Brief intervention based on Naikan therapy for a severe pathological gambler with a family history of addiction: emphasis on guilt and forgiveness

The prevalence of pathological gambling (PG) varies between 0.2 and 5.3% according to the parameters used for its definition, and the availability and accessibility of gambling activities (Wardle 2007). In Japan, availability and accessibility of gambling is high, which renders it a common activity. The major types of gambling which cause problems for Japanese are Pachinko and slot machines. The prevalence of pathological gambling (defined by a score of ≥5 on the South Oaks Gambling Screen; SOGS) (Lesieur and Blume 1987) is estimated at 5.5% across all adults (Higuchi 2008). Usually, gambling disorders are characterized by a progressive maladaptive pattern of gambling resulting in psychological and social problems (American Psychiatric Association 2013).

In Japan the most harmful result is suicidal attempt. However, approximately half of all such gamblers appear to recover of their own volition (Slutske 2006); others continue to worsen progressively in their behavior. In the DSM-5, the former are called episodic gamblers, and the latter are chronic gamblers (American Psychiatric Association 2013).

Generally, suicide attempts and bankruptcy represent the most severe consequences of, and most important indicators of, the more extreme variants of PG (Grantet al. Grant et al. 2010; Petry and Kiluk 2002). Evidence suggests that suicidal gamblers begin gambling at an earlier age, accrue larger debts, are more likely to experience marital difficulties, and have family histories of addiction. On the other hand, gamblers who file for bankruptcy are likely to be unmarried, diagnosed with depressive and substance abuse disorders, and have an early onset of problem gambling in addition to a first-degree relative or family member with gambling problems. I similarly reported that the most significant independent predictor of suicide attempts and bankruptcy was a family history of addiction (Komoto 2014). I consider a family history of addiction to be a reliable predictor of early onset gambling, marital problems, and psychiatric complications. Therefore attending to negative feelings resulting from addiction-accented family dynamics should take precedence over specialized treatment for pathological gambling.

Naikan therapy is an insight-oriented psychotherapy originating from Japan (Maeshiro 2009). In Naikan therapy, a specialist, who has also experienced Naikan, assists patients by looking back at their life histories and uncovering their true purpose, by giving as much consideration as possible to every aspect of their current lives. In the Naikan approach, and in contrast to free association, there are three fundamental questions (“Three Naikan Themes”) that patients should consider: “What have others done for you?” “What have you done for others in return?” and “What troubles have you caused to others?” Patients are invited to consider their own behaviors toward a target person, such as their mother, in accordance with the three themes and in a chronological manner. This technique has been shown to ameliorate negative cognitions and inferiority complexes through asking the patient to recall an instance of parental (or caregiver) love (Komoto 2013; Nagayama 2013). This amelioration is brought by two factors of the Naikanistic philosophy: (1) human beings are fundamentally selfish and guilty, (2) yet at the same time they are rendered incommensurate benevolence from others. If put in psychoanalytical terms, this would mean the practitioner simultaneously realize his guilty self and his beloved (namely forgiven) self (Chervenkova 2014) (Figure 1). If conflicts pertaining to parents impede recovery from a gambling disorder, then we first treat these conflicts via interviews based on Naikan therapy principles (Naikan interview). Naikan therapy is intensive, usually requiring hospitalization for 1 week. In contrast, the Naikan interview, which is applied to outpatients, consists of only a few sessions (intervention and follow-up).

In the present study, I present a progressive case of pathological gambling in a woman whose father was a violent alcoholic. Excessive feelings of guilt towards her mother, and resentment of her father, rendered the patient’s gambling behavior progressively more severe. Therefore I treated her not only via a brief cognitive-behavioral therapy (CBT) intervention, which focused on abstinence, but also with Naikan therapy, which focuses specifically on the relief of guilt. This relief motivated her to participate in subsequent CBT sessions and to achieve abstinence. Following treatment, feelings of guilt and resentment decreased, and the patient has been able to remain abstinent for approximately 1 year.

Throughout these three sessions, patients are provided with tools and skills to facilitate their abstinence from gambling.

Ms. A was a 66-year-old Japanese woman who had settled in a large city in the east of Japan. Her father was a violent alcoholic; her mother worked hard because her father did not work regularly. Her father died when Ms. A was in her twenties. She married at 25 years old, and had one daughter and one son. Following her divorce at age 37, she began working as a transportation driver. Since the age of 62, she has been on welfare because of her being bankrupt.

Ms. A started gambling on Pachinko games at age 37, ostensibly for a change of pace, and occasionally bet small amounts of money. During her 40s, she gambled every weekend, but she did not lose a control. At age 53, her mother died in a rest home for older persons. The cause of death was pneumonia, which presented subsequent to a falling incident and resultant thighbone fracture. Although this death was an accident, Ms. A nonetheless felt deep guilt, thinking, “My mother might not have died if she had been living with me.” Subsequent to her mother’s death, Ms. A began to engage in gambling behavior during her free time, every day, except during working hours, in an attempt to relieve these guilty feelings, or, as she herself puts it, “to forget it all.”

