Although gambling is often associated with other psychiatric disorders (eg depression), or other addictive disorders (eg alcohol dependence), it has not traditionally been associated with violence. In this chapter, some myths about violence will be challenged, and the relationship between violence and gambling will be examined. Finally, specific suggestions will be provided for dealing with some of these issues in a clinical setting.In recent years, along with the increase in the incidence of gambling, and the amount of money spent by New Zealanders on gambling (Department of Internal Affairs, 2002), there has been a growing correlation of violence with gambling. As legitimate sources of money run out, and problem gamblers continue to have increasing access to gambling opportunities, they may often resort to less desirable means of acquiring funds, which can include using violent methods. For many problem gamblers, their lifestyle results in increased stress levels, which leads to more gambling, which can enhance anxiety and depression and, in some cases, anger, leading to violence in its many forms.

Myths and misconceptions
In the past there was an assumption that gambling was much more likely to involve criminal offending related to theft or fraud only. Although gambling is a behavioural 'addiction', and therefore does not involve the use of a mind-altering, disinhibiting drug such as alcohol, which is positively correlated with violence, there have been a number of violent incidents involving gambling. Abbott, McKenna & Giles (2000) found that 76% of male problem gambling prisoners were also hazardous alcohol drinkers, compared with 61% of non-problem gambling inmates. They also found that individuals with gambling and alcohol problems were likely to be serving sentences for violent offences.

It is often assumed that violence (and gambling) is primarily a male domain, but this is changing. Women are the fastest growing group of problem gamblers, with the number seeking personal counselling having quadrupled since 1997, an increase of 309.7% (Paton-Simpson et al, 2002). They are now nearly equal to males in presentations for help, and more likely to be more negatively affected by their gambling. In 2001, 51.3% of women seeking counselling for problem gambling scored more than 11 on the South Oaks Gambling Screen (SOGS), compared to 42.8% of males (Paton-Simpson et al, 2002). Furthermore, according to Abbott and his colleagues (2000), one in three women in New Zealand prisons are likely to be problem gamblers, compared with one in four incarcerated males. Abbott and McKenna (2000, p 61) found that: "while the female problem gamblers report few instances of violent or other crimes against persons, they were no less likely than their non-problem gambling counterparts to report having ever been convicted for violent crimes". In addition, these researchers found that over half of the female problem gambler inmates were hazardous alcohol users, but were not statistically more so than non-problem gamblers. Overall, these researchers found that problem gambling inmates who misused alcohol were more likely to be Maori, and much more likely to be serving sentences for violence. Therefore, there appears to be a growing correlation of women, gambling, and criminal offending, which may include violence.

Dimensions of violence
Violence related to gambling includes self-harm, such as suicide, which can be a risk factor for both the gambler and their spouse, particularly when the extent of the gambling consequences are revealed (see Chapter 12). It is reported in the DSM-IV (American Psychiatric Association, 1994) that 20% of gamblers, both males and females, may have attempted suicide as a result of their gambling. Some spouses who suddenly realise their savings and assets have disappeared without their knowledge may feel betrayed, angry, depressed, and sometimes hopeless. In extreme situations gamblers who become suicidal on feeling the desperation of their situation, and guilt and remorse over the financial harm their gambling has inflicted on the family, decide their family would be better off dead, or without them. In some cases this has resulted in fatal consequences for family members, as well as for the gambler, who afterwards attempts (often successfully) to take their own life. In New Zealand in recent years there have been several cases of men in desperate financial situations who, after a further bout of gambling and unsuccessful attempts to stop, have murdered their wives, and in one case also killed their two children. Two of these men also tried, unsuccessfully, to take their own lives; all three were found guilty of murder and were imprisoned (Wall, 2000). In the USA "domestic violence murders in at least 11 states have been traced to gambling problems since 1996" (Reno, 2002).

Another dimension of gambling-related violence concerns the need to get money; to continue the gaming process even though the usual financial means are exhausted. This may involve various forms of aggravated robbery, which may or may not involve the use of weapons. On bizarre case described in The Press (Christchurch, New Zealand) involved a man who used a pitchfork to threaten and intimidate a woman to obtain money while "in the grip of a fierce gambling addiction" (Addiction, 2002, pA13). He was jailed for four years. There are numerous other cases which can be found in the media. The driving force behind these acts is problem gambling, while at times there are other aggravating factors such as alcohol or other drugs. In research conducted in a medium security prison, problem gamblers who didn't misuse alcohol were more likely to commit violent offences such as armed robbery than problem gamblers who did misuse alcohol, suggesting that although alcohol may often be an aggravating influence, gambling problems for some may exceed this factor (Sullivan el al, 2002).

