Introduction

Gambling disorder (GD) is defined as a maladaptive and persistent gambling behavior that leads to adverse consequences at the individual and community levels (American Psychiatric Association 2013). GD, also called gambling addiction (GA), is currently considered a worldwide public health issue (Calado and Griffiths 2016) and has attracted the attention of a number of researchers, who have mostly examined the topic through diverse perspectives, including ethnographical and anthropological approaches, that have contributed to an understanding of the phenomenon (Núñez 2017; Cassidy, Loussouarn, and Pisac 2013; Chumley and Wang 2013; Reith 2007; Schüll 2012). Studies have yielded consistent data about the risk factors accounting for the disorder and its psychopathological correlates. Additionally, several groups of researchers examined specific topics related to GD using qualitative analyses of interviews and identified useful clinical indications (Hing et al. 2015; Moreau et al. 2015; Dufour, Petit, and Brunelle 2013; Wood and Griffiths 2007). In Italy, preliminary studies analyzed the narratives of Italian addicted gamblers (AGs) following a constructivist theoretical framework (Venuleo et al. 2018; Venuleo and Marinaci 2017; Pini 2012). Interesting results emerged, highlighting the internalization of addiction identity and noting specific aspects related to GD and its treatment.

As a whole, the qualitative literature on gambling addiction has provided valuable information and revealed aspects of the disorder previously identified by quantitative research. However, most of these studies investigated specific constructs in populations of gamblers recruited from non-clinical populations. Researchers mainly focused on specific aspects of the gambling experience, neglecting the examination of the narratives of the whole life story of AGs. Recently, it has been stated that the conceptualization of addiction should not be reduced to a range of behavioral, cognitive and neurobiological symptoms but should be understood as a disorder underlain by specific self-narratives (McConnell 2016). In relation to GD, this assertion fits well with empirical data showing that the disorder involves broad modification of the self-concept and the relocation of an individual’s place within society and his/her family (Reith and Dobbie 2013; Heineman 1994). In that sense, the understanding of the disorder for AGs is built through an interpersonal and narrative process based on ongoing dialogue with external models. In other words, the experience of GD should not be considered an isolated condition but rather a component of the understanding of one’s life (Kleinman 1998). In line with this, some central processes that account for the development and maintenance of GD may emerge from the examination of narratives of the life story. For instance, some psychosocial variables closely connected to GD, such as personality traits (e.g., impulsivity), value orientation (e.g., materialism), and emotional (e.g., affective stability) and interpersonal capacities, may be rooted in the early stages of development and result from the subjective experience of life events (Rogier and Velotti 2018a, b; Tabri et al. 2017; Otto, Loreen, and Douglas 2006). To our knowledge, there is still lacking a qualitative exploration of how AGs integrate the experience of GD into the narrative of their whole life, establishing relationships between some aspects of their personal stories and the development of GD. This issue appears clinically relevant because closely related to a key aspect involved in treatment-seeking, compliance to treatment and relapse prevention that is awareness of the disorder.

In relation to this point, a central issue in the subjective experience of mental illness is awareness of the disorder. Disorder awareness corresponds to the definition of GD as a psychological problem in its cognitive, behavioural and emotional components. An individual aware of his GD should be able to give a plausible explanation of the way personal experiences have promoted the development and maintenance of the disorder. Additionally, awareness includes the subjective perception of how the disorder impacts multiple domains of life. As has been asserted for other disorders (Lysaker et al. 2009), lack of awareness of the disorder may lead to difficulties in the treatment phase. For example, naïve theories (the spontaneous explanations that an individual gives regarding his mental illness) about the disorder and the way to cope (e.g., cognitive biases, metacognition, self-stigma) might hinder successive treatment steps, such as establishing the therapeutic alliance, towards achieving therapy’s aims and methods (Baxter et al. 2016; Gainsbury, Hing, and Suhonen 2013; Evans and Delfabbro 2005). Accordingly, interventions aiming to increase awareness of the disorder (e.g., motivational interviewing, psychoeducational sessions) are often used during the early stages of therapy (McIntosh and O’Neill 2017; Yakovenko et al. 2015). Although the topic of disorder awareness is a central issue in clinical practice, there are still few studies examining this dimension.

