamble?’ and variations on it, such as ‘Why do people gamble when most people consistently lose?’ All surveys of gambling have shown that there are a broad range motivational factors that are central to gambling, and that attitudes towards gambling are positively related to availability and cultural acceptability. However, this perspective fails to take into account many key findings and observations in gambling research. Surveys have also shown that not everyone gambles and some people gamble more than others (e.g., professional gamblers, problem gamblers). Research has consistently shown that people often gamble for reasons other than broad social and economic reasons. These other motivations may vary according to personal characteristics of the gambler and the type of gambling activity. Additionally, broad social and economic theories fail to explain why certain gambling activities are more popular or ‘addictive’ than others.

Variations in gambling preferences are thought to result from both differences in accessibility and motivation. Older people tend to choose activities that minimise the need for complex decision-making or concentration (e.g., bingo, slot machines), whereas gender differences have been attributed to a number of factors, including variations in sex-role socialisation, cultural differences and theories of motivation. Stereotypically, women tend to prefer chance-based games and men tend to prefer skill-based games. Even some games that are predominantly chance-based, men attempt to impose some level of skill. For instance, poker – which people regard as skill-based – has a massive amount of chance involved. Similarly, men often, in their own minds, change playing a slot machine from a chance-based event into a more skill-based activity via cognitive processes such as the illusion of control. The other factor to consider is that (in general) women don’t like it when other people see them losing. On a slot machine, no-one sees the player is losing so it’s very often a very guilt-free, private experience. Men, on the other hand, even when they lose big, there’s a machismo attached to it that says: “Yes, I’ve lost £500 but I can afford it.”

Variations in motivation are also frequently observed among people who participate in the same gambling activity. For example, slot machine players may gamble to win money, for enjoyment and excitement, to socialise and to escape negative feelings. Some people gamble for one reason only, whereas others gamble for a variety of reasons. A further complexity is that people’s motivations for gambling have a strong temporal dimension; that is, they do not remain stable over time. As people progress from social to regular and finally to excessive gambling, there are often significant changes in their reasons for gambling. Whereas a person might have initially gambled to obtain enjoyment, excitement and socialisation, the progression to problem gambling is almost always accompanied by an increased preoccupation with winning money and chasing losses.

Gambling is clearly a multifaceted rather than unitary phenomenon. Consequently, many factors may come into play in various ways and at different levels of analysis (e.g., biological, social, or psychological). Theories may be complementary rather than mutually exclusive, which suggests that limitations of individual theories might be overcome through the combination of ideas from different perspectives. This has often been discussed before in terms of recommendations for an ‘eclectic’ approach to gambling or a distinction between proximal and distal influences upon gambling. However, for the most part, such discussions have been descriptive rather than analytical, and so far, few attempts have been made to explain why an adherence to singular perspectives is untenable.

Gambling is one of those activities where people effectively can get something for nothing, which is why some people will take risks. The attraction of a lotter for example is that, for a very small stake, the individual can have a life-changing experience (and things are further complicated by the fact that most lottery players don’t see the activity as gambling). People who enjoy playing roulette or betting on a football match enjoy the betting or gaming experience itself. In short, each gambling activity has its own unique psychology (although there are undoubted overlaps).

Most economists claim that gamblers are primarily driven by the profit motive. However, the psychological evidence is overwhelming that other desires affect gambling actions. Put simply, for most gamblers, our actions contradict the desire to maximize profits. Whilst I am no Freudian, there appear to be a whole range of unconscious factors at play in gambling. For instance, if players make a successful bluff during a card game, it’s human nature to want to let people to know how smart they are. The golden rule in poker is never to give anything away but the human psyche works in such a way that we usually want to show off once in a while. Our psychological make-up also means that we let pride get in the way of minimizing losses. There are always games that should have been avoided but players end up staying in them long after they knew it was a mistake. None of us like to lose to who we think are weaker players, or admit that the game was too hard. How many times does a player continue playing because they want to try and get the better of a great player or show off because there is someone they are trying to impress? Although it’s a cliché, pride before a fall is commonplace. These short-term psychological satisfactions will almost always have a negative impact on long-term profits.

Because there are many non-financial types of rewards from many different sources while gambling, some people view losses as the price of entry. To these players (and I include myself as one of them), winning may be a bonus. However, most of us don’t like losing – and we especially don’t like persistent losing, regardless of whether there are other types of reinforcement. In the cold light of day, we are all rational human beings. In the height of action, rationality often goes out the window. I’ve done it myself at the roulette table and standing in front of a slot machine. While gambling I have felt omnipotent. It is only after I walk away penniless that the non-financial rewards are short-term and not worth it.

Understanding our own psychological motives is clearly important while gambling. Most players know the strategies they should be adopting but fail to apply them in real gambling situations. Players do not lack the information. It is far more profitable to learn why we don’t apply the lessons we have already learned, then ensure that we apply them. Until we understand and control our own motives — including the unconscious ones — we cannot possibly play to our best ability.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Calado, F., Alexandre, J. & Griffiths, M.D. (2014). Mom, Dad it’s only a game! Perceived gambling and gaming behaviors among adolescents and young adults: An exploratory study. International Journal of Mental Health and Addiction, in press.