Winners of money through gambling can also be victims of gambling-related violence. For example, an elderly woman may be punched and robbed of her winnings in a casino car park. Gamblers can also be the victims of violence in other ways. The need for more money is often paramount, and unscrupulous money-lenders who know this often charge exorbitant interest rates and impose impossible repayment schedules. Although there may be the intention to pay back loans, this often fails to eventuate in the face of continuing losses or re-investment to maximise winnings. The consequences of non-payment can be severe and often involve violence, with some frightened victims fleeing to other cities to escape the wrath of the money-lender or their debt collectors. In the New Zealand Herald: "Detective Koria … said Asian men and women who frequent the Casino are targeted by loan sharks charging exorbitant interest. One man who had to pay $250 a week on a $5000 loan had to flee Auckland after he was beaten for not keeping up payments" (Wall, 2000). Violence can also include threats to safety. In 2002, the New Zealand Herald reported that "two regular gamblers say their lives were threatened because they competed against the Wu family for slot machine jackpots" (Wall, 2002).

Gambling clients and/or their families presenting for treatment and support may reflect any of the above scenarios to some extent. Suicidal thoughts and attempts by gamblers and family members are a relatively common occurrence, and questions relating to suicidal thoughts need to be asked at assessment, for safety reasons. A client may have been the victim of some form of violence from others, and therefore may have some issues regarding trauma, which has affected their health and well-being, to be dealt with. Gamblers who are perpetrators of a violent act, and who may be at some point of contact with the justice system, are likely to be referred for treatment also, and their gambling-related violence needs to be addressed in the context of their lifestyle and total rehabilitation. Domestic violence in the gambling context however, is a scenario that can present either in a problem gambling treatment clinic or in the context of a stopping violence programme.

Domestic violence and gambling
Domestic violence, like problem gambling, is often a 'hidden' problem, because of the shame, sigma and guilt that accompanies it. There is no easy way to 'make it OK' for people, because it is not acceptable behaviour in any context, although there will have been many attempts to rationalise it internally. However, instilling trust is the first step in eliciting disclosure, and the therapist's advantage is that the client has come to the counsellor for help with behaviour that has become dysfunctional and 'out of control'. In the process of engagement, the client will be aware from the therapist's questions and responses of any apparent judgements and/or disapproval, and will gauge whether they can safely let down their guard. There is an important distinction between hearing the client's story without bias and judgment (while supporting appropriate attitudinal change and responsibility taking), and colluding. Some clients will clearly not be ready for disclosure; it is not what they came in about, and they have no intentions of disclosing violence, as it's not the 'real problem'. However, they may recognise and acknowledge the role of gambling in the cycle of violence, or vice-versa, once it is out in the open. Questioning too soon may bring out defensiveness in the client, and they may not return to deal with the gambling issues if this occurs. It is therefore important to take things slowly, and to build up trust and confidence in the counselling relationship before challenging, unless the client alludes to it first.

If domestic violence is disclosed or identified in a problem gambling treatment agency, and the perpetrator client is willing to accept referral to a stopping violence-type programme, it will undoubtedly have a positive effect on both the relationship and the gambling behaviour. Anti-violence programmes may be overstretched however, and counsellors may not consider they have the expertise to incorporate the gambling issues into their programme, particularly in group situations. Therefore, working in partnership with the programme can be helpful, and mutual consultancy can be a learning experience for clinicians, as well as optimising the outcome for the client. Unfortunately, some clients may be reluctant to go to yet another service, or may be reluctant to self-identify with a 'violent' client group, especially if they see themselves as, for example, 'only verbally abusive'. However, with consideration of the safety issues involved, particularly with physically violent clients, referral is to be recommended and encouraged, with consultative support offered by both agencies.

Verbal and emotional abuse
One of the tools utilised in stopping violence programmes is the Power and Control Wheel developed by the Domestic Abuse Intervention Project, Duluth, Minnesota. There are a number of 'spokes' to the wheel, representing types of abuse, including intimidation, encircled by 'male privilege' on the outside and 'physical violence' as the rim.

In the 'economic abuse' section of the wheel, items mentioned include: making the woman ask for money, giving her an allowance, taking her money, and not letting her know about or have access to family income. In the case of a female partner who has a gambling problem, one could see where the boundaries between imposed 'money control' to assist in reducing problem gambling spending and abusive/controlling behaviours (which may appear legitimate on the surface) could become blurred. Trust issues around money control could be an issue for both parties, and more historical information regarding the origins and context of this behaviour would be necessary. For some women, it is possible that gambling may offer hope for 'escape' from an oppressive domestic regime.

