Against the odds: exploring individuals' pushback mechanisms against commercialized football gambling.

Introduction: The need for money, the pursuit of pleasure, and the liberalized access to gambling have been documented in several pieces of literature as the drivers of gambling. Such drivers are predicated on commercialized gambling, leading to the growth of the gambling industry and constituting a structural influence that normalizes the activity among young people. Methods: Through a qualitative inquiry, this study investigates the social agentic factors of individuals who are susceptible to gambling. Fifteen non-gamblers were recruited across three commercial cities in Africa, namely Nairobi, Lagos, and Johannesburg. We first established the gambling susceptibility of the participants: their need for money, their passion for football, ownership of a smartphone, access to the internet, and exposure to football gambling marketing. Results: Consequently, we probed for their agency, which is indicative of why they do not gamble, despite being susceptible to engaging in the activity. Four major agentic factors were identified from the participants; knowledge of the industry's business model, conserving the integrity of football, identity of self, morality and/or religion model. Discussion: As such, these factors may be utilized to develop an intervention program for gamblers within the geographical context.

Binge Drinking Among Sports Gamblers.

This survey study examines whether or not individuals who wager on sports are at greater risk of binge use of alcohol.

Treatment seeking for gambling disorder in nationwide register data - observations around a major shift in legislation.

Background: Treatment seeking for gambling disorder is known to be low and there has been a lack of longitudinal research regarding treatment opportunities. The present study aimed to assess possible changes in treatment uptake after a formal introduction of gambling disorder in social services and health care legislations, by using register data, including patient characteristics with respect to socio-demographics and comorbidities. Methods: Nationwide register data were collected for the years 2005-2019, describing diagnoses in specialized out-patient health care and in in-patient hospital care. Numbers and characteristics of patients with gambling disorder were followed longitudinally. Also, a new legislation for treatment by public institutions was introduced in 2018, and data were compared for the years before and after the shift in legislation, both nationally, for each of the three major urban regions, and for the rest of the country. Comparisons were made with respect to concurrent mental health comorbidities, age and gender. Results: The number of out-patient gambling disorder diagnoses increased over time, but without any significant step changes around the shift in legislation. Over time, patients were younger, became more likely to have gambling disorder as their primary diagnosis, and less likely to have mental health comorbidities, whereas gender distribution did not change. Among the smaller group of patients diagnosed in in-patient settings, mental health comorbidity increased over time. Despite gradual changes over time, no changes in demographics were seen around the actual shift in legislation, although the psychiatric comorbidity appeared to increase after this change. Conclusion: After the introduction of gambling disorder in the responsibility of social services and health care settings in Sweden, the number of patients diagnosed with gambling disorder increased only modestly. Likely, further implementation of gambling disorder treatment is required in the health care services. Also, longer longitudinal studies are needed in order to understand to what extent patients not seeking health care treatment are received by municipal social services or remain outside the treatment system.

A scoping review on self-regulation and reward processing measured with gambling tasks: Evidence from the general youth population.

Aberrant reward processing and poor self-regulation have a crucial role in the development of several adverse outcomes in youth, including mental health disorders and risky behaviours. This scoping review aims to map and summarise the evidence for links between aspects and measures of reward processing and self-regulation among children and adolescents in the general population. Specifically, it examined the direct associations between self-regulation (emotional or cognitive regulation) and reward processing. Studies were included if participants were <18 years and representative of the general population. Quantitative measures were used for self-regulation, and gambling tasks were used for reward processing. Of the eighteen studies included only two were longitudinal. Overall, the direction of the significant relationships identified depended on the gambling task used and the self-regulation aspect explored. Emotional regulation was measured with self-report questionnaires only, and was the aspect with the most significant associations. Conversely, cognitive regulation was mainly assessed with cognitive assessments, and most associations with reward processing were non-significant, particularly when the cognitive regulation aspects included planning and organisational skills. Nonetheless, there was some evidence of associations with attention, cognitive control, and overall executive functioning. More longitudinal research is needed to draw accurate conclusions on the direction of the association between self-regulation and reward processing.

Keeping you connected or keeping you addicted? Weekly use of social media platforms is associated with hazardous alcohol use and problem gambling among adults.