Griffiths, M.D. (1990). The dangers of social psychology research. BPS Social Psychology Newsletter, 23, 20-23.

Griffiths, M.D. (1999). The psychology of the near miss (revisited). British Journal of Psychology, 90, 441-445.

Griffiths, M.D. (2006). An overview of pathological gambling. In T. Plante (Ed.), Mental Disorders of the New Millennium. Vol. I: Behavioral Issues. pp. 73-98. New York: Greenwood.

Griffiths, M.D. (2007). Gambling psychology: Motivation, emotion and control, Casino and Gaming International, (3)4 (November), 71-76.

Griffiths, M.D. & Wood, R.T.A. (2001). The psychology of lottery gambling. International Gambling Studies, 1, 27-44.

McCormack. A. & Griffiths, M.D. (2012). What differentiates professional poker players from recreational poker players? A qualitative interview study. International Journal of Mental Health and Addiction, 10, 243-257.

Parke, A. & Griffiths, M.D. (2011). Poker gambling virtual communities: The use of Computer-Mediated Communication to develop cognitive poker gambling skills. International Journal of Cyber Behavior, Psychology and Learning, 1(2), 31-44.

Parke, A. & Griffiths, M.D. (2012). Beyond illusion of control: An interpretative phenomenological analysis of gambling in the context of information technology. Addiction Research and Theory, 20, 250-260.

The weighting game: Gambling with the nation’s health (revisited)

A couple of weeks ago I wrote a blog on why problem gambling should be considered a health issue. Earlier this week, I came across an interesting study carried out by jackpot.co.uk who surveyed 2,131 online gamblers (58% males and 42% female) about their health. After the self-reported data had been collected, the gamblers were classed into one of nine categories based on the casino game type that the gambler played most often (i.e., slot machines, video poker, blackjack, roulette, dice/craps, baccarat, poker, pai gow, and ‘other’). The data were then tabulated so that all the health variables (including obesity) corresponded to the gambler’s preferred casino game.

I was interested in the findings not only because I am a Professor of Gambling Studies, but also because I was a member of the Department of Health’s ‘Expert Working Group on Sedentary Behaviour, Screen Time and Obesity’ (a reference to our final report to the British government can be found in the ‘Further Reading’ section below). The study took an objective measurement of physical condition by asking each gambler their height (centimetres) and their weight (kilograms) to calculate each person’s Body Mass Index (BMI) by dividing the gamblers’ weight by height (metres) and dividing by height again (for example, someone who weighs 80kg and is 180cm tall, the BMI is 24.1 as this is 80/1.80)/1.80). The survey then asked s few general health and lifestyle questions (similar to ones that we have used in the last few British Gambling Prevalence Surveys:

• Do you normally drink more than the recommended limit for weekly alcohol consumption (21 units of alcohol for men and 14 for women)? (Yes/No)
• Do you smoke regularly? (Yes/No)
• Do you normally engage in at least 30 minutes of physical activity, 5 times per week? (Yes/No)

Overall, the survey found that British casino gamblers as a group were no less healthy than the rest of the British population, with an average Body Mass index (BMI) of 27 (which is the same as the UK national average). However, the survey also reported that the average BMIs, health, and lifestyle choices (such as smoking cigarettes, engaging in exercise, and drinking alcohol varied considerably depending on the casino games that the respondents played. Here are some of the main findings:

• Slots players were the least healthy. They took less exercise and had an average BMI of 31, pushing them into the category of obese (which is linked to increased chance of developing illnesses such as Type 2 diabetes and reduced life expectancy)
• Roulette, blackjack, video poker and craps/dice players were not far behind slots players, each having BMI levels higher than the national average.
• Those that played poker, baccarat and Pai Gow had an average BMI of 25 or under (well within the normal range recommended by the World Health Organisation.
• Whilst drinking levels might be reasonably high among poker players, they were very exercise conscious, with 58% engaging in physical activity for at least 30 minutes, five times a week. For slots players the figure was 27% meeting this government recommended target.
• Overall slots players drink the most, with 24.1% drinking over the recommended weekly limit. Poker players are not far behind on 23%. Female slots players were the biggest drinking subgroup, closely followed by male poker players.
• Slots players also smoked more, with 24% being regular smokers (compared to the UK national average of 20%). Blackjack and roulette players smoked slightly more than average, on 21% and 22% respectively, while poker players smoked slightly less than average, on 19.5%.

None of these results is overly surprising as there are many studies (including my own) showing comorbidity between gambling and other potentially addictive behaviours. However, very few academic studies have ever looked at these health variables by game type. Although this was not an academic study, the results will likely be of interest to those in the gambling studies field.