In the 'emotional abuse' section of the wheel, items include: putting the woman down, attempting to make her feel bad about herself, calling her names, playing mind games and attempting to humiliate her. If the female partner had a gambling problem, it would be easy to imagine the kind of negative criticism which could be levelled at her, and then perhaps guilt and remorse would add to her sense of shame and contribute to lower self-esteem. These feelings could then be manipulated by a partner who wished to use power and control strategies.

Physical violence
With regard to physical violence, two aspects immediately come to mind from personal clinical experiences. The first case occurred at a gambling treatment agency. The male client was a problem gambler who had, on a few occasions early in the relationship, been physically violent to his wife. In later years, after the gambling became more frequent, he found that intimidation (ie angry looks and threats) was sufficient to enable him to leave the home to gamble and to return late without any questions from his wife, even if she suspected he had been gambling.

The second example is from a stopping violence programme perspective. This client was well motivated to address his issues around physical violence, but acknowledged that his partner had a gambling problem that had not responded to treatment. In spite of attending with her as a family member on a few occasions, he admitted he did not understand that problem, and felt powerless to deal with her uncontrolled spending of his money. His response was to lapse into further physical violence as a 'punishment', and at times he felt justified in doing so. In this case, his response to his partner's gambling formed part of his 'cycle of violence' and strategies to deal with this were part of his treatment plan.

Treatment approaches
'Motivational interviewing' skills can be utilised strategically to bring the client to their own belief of the need to be completely honest, in order to deal fully with the inter-connected violence and gambling. Dishonesty, apportioning blame to others, manipulation, and denial of the impact on others can be common to both behaviours, as is isolation. Therefore, 'motivationally' acknowledging with clients the difficulties in keeping up the illusion of coping and 'leading a double life', can give them 'permission to be real' with their therapist and may offer some relief from the stress of secrecy. More widespread disclosure may take additional time and confidence building.

If violence is disclosed
Initially, it will be useful to unravel 'the pattern' of gambling and violence, which will improve the client's understanding of the inter-connectedness of their behaviour. It has been suggested that three phases are involved in domestic violence: (1) the explosive phase; (2) the honeymoon phase; and (3) the tension-building phase (LaPlante, 2002). (See Figure 13.1 for a diagram illustrating this three-phase cycle.) This cycle can be useful for working with a violent client. If that person is also a problem gambler, it may be helpful to check out additional factors in reference to the tension building phase (eg the relevance of negative events, financial and other stresses, negative self-image, anxiety and depressed mood). If further gambling is a preferred 'solution' to problems, this may add to other stressors, which may further increase tension and irritability. If tactics of blame and avoidance of responsibility are also used in relation to gambling, this can create further relationship problems, leading to further isolation and desperation. Inevitably, as tension builds, it may only take a small trigger or an unexpected negative event to culminate in an explosion of violence. This, together with the guilt from consequences of further gambling behaviour, may increase suicidal ideation or risk, and therefore safety issues for all concerned are paramount.

In some cases, however, the shock and remorse may also trigger promises of reform and determination for change, which may lead to an intent to cease gambling, as well as violent behaviour, and may also be a catalyst for treatment inquiries. If issues are not addressed, it is likely that the consequences and feelings that follow abuse will form the beginning of the next round of tension building, and the cycle will continue. For those who are problem gamblers, it is possible that the subsequent increased tension may also lead to further gambling.

The 'wheel of change' model (DiClemente & Prochaska, 1998) is helpful for identifying readiness to change. It combines well with motivational interviewing techniques, used to elicit, enhance and maintain impetus for change. There will often be a 'window of opportunity' when a client is vulnerable, typically because of guilt and remorse. Awareness of this opportunity, coupled with a supportive attitude and a number of options that give the client some power and apparent choice, may create an effective therapeutic alliance, which can lead to treatment success.

There are a number of aspects common to both gambling and violence in terms of treatment approaches. These include: acceptance of the behaviour as problematic in itself and the impact it has on functioning and relationships (therefore the need to take responsibility); 'loss of control' and the need for safety strategies; cognitive distortions in thinking processes; and the need to be honest and open for support, and to prevent relapse. The clinician needs to challenge behaviour based on suspicions or assumptions, to assist the client to avoid lies and mistrust, and to develop honest relationships. In addition, there are a number of relevant and appropriate cognitive-behavioural techniques that may enable the client to make lifestyle changes. For example, it may be useful for the client to create a chart of stressful activities or events, and to identify their feelings and responses, which will increase their self-knowledge. The client can then identify some alternative relaxing diversion to avoid stress build-up and aggressive behaviour.