To bridge such gaps, we conducted a qualitative study, administering interviews focused on awareness of GD and eliciting narratives of both the disorder and the whole life of participants. The first aim of the study was to explore dimensions related to awareness of the disorder in AGs. In line with this, we explored whether and how central features of the disorder (e.g., mechanisms, determinants and consequences) were subjectively experienced, described, and explained by AGs. Additionally, our purpose was to outline how AGs represent the complex interweaving of aspects of psychological functioning developed in their life story with the development and maintenance of GD. Finally, we explored the awareness of AGs of the strategies that they may implement to cope with GD features.

In doing so, we adopted both qualitative and quantitative methods of research (Krippendorff 2004) and applied computer-aided content analysis (described below). Indeed, this approach has been shown to be suitable for the investigation of representations of health and illness (Velotti et al. 2016; Pace, Velotti, and Zavattini 2012) as well as problem gambling (Caputo 2015). Specifically, textual analysis appears useful to capture a representation of textual corpus content through a few significant thematic domains based on the semantic variability of the text rather than ad hoc categories established by the researcher. Indeed, the interpretative process of each domain (labeled by the researcher) is a bottom-up approach to textual data that progressively infers the emotional experience and psychological processes of participants as they emerge directly from their narratives. In that sense, textual analysis is used in exploratory research to understand how groups of people communicate about and make sense of a specific phenomenon. In our case, given the subjective nature of the issue investigated, (i.e., representations of GD), it appears to be a useful tool to reveal new insights on and the complexity of GD awareness.

Method

Participants and Procedure

The 15 participants were Italian males aged from 31 to 80 years (Mean = 50.01; SD = 15.94). All participants were treatment-seeking gamblers recruited in a public clinical center in Rome using a convenience sampling method. Demographic information indicated that two participants finished their primary education, whereas the others pursued further education, with six having completed middle school and eight junior high school. Regarding income level, the sample was quite homogeneous, with all participants being grouped into the low (86.67%) or medium (13.33%) income brackets.

After a brief presentation of the aims of the study, information related to privacy was communicated, and written informed consent was obtained. A semi-structured interview was then conducted. All procedures complied with the official guidelines established by the American Psychological Association and were approved by the Research Ethics Board of the Department of Dynamic and Clinical Psychology of the University of Rome.

Material

The Psychiatric Illness Interview for Gambling Addiction (PIIGA; Velotti et al. 2019) is an adaptation of the Indiana Illness Psychiatric Interview (IIPI, Lysaker and Lysaker 2002), a semi-structured interview that aims to elicit illness narratives and the understanding that individuals have of their own difficulties. The IIPI has been successfully used in its Italian version in several studies (e.g., Popolo et al. 2017). In our study, the original interview was modified, replacing some references to mental illness with the more specific expression “problem with gambling”. The interview encompasses four sections investigating (1) the story of the individual’s life; (2) the description and understanding of the disorder; (3) the mental illness’s control over the individual’s life and the individual’s control over the mental illness; and (4) the exploration of expectations for the future.

Textual Data Analysis

Several multidimensional statistical techniques were carried out using text analysis software, in our case T-LAB. “Thematic analysis of elementary context” transforms the textual corpus into a digital “presence-absence” matrix. To do this, each headline/subheading was considered as a segment of the corpus (namely, an elementary context unit) and represented a row of the matrix, while all the words present in the corpus represented the columns of the matrix.

Cluster analysis allows the detection of some groupings of words co-occurring in the same text segments (the so-called elementary context units) with the highest probability, as indicated via Chi square test (χ2). Clusters are labeled by the researcher based on the typical vocabulary and sentences of which they are composed. Then, correspondence analysis detects dimensions, organizing the semantic oppositions between clusters (Greenacre 1988; Lebart, Morineau, and Piron 1995). Indeed, the interpretative analysis of each dimension is based on the meaningful themes representing different and opposite symbolic content pertaining to the same issue.

Results

Cluster analysis detected five thematic domains, of which we report the percentage of context units, indicating their relevance in the overall textual corpus, and some of the most characteristic key words (lemmas) (Table 1).