The survey also examined the most common platform on which the gamblers played casino games. The most common was the desktop computer (65%), followed by mobiles and tablets (20%) and land-based casinos (14%). This is not surprising given the survey was completed by online gamblers. Interestingly, desktop use was linked to higher levels of obesity, drinking and smoking. This is something that I would expect given that online gambling is the most sedentary of these activities.

There are (of course) some limitations with the data collected particularly as it comprised a self-selected sample of online gamblers that played via jackpot.co.uk websites. We have no idea as to whether the sample is representative of all online gamblers but as I noted above, it is no surprise that online gamblers preferred playing casino games online compared to offline (i.e., land-based casinos). The data were also self-report and are therefore open to any number of individual biases including recall biases and social desirability biases. Also, we have no geographical breakdown of the sample as the internet (by definition) is global. However, the sample size is good in comparison to many published studies on gambling and the sample included individuals that were actually gamblers (as opposed to university undergraduates or members of the general public). According to Sam Marsden (editor of jackpot.co.uk and author of the report):

“There’s an undeniable link connecting passive games like slots and video poker to unhealthy, sedentary lifestyles. On the other hand, games that require concentration, strategy and some physical stamina like poker and blackjack seem to fare much better in the health stakes. It seems it’s less a case of ‘you are what you eat’ and more ‘you are what you play’.”  

Although such a conclusion could be argued to be PR spin on the findings, the results suggest that more rigorous studies could be carried out in the area including secondary analyses of the robust datasets that already exist including the British Gambling Prevalence Surveys, the English Health Surveys, and the Scottish health Surveys.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Biddle, S., Cavill, N., Ekelund, U., Gorely, T., Griffiths, M.D., Jago, R., et al. (2010). Sedentary Behaviour and Obesity: Review of the Current Scientific Evidence. London: Department of Health/Department For Children, Schools and Families (126pp).

Griffiths, M.D. (2001). Gambling – An emerging area of concern for health psychologists. Journal of Health Psychology, 6, 477-479.

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association (ISBN 1-905545-11-8).

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2010). Gambling, alcohol consumption, cigarette smoking and health: findings from the 2007 British Gambling Prevalence Survey. Addiction Research and Theory, 18, 208-223.

Griffiths, M.D., Wardle, J., Orford, J., Sproston, K. & Erens, B. (2011). Internet gambling, health. Smoking and alcohol use: Findings from the 2007 British Gambling Prevalence Survey. International Journal of Mental Health and Addiction, 9, 1-11.

Marsden, S. (2014). Booze, bets, and BMI. Jackpot.co.uk, October 6. Located at: http://www.jackpot.co.uk/online-casino-articles/booze-bets-bmi

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Wardle, H., Griffiths, M.D., Orford, J., Moody, A. & Volberg, R. (2012). Gambling in Britain: A time of change? Health implications from the British Gambling Prevalence Survey 2010. International Journal of Mental Health and Addiction, 10, 273-277.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Wardle, H., Sproston, K., Orford, J., Erens, B., Griffiths, M. D., Constantine, R., & Pigott, S. (2007). The British Gambling Prevalence Survey 2007. London: National Centre for Social Research.

The national wealth service: Problem gambling is a health issue

Over the last decade, the United Kingdom has undergone major changes of gambling legislation (most notably, the 2005 Gambling Act that came into force on September 1, 2007). The Gambling Act has provided the British public with increased opportunities and access to gambling like they have never seen before. Gambling legislation was revolutionized and many of the tight restrictions on gambling dating back to the 1968 Gaming Act were relaxed (particularly in relation to the advertising of gambling). The deregulation of gambling has also been coupled with the many new media in which people can gamble (internet gambling, mobile phone gambling, interactive television gambling, gambling via social networking sites). Given the expected explosion in gambling opportunities, is this something that the health and medical professions should be concerned about?

Gambling has not been traditionally viewed as a public health matter although research into the health, social and economic impacts of gambling has grown considerably since the 1990s. In August 1995, the British Medical Journal published an editorial called ‘Gambling with the nation’s health?’ which argued that gambling was a health issue because it widened the inequalities of income and that there was an association between inequality of income in industrialized countries and lower life expectancy. However, there are many other more specific reasons why gambling should be viewed as an issue for the medical profession.

According to the last British Gambling Prevalence Survey (BGPS) published in 2011, just under 1% of the British population have a severe gambling problem although the rate is approximately twice as high in adolescents, particularly as a result of problematic slot machine gambling. Disordered gambling is characterized by unrealistic optimism on the gambler’s part. All bets are made in an effort to recoup their losses. The result is that instead of “cutting their losses”, gamblers get deeper into debt pre-occupying themselves with gambling, determined that a big win will repay their loans and solve all their problems.