The 'time out' strategy is used in stopping violence programmes as a safety mechanism to avoid violence when the client's anger is escalating rapidly. This needs to be mutually negotiated between the perpetrator and all persons who are likely to be at risk. Information about the procedure and the purpose of the technique (for the perpetrator to take responsibility and ensure safety) should be provided to significant others before use. If potentially violent individuals remove themselves from the situation, they avoid being further 'wound up', and they can't be abusive to their partner or family members. However, if clinicians are going to suggest this technique, they need to ensure that their client knows this is not an abusive tactic to avoid listening. Instead it is a 'responsibility-taking' strategy to keep others safe. Also, it is important to tell clients not to drive cars when angry, since this is potentially dangerous. They also need to avoid alcohol and other drugs, which usually increase anger and reduce inhibitions rather than increasing responsibility. It is also unhelpful to go gambling while 'cooling off', as this allows people to avoid processing of the event (potentially developing new insights), and can create further negative consequences. It is useful for the client to have a plan of where they will go and what they will do while 'cooling off', before returning to the situation. The plan should include an agreement with former or potential recipients of violence that:

1. They will use 'time out' and take responsibility for enacting the strategy when they become angry.
2. They will work out with family members what they will say to the other person when beginning a 'time out'.
3. It is often helpful to exercise while on a time out (ie go for a walk, for a run), since this will work off the excess adrenalin.
4. They should plan to stay away about an hour (or as long as it takes) to contemplate different perspectives, and to avoid 'picking up where they left off'. They client should then return to the other person to discuss their experience, as a relationship building process, and to avoid future conflict.

Family members and violence
There are two common scenarios involving gambling and violence that relate to spouses and other family members. The first concerns women who gamble and then receive 'punishment' because they overspent, stayed out too long, or 'neglected' family members or duties. The abuser may feel their response is 'justified' under the circumstances, and this violence may form part of the gambling patter for the victim (ie they may use gambling to deal with the feelings engendered by the abuse). For some victims of violence ongoing abuse may be used as justification to continue gambling (ie to have control and 'hope' in at least one area of their lives). Most stopping violence programmes have a 'partner programme', or in some cases offer individual counselling for women in violent situations. These services can also offer assistance to problem gambling clinicians dealing with violent clients. If the perpetrator is not on a stopping violence programme, their partners can be encouraged to contact stopping violence programme, their partners can be encouraged to contact stopping violence services, or Women's Refuse, for further support.

The other typical scenario concerns family members who may inflict violence on the gambler after monetary losses are revealed. This is clearly described in an on-line resource.

"The family members of pathological gamblers commonly experience anger or rage when the depths of their financial losses due to gambling are disclosed during treatment. They exhibit tremendous hostility, almost a vengeful indignation … The family members of alcoholics may have reason to fear violence from their alcoholic, but the family members of a pathological gambler seem to be more likely to perpetrate the violent acts." (Gambling Problems Resource Centre, n.d.)

The most helpful approach in this case may be to involve the family members in treatment. This means that the therapist works with the gambler and their family to manage family responses to their situation, and to assist them with financial restructuring and budgeting options, or other support. The clinician will also be structuring the treatment and safety strategies to work toward further openness and accountability among family members.

Conclusion
The issue of violence has not been historically linked with gambling, but it appears to be a growing and extremely important factor for gambling clinicians to consider. The fact that the presented case studies involved both secrecy and isolation is probably an important reason for a past lack of awareness on the part of therapists. This is an era of expansion in regard to the provision of gambling opportunities of increasing varieties and with the advent of newer technology, there is growing addictive potential. This will inevitably add to the current trend of escalating presentations of clients affected by problem gambling, often with co-existing mental health conditions or other problems, which may include abusive behaviour in a variety of forms. It is therefore important for helpers and clinicians to increase their awareness of the connections between gambling and violence, and to be prepared to refer clients to other services, or to work in partnership with other agencies. When this approach is not viable, any intervention that can be made in the context of a therapeutic engagement will be helpful for promoting safety and support for the client for their partner. Working with both issues simultaneously is essential for best practice, and will be more likely to result in optimum treatment outcomes for both gambling clients and their family members.

Figure 13.1. The Cycle of Violence