AIMS: A wide variety of social media platforms exist, each offering tailored solutions to attract specific target audiences based on their social media needs and interests. This diversity may pose a risk factor for the development or perpetuation of harmful behaviors. Research has established a connection between social media use and increased health risk behaviors. This six-wave exploratory longitudinal study investigated the associations between active social media use, hazardous alcohol use, and problem gambling among adult social media users. METHODS: Data were collected via surveys in 6-month intervals, starting in March-April 2021 (T1: N = 1530; Mage = 46.67; SD = 16.42; 50.33% male). Of the T1 respondents, 58.10% participated in T6 (n = 889). Measures included the frequency of use of different social media platforms, the 3-item Alcohol Use Disorders Identification Test (AUDIT-C), and the Problem Gambling Severity Index (PGSI). Hybrid multilevel regression models were used for analyses. RESULTS: We found positive within-person effects of weekly Facebook use and between-person effects of weekly use of Facebook, TikTok, and gambling-related online communities on drinking. These results suggest an increase in hazardous alcohol consumption over time among the platforms' active users. Weekly Instagram use had a negative between-person effect on hazardous alcohol use. Individuals using TikTok or gambling communities weekly were more prone to problem gambling compared to non-weekly users. CONCLUSIONS: There are risks involved in the active use of some social media services among adult users. Prevention work, including digital health interventions, should be targeted according to the appropriate user group.

Severity of gambling behaviors: exploring associations with venues, legality, and substance use.

INTRODUCTION: The COVID-19 pandemic has been linked to an increase in gambling behaviors, potentially leading to Gambling Disorder (GD) and adverse health and social consequences. Problematic gambling has received little research attention over the years in Israeli society and the issue of gambling is not high on the list of priorities of Israeli policymakers. The present study examined gambling behavior in Israel on a continuum of severity and its association with venues where the gambling occurs, legality, attitude toward the legalization of casinos and poker, and substance use. METHODS: The study questionnaires were distributed to approximately 15,000 Jewish-Israeli adults via internet panel. From 3,088 Israeli adults who answered the questionnaire, 1,251 (40.5%) reported gambling in the last year and were included in the analyses. RESULTS: Based on the Problem Gambling Severity Index, 60% of participants were classified as non-problem gamblers, 25% as at low-risk for a gambling problem, 11% as at moderate risk, and 4% as having a gambling problem. Most online gambling was practiced by non-problem gamblers (40%) and most illegal gambling was by low-risk gamblers (34%). The more severe the gambling behavior was on the continuum, the more it was associated with illegal substance use and positive attitudes toward legalized casinos in Israel. Logistic regression showed the odds of developing moderate and problem gambling were 3.8 times higher for online gamblers (OR = 3.8; CI 2.6-5.4; p < 0.000) and 3.3 times higher for illegal gamblers (OR = 3.3; CI 2.2-4.9; p < 0.000). CONCLUSION: Though more research attention should be paid to gambling behaviors, harm reduction gambling interventions should be made available to all categories on the continuum of severity of gambling behaviors. The present study provides evidence-based information to promote health policies that aim to prevent and reduce harm for Israeli gamblers.

Intersection of gambling with smoking and alcohol use in Great Britain: a cross-sectional survey in October 2022.

OBJECTIVES: Gambling is associated with cigarette smoking and alcohol consumption. We explored the intersection of gambling across all risk levels of harm with smoking and alcohol use among adults in Great Britain. DESIGN: A nationally representative cross-sectional survey in October 2022. SETTING: Great Britain. PARTICIPANTS: A weighted total of 2398 adults (18+ years). OUTCOME MEASURES: We examined the prevalence of past-year gambling and, among those reporting gambling, assessed the associations between the outcome of any risk of harm from gambling (scoring >0 on the Problem Gambling Severity Index) and the binary predictor variables of current cigarette smoking and higher risk alcohol consumption (AUDIT-C score≥4). We also explored data on weekly expenditure on gambling with smoking and alcohol use among those categorised at any-risk of harm from gambling. RESULTS: Overall, 43.6% (95% CI 41.2% to 45.9%) of adults gambled in the past year. Among these, 7.3% (95% CI 5.3% to 9.3%) were classified at any-risk of harm from gambling, 16.0% (95% CI 13.2% to 18.8%) were currently smoking and 40.8% (95% CI 37.2% to 44.4%) were drinking at increasing and higher risk levels. There were no associations between any risk of harm from gambling and current smoking (OR adjusted=0.80, 95% CI 0.35 to 1.66) or drinking at increasing and higher risk levels (OR adjusted=0.94, 95% CI 0.52 to 1.69), respectively. Analyses using Bayes factors indicated that these data were insensitive to distinguish no effect from a range of associations (OR=95% CI 0.5 to 1.9). The mean weekly spend on gambling was £7.69 (95% CI £5.17 to £10.21) overall, £4.80 (95% CI £4.18 to £5.43) among those classified as at no risk and £45.68 (95% CI £12.07 to £79.29) among those at any risk of harm from gambling. CONCLUSIONS: Pilot data in a population-level survey on smoking and alcohol use yielded similar estimates to other population-level surveys on gambling participation and at-risk gambling. Further data are needed to elucidate the intersections more reliably between gambling, smoking and alcohol use and inform population-level approaches to reduce harm.