It is clear that the social and health costs of problem gambling can be large on both an individual and societal level. Personal costs can include irritability, extreme moodiness, problems with personal relationships (including divorce), absenteeism from work, family neglect, and bankruptcy. I have also reported in a number of my papers (including a 2007 report I wrote for the British Medical Association) that there can also be adverse health consequences for both the gambler and their partner including depression, insomnia, intestinal disorders, migraines, and other stress-related disorders. In the UK, preliminary analysis of the calls to the national gambling helpline also indicated that a significant minority of the callers reported health-related consequences as a result of their problem gambling. These include depression, anxiety, stomach problems, other stress-related disorders and suicidal ideation.

There are also other issues relating to problem gambling that may have medical consequences. One US study published in the Journal of Emergency Medicine by Dr. Robert Muellman and his colleagues found that intimate partner violence (IPV) was predicted by pathological gambling in the perpetrator. In a sample of 286 women admitted to the emergency department at a University Hospital in Nebraska, findings revealed that a woman whose partner was a problem gambler was 10.5 times more likely to be a victim of IPV than partners of a non-problem gambler.

Health-related problems due to problem gambling can also result from withdrawal effects. In a study published in the American Journal of the Addictions, Dr. Richard Rosenthal and Dr. Henry Lesieur found that at least 65% of pathological gamblers reported at least one physical side-effect during withdrawal including insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulty and/or chills. Their results were also compared to the withdrawal effects from a substance-dependent control group. They concluded that pathological gamblers experienced more physical withdrawal effects when attempting to stop than the substance-dependent group. I also found similar things in a small study that I published in the Social Psychological Review (with Michael Smeaton).

Pathological gambling is very much the ‘hidden’ addiction. Unlike (say) alcoholism, there is no slurred speech and no stumbling into work. Furthermore, overt signs of problems often don’t occur until late in the pathological gambler’s career. If problem gambling is an addiction that can destroy families and have medical consequences, it becomes clear that medical professionals should be aware of the effects of gambling in just the same way that they are with other potentially addictive activities like drinking (alcohol) and smoking (nicotine).

However, gambling addiction is an activity that is not (at present) being treated via the British National Health Service (NHS). This was shown in a paper that I published with Dr. Jane Rigbye in a paper we published in a 2011 issue of the International Journal of Mental Health and Addiction. We sent a total of 327 letters were sent to all Primary Care Trusts, Foundation Trusts and Mental Health Trusts in the UK requesting information about problem gambling service provision and past year treatment of gambling problems within their Trust under the Freedom of Information Act. Our findings showed that 97% of the NHS Trusts did not provide any service (specialist or otherwise) for treating those with gambling problems (i.e., only nine Trusts provided evidence of how they deal with problem gambling). Only one Trust offered dedicated specialist help for problem gambling. Our study showed there was some evidence that problem gamblers may get treatment via the NHS if that person has other co-morbid disorders as the primary referral problem.

Problem gambling is very much a health issue that needs to be taken seriously by all within the health and medical professions. General practitioners routinely ask patients about smoking and drinking but gambling is something that is not generally discussed. Problem gambling may be perceived as a somewhat ‘grey area’ in the field of health and it is therefore very easy to deny that those in the medical profession should be playing a role. If the main aim of practitioners is to ensure the health of their patients, then it is quite clear that an awareness of gambling and the issues surrounding it should be an important part of basic knowledge.

As briefly outlined above, opportunities to gamble and access to gambling have increased because of deregulation and technology. What has been demonstrated from research evidence in other countries is that – in general – where accessibility of gambling is increased there is an increase not only in the number of regular gamblers but also an increase in the number of problem gamblers – although this may not be proportional. This obviously means that not everyone is susceptible to developing gambling addictions but it does mean that at a societal (rather than individual) level, in general, the more gambling opportunities, the more problems. Other countries such as Australia, Canada and New Zealand have seen increases in problem gambling as a result of gambling liberalization. In the UK, the last BGPS showed that problem gambling in Great Britain had increased by 50% compared to the previous BGPS published in 2007. (However, the latest data from the combined Health Survey for England and the Scottish Health Survey in 2014 reported that problem gambling had fallen to about 0.5%).

Gambling is without doubt a health and issue and there is an urgent need to enhance awareness within the medical and health professions about gambling-related problems and to develop effective strategies to prevent and treat problem gambling. The rapid expansion of gambling represents a significant public health concern and health/medical practitioners also need to research into the impact of gambling on vulnerable, at-risk, and special populations. It is inevitable that a small minority of people will become casualties of gambling in the UK, and therefore help should be provided for the problem gamblers. Since gambling is here to stay and is effectively state-sponsored, the Government should consider giving priority funding (out of taxes raised from gambling revenue) to organizations and practitioners who provide advice, counselling and treatment for people with severe gambling problems.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Griffiths, M.D. (2004). Betting your life on it: Problem gambling has clear health related consequences. British Medical Journal, 329, 1055-1056.

Griffiths, M.D. (2007). Gambling Addiction and its Treatment Within the NHS. London: British Medical Association.

Griffiths, M.D. (2011). Adolescent gambling. In B. Bradford Brown & Mitch Prinstein (Eds.), Encyclopedia of Adolescence (Volume 3) (pp.11-20). San Diego: Academic Press.

