The stigma of problem gambling: Public prejudice, private pain and implications for public health

Centre for Gambling Education & Research

The stigma of problem gambling: Public prejudice, private pain and implications for public health

Professor Nerilee HingThis study was funded by the Victorian Responsible Gambling Foundation

International Gambling Conference 10-12 February 2016, Auckland

1


Background

Recreational gambling is a popular, socially accepted and normalised activity.

But problem gambling appears to be highly stigmatised.

People experiencing PG report that stigma deters or delays:

• problem acknowledgement• disclosure to others• help-seeking• treatment adherence

But, very little previous research into PG and stigma.

2


What is stigma?

A social process which occurs when individuals are devalued or discredited in a particular social context because of a perceived negative attribute which disqualifies them from full social acceptance.

(Goffman, 1963; Crocker, Major, & Steele, 1998) • Reaction of others (labelling, stereotyping, judgment, prejudice)• To an undesirable attribute (e.g., race, obesity, addiction, disability)• Context specific (varies by culture, gender, time period, etc)• Spoiled identity (from a “normal” to “tainted” identify)• Become “them” rather than “us”

3


Types of stigmaPublic stigma: the reaction of society to those with a stigmatising condition and the formation of negative attitudes towards the stigmatised population (Corrigan 2004). Problem gamblers are stupid and irresponsible.

Perceived stigma: the belief that others have passed judgment and/or hold stigmatising thoughts and ideas about a stigmatising condition (Barney et al. 2006).Most people believe that problem gamblers are stupid and irresponsible.

Self-stigma: when individuals with a stigmatised condition internalise and apply negative societal conceptions to themselves, resulting in diminished self-esteem, self-efficacy and perceived social worth (Corrigan 2004). Can occur whether stigma is directly experienced or perceived.I am stupid and irresponsible because I am a problem gambler.

4


Overall project aimTo examine the characteristics, causes, and consequences of PG stigma to:

• deepen understanding of how and why problem gambling is stigmatised, and

• how this stigmatisation impacts on people with gambling problems.

5


Research approach1. Literature review

2. Victorian adult survey (N = 2,000)

3. Survey of people with gambling problems (N = 203)

4. In-depth interviews with 44 people with problem gambling

5. In-depth interviews with 9 gambling counsellors

6


Stage 1: Literature review• Not much!

• All previous studies based on student samples (Dhillon et al., 2011; Feldman & Crandall 2007; Horch & Hodgins 2008, 2013) – except Horch & Hodgin 2015 on self-stigma.

• Except a qualitative study (Carroll et al., 2014).

• We drew on literature, research designs and measures for mental health stigma.

7


Stage 2: Victorian adult survey

8


FocusThe public stigma of PG in the Victorian adult community:

• Perceived dimensions of PG that might affect its public stigmatisation

• Process of stigma creation for PG

• Relative intensity of public stigma associated with PG

• How public stigma stigma associated with PG varies amongst different groups

• But first, some theory…

9


Dimensions of a condition that affect public stigma (Jones et al. 1984)

Origin• Attribution theory (Weiner 1986)• Perceived origin determines emotional responses, attitudes and behaviours.• External attributions (e.g., genetics, accident) pity, helping.• Internal attributions (e.g., poor choices, lack of self-control) anger, punishing.• Explains why mental illness, esp. addictions, are most stigmatised.

Peril (to others)• Danger appraisal hypothesis (Corrigan et al. 2003)• Perilous conditions fear and avoidance response (e.g. schizophrenia).

Noticeability: more noticeable more stigmatisedCourse: more recoverable/reversible less stigmatisedDisruptiveness: more disruptive to self more stigmatised

10


The process of stigma creation (Link et al. 2004)

Labelling

Stereotyping

Separating

Emotional reactions

Status loss & discrimination

• E.g. “mental illness”, “problem gambler” emphasises difference, defines person by their condition, triggers stereotypes.

• Apply beliefs about a particular social group to someone perceived to be a member of that group.