Table 1 Main thematic domains emerged from the cluster analysis
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Thematic Domains

Cluster 1: Gambling as Dissociation

This cluster includes 27.18% of elementary context units and highlights several features characterizing the cycle of gambling addiction, which may suggest the lack of normal integration of thoughts, feelings and experiences and the presence of dissociative processes contributing to the development and maintenance of gambling addiction. As illustrated from the following sentences, the feeling of being dependent upon an external force, which appears to have control over one’s identity, emerged:

  • It is like a compulsion; while I was gambling I could not stop, I did not think to stop, I felt it go inside of me, I continued, continued, continued (RG17).

  • The onset of my illness has gradually taken my brain away and not an hour went by without thinking about gambling; it started slowly then I do not know what created my addiction (RG1).

Complementarily, AGs report perceptions of being detached from their actions and of entering an altered state:

When you are in front of the slot machine, you are mentally detached, space and time do not exist […] The whole time I was in front of the slot machine I just compulsively pushed the button; I could not go away until the money was gone (RG2).

Cluster 2: Materialistic Thinking

This cluster includes 16.87% of elementary context units and converges on the component of materialism. Materialism has been defined as a personal value that emphasizes the importance of possessing material goods (Richins and Dawson 1992). Indeed, AGs show a concrete style of thinking characterized by the absence of reference to emotional or meta-representational components. The poverty of such representations of reality, together with a focus on money and gambling, strongly influences the definition of identity and personal values. For instance, an AG stated:

I was someone; at that time I already had a car from 1972, a beautiful Taunus of cylinder capacity of 2000, I have always had big cars. Surely, I have never lacked money. (RM1)

Finally, these concrete objects, because of their extreme and exclusive preeminence, appear as fixed ideas. The following participant statements illustrate this issue:

  • My thought went entirely and exclusively, still goes entirely and exclusively, to gambling, to how to find money, or how to find time or how to find the location. (RG2)

  • Even now in my mind, sometimes I have some flash specifically, when I am stressed because of work, financial problems, the idea flashes in my mind as “If I won a lottery”, these types of ideas. (RG17)

Cluster 3: Escape from Social Difficulties

This cluster includes 19.50% of elementary context units. The thematic domain of avoidance emerged from the analysis. First, the narratives of the AGs converged toward stories of difficulties in social and interpersonal domains, related to a high level of anxiety and fear of the future. For example, a participant express this issue in the following way:

Then I never, I never succeed to insert myself in social context, professors, lessons, groups at work. (RG15)

As illustrated in the following statements, gambling activities appear to be escape-based strategies, supporting the subjective association between social difficulties and fear of relapse.

  • In betting, and from this point the addiction began, I believe fundamentally, from something to fill my days, which came from my lack of interest in school so, in the afternoon, instead of studying or doing what I have to do, I go to bet. It began in this way. (DN1)

  • Maybe my brain is used to being programmed to act in a specific way so if a problem comes up to me, consequently I am used to front it, to avoid it, to not think about it, doing other things like drink, gamble. (RG10)

As such, AGs who decide to cease gambling might feel deprived of their prevalent, although dysfunctional, coping strategy and, consequently, newly experience anxiety related to social and interpersonal challenges.

Cluster 4: Awareness

The fourth cluster contains 7.68% of elementary context units. A key for changing, according to AGs, is to shift from the sensation of being overwhelmed by an external force to the awareness of personal difficulties. Hence, this cluster includes aspects related to the process of change and recovery from GD. Recovery is not limited to the interruption of gambling behavior but involves an increased capacity to deal with one’s emotions and a rediscovery of intimate parts of the self, which should lead to a new sense of self-realization. This concept is clearly expressed in the following participant statements:

  • This is surely something that is close to my heart. Regain myself and be myself. (RG9)

  • Now, I made peace with this past. I accepted it and I go on with the awareness of who I was, and who I am. (RG10)

  • To lay oneself bare and especially to discover one’s own fragilities which, which anyway it is not beautiful, the awareness of having them [fragilities], only this gives me the strength, because what I say is, in the end, being under the illusion of being stronger than one is, is useless, in the end one has to confront oneself, the reality. (RM2)