Assessing gambling disorder using frequency- and time-based response options: A Rasch analysis of the gambling disorder identification test.

OBJECTIVES: The Gambling Disorder Identification Test (GDIT) is a recently developed self-report measure. The GDIT includes items with multiple response options that are either based on frequency or time, and item response theory evaluations of these could yield vital knowledge on its measurement performance. METHODS: The GDIT was evaluated using Rasch analysis in a study involving 597 Swedish gamblers. RESULTS: In a three-dimensional Rasch model, the item response difficulty range extended from -1.88 to 4.06 and increased with higher time- and frequency-based responses. Differential item functioning showed that some GDIT items displayed age and gender-related differences. Additionally, person-separation reliability indicated the GDIT could reliably be divided into three to four diagnostic levels. CONCLUSIONS: The frequency- and time-based item response options of the GDIT offer excellent measurement, allowing for elaborate assessment across both lower and higher gambling severity. The GDIT can be used to detect DSM-5 Gambling Disorder, thereby holding significance from both epidemiological and clinical standpoints. Notably, the 3-item GDIT Gambling Behavior subscale also shows potential as a brief screening tool for identifying at-risk gambling behavior.

Silymarin (Milk Thistle) Treatment of Adults With Gambling Disorder: A Double-Blind, Placebo-Controlled Trial.

OBJECTIVE: Data on the pharmacological treatment of gambling disorder are limited. Silymarin (derived from milk thistle) has antioxidant properties. The goal of the current study was to determine the efficacy and tolerability of silymarin in adults with gambling disorder. METHODS: Forty-three individuals (18 [41.9%] women; mean age=49.61 [±13.1] years) with gambling disorder entered an 8-week, double-blind, placebo-controlled study. Dosing of silymarin ranged from 150 to 300 mg twice a day. The primary outcome measure was the Yale Brown Obsessive Compulsive Scale Modified for Pathological Gambling (PG-YBOCS). Secondary outcome measures comprised the Gambling Symptom Assessment Scale and measures of depression and anxiety. Outcomes were examined using mixed-effect models. RESULTS: Silymarin did not statistically differentiate from the placebo on any of the outcome measures of interest, in terms of treatment group×time interactions. There was a robust response in the placebo group (57% reduction on the PG-YBOCS), and on average there was a 56% reduction in YBOCS score for the milk thistle. CONCLUSIONS: The findings of this study do not support the use of silymarin/milk thistle in the treatment of gambling disorder but highlight the large placebo response seen in gambling disorder. Treatment interventions for gambling disorder need to better understand and address the placebo response. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02337634.

Availability restrictions and mandatory precommitment in land-based gambling: effects on online substitutes and total consumption in longitudinal sales data.