• Stigmatised social groups categorised as “them”, resulting in social distancing from (the more powerful) “us”.

• Pity/helping when external cause. Irritation/anger when internal cause. Fear/apprehension when perceived as perilous.

• Stigma provides rationale for powerful actors to devalue (attitudes) and discriminate (behaviours) e.g. interpersonal, employment, housing, etc.

11


MethodsSample:

• 2,000 adult residents of Victoria• Recruited thru online panel provider• Representative age, gender & location quotas• Weighted to 2011 Census

Measures:• based on responses to vignettes of PG• and vignettes of other health conditions• perceived dimensions of PG• the process of stigma creation• individual difference variables – demographics, gambling

involvement, PGSI, level of contact with PG

12


Vignettes

Conditions:1. Problem gambling2. Alcohol use disorder3. Schizophrenia

Controls:4. Sub-clinical distress5. Recreational gambling

13

Whole sample saw vignettes 1 and 4, and

were randomly allocated to 2, 3 or 5.

Order of vignettes randomised.


Example of vignetteProblem gamblingDan is a man who lives in your community. During the last 12 months, he has started to gamble more than his usual amount of money. He has even noticed that he needs to gamble much more than he used to in order to get the same feeling of excitement. Several times, he has tried to cut down, or stop gambling, but he can't. Each time he has tried to cut down, he became agitated and couldn't sleep, so he gambled again. He is often preoccupied by thoughts of gambling and gambles more to try to recover his losses. Dan has also lied to his family and friends about the extent of his gambling.

14


Perceived dimensions of PG expected to affect its public

stigmatisation

15


Perceived origin of PG16

God’s will

His bad character

A genetic or inherited problem

A chemical imbalance in his brain

The way he was raised

Stressful circumstances in his life

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

0.5

1.5

1.6

1.9

1.9

2.7

0 = extremelyunlikely

How likely do you think it is that Dan’s situation is caused by …

4 = extremely likely

Main perceived origin for:• Recreational gambling: The way he was raised • Alcohol use disorder: Stressful circumstances in his life • Sub-clinical distress: Stressful circumstances in his life• Schizophrenia: A chemical imbalance in the brain


Other dimensions

Proble

m gamblin

g

Sub-cl

inical g

ambli

ng

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phre

nia0

2

4 Noticeable

Problem gam

bling

Sub-cl

inica

l gam

bling

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phre

nia0

2

4Course (recoverability)

Problem gam

bling

Sub-cl

inica

l gam

bling

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phre

nia0

2

4 Disruptiveness

Green bars sig lower than PGRed bars sig higher than PGBlue bars not sig diff to PG

Problem gam

bling

Sub-cl

inica

l gam

bling

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phre

nia0

2

4 Peril to others

Problem gambling was perceived as highly disruptive to self, moderately noticeable and recoverable, but not

particularly perilous to others.

17


Conceptualisations of PG

18

A men

tal he

alth d

isorde

r

A phys

ical h

ealth

diso

rder

An add

iction

A dise

ase o

r illne

ss

A diag

nosa

ble co

nditio

n0.0

20.040.060.080.0

100.0

28.1

66.4

1.0

37.1

14.8

37.5

28.5

3.4

35.5 33.634.4

5.1

95.6

27.4

51.6

No Unsure Yes

% o

f res

pond

ents


The process of stigma creation

19

“It’s not the social stigma.

It’s the mercury.”


After labelling comes stereotyping …

Dan tended to be stereotyped as:

impulsiveirresponsible

greedyirrational

anti-socialuntrustworthyunproductive

foolish

20


Separating: PG

21

Have Dan marry into your family

Start working closely with Dan on a project

Move next door to Dan

Have a group household in your neighbourhood for people in Dan’s situation

Make friends with Dan

Spend an evening socialising with Dan

0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

1.0

1.8

1.9

2.1

2.1

2.2

If you were aware of Dan’s situation, how willing would you be to …

0 = definitelyunwilling

Committed or enduring

relationships not OK

Incidental relationships

OK

4 = definitely willing


Emotional reactions: PG

22

Pity Anger Fear0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

2.5

1.7 1.7

9-item scale to measure emotional reactions to the vignette character if they met him in real life