Griffiths, M.D., Scarfe, A. & Bellringer, P. (1999). The UK National telephone Helpline – Results on the first year of operation. Journal of Gambling Studies, 15, 83-90.

McKee, M. & Sassi, F. (1995). Gambling with the nation’s health. British Medical Journal, 311, 521-522.

Muelleman, R. L., DenOtter, T., Wadman, M. C., Tran, T. P., & Anderson, J. (2002). Problem gambling in the partner of the emergency department patient as a risk factor for intimate partner violence. Journal of Emergency Medicine, 23, 307-312.

Rigbye, J. & Griffiths, M.D. (2011). Problem gambling treatment within the British National Health Service. International Journal of Mental Health and Addiction, 9, 276-281.

Rosenthal, R. & Lesieur, H (1992). Self-reported withdrawal symptoms and pathological gambling. American Journal of the Addictions, 1, 150-154.

Setness, P.A. (1997). Pathological gambling: When do social issues become medical issues? Postgraduate Medicine, 102, 13-18.

Wardle, H., Moody. A., Spence, S., Orford, J., Volberg, R., Jotangia, D., Griffiths, M.D., Hussey, D. & Dobbie, F. (2011). British Gambling Prevalence Survey 2010. London: The Stationery Office.

Wardle, H., Seabury, C., Ahmed, H., Payne, C., Byron, C., Corbett, J. & Sutton, R. (2014). Gambling behaviour in England and Scotland: Findings from the Health Survey for England 2012 and Scottish Health Survey 2012. London: NatCen.

Net losses: What are the downsides of online therapy for problem gamblers and clinicians?

In my last blog, I briefly looked at the advantages of online therapy. However, the growth of online therapy is not without its critics. I may have given the impression in my previous blog that online therapy has nothing but positive implications. However, this blog briefly examines some of the main criticisms that have been levelled against online therapy. This loist is not exhaustive but hopefully covers the key concerns:

• Legal and ethical considerations: As Internet counselling services grow, attention will have to be focused on the specialist construction of a legal and ethical code for this type of work. Cyberspace transcends state and international borders, therefore, there are many legal and regulatory concerns. For example, client/doctor confidentiality regulations differ from one jurisdiction to another. It may not be legal for a clinician to provide chat-room services to problem gamblers who are in a jurisdiction in which the clinician is not licensed. Furthermore, some problem gamblers may be excluded from telehealth services because they lack the financial resources to access the Internet. One potential ethical and legal dilemma is the extent to which service quality can be ensured. It is possible that individuals who register to provide counselling services online do not have the qualifications and skills they advertise. They may not even be licensed to practice. There are also issues regarding the conduct of practitioners engaged in all forms of telecommunication therapy. For example: issues of informed consent, the security of electronic medical records, electronic claims submissions and so forth. Therapy provided over the Internet holds promise but there is a need to check that it works and see to it that, if it is done then it is done well. Underlying guidelines that are applicable to all forms of counselling are that: (i) the therapist must be trained, supervised and accountable with qualifications that can be checked against a list held by a mainstream organisation, and (ii) the nature of the contract between client and practitioner must be spelled out so clients understand the boundaries of what they are receiving for what they are paying.
• Effectiveness of online therapy: There are a growing number of evaluation studies that have examined whether online therapy is an effective treatment approach. With specific regard to problem gambling, my research colleague Dr. Gerry Cooper reported that about 70% spoke of how they benefited from their exposure to and involvement with GAweb, an online peer support group. An evaluation that I carried out with Dr. Richard Wood of Gam-Aid also showed that participants derived great benefit from using the online service and was particularly attractive for problem online gamblers (that are already comfortable with interacting online).
• Confidentiality: Online therapy may compromise privacy and confidentiality, particularly if a skilled computer ‘hacker’ is determined to locate information about a particular individual. There is also some evidence that as more personal information is required of counselling sites online, the attractiveness of these sites is reduced. On the other hand, one of the things that the Internet is especially helpful with is its ability to afford the consumer the control over self-disclosure. In this way, individuals may overestimate the degree to which their information is safe and secure from computer hackers.
• Encryption: No online therapist can confidently promise a problem gamblers confidentiality given the limitations of the medium. That being said, there are some sites that now offer secure messaging systems that offer the same level of protection as banking institutions. To protect confidentiality, care will have to be taken to prevent inappropriate and deliberate hacking into counselling sessions on the Internet. There will need to be a continuous upgrading of technology to stay ahead of hackers’ ability to breach security.
• Complicated payment structures: Given the cross-national nature of the Internet, there may be complicated pay structures for problem gamblers to overcome when selecting a therapist. While universally-accepted credit cards might actually make payment easier (since one can use their credit card online and the credit card company will automatically calculate the currency exchange for the transaction), one may not immediately understand how much the online counselling has cost in their own currency. They may not know this until their credit card invoice arrives at a later date.
• Cost-effectiveness to the therapist: For the therapist, there is the problem that online counselling may be as time consuming as face-to-face therapy with substantially less financial remuneration.
• Identity problems: One of the major potential problems is that online problem gamblers may not be who they say they are, i.e., counsellors may not always know the true identity of their online clients (although identity is an issue only applicable to those services that are not anonymous). This is clearly a major issue since some assumptions (rightly or wrongly) are made by the clinician depending on what the problem gambler presents (including age and other demographics). However, to some extent, these issues also apply to telephone and face-to-face counselling as the therapist has to accept what is said at face value. Additionally, some might argue that merely responding to the words that a problem gambler chooses to use necessitates more focus on the part of the therapist. As a result, this may lead to a more democratic counselling environment. In other words, the role of therapist and problem gambler becomes more equal in this situation. Some therapists may have difficulty adapting to these new roles.
• Severity of client problems: Some clients’ problems may be just too severe to be dealt with over the Internet. To some extent, there can always be contingencies, but because people can come from anywhere in the world and have a multitude of circumstances, online clinicians may be hard-pressed to meet everyone’s needs. It is important to acknowledge that this is not a panacea; that online help will not solve everybody’s problems (to be sure, those who are illiterate will likely have a difficult time of it without some additional support nearby). On the other hand, it is likely to go a long way in helping a great many more people than otherwise would have been the case.
• Client referral problems: One obvious difficulty for the counsellor is how to go about making a referral for someone in a faraway town or another country. Once again, one would need to establish basic contingencies. Over time, it could be expected there would be many more international-regional clearinghouses regarding where to get immediate assistance, but to date it is very difficult to know what services are available for many parts of the world.
• Establishing client rapport: It could perhaps be argued that there might be difficulty in establishing rapport with someone that the therapist has never seen. This is an interesting area where clearly more information is needed. One might also argue that because the problem gambler is in a more equal relationship with the therapist, they will feel more comfort. That is, since the problem gambler controls all of the personal disclosure levers, rapport might be established much more easily.
• No face-to-face contact: Online therapy leads to a loss of non-verbal communication cues such as particular body language, voice volume and tone of voice. Furthermore, the lack of face-to-face interaction between problem gambler and therapist could result in a wrong referral or diagnosis. What is known about online communication where cues are filtered out, is that it typically takes more work to accomplish a task where more than one person is involved. It may be the case that with time and experience, therapists who work online will develop skills that will help them compensate for the absence of visual cues. For example, they might become much more skilled and precise with the words they choose to use.
• Incomplete information: The written information provided in online therapy may be incomplete. Online therapy (via e-mail) may not allow the opportunity for immediate follow-up questions. Making a provisional recommendation or diagnosis is fraught with potential problems. For instance, a problem gambler may describe problems that are symptomatic of other more serious underlying disorders. However, diagnostic processes are quite heterogeneous practices even in face-to-face settings. Diagnoses are often provisional and therapists usually require more information to validate initial observations. In fact, clinicians might have better access to their clients through e-mail than trying to track them down face-to-face or exchanging telephone answer messages, should they need further information. Still, the information derived from problem gamblers in online formats may be unverifiable, more so than in face-to-face contexts.
• Loss of therapist contact: Although perhaps more of a possibility than a reality, therapists can just ‘disappear’ only to re-emerge weeks later saying that their server failed and/or leave a problem gambler mid-therapy with little that the problem gambler can do about it. The same problem could occur with some clinicians in face-to-face settings although being online may be more of a problem in finding out what has happened.
• Commercial exploitation: Consumers theoretically are not always as anonymous as they might think when they visit health sites because some sites share visitors’ personal health information with advertisers and business partners without consumers’ knowledge or permission. Some sites allow third-party advertisers to collect visitors’ personal information without disclosing this practice. As a result, visitors may get e-mails from advertisers about their products and services. Information can be collected during a variety of tasks including the visiting of chat rooms and bulletin boards, searching for information, subscribing to electronic newsletters, e-mailing articles to friends or filling out health-assessment forms. This allows third parties to build detailed, personally identified profiles of individuals’ health conditions and patterns of Internet use. In relation to gamblers, this is a real issue. By virtue of posting to places where problem gamblers talk to each other online with an accurate e-mail address shown, online gambling operators have the potential to collect such information in order to later send junk e-mail promoting their gambling websites. Other questionable and fraudulent marketing practices by online operators have also been outlined in my previous blogs.
• Emergency situations: Being online and geographically distant has the potential to cause problems in an acute situation. For instance, if a clinician does not know where a problem gambler lives or can be located, they cannot call for help in the case of an emergency such as a suicidal threat.
• Convenience: Although convenience was outlined as an advantage in the previous section, it can also have a downside. For instance, it may mean that the problem gambler is less likely to draw on their own existing coping strategies and use the online therapist as a convenient crutch (something which is actively discouraged in face-to-face therapy).