BACKGROUND: Gambling causes important harms in societies. According to the public health approach, the most effective policies to reduce harms target full populations. Availability restrictions and mandatory precommitment are among the most effective measures. However, restrictions on the availability of some gambling products or channels may also be offset by increased consumption in other products. Substitution effects can have negative public health impacts due to differing harm potential across different gambling products. This paper uses longitudinal sales data (2019-2022) from the Finnish gambling monopoly Veikkaus. During the observation period, the availability of gambling was restricted in Finland due to subsequent waves of Covid-19-related restrictions. In addition, the gambling monopoly introduced mandatory precommitment to land-based EGMs. We focus on how these restrictive policy changes impacted the total consumption of gambling and possible substitution effects. METHODS: The Finnish gambling monopoly provided weekly theoretical loss data per gambling product category and gambling channel (online, land-based) for the period of January 2019 - July 2022 based on a statutory obligation. We analysed the effects of availability restrictions and other public health measures on the consumption of different products using descriptive time series and regression analyses. We compared the sale of land-based products to online equivalents at product category level and included main policy change periods in the models. RESULTS: Total consumption of gambling declined during 2019-2022 mainly due to reduced land-based electronic gambling machine (EGM) consumption. Declines in land-based EGM sales were not offset by online alternatives or other close substitutes in the long term. However, during the first wave of Covid-19, there was an observable substitution of land-based table games by online alternatives and land-based horse betting and possibly sports betting by online horse betting. Overall, the results also show that Covid-19 functioned as a boost to an already existing trend of increasing digitalisation of gambling. CONCLUSIONS: The study provides empirical support for the effectiveness of public health-oriented policies in reducing the total consumption of gambling. Availability restrictions and mandatory precommitment are therefore likely to also reduce the burden of harms of gambling to individuals and societies.

[Substance use and the usage of social media, computer games, and gambling among apprentices at vocational schools]. / Substanzkonsum und Nutzung von sozialen Medien, Computerspielen und Glücksspielen unter Auszubildenden an beruflichen Schulen.

BACKGROUND: The aim of the current study was to assess the prevalence of the (problematic) consumption of alcohol, tobacco, and cannabis as well as the (problematic) use of social media, e­products, computer games, and gambling among apprentices. METHOD: Cross-sectional survey of 4591 apprentices at 17 vocational schools from Bavaria, Schleswig-Holstein, and Hamburg. Data was collected using questionnaires between March 2021 and April 2022. The primary endpoints were the 30-day prevalence and the problematic consumption and usage behavior of the mentioned substances/behaviors using screening instruments. RESULTS: Among the assessed substances/behaviors, social media were used most frequently by the apprentices with a 30-day prevalence of 97.7%, followed by alcohol (64.3%) and computer games (55.8%). Cigarettes were consumed by 35.1%, e­products by 17.9%, and cannabis by 15.4% of the apprentices. Of the apprentices, 12.2% reported having gambled in the past 30 days. Rates of problematic use were 47.4% for alcohol, 18.0% for tobacco, 6.2% for e­products, and 1.6% for cannabis. Problematic use of social media was indicated by 45.0% of the apprentices, of gambling by 2.2%, and of computer games by 0.7%. DISCUSSION: These results suggest that apprentices constitute a risk group for problematic substance use, indicating increased need for intervention. In particular, secondary prevention efforts in the areas of alcohol and social media should be taken into consideration due to their widespread prevalence in the vocational school setting.

Cash outs during in-play sports betting: Who, why, and what it reveals.

Cashing out is a popular feature of modern 'in-play' sports betting that allows sports bettors to withdraw a bet before the sporting event on which the bet was placed is finalized. Previous studies have shown that use of the cash out feature is positively related to problem gambling symptomatology. However, little is known about demographic and psychological characteristics of in-play sports bettors who use the cash out feature, or their motivations for use. To fill this knowledge gap, we recruited 224 adults (18 + years) from Ontario who engaged in in-play sports betting in the past three months. Participants completed self-report measures of psychological and gambling-related variables. Participants also provided qualitative responses for their motivations for using the cash out feature. Approximately half (51.8 %) of the participants reported using the cash out feature. No statistically significant demographic differences were found between participants who used and did not use the cash out feature. Participants who used the feature (compared to those who did not) reported higher problematic alcohol and cannabis use, feelings of depression, anxiety, and stress, and were motivated to gamble to make money. The primary reasons for cashing out were to access money immediately, to cut losses, and because cashing out felt like a less risky option. The current findings shed light on underlying psychological vulnerabilities associated with individuals who use the cash out feature, which can inform initiatives to reduce the harms associated with this popular feature of sports betting.

Insular and prelimbic cortices control behavioral accuracy and precision in a temporal decision-making task in rats.

