I think so. Based on the quantifiable responses, you can perhaps build a typology of gambling, much like what people have done for alcohol misuse; many of these studies have important treatment implications. Also, based on what you described, perhaps you'd be interested in the role of "volition" in these responses; e.g.,

http://www.ncbi.nlm.nih.gov/pubmed/22963577

Hi Catalin,

I certainly agree that a personalized treatment approach is necessary for tackling many addictions. The variability in individual reactions to warning messages may be due in part to the addicted individual's inability to rationally project future consequence. As in, a 25-yr old smoker who sees a tracheostomy patient may not be deterred from smoking as this "possible future" is just that --- a possibility and not of immediate concern. I believe there is sufficient literature looking at cocaine addicts with respect to future decision making (e.g., http://www.ncbi.nlm.nih.gov/pubmed/16236455 and http://www.ncbi.nlm.nih.gov/pubmed/21517195). Some major considerations for the future of addiction research is to focus on both reducing impulsivity while, in concert, increasing executive functioning (e.g., delay discounting).

I am tempted to think that perhaps increased awareness of negative consequences of temporal significance from any given addiction to an addict with intact delay discounting ability may produce an additive effect in abstaining or otherwise reducing addiction behaviors, but this is speculation. Without a doubt, individualized behavioral and pharmacological therapy is necessary for many addictions, particularly with drugs of abuse. A second school of thought, although not demonstrated to be all too effective, is the idea of forming new connections between addictive behavior and consequence so that, for example, cocaine use is no longer as strongly associated with euphoria as it is with terrible withdrawal/poverty (this links closely with impulsivitiy and decision making). In essence, associations need to be re-learned, but easier said than done...

I feel that the research direction you are thinking needs a flavor added that would add to its therapeutic potential. For example, examination of warning message intensity and frequency along with a pharmacotherapy may show an additive therapuetic efficacy.

Cheers,

SS

---

Steven Simmons

Brain and Cognitive Sciences Ph.D. Student

College of Liberal Arts: Neuroscience Program

Temple University

Philadelphia, PA

(856) 571-3894

[email protected]

I think Steven hit a good point that reactions will undoubtedly be age-dependent, and reactions will also be dependent on the amount of time a person has spent performing the addictive behavior (say 2 months of gambling versus 10 years gambling). As someone who has worked with addicts, I also agree that the question you raise could possibly identify those who would be willing to be treated (someone who finds the warnings disturbing may be more apt to seek treatment or want to quit rather than someone who is more flippant about the warnings, for example), but to say reactions to the messages could indicate the types of addiction would be confounded. Compulsion and addiction-perpetuating behaviors would be a common theme, but also there will be different patterns of thought (gamblers of course will be more likely to talk about "winning" than a heroin user).

You have a model that says: "addiction can be controlled with alarm messages, these messages are usually ignored and each addiction has a particular post-message behavior, and according to what you put it, this behavior is itself a counter-message, that the practitioner might thwart to improve the effectiveness of prevention or care." I think this model is simplistic and reductionist and does not take into account the complexity of addictions.

Already, it is not certain that there is a uniqueness in counter-messages. The same counter-messages could be applied to different types of addiction. An alarm message and a counter-message obey both to a mental substructure, sometimes it can be the same theory. For example, the "denial of self-will" is supported by all the works in neurobiology that show the brain marking in addiction: "I can't quit because it's organic, it's my brain, it's my neurons, ask the neurobiologist!" However, this theory of "denial of self-will justified by biology" may very well be made ​​for a compulsive gambler, a sex addict or heroin consumer. Many Addicts know more or less what a "brain reward system" is, according to some popular magazines.

For the gambler his theory is an "overestimation probability of gain" (or "underestimation probability of loss"): "This is my chance, a sign of destiny, it's the good machine, ask the magician!" This theory can also be found in other addictions, such as risk-taking in sport, driving, sexual behavior. But you can also find this theory of "underestimation of risk" in drug, tobacco or alcohol addictions too.