Cluster 5: Closeness

Cluster 5 contains 28.78% of the elementary context units and clearly refers to the role played by intimate relationships in GD. This cluster describes the multiplicity of roles assumed by family, described as a determinant of both the development of and recovery from GD as well as an external regulator of gambling behavior. For instance, participants asserted the following:

  • The reason because, the justification I gave to myself for why I turned back to gambling is the fact that I discovered the infidelity of my wife. (RG1)

  • I have to be honest, maybe if I was not married at the beginning and I did not have children, I think I would have continued to gamble. (SA3)

  • I said to my wife “Stop, I don’t want that my children have to control me. It is not I who is a father, there are the children. It is I who control them, not them who control me.” (SA8)

The picture of AGs emerging from such narratives is of an individual strongly determined by family influences – both negative and positive – and having difficulty assertively expressing his autonomy.

Factors

Correspondence analysis allowed the detection of four factors that together explained 100% of the data variance. The relationship between clusters and factors is indicated by absolute contributions, as reported in Table 2.

Table 2 Relationship between clusters and factors (absolute contributions)
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The first factor explains 44.08% of the data variance and opposes clusters 1 and 4 on the positive pole to cluster 5 on the negative pole. Clusters 1 and 4 are mainly focused on the narrative about GD, in terms of the struggle against the compulsion one feels dependent on and tries to recover from. Instead, cluster 5 addresses the life story narrative, specifically regarding family relationships as a potential resource to tackle GD and fulfil needs for closeness and safety. Whereas the sense of identity is perceived as totally absorbed by addiction as an external and overwhelming force disrupting integration and coherence in self-development, the family-supportive environment is symbolically represented as an external regulator that tends to reinforce a good self-image, thus guaranteeing a sense of constancy. In this sense, both GD and family closeness may suggest functioning characterized by lack of autonomy and identity integration, as well as by passive and dependent feelings and external attributions in exerting control over one’s life.

The second factor explains 29.40% of the data variance and opposes cluster 2 and cluster 3 on the positive and negative poles, respectively. Cluster 2 mainly relates to a materialistic attitude characterized by beliefs in possession-defined success, where winning is the main pursuit and money and gambling are central values for meaningfulness in life. In contrast, cluster 3 refers to the sense of inadequacy in social relationships and the experience of failure and difficulty across educational and job domains, which have progressively led to escape-based strategies. In this sense, gambling may be conceived as a sort of reaction, where the tendency to bet represents a compulsive ritual for goal achievement and handling money is a substitutive way to acquire power and control.

The third factor explains 18.10% of the data variance and opposes cluster 1 and cluster 4 on the positive and negative poles, respectively. Whereas cluster 1 mainly relies on the cycle of GD and the presence of dissociative processes contributing to its maintenance, cluster 4 refers to increasing awareness and acceptance of addiction for recovery and change. On the one hand, compulsion to gamble is perceived as an external force that takes possession of one’s entire identity, leading to feeling like a different person; on the other hand, there is the tendency to preserve oneself from compulsion by searching for self-integration and coherence and recognizing one’s inner psychological states. In this sense, gambling is experienced as a persecutor that one must dominate, thus explaining the presence of dissociative processes, emotional and impulse dysregulation and repeated unsuccessful efforts to control gambling.

The fourth factor explains 8.43% of the data variance and opposes cluster 1 and cluster 2 on the positive and negative poles, respectively. Whereas cluster 1 mainly relies on GD as absorbing and intense compulsion and on subsequent feelings of dependence and personal detachment from one’s actions, cluster 2 almost entirely refers to gambling as a pervasive and fixed idea affecting perception of time and space organization. Overall, this factor seems to suggest the obsessive–compulsive nature of gambling: on the one hand, gambling dominates one’s thoughts and feelings as a persistent idea that takes up more and more of individual’s life; on the other hand, it represents a constant source of concern as unwanted compulsion which is perceived as ego-dystonic because it is inconsistent with self-image.

Discussion

The aim of the present study was to explore the subjective experience of AGs and to identify some of the psychological processes underlying their narratives about addiction and their life story. Five main thematic domains were found: gambling as dissociation, materialistic thinking, escape from social difficulties, awareness and closeness.