Sorry for, sympathy,

need to help Annoyed, angry,

disgusted

Scared, uncomfortable, apprehensive

4 = strongly agree

0 = strongly disagree


Status loss & discrimination: PG

23

% agree/strongly agree that “most people would …

Think less of Dan if he needed professional help

Take Dan's opinions less seriously

Think less of people in Dan's situation

Pass over Dan in favour of another applicant

Most women would be reluctant to date Dan

Hire Dan to take care of their children

Believe that Dan is just as trustworthy as the average citizen

Accept Dan as a teacher of young children in a public school

Willingly accept Dan as a close friend

Hire Dan if he was qualified for the job

Treat Dan just as they would treat anyone

Believe that Dan is just as intelligent as the average person

0 10 20 30 40 50 60 70

19.4

35.9

39.7

59.3

66.3

9.2

11.6

14.3

20.8

25.5

30.9

42.3


Relative intensity of public stigma associated with PG

24


Separating: all conditions25

Problem

gambli

ng

Sub-cl

inica

l gam

bling

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phren

ia0

1

2

3

4

5

Lower scores = more social distance desired

Green bars sig lower than PGRed bars sig higher than PGBlue bars not sig diff to PG

When measured on social distance, PG was:• more stigmatised than recreational gambling and sub-clinical distress• slightly less stigmatised than alcohol use disorder and schizophrenia.


Status loss & discrimination: all conditions

26

Problem

gambli

ng

Sub-cl

inica

l gam

bling

Sub-cl

inica

l dist

ress

Alcoho

lism

Schizo

phren

ia0

2

4

Higher scores = higher expected status loss and discrimination

When measured on expected status loss & discrimination, PG was:• more stigmatised than recreational gambling and sub-clinical distress• slightly less stigmatised than alcohol use disorder and schizophrenia.


Who stigmatises problem gamblers? Implications for stigma

reduction

27


Greater social distance desired by those who …• Believe problem gamblers are perilous to others • PG is a noticeable condition• People cannot recover from PG• PG is disruptive • PG is due to bad character or poor upbringing • Have negative stereotypical views of PG• Believe they would lose social status or be discriminated against• Feel more anger and/or fear, and less pity• Do not speak English at home• Are more conservative in political orientation• With less gambling involvement themselves• Less contact with PG

Implications for stigma reduction:• Messages and target groups• Community contact with PG

28


Stage 3: Survey of people with gambling problems

Experiences of and responses to public stigma amongst those with gambling problems

29


MethodsSample:

• 203 respondents• PG in previous 3 years• 18 yrs+• Living in Australia• 66.5% male, mean age = 40.9• 87.2% PGSI 8+ in previous 12 mths• Mean PGSI score = 15.3.

Recruitment: • 117 previous CGER research participants• 86 Google advertising

30


Measures• Demographics• Perceived public stigma associated with PG• Self-stigma• Experiences of devaluation & discrimination because of PG• Coping and disclosure• Impacts on help-seeking, before & after relapse• Psychological measures:

• PGSI• self-esteem• psychological distress• self-consciousness• social anxiety

31


Perceived stigma – how did our gambler respondents perceive the public stigma associated with PG?

32


Perceived relative stigma of PG

33

Drug ad

diction

Problem gam

bling

Alcoholism

Obesity

Bankru

ptcy

Depres

sion

Schizophren

ia

Recrea

tional

gambling

Cancer

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

3.1 3.02.7 2.7

2.3 2.3 2.3

1.6 1.4

4 = an extreme amount

0 = none

How much stigma do you feel society attaches to each of the following?

“a large amount”


Perceived stigma• Perceived public stereotypes:

• irresponsible, impulsive, foolish, untrustworthy, secretive.

• weak self-control, addictive personality, would be addicted to something else if not PG, bored and lonely, always in debt.

• Underestimated how much the public thinks that PG is noticeable, recoverable and disruptive.