This shows that the society (with the help of scholars) develops alarm messages against addictions from beautiful theories, but the addicts develop their conter-messages from theories, sometimes identical to scholars' ones, sometimes magical. And more over, these theories, of society and addicts, may apply differently to various addictions. In conclusion, the distinction you want to make between the different addictions according to the theories that sustain cognitive behaviors post-warning messages seems difficult to sustain for me.

Besides the concept of addiction is not very clear or unambiguous. You oppose a substance addiction to a behavioral addiction. But doing this you forget that both are underpinned by the same brain circuits and similar neurobiological mechanisms. This also ignores the co-addictions (I gamble, I smoke and I drink alcohol) and chaining addictions (I stopped smoking and I went to binging, I stopped binging and I became sex addict). How to find a good prevention message while many addictions are operating in the same individual, when this individual may move from one addiction to another, when this individual can thwart any message with a personal counter-theory and a counter-message justifying the pursuit of his addiction?

What I think is that we must consider addictions (plural) following their trajectory(ies). So the important thing is not so much the nature of the prevention message, but the meeting of the individual with a message, any message, finally. The meeting with tertiary prevention and care must be as "magic" as the meeting with the hedonic source that allowed the installation of addiction. The meeting with care is like a romantic meeting and sometimes it works as long as a love story ...

This is a very interesting query in my educated opinion. All contributors to this post thus far had many intelligent and common sense responses. All ideas for further research in regards to the previous answers or possibilities to get answers... all made sense to me. I will add to this query: I believe that warning labels, commercials and/or any propaganda type information automatically if read or viewed, becomes a subliminal memory; whether outwardly recalled or not. The brain stores information on so many levels and in so many parts of the brain. The repeated use of an ad campaign for example (the pictures of before and after of meth users comes to mind) needs to be repeated in order for the memory that is stored from the first contact of such ad to go from the back of the brains storage unit to the front. I noticed many uses of the word association and I could not agree more. Association is what helps us to respond or to think or in scholarly terms; to help us get to the contemplation stage of change. A smoker might, yes, as a young person not see themselves in an ad depicting an older smoker coughing and looking older than they are all the whilst with a trach attached. The mere difference in age (which I believe was mentioned) is what I refer to as 'reverse association.' The contact has been made and stored (person and ad) but the age difference makes the association impossible to understand. For example, both ad and viewer smoke... that is the constant. The variable is the age difference. We as animals can only associate a negative outcome to a current condition (addictions for example as used herein) when we can relate with the association. An association is stored as a memory once it is received. The association between the viewer or reader of such ad campaigns is ONLY an association because it was viewed or read. The actual intention to get people to associate their bad habits or addictions is of no use unless there are more commonalities between the ad and the viewer. To further this query, I believe that people need to be in emanate danger before they make a change. Ad campaigns or warning messages, in my opinion are quite good and reasonable because it allows the brain to think about how the addiction that was thought to 'give a good high' is now a new stored memory of the ad that tells the 'high' might not be so great anymore. The justifying as also mentioned is common. A person MUST go through all phases of grief before they decide that the 'high' is gone. The association with this new stored memory between possibilities of past highs and potential future death of that high NEVER happens immediately and rarely do we see anyone quit a habit due to this type of association. The brain has to experience more non contact associations on a constant basis (non contact meaning the reverse association between the constant similarity of the addiction) in order for the mind to begin to relate on a contact association level. Once embedded in the brain by use of constant messages; eventually and in time the brain will see or read the ad and do an 'aha' type yelp and begin to slowly clear the generation or difference (reverse) association. The synapse will begin to close that gap and the brain will eventually not justify a difference thus allowing an addict to form a relationship with the current condition and the impossible past relationship of a non contact differential. The most important idea for researchers and professionals dealing with helping to cure addictions is that it takes time and the sooner in a persons biological life this association can begin, the sooner the person will have a chance to changer their behaviours. It is also true that some people simply age out of their addictions.