In her late 50s, Ms. A began to borrow money from her relatives and friends to compensate for her gambling losses. She often lied to her daughter about her gambling and debts, and arguments between her and her daughter were frequent occurrences. She occasionally frightened her daughter and relatives into giving her money by threatening to commit suicide. Gradually she began to be absent from work because of her gambling, until she was finally dismissed, thereby necessitating that she receive welfare, owing to bankruptcy, at the age of 62.

In spite of these harmful consequences, Ms. A could not prevent herself from gambling. She attended GA meetings several times, but derived no comfort from the GA group, where her feelings of guilt and shame continued to increase. At the age of 66, her daughter ordered her to visit a psychiatric hospital because of her repeated self-harming behavior. Her daughter hoped that she quitted gambling. Eventually, she visited our hospital after an unsuccessful suicide attempt. She remained abstinent for 2 months prior to her first hospital visit.

Ms. A exhibited a depressed countenance, and stated, “I really want to stop gambling, but irritability and guilt over my mother rise up and I fall into repeated gambling. I am so ashamed”. Ms. A conveyed the impression that her overwhelming desire to gamble gave her pain. However, we found that she had feelings of resentment toward her father, as evidenced by her statement, “My father frightened my mother with his violence and alcoholism”. Ms. A also spoke uncomfortably also about her daughter, saying, “I have brought up her through many troubles. Nevertheless she speaks unkindly about my gambling, and says that it is shameful”.

Ms. A exhibited persistent and recurrent maladaptive gambling behavior, which could not be accounted for by a manic episode. She satisfied DSM-5 criteria (8/9) for gambling disorder (American Psychiatric Association 2013), which are as follows: (1) increased preoccupation with gambling; (2) unsuccessful efforts to stop gambling; (3) restlessness and irritability when trying to stop gambling; (4) after losing money gambling, returning another day in order to get even (“chasing” her losses); (5) hiding the extent of her gambling from her family; (6) feeling she was jeopardizing her relationship with her daughter as a result of her gambling; (7) gambling as a way to relieve a dysphoric mood; and (8) relying on others to provide money to relieve her financial situation.

Although she did not satisfy one of the foregoing criteria, “Increasing amounts of money to achieve excitement,” Ms. A was nonetheless classifiable as severe and persistent. Her SOGS score was 14 (Kido and Shimazaki 2007). And her score of The Gambling Symptom Assessment Scale (G-SAS) was 31 (48) (Kim et al. 2009). In addition, her negative feelings towards her parents had been governing her own behavior and exerting an influence on the extent of her gambling. Ms. A reported experiencing several depressive symptoms over the past few weeks, including dysphoria, or little pleasure in doing things, guilt, and increased irritability. However, she did not meet the diagnostic threshold for any other psychiatric disorder, including depression.

A Naikan interview was performed initially in an attempt to resolve Ms. A’s excessive feelings of guilt and resentment. The process was conducted across three sessions (one per week), and consisted of one intervention and two follow-up sessions (Figure 2).

Initially, Ms. A repeatedly apologized to her mother, for allowing her to stay in a rest home, thereby, in Ms. A’s estimation, facilitating her death. At the same time, however, Ms. A desperately sought to justify why she could not care for her mother, saying, “I was too busy to care for her because I was working and raising my children.”

During the intervention session, the therapist asked Ms. A to recall other facts according to the three Naikan themes, with special emphasis on “What has your mother done for you?” Ms A. recalled several facts, such as “My mother worked for the benefit of her children until late at night. Nevertheless, I became delinquent in my teens and left home for 10 years, and made her sorrowful.” Ms. A felt that her conduct was more sinful than the conduct of her father. These recalled facts strengthened her feelings of guilt toward her mother, and weakened her resentment toward her father. Ms. A realized that she had used her guilt and resentment toward her parents as a justification for her own gambling. In addition, she stated, “My daughter believed me when I said that I’d quit gambling. Similarly, my mother also believed my explanation of her staying in a rest home.” Ms. A then stated, and with regard to her having taken advantage of the faith of her mother and daughter, “I’m really the lowest person of all.”

During these painful admissions of guilt, Ms. A suffered from panic attacks with hyperventilation, which had occasionally appeared over the past few years. After the panic attack naturally subsided, Ms. A was able to recall some previously forgotten facts; namely, that “Mother tenderly thanked me for staying in a rest home.” Ms. A had, therefore, already been forgiven by her mother. After she recalled this fact, and felt its reality, she could also accept the many troubles that she had caused to her mother, and that had been denied. Ms. A recalled that she sometimes wished for her mother’s death. This discovery evoked excessive guilt toward her mother and her father. Ms. A understood with quiet sorrow that keeping this guilt was nonsensical in the face of her own sinful acts and forgiveness by her mother. Ms. A was convinced that she had been loved by her mother.