Putting our findings into perspective, the issue of dissociation seems to be a relevant concern in psychological research about GD as well as other substance-related behaviors (Penta 2000), even in the Italian context (Imperatori et al. 2017). Specifically, from a general theory of addiction (Jacobs 1988), dissociation is reported as a central process that broadly refers to a lack of normal integration of thoughts, feelings and experiences into the stream of consciousness and memory (Garofalo et al. 2015; Bernstein and Putnam 1986). Indeed, experiences of gambling are often associated with feeling like a different person and losing touch with reality or track of time (McCormick, Delfabbro, and Denson 2012). Ethnographic descriptions of AGs further highlight the dissociative processes underlying GD. For instance, Schüll (2012:196) identified the gambling zone as a “dissociative bubble” in which the gambler is immersed. Furthermore, some authors analyzed the specific experience of time in gambling in an attempt to identify its specific characteristics. For instance, it has been proposed that this dissociative experience may be due to a property of gambling, namely, that it disrupts the traditional chronology of time, turning it into a series of independent events (Benjamin 1939 in Schüll 2012).

In such a state, people feel compelled to do something and are unable to prevent themselves from stopping (Dell 2001), and their behavior is not governed by a process of critical evaluation or systematic decision-making (Jacobs 1988). Additionally, we found that gamblers experience the disorder as an external force controlling their identity, converging with the conclusions drawn by Venuleo and Marinaci (2017) that underlined the role played by the biomedical discourse in the way AGs represent their own disorder. Notably, the perception of the gambling impulse as an external force may undermine gambling refusal self-efficacy. In that sense, psychoeducational interventions as well as campaigns to raise public awareness of GD should stress the role of psychological determinants in the development and maintenance of GD. Such an approach would predispose patients to abandon their passive position towards therapeutic interventions. Additionally, the topic of the perceived loss of personal identity in GD may further be understood through the complementary perspective of Reith (2007). Working within a Foucauldian framework, she asserted that losing self-control in consumeristic behavior (i.e., impulsively spending money) is a central feature of the modern cultural figure of the pathological gambler. The social representation of the pathological “subject” was shaped by the “consumption ethic” of modern societies based on the values of self-controlled and responsible consumption behavior. Furthermore, according to this modern ethic, individuals use consumption behaviors as a means of self-expression that allows the construction of a coherent narrative of the self. This perspective may explain why dysregulated consumption behaviors in GD may induce a sense of loss of personal identity, as reported in the narratives of our participants.

With regard to materialism, other research has supported the presence of a materialistic attitude in gambling addiction behavior, and a focus on financial success can represent a risk factor for GD (Tabri et al. 2017). Moreover, materialism may increase concrete thinking, which in turn undermines self-control (Kim 2013) and triggers beliefs in possession-defined success and acquisition as the pursuit of happiness (Richins and Dawson 1992). Indeed, money can be regarded as a sign of success and an important means by which enjoyment, security and success can be achieved, and the motivation to gamble can arise from the salience given to extrinsic values in life (Oleson 2004). This result may be further put in perspective by the anthropological study of Schüll (2012), which reported that money seems to paradoxically lose its socially defined value in gambling and became a kind of fetishistic terminal gratification. From a clinical point a view, these considerations suggest that a therapeutic approach focused on ways to clarify personal values and eventually to increase the coherence between them and behavior may be useful for GD.

Another relevant theme refers to difficulties in facing certain aspects of life in both the interpersonal and work domains and the potential use of gambling as an escape-based strategy. Consistent with the literature, interpersonal detachment and avoidance of life challenges represent two main issues shaping the subjective experience of gambling (Caputo 2015). In addition, interpersonal sensitivity, distrust of others and low achievement striving are reported as characterizing AGs compared with non-addicted gamblers (Reid et al. 2011). In line with this, most of the AGs interviewed by Schüll (2012) reported the attempt to restore, through gambling, a sense of self-agency, undermined by repeated passive distress experienced in the previous steps of social life. Indeed, a higher risk of GD seems to be predicted by a low level of decisional self-esteem and higher proneness to hypervigilance or panic, which contribute to avoidance-based strategies (Phillips and Ogeil 2011). This issue indicates that working on the implementation of effective emotion regulation strategies, problem solving capacities and interpersonal skills among AGs may be strategic interventions.