Renate

BS Psychology;Trine University

AS Counseling and Therapy; Ivy Tech College

MS current; Forensic Psychology; Trine University

Eric,

Just to clarify: I did not say that "addiction can be controlled with alarm messages". I used the term "warning message" in sense of a (beginning) part of a cognitive intervention, some brief material which to summarize the basic ideas of the warning. It is true that there is another sense of it, in the commercial side, namely a warning label to put on the products or the environments that are subject to addiction danger. Even with this latter sense, I still think the post-message behavior is different for the various types of addiction. I admit the problem I posed is too general (and include here your point that addiction should be defined adequately) and agree that warning messages have no value if not followed by a proper cognitive therapy. This is exactly the point I want to reach. My view is that the tools used in treating cognitively the addictions (also reflected in the warning mesages) should be differentiated. In gambling, you cannot treat adequately addiction without mathematics, which of course is not true for smoking, for instance. At this point, I think gambler's issue is more than "overestimation of probability of gain"; there are several specific fallacies and issues of interpretation of the mathematical concepts that must be acknowledged and corrected (including epistemic knowledge related to probability, mathematical modelling, etc.). Such cognitive therapies can be designed only for gambling addiction. In conclusion, I agree that dealing with addictions is a complex issue - like humans are complex - and warning messages is just a minute part of the matter of research needed.

Very interesting observation worth testing. It could be that both smokers and gamblers actually say the same thing... "I can't do it but, even if I could, the bad thing (cancer, losing big) won't happen to me." For all addictions, there is an element of ego syntonic versus ego dystonic behavior. As long as the behavior remains ego syntonic, regardless of the perception of self efficacy over quitting, the behavior will continue. In gambling we've been applying behavioral economics paradigms-- how people make decisions under conditions of risk-- to investigate persistence in gambling (chasing) in a loss versus win condition. That data is in the write up stage but should be published soon. It might be that the immediate risk involved in gambling episodes is more "real" in gambling and, therefore, triggers predictable behavioral responses irrespective of warnings, as compared to smoking where real health risks are usually years away or, if imminent, perceived as too late to affect. We have developed a popular typology -- the Pathways Model -- that looks at etiological differences and has been tested; it might have some implications for your work or for formulating your hypotheses.

Professor Nower,

Your ongoing study on how people make decisions under conditions of risk seems to be applicable to the post-warning message issue. The imminent versus late risk is definitely one of the factors making the difference in gamblers' and smokers' behavior. As a non-psychologist, I am more interested in prevention/treatment rather than etiology and my thesis would be that mathematics - currently unexploited at its full potential - can bring decisive contributions for the former in the case of problem gambling. Coming to the issue of post-warning behavior, do you think that the content of the warning message is crucial (in general or in particular for gambling; and thus it can be hypothesized that an optimal message does exist) or it has low importance comparing to other factors strictly related to the individual (I understand that the ego-syntonic factor prevails over any warning message)?

Have a look at conditioning and genes for a possible answer. I am attaching two articles of interest. The first is:

And the second is:

So maybe "aversion" methods using "sign-tracking" could be useful. Any comments after reading the two articles?

John,

Thnak you for the articles. Will look over them this evening.

Catalin,

I think the impact of messages may vary based on the etiology of excessive play in the individual. I also think that, more than a generic warning --, telling the person how much they've gambled and some estimate of that relative to other players or an algorithm of losses that will accrue at that rate over time -- is more important. However, if the person is gambling for escape (our pathway 2) or dopamine pathways surge (our pathway 3) then the messages will make little difference. It might with Pathway 1 gamblers. The new decision-making study found that subjective goal setting was a big factor.... Those who set higher win goals for themselves were more likely to persist in the face of losses than those with smaller goals. So giving some specific math information about where they fall relative to others may make a difference to some. We published two articles. A few years back on warning messages but those studies were done with college students and static messages.