At the end of this initial Naikan interview, Ms. A’s guilt and resentment decreased. During the next two Naikan interviews, this reduction in negative feelings continued and she began to appear more at ease. Her G-SAS score had dropped to half (31 to 14). Ms. A subsequently attended three sessions of CBT outpatients program for gambling disorder to judge her gambling behavior rationally. Following these two interventions (Naikan interview and the CBT program), she has continued to visit our hospital every month, and has remained abstinent for an entire year. Additionally she has been medicated with some hypnotics and minor tranquilizers during 1 year. She has experienced strong cravings for gambling on only one occasion, in which she quarreled with her daughter about her past debts. Ms. A recently stated, “I tried to live my mother’s life. But now I will live my own life.”

To the best of my knowledge, this represents the first case report examining the efficacy of an interview intervention based on Naikan therapy for treating pathological gamblers. At present, the most widely reported and approved treatment for PG is CBT. Nevertheless, some cases have a poor prognosis in spite of CBT treatment (Gooding and Tarrier 2009; Hodgins et al. 2011; Leung and Cottler 2009). If craving for gambling are associated with strong emotions, then it may be difficult to correct deviant cognitions pertaining to gambling through CBT alone. In CBT, cognitive correction is achieved by examining experiences related only to gambling, slowly and systematically, while also skillfully avoiding evocation of strong emotions, such as guilt. Therefore, we conducted the Naikan interview before the CBT program in order to first alleviate any feelings of guilt, which represent a core factor in the present case. Naikan therapy is not only assist in addressing maladaptive cognition pertaining to guilt (concerning the patient’s mother in the present context), but can also increase self-esteem. By presenting this case, I suggest that the most important treatment strategy for progressive pathological gamblers is not being in a state of abstinence, but rather in a state of forgiveness. Additionally Japanese cultural climate, which is congenial to the emotional relationship among familial members, may facilitate this Naikanistic recovery process.

I will next explain the mechanisms underlying the decreases in guilt in response to a Naikan interview. Naikan therapy involves a paradoxical component, where any sense of guilt may be deepened, albeit within a protective framework, by forcing patients to recall many of their past, deleterious behaviors that have not yet been compensated for. Recovery necessitates that the patient is cognizant of the impossibility of compensating for all of their past transgressions through their future, redemptive behavior. In other words, when redemptive behavior is devalued, so too is guilt strengthened. In the midst of this feeling of despair, one fact, pertaining to that which others have done for the patient, resonates clearly as a symbol that the patient has indeed already been forgiven. Consequently, guilt as pain turns into guilt as a feeling of remorse, which is indicative of a calm mind without desire for immediate forgiveness. It is important that this forgiveness is not conferred by an actual person, such as the client themself, living family members, or the therapist, but rather by an essentially invisible, purified being (for example an idealized mother, higher power, etc.), because forgiveness is apt to degenerate into defensiveness or dependence when a real person grants actual forgiveness (Squires et al. 2012). By creating a space in which this purified being can exist, we must be attentive to our own excessive desire for a successful treatment outcome, and strive to remain therapeutically ascetic; essentially, the above-delineated principles of the Naikan interview must be adhered to (Figure 2).

A family member with an addiction disorder is apt to engender maladaptive emotional coping skills in other family members (Bijttebier and Goethals 2006). A limited ability to seek help represents a coping strategy associated with shame, and which usually coincides with guilt and resentment towards the original family members (Yi and Kanetkar 2011). This strategy often facilitates the development of PG and results in suicide attempts and/or bankruptcy. Therefore, psychotherapeutic strategies aimed at pathological gamblers with a family history of addiction should carefully address feelings of guilt, where such feelings principally consist of low self-esteem and shame. Although Naikan Therapy originated from Japanese culture-specific Buddhist approach (Ozawa-de-Silva 2006; Murase and Johnson 1974; Tanaka-Matsumi 1979) and best understood in the context of Japanese society where human relations are defined in terms of mutual obligations, the current case study has implications to the application of Naikan Therapy across different cultural contexts for treating problem gamblers who have strong sense of guilt and resentment with family members.

We have presented the case of a female pathological gambler, whose father was an alcoholic, and illustrated the role of guilt in both PG severity and treatment. Through a Naikan interview, feelings of guilt were weakened and feeling of forgiveness were strengthened. Subsequently the client was motivated to attend CBT sessions. For severe pathological gamblers with a family history of addiction, issues of guilt and/or resentment should first be addressed and treated; the problem of gambling itself should not represent the initial primary focus.