• Overestimated how much the public thinks/feels:• PG is the gambler’s own fault• fear and anger towards problem gamblers• how irresponsible problem gamblers are• they want to avoid problem gamblers• they would look down upon problem gamblers

34

They either can’t be

bothered with you or they

just think you are an idiot

They think they’re thieves. They’re liars.

They have no life. They have no family


Self-stigma – how did our gambler respondents feel about themselves

because of their gambling?

35

Sick, ashamed, angry and guilty

I feel less of a person that I can’t control something

They’re looking at you and seeing that weakness and perhaps that’s all they’re

ever going to see … they’re never going to be

able to see you as successful or well-rounded

what they think doesn’t matter, but

I can’t get away from what I feel about myself

Makes me feel very depressed. You

know, it lowers my self-esteem

I don’t even want their pity, you know, I just want them to think of me, same as others


Self-stigmatising beliefs

36

Socially unacceptable

That you are entirely to blame

A failure or loser

That there is something wrong with you

Shocked at yourself

Embarrassed

Guilty

Disappointed in yourself

0 10 20 30 40 50 60 70 80 90 100

54.2

69.5

73.9

75.9

76.4

76.8

77.8

78.4

80.3

80.3

83.7

85.2

86.7

87.7

93.1

% agree/strongly agreeHow strongly do you agree or disagree that your gambling has made you feel …


Experiences of devaluation and discrimination

37


Devaluation and discrimination> 50% respondents reported at least occasionally being devalued because others thought they had a gambling problem:

• inferior• not smart• less politely• with less respect• as if they were dishonest• insulted or called names

Minority reported discrimination because of their gambling:• denied a bank loan (23.1%)• denied or received second-rate financial advice (9.9%)• fired from a job (8.9%)• prevented from renting somewhere to live (7.9%)• not given a promotion (6.9%)

38

Probably because so few

had disclosed their PG

they look at you as lower

citizens incapable of being a

normal human

Like being looked down on, almost as if it was criminal


Coping with stigma

39


Coping orientation40

Secrecy Withdrawal Challenging Distancing Education0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

3.2

2.1 2.11.8 1.7

4 = strongly agree

0 = strongly disagree

Mean scores for stigma coping mechanisms used


Actual disclosure of gambling

41

Your employer

Children

Other work colleagues

Welfare of other service providers you are in contact with

Other family members

Your doctor/other health professionals you are in contact with

Friends you don't gamble with

Partner/spouse

Parents

Friends you gamble with

Gaming venue mgrs or staff where you gamble

0 5 10 15 20 25 30 35 40 45 50

8.4

9.4

9.9

12.3

15.3

15.8

17.7

18.7

19.2

31.5

45.3

% of respondents reporting that these parties knew the extent of their gambling

Can friends be

harnessed as support?

Can venues do more with

this knowledge?


Stigma, help-seeking and relapse

42


Stigma and help-seeking• Most respondents had never

sought help, except from family and friends or self-help.

• Help-seeking more common after relapse.

• Compared to non-help-seekers, help-seekers had higher scores on the various stigma scales (self-stigma, perceived stereotyping, devaluation, discrimination). Causal direction?

Counsellors emphasised the fear

clients have to overcome to attend

counselling

They’re there to help you, but everybody is judgmental in some way whether they

realise they do it or not

43


Embarrassment of help-seeking after relapse

44

45.7

34.8

19.5More embarrassingEqually embarrassingLess embarrassing

Did you find it more or less embarrassing to seek this help after relapsing compared to before relapsing?

(% of respondents who had sought help both before and after relapse)

Relapsers also scored more highly on the self-stigma

scale, compared to non-

relapsers.

The counsellor is just waiting for me to fall out of line, and then it’ll be

no stopping her

But counsellors maintained that addressing self-stigma and

preparing clients for relapse is an early & key part of treatment


Who feels the most self-stigma due to their gambling?