The present study also reveals the ego-dystonic nature of addiction resulting from the struggle against compulsion when facing treatment, which requires increasing awareness and acceptance. Interestingly, this topic previously emerged in other qualitative studies (e.g., Reith and Dobbie 2017) in relation to the reduction of gambling activity. Indeed, the gap between the understanding of problems and action based on that understanding can be hard to bridge (Anderson, Dobbie, and Reith 2009). Unwillingness to admit gambling problems has been shown to be a strong obstacle to seeking treatment (Suurvali et al. 2009), and acceptance is considered a primary objective for effective recovery in integrated and third-wave treatments (de Lisle, Dowling, and Allen 2014). Therefore, awareness seems to be not only a trigger for accessing treatment but also the key to the change process over the course of treatment because of the ambivalence experienced by gamblers between their genuine desire to stop and the compelling feeling that they should stop (Anderson, Dobbie, and Reith 2009).

The last theme emerging from gamblers’ narratives is focused on intimate relationships, which are often reported as involved in and negatively affected by problem gambling in terms of both financial, increased responsibility and psychosocial impacts (Dowling et al. 2016). These results further extend previous findings from qualitative studies conducted with Italian (Venuleo et al. 2018) and English AGs (Reith and Dobbie 2017). In particular, the family environment seems to play a role in the regulation of gambling behaviors. Indeed, as confirmed by previous research on AGs, dissatisfaction with family relationships (Ciarrocchi and Hohmann 1989) and a sense of isolation and lack of connection with others emerge (Hopson 1993). This aspect has also been widely identified by Schüll (2012), who conceptualized the gambling zone as a perfect contingent environment perceived as reassuring and comfortable, in contrast with ‘the nebulous and risky calculative matrix of social interaction’ (Schüll 2012:194). Additionally, family relationships may serve as protective factors against problem gambling (Hardoon, Gupta, and Derevensky 2004). Thus, our results support the idea asserted elsewhere that family involvement in treatment may be associated with better prognosis (Kourgiantakis, Saint-Jacques, and Tremblay 2013).

With regard to the detected latent factors, our study suggests the presence of four main psychological processes underlying AGs’ narratives. The first process relies on a lack of autonomy and identity integration and greater proneness to external attribution. Such a result is consistent with previous findings about deficient ego strength (Taber, Russo, Adkins, and McCormick 1986), as well as with the deterioration of self-worth and self-esteem and greater use of primitive defense mechanisms in GD (Fong 2005). A second process refers to a counterphobic attitude, where materialism-based control strategies emerge to defend against the fear of the future and anxiety. Indeed, as highlighted in previous research, given the internal need to prove one’s self-worth by beating the competition (Fong 2005), materialism can indicate that power and success can be achieved (Oleson 2004). Additionally, gamblers tend to hold exaggerated beliefs regarding the importance of winning as a means of overcoming their sense of social and personal inadequacy (Blaszczynski and McConaghy 1989). A further mechanism emerges regarding the ego-dystonic nature of the addiction, perceived as an external persecutor. Interestingly, this aspect has been previously noted in other qualitative studies (Schüll 2012; Reith and Dobbie 2017). In this regard, previous research on GD identified stronger defenses in dealing with conflict through attacking a real or presumed external frustrating object (Sharma, Sharma, and Upadhyay 2013). Specifically, triggering greater hostility to and competitiveness against other gamblers is reported as the easiest way to avoid being a “victim” of gambling (Parke and Griffiths 2005).

The last factor addresses the obsessive–compulsive processes that underlie the gambling experience, as also suggested by the potential presence of comorbidity between gambling addiction and obsessive–compulsive disorders (Tavares and Gentil 2007). Indeed, both of these disorders share some common features, such as repetitive, ritualistic and potentially harmful behaviors, ruminative thinking and impaired control over mental and motor activities (Grant and Potenza 2006).

In sum, some limitations should be acknowledged about the present study. For example, the convenience nature of the sample and the small number of participants do not allow the generalization of the results to the entire male population of AGs following treatment. However, the added value of our study consists in the detection of psychological processes potentially accounting for the GD experience, thus providing an integrative perspective on several central aspects of the disorder that were previously identified in the literature.