Hopefully this blog has redressed the balance of my previous blog on the positive benefits of online therapy. Anyone that seeks online advice, help, and/or treatment needs to carefully do their own cost-benefit analysis as to whether such an online service will be of direct benefit to them after taking into account some of the disadvantages outlined here.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bloom, W. J. (1998). The ethical practice of Web Counseling. British Journal of Guidance and Counselling, 26 (1), 53-59.

Connall, J. (2000). At your fingertips: Five online options. Psychology Today, May/June, 40.

Griffiths, M.D. (2001). Online therapy: A cause for concern? The Psychologist: Bulletin of the British Psychological Society, 14, 244-248.

Griffiths, M.D. (2005). Online therapy for addictive behaviors. CyberPsychology and Behavior, 8, 555-561.

Griffiths, M.D. (2010). Online advice, guidance and counseling for problem gamblers. In M. Manuela Cunha, António Tavares & Ricardo Simões (Eds.), Handbook of Research on Developments in e-Health and Telemedicine: Technological and Social Perspectives (pp. 1116-1132). Hershey, Pennsylvania: Idea Publishing.

Griffiths, M.D. & Cooper, G. (2003). Online therapy: Implications for problem gamblers and clinicians, British Journal of Guidance and Counselling, 13, 113-135.

Rabasca, L. (2000). Self-help sites: A blessing or a bane? APA Monitor on Psychology, 31(4), 28-30.

Segall, R. (2000). Online shrinks: The inside story. Psychology Today, May/June, 38-43.

Wood, R.T.A. & Griffiths, M.D. (2007). Online guidance, advice, and support for problem gamblers and concerned relatives and friends: An evaluation of the Gam-Aid pilot service. British Journal of Guidance and Counselling, 35, 373-389.

Wood, R. T., & Wood, S. A. (2009). An evaluation of two United Kingdom online support forums designed to help people with gambling issues. Journal of Gambling Issues, 23, 5-30.

Net gains: What are the benefits of online therapy for problem gamblers and clinicians?

“A 35-year old man comes home very late from a night out at the casino having lost all his savings at the roulette wheel. Unable to sleep, he logs onto the Internet and locates a self-help site for problem gambling and fills out a 20-item gambling checklist. Within a few hours he receives an E-mail which suggests he may have an undiagnosed gambling disorder. He is invited to revisit the site to learn more about his possible gambling disorder, seek further advice from an online gambling counsellor and join an online gambling self-help group” (from Griffiths and Cooper, 2003)

On initial examination, this fictitious scenario appears of little concern until a number of questions raise serious concerns. For instance, who scored the gambling test? Who will monitor the gambling self-help group? Who will give online counselling advice for the gambling problem? Does the counsellor have legitimate qualifications and experience regarding gambling problems? Who sponsors the gambling website? What influence do the sponsors have over content of the site? Do the sponsors have access to visitor data collected by the website? These are all questions that may not be raised by a problem gambler in crisis seeking help but they are important questions that require answers. Of course, these are also questions that should apply to any comparable face-to-face interventions.

The Internet could be viewed as just a further extension of technology being used to transmit and receive communications between the helper and the helped. If gambling practitioners shun the new technologies, others who might have questionable ethics will likely come in to fill the clinical vacuum. Online therapy is growing. Furthermore, its growth appears to outstrip any efforts to organize, limit and regulate it. It has been claimed that online therapy is a viable alternative source of help when traditional psychotherapy is not accessible. Proponents claim it is effective, private and conducted by skilled, qualified, ethical professionals. It is further claimed that for some people, it is the only way they either can or will get help (from professional therapists and/or self-help groups).

Psychological services provided on the Internet range from basic information sites about specific disorders, to self-help sites that assess a person’s problem, to comprehensive psychotherapy services offering assessment, diagnosis and intervention. Most experts agree that online therapy currently available is not traditional psychotherapy. For many, it appears to be an alternative for those who are either unable or reluctant to seek face-to-face treatment. There have been many reasons put forward as to why online assistance is advantageous. Here are the main ones:

• Online therapy is convenient: Online therapy is convenient to deliver, and can provide a way to seek instant advice or get quick and discreet information. In the case of counselling by E-mail, one needs to keep in mind that therapy per se can occur either via professionally delivered formats or via peer-delivered self-help groups. In addition, the counselling might not necessarily be restricted to E-mail; some might augment face-to-face counselling with E-mail ‘booster’ sessions. In this way, correspondence happens at the convenience of both the client and the counsellor. Online therapy avoids the need for scheduling and the setting of appointments, although for those who want them, appointments can be scheduled over a potential 24-hour period. For problem gamblers who might have a sense of increased risk or vulnerability, they can take immediate action via online interventions, as these are available on demand and at any time. Crisis workers often report that personal crises occur beyond normal office hours, making it difficult for people to obtain help from mental health clinicians and the like. If a problem gambler has lost track of time at the casino only to depart depressed, broke, and suicidal at 4am in the morning, they can perhaps reach someone at that hour who will be understanding, empathic and knowledgeable. They likely have a better chance of finding someone at an online peer-support site like GamTalk (gamtalk.org) than they would at their local mental health centre.
• Online therapy is cost-effective for clients: Compared with traditional face-to-face therapies, online therapy is cheaper. This is a big selling point often used by those selling their services online (for instance, some sites advertise their online services as ‘less than the customary cost of a private therapy session’ or ‘help and therapy at a reasonable fee’). This is obviously an advantage to those who may have low financial resources. It may also allow practitioners to provide services to more clients because less time is spent travelling to see them. Since there are financial consequences for a gambler, cheaper forms of therapy such as online therapy may be a preferred option out of necessity rather than choice. The cost factor is particularly important in countries where people are often forced to pay for health care (for example, in the United States). With the Internet, quality information and support (even if treatment is not yet freely available online) is available without cost. Arguably, one needs Internet access, but this too is becoming more freely available, and conceivably, even those who are homeless would be able to utilize such services through places like public libraries (although, literacy would continue to be an important requirement).
• Online therapy overcomes barriers that otherwise may prevent people from seeking face-to-face help: There are many different groups of people who might benefit from online therapy. For example, those who are (i) physically disabled, (ii) agoraphobic, (iii) geographically isolated and/or do not have access to a nearby therapist (military personnel, prison inmates, housebound individuals etc.), (iv) linguistically isolated, and (v) embarrassed, anxious and/or too nervous to talk about their problems face-to-face with someone, and/or those who have never been to a therapist before might benefit from online therapy. Some like those with agoraphobia and/or the geographically isolated, might be more susceptible to activities like online gambling because they either tend not to leave home much or they do not have access to more traditional gambling facilities (like casinos, bingo halls, racetracks and so forth). It is clear that those that are most in need of help (whether it is for mental health problems, substance abuse or problem gambling often do not receive it).
• Online therapy helps to overcome social stigma: The social stigma of seeing a therapist can be the source of profound anxiety for some people. However, online psychotherapists offer clients a degree of anonymity that reduces the potential stigma. Gambling may be particularly stigmatic for some because they may find it is a self-initiated problem. Others have found that the issue of stigma has caused some problem gamblers to avoid seeking treatment. Furthermore, in an exploratory study, my research colleague Dr. Gerry Cooper found that there was a correlation between higher levels of concerns about stigma and the absence of treatment utilization, and that lurking (i.e., visiting but not registering presence to other users) at a problem gambling support group website made it easier for many to seek help including face-to-face help. It should also be noted that there is strong emerging evidence for the power and effectiveness of narrative therapies. For example, there is some evidence to suggest that a person’s use of positive emotion words in their written articulations of difficult or problematic experiences lead to improved health changes.
• Online therapy allows therapists to reach an exponential amount of people: Given the truly international cross-border nature of the Internet, therapists have a potential global clientele. Furthermore, gambling itself has been described as the ‘international language’ and has spread almost everywhere within international arenas.

From the brief outline presented here, it would appear that in some situations, online therapy can be helpful – at least to some specific sub-groups of society, some of which may include problem gamblers. Furthermore, online therapists will argue that there are responsible, competent, ethical mental health professionals forming effective helping relationships via the Internet, and that these relationships help and heal. However, online therapy is not appropriate for everyone. As with any new frontier, there are some issues to consider before trying it. In my next blog I will look at some of the downsides of online therapy.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Bloom, W. J. (1998). The ethical practice of Web Counseling. British Journal of Guidance and Counselling, 26 (1), 53-59.

Connall, J. (2000). At your fingertips: Five online options. Psychology Today, May/June, 40.

Griffiths, M.D. (2001). Online therapy: A cause for concern? The Psychologist: Bulletin of the British Psychological Society, 14, 244-248.

Griffiths, M.D. (2005). Online therapy for addictive behaviors. CyberPsychology and Behavior, 8, 555-561.

Griffiths, M.D. (2010). Online advice, guidance and counseling for problem gamblers. In M. Manuela Cunha, António Tavares & Ricardo Simões (Eds.), Handbook of Research on Developments in e-Health and Telemedicine: Technological and Social Perspectives (pp. 1116-1132). Hershey, Pennsylvania: Idea Publishing.

Griffiths, M.D. & Cooper, G. (2003). Online therapy: Implications for problem gamblers and clinicians, British Journal of Guidance and Counselling, 13, 113-135.

Rabasca, L. (2000). Self-help sites: A blessing or a bane? APA Monitor on Psychology, 31(4), 28-30.

Segall, R. (2000). Online shrinks: The inside story. Psychology Today, May/June, 38-43.

Wood, R.T.A. & Griffiths, M.D. (2007). Online guidance, advice, and support for problem gamblers and concerned relatives and friends: An evaluation of the Gam-Aid pilot service. British Journal of Guidance and Counselling, 35, 373-389.

Wood, R. T., & Wood, S. A. (2009). An evaluation of two United Kingdom online support forums designed to help people with gambling issues. Journal of Gambling Issues, 23, 5-30.