Professor Nower,

Definitely math-oriented warning messages are for the pathway-1 gamblers. Gambler's goals of playing are very important in designing the professional help. I am a proponent of mathematical didactical interventions adapted for pathway-1 gamblers. I know that past studies on whether mathematical knowledge can change gambling behavior were not conclusive and some of them tended to answer (unexpectedly) "no" to this hypothesis. However, I also found that all the involvement of mathematics in problem-gambling research thus far was statistically inclined and experimental mathematical interventions were in the vein of standard Probability&Statistics curricula of secondary and post-secondary schools and this may be one of the issues. I currently do some research in this matter and hope to find what is missing in the current mathematical interventions for taking effect on excessive gamblers. Beside didactical interventions, I think that mathematics can also contribute directly to the (psycological) cognitive therapies with knowledge not necessarily statistical.

Without doing research, addictions all have triggers and usually are utilized as a coping mechanism. I am more familiar with criminal profiling and addiction. I have learned that developmental behavior in the home/family environment play an important component in addictions. Timelines are extremely useful, and am learning to transfer that from law enforcement into marriage and family counseling. Timelines usually will show when the stress er entered, learned behavior is also a factor--your question is fascinating and would love to look into it along with you. I don't have the time, however, I will tell you that you are not having irrational thoughts, you are being very analytical-excellent area for research. Leanna

Post-warning behavior is likely influenced by addiction elements, idiographic elements, contextual elements and interactions among these. The question you raise is the meeting of factor analysis and cluster analysis - identifying the groups of features and the groups of people. At its core, you are raising the Aristotelian question of multiple addictions and pitting it against a more Galilean perspective of a dynamic addiction with many different expressions. From these philosophic foundations, decisions can be made to guide research into this important question that goes far beyond gambling: how do people respond to health messages.

Professor Shaffer,

Very good abstracting. I know psychologists/psychiatrists tend to have a holistic approach of addictions, being mostly focused on the medical nature of the phenomenon and in part on its social nature. Obviously, distinctions between addictions have been made in several directions, from primary causes, pathways, damages, to responses to treatment. These are all about health, including in gambling. What I claim as a a non-psychologist is that gambling is a very different kind of addiction, if the goal of making money is present. This particular goal makes that cut-off distinction, in that that it is an "objective" or practical - if you prefer - goal. This goal is more generated in the relation of the individual with the society (which makes it objective; I do not refer here to environment as a factor; simply "I need more money in this society"), rather than self-generated, which is the case of most of the other addictions. As a brief example, electronic-gaming or smoking have no objective goal (I call goals such as filling spare time or the like as non-objective), but gambling for money does have one. And with this goal gambling interacts with mathematics. How do people respond to health messages is obviously a big question and I would place it far beyond addictions, not only gambling. Not every bad response to health messages has an addiction behind it, but it can have personal convictions and beliefs instead. Here again is the case of gambling. A gambler may not be addicted to continue gambling by ignoring warning messages, but have irrational beliefs, for instance. What I mean overall is that problem gambling should be somehow pulled out a little bit from the health/medical approach in order to both gain new directions of research and come to improved treatment.

Addictive behaviors are functional. Sometimes the goal is objective, sometimes the goal is subjective. However, the value of shifting subjective states is as valuable or perhaps more valuable than financial values. So all expressions of addiction reflect some meaningful objective. Relieved dysphoric subjective states is a powerful motivation, and the most common among people who experience addiction. All gamblers, disordered and recreational have irrational thoughts; people often forget that the illusion of control, for example, is not a distinguishing feature of gambling disorder.

Professor Shaffer,

To some extent we can consider all goals as objective (don't know if there is a right definition of goal's objectiveness in addiction research), as I agree that all expressions of addiction reflect meaningful objectives and have strong motivations behind, including acquiring certain (subjective) states. It is important to see what is the prevalence of the goals based on subjective states over the financial goal (are there any studies on this issue?) in the problem-gambling population. Not all gamblers have irrational thoughts or at least irrational thoughts of a certain type. Take for instance mathematician gamblers (if any in a relevant share), who know how probability and expectation laws work. It may be hypothesised that a mathematican gambler is motivated by subjective goals, although the financial one cannot be excluded entirely.