The anterior insular cortex (AIC) comprises a region of sensory integration. It appears to detect salient events in order to guide goal-directed behavior, code tracking errors, and estimate the passage of time. Temporal processing in the AIC may be instantiated by the integration of representations of interoception. Projections between the AIC and the medial prefrontal cortex (mPFC) - found both in rats and humans - also suggest a possible role for these structures in the integration of autonomic responses during ongoing behavior. Few studies, however, have investigated the role of AIC and mPFC in decision-making and time estimation tasks. Moreover, their findings are not consistent, so the relationship between temporal decision-making and those areas remains unclear. The present study employed bilateral inactivations to explore the role of AIC and prelimbic cortex (PL) in rats during a temporal decision-making task. In this task, two levers are available simultaneously (but only one is active), one predicting reinforcement after a short, and the other after a long-fixed interval. Optimal performance requires a switch from the short to the long lever after the short-fixed interval elapsed and no reinforcement was delivered. Switch behavior from the short to the long lever was dependent on AIC and PL. During AIC inactivation, switch latencies became more variable, while during PL inactivation switch latencies became both more variable and less accurate. These findings point to a dissociation between AIC and PL in temporal decision-making, suggesting that the AIC is important for temporal precision, and PL is important for both temporal accuracy and precision.

The prevalence of gambling problems in prison populations: A systematic review and meta-analysis.

Introduction: The overall prevalence of gambling problems across prison populations is currently unknown. The objective of the present study was therefore to quantitatively synthetize prevalence estimates of gambling problems in prison populations using a random effects meta-analytic model and to investigate if the estimates were moderated by time frame, cut-off levels, and sample size. Methods: To be included the studies had to report original data on the prevalence of gambling problems in a prison sample and to be written in a European language, whereas data based on abstracts or qualitative reports were excluded. The search ended on December 1, 2023 and were conducted in Web of Science, PubMed, Cinahl, PsycINFO, Embase, Google Scholar, Grey Literature Report, and GreyNet. Risk of bias was assessed with a standardized 10-item measure for epidemiological studies. Results: A total of 26 studies comprising 9,491 participants were included. The vast majority of the participants were males. The most commonly used instrument for assessment of gambling problems was the South Oaks Gambling Screen. The pooled random-effects gambling problems prevalence estimate was 30.8% (95% CI = 25.1-37.3). The meta-regression analysis showed that none of the three moderator variables (criteria, timeframe, sample size) were related to the gambling problems prevalence. Common limitations of the included studies entailed not being representative nationally or for the target population, lack of randomization, and low response rate. The meta-analysis was restricted to studies published in a European language. Conclusions: Overall, the studies show that 1 in 3 prisoners has gambling problems and suggests that more emphasis on relevant prevention and treatment is warranted for this population. The study was funded by the Norwegian Competence Center for Gambling and Gaming Research and pre-registered at PROSPERO (CRD42023390552).

A Systematic Review on Intervention Treatment in Pathological Gambling.

Over the last century, there has been a growing interest in researching pathological gambling, particularly in industrialized nations. Historically, gambling was widely perceived as morally questionable, condemned by religious groups. However, contemporary concerns have shifted towards the health repercussions of gambling disorders and broader societal impacts like increased crime and money laundering. Governments, aiming to mitigate social harm, often regulate or directly oversee gambling activities. The global surge in legal gambling has resulted in a substantial rise in its prevalence, popularity, and accessibility in the last two decades. This paper provides a comprehensive overview of global research on interventions for pathological gambling. Through a systematic search on platforms such as EBSCO, PubMed, and Web of Science, 13 relevant records were identified. The revised findings indicate a heightened occurrence of behavioral addictions, linking them to the early onset of gambling issues and their severe consequences. The research emphasizes the active role that clients play in the process of self-directed change and therapy. Therapists recognizing clients as both catalysts for change and potential obstacles can enhance their effectiveness. A common source of resistance arises when clients and therapists are in different stages of the change process, underlining the importance of therapists aligning with clients' readiness for change. Recognizing the urgent need for a better understanding of this problem in adolescents, this study emphasizes the necessity to tailor prevention and treatment plans based on gender and age-specific requirements.

Topological features of functional brain networks and subclinical impulsivity: an investigation in younger and older adults.