45


Scores on the self-stigma scale highest for…

• Females• Those whose most problematic form was EGMs• Higher psychological distress• Higher public self-consciousness• Higher social anxiety • Lower self-esteem• Higher PGSI scores• Help-seekers• Relapsers

46

Well, I thought they’d support me but they haven’t … I’ll say, ‘Look, I enjoy going to the club’, and then I can see the look of disdain in their faces.

You know, can’t you do something better like clean your house instead of spending all the time

at [the club]? (8, F, 55-64).

It’s probably more acceptable in the

male community … women who play the pokies … it’s

the lowest form (46, F, 45-54).


Concluding comments

47


Summary• Public stigma of PG is alive and well. Why?

• PG perceived as mainly due to poor coping with stressful life circumstances (blame?) and as highly disruptive to self and others.

• Easier to blame and stereotype than to understand how difficult it is to “just stop” when addicted.

• PG not quite as heavily stigmatised as alcoholism and schizophrenia, but people with gambling problems think it is more stigmatised.

• How does this stigma impact on them?• Encourages secrecy• Delays and deters help-seeking• Undermines treatment adherence, esp. after relapse• Leads to self-stigmatising beliefs• Which diminish self-esteem and self-efficacy• Adds a double burden• Worse for some groups (e.g. female, EGMs, high psych. distress, anxiety, PGSI)

48


49

Implications• Treatment needs to help clients overcome self-stigmatising beliefs:

• restore self-esteem• enhance stigma coping skills• foster a belief that recovery is possible• prepare clients for relapse

• Addressing public stigma of PG is critically important.

• Lowering public stigma requires improving:• knowledge (about PG, its dimensions, struggling with an addiction rather than weak)• language (labels)• attitudes (stereotypes, emotional reactions, devaluation)• behaviours (social distancing, discrimination)

• Public education strategies needed; careful not to stigmatise further.• Increasing community contact with PG a promising strategy.• Research needed into optimal stigma reduction strategies.


ReferencesCarroll, A., Rodgers, B., Davidson, T., & Sims, S. (2013). Stigma and help-seeking for gambling problems.

Canberra: Australian National University.Corrigan, P.W. (2004). How stigma interferes with health care. American Psychologist, 59(7), 614-625.Corrigan, P.W., Markowitz, R.E., Watson, A., Rowan, D., & Kubiak, M.A. (2003). An attribution model of

public discrimination towards persons with mental illness. Journal of Health and Social Behavior, 44, 162–179.

Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In D. T. Gilbert, S. T. Fiske & G. Lindzey (Eds.), The Handbook of Social Psychology: Vol. 2. (4th ed., pp. 505–553). New York, NY: McGraw–Hill Companies, Inc.

Dhillon, J., Horch, J.D., & Hodgins, D.C. (2011). Cultural influences on stigmatization of problem gambling: East Asian and Caucasian Canadians, Journal of Gambling Studies, 27(4), 633-647.

Feldman, D.B., & Crandall, C.S. (2007). Dimensions of mental illness stigma: What about mental illness causes social rejection? Journal of Social and Clinical Psychology, 26, 137–154.

Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. London: Penguin. Horch, J. & Hodgins, D. (2008). Public stigma of disordered gambling: Social distance, dangerousness, and

familiarity. Journal of Social and Clinical Psychology, 27(5), 505-528. Horch, J., & Hodgins, D. (2013). Stereotypes of problem gambling. Journal of Gambling Issues, 28, 1-19.Jones, E.E., Farina, A., Hastorf, A.H., Marcus, H., Miller, D.T., & Scott, R.A. (1984). Social stigma: The

psychology of marked relationships. New York, NY: Freeman and Company.Link, B.G., Yang, L.H., Phelan, J.C., & Collins, P.Y. (2004). Measuring mental illness stigma. Schizophrenia

Bulletin, 30(3), 511-541.Weiner, B. (1986). An attributional theory of motivation and emotion. New York, NY: Springer-Verlag.

50

The stigma of problem gambling: Public prejudice, private pain and implications for public health

Education

Transcript of The stigma of problem gambling: Public prejudice, private pain and implications for public health