Even the best educated about statistical probability and independent events can experience irrational thoughts (e.g., gambler's fallacy). Consider the gambler's fallacy. Consider a player betting on a sequence of coin tosses who observe 4 or 5 consecutive heads; they are much more likely to bet tails after a run of heads. This is irrational thinking, so long as the coin is fair. This circumstance doesn't mean that this person has a gambling problem, just an irrational thought.

About goals: all goals ultimately are subjective. We need to understand what objective or subjective goals mean to a player if we are to understand this player's motivation. For example, $5.00 means something different to people of different means, so even seemingly objective metrics require subjective interpretation.

The challenge of trying to change behaviour with the right information is appealing - approaches such as the Health Belief Model (HBM) have reported success in a range of settings.  I wrote the text and oversaw production of an animated video educating slots players, consistent with HBM principles and with the goal of reducing the extent to which players exceeded their limits in gambling sessions.  It can still be found at https://www.youtube.com/watch?v=YBQhCP1IdWo 

The evaluation recruited players as they were entering slots venues, and asked them to watch the video and fill out pre and post questionnaires before proceeding to their gambling sessions. They were also asked to return after the gambling session and complete another questionnaire.  In the interests of brevity, it was found that viewing the video shifted HBM measures in the right direction (knowledge of the risk behaviour; increased perceptions of the seriousness of associated consequences, increased perceptions of personal susceptibility to consequences if the risk behaviour was adopted, increased efficacy in avoiding the risk behaviour, and increased behavioural intentions to avoid the risk behaviour).  Following the subsequent gambling session, subjects reported staying within their limits to a significantly greater extent than their usual practices (as reported in the pretest questionnaire before seeing the video).  This was exactly what had been hoped for.

Then, the 30 day follow-up showed a near complete reversion to pre-test levels of play, including rates for exceeding limits.  Virtually all behavioural effects were extinguished. And so, the question is: Why?  Here, the answer becomes speculative on my part. 

After the first session following the video, subjects were reintegrated into the myriad relentless pressures in the gambling environment to gamble more frequently and longer, to bet more, to access money from ATMs, and so on.  Loyalty programs promoted more frequent visits and normalized high loss levels.  Deceptive game design features fostered extended duration of play and bet size, enhanced by staff contributions such as pointing out machines that hadn't paid out in a while.  Operating policies such as allowing patrons to have their machines shut down while they took breaks reinforced beliefs that wins were more likely the longer you play.  And so on.  

My guess is that the total gambling environment was more than adequate to restore previous patterns of play and to ignore the well-learned information in the video.  Although longer term follow-up was not done, my guess is that we would see some of the subjects increasing the frequency of exceeding limits over time, as well as the amounts by which limits were exceeded.

My conclusion is that expecting educational approaches to have any impact on the adoption of self-protective gambling behaviour is fruitless.  The answer to stopping excessive play (such as exceeding limits) is to stop casinos from the wide range of strategies they employ to cause it. In most other areas (e.g., smoking), this would be accomplished through evidence-based policy-making by government to curtail factors that increase risk exposure.  Unfortunately, governments are compromised in relation to gambling by their direct pecuniary conflict of interest.  As a result, they join forces with gambling providers to redirect attention to educational campaigns, creating putative "informed consumers", and focussing on after-the-fact harm through treatment responses.  Oh yes, and touting the merits of "voluntary" self exclusion programs.

To resort to the vulgar, my friend, gambling education is like "pissing into the wind".

Having said this, there is one approach that I think may still hold promise - a media literacy strategy that plays up the exploitation element of gambling "suits" laughing as they convince you to part with your money in a sucker's game.

Yes, behavioral responses to warning messages can indeed be considered as a characteristic that distinguishes between various types of addiction. Different types of addiction, whether substance-related (such as drug or alcohol addiction) or behavioral (such as gambling addiction or internet addiction), often involve distinct patterns of behavior in response to warnings or attempts to intervene.