Impulsive traits (i.e., the tendency to act without forethought regardless of negative outcomes) are frequently found in healthy populations. When exposed to risk factors, individuals may develop debilitating disorders of impulse control (addiction, substance abuse, gambling) characterized by behavioral and cognitive deficits, eventually leading to huge socioeconomic costs. With the far-reaching aim of preventing the onset of impulsive disorders, it is relevant to investigate the topological organization of functional brain networks associated with impulsivity in sub-clinical populations. Taking advantage of the open-source LEMON dataset, we investigated the topological features of resting-state functional brain networks associated with impulsivity in younger (n = 146, age: 20-35) and older (n = 61, age: 59-77) individuals, using a graph-theoretical approach. Specifically, we computed indices of segregation and integration at the level of specific circuits and nodes known to be involved in impulsivity (frontal, limbic, and striatal networks). In younger individuals, results revealed that impulsivity was associated with a more widespread, less clustered and less efficient functional organization, at all levels of analyses and in all selected networks. Conversely, impulsivity in older individuals was associated with reduced integration and increased segregation of striatal regions. Speculatively, such alterations of functional brain networks might underlie behavioral and cognitive abnormalities associated with impulsivity, a working hypothesis worth being tested in future research. Lastly, differences between younger and older individuals might reflect the implementation of age-specific adaptive strategies, possibly accounting for observed differences in behavioral manifestations. Potential interpretations, limitations and implications are discussed.

Sex modulated the relationship between trait approach motivation and decision-making.

It has been observed that one's Behavioral Approach System (BAS) can have an effect on decision-making under uncertainty, although the results have been mixed. To discern the underlying neural substrates, we hypothesize that sex may explain the conflicting results. To test this idea, a large sample of participants was studied using resting state fMRI, utilizing fractional Amplitude of Low Frequency Fluctuations (fALFF) and Resting-State Functional Connectivity (rsFC) techniques. The results of the Iowa Gambling Task (IGT) revealed an interaction between sex and BAS, particularly in the last 60 trials (decision-making under risk). Males with high BAS showed poorer performance than those with low BAS. fALFF analysis showed a significant interaction between BAS group and sex in the left superior occipital gyrus, as well as the functional connectivity between this region and the left ventrolateral prefrontal cortex. Additionally, this functional connectivity was further positively correlated with male performance in the IGT, particularly in the decision-making under risk stage. Furthermore, it was found that the functional connectivity between left ventrolateral prefrontal cortex and left superior occipital gyrus could mediate the relationship between BAS and decision-making in males, particularly in the decision-making under risk stage. These results suggest possible sex-based differences in decision-making, providing an explanation for the inconsistent results found in prior research. Since the research was carried out exclusively with Chinese university students, it is essential to conduct further studies to investigate whether the findings can be generalized.

Emotions and motivations of gambling: A comparison between scratch card, slot-machines, and casino gamblers.

INTRODUCTION: In the last 20 years, gambling has become more and more widespread in Italy. The aim of the present study is to compare the motivations for gambling and the emotions felt while gambling in three different subgroups: scratch card gamblers, slot-machine gamblers, and casino gamblers. METHODS: Three versions of a questionnaire have been distributed in a casino, in scratch card vendors, and slot-machines venues. All versions included sociodemographic variables, the two-question Lie-Bet instrument, a scale for motivations toward gambling, and a list of positive and negative emotions felt while gambling. RESULTS: Participants (N = 425, F 47.5%) are gamblers potentially pathological (N = 162, 38.1%) and not (N = 263, 61.9%). Different games seem connected to different motivations and emotions: the scratch gamblers show less Coping and Social Motivation and experience less Negative Emotion. However, the motivation and emotion most intensely experienced by the gamblers (Enhancement and the Positive Emotions) do not show differences between the different types of games. CONCLUSION: The pathological gamblers have a more intense and internal connection with the game (have more Enhancement and Coping motives, Positive and Negative Emotion). In sum, our findings support the theoretical hypothesis that gambling can be a tool for regulating emotions.

[Addictive behavior among teenagers: new trends]. / Conduites addictives chez les adolescents, les nouvelles tendances.

The majority of teenagers benefit from scientific advances, whether pharmacological or technological, but the most vulnerable use them to their detriment. While only certain substances or activities are potentially "addictive", the psyche, personality and environment play a major role in the onset of an addiction. Pleasure-seeking motivates gambling and drug use. Suffering will drive the adolescent to pursue this practice, which provides pleasure and relief, to the detriment of any other activity. It becomes exclusive, toxic and alienating. The therapist must rise to the challenge.