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INTRODUCTION
The gambling environment in South Korea has drastically changed in recent times. Historically, the government-sponsored national lottery was the only gambling option allowed for Korean citizens by Korean law. For many decades, 16 small-scale casinos have been available but these places mainly targeted foreign tourists, while prohibiting domestic citizens from playing. Since the first and only casino for the domestic population opened in 2000, Korean society has witnessed an exponential growth in its revenue. Since it was first studied in 2006, the prevalence of problem gambling among Korean adults has shown steadily high rates of 1.5 %(about 57 million)[1], which is much higher than in other industrialized countries using the same tool (The Canadian Problem Gambling Index [CPGI]), such as 0.7% in the United Kingdom [2], 0.7% in Australia [3], and 0.7% in Canada [4].
Problem gambling (PG) is defined as 'persistent and recurrent maladaptive gambling behavior' characterized by an inability to control gambling, leading to significant deleterious psychosocial consequences: personal, familial, financial, professional, and legal [5]. Culturally, Korean society has ambivalent attitudes toward gambling. On the positive side, gambling is traditionally seen as an acceptable and harmless form of entertainment, and as a pastime that can be enjoyed among friends and family. However, the current discussion on gambling is mostly focusing on the negative side of it. The Korean society perceives gambling as a great threat to an ethical and social way of life. Bankruptcy and broken families are common images strongly associated with gambling [6].
The prevalence rates of Korean PG for men and women in 2014 were 2.8% (53.2 million) and 0.2% (3.8 million) respectively [1]. As it can be seen in the prevalence rates differences, men are more likely to be problem gamblers than women in Korea. In comparison with other countries in Asia, the prevalence of Korean women PG is similar to the rates of 0.2% in Singapore [7] and lower than 1.6% in Japan where the video lottery terminal (Pachinko) parlors are highly developed [8]. However, women are now the fastest growing population seeking help for gambling problems in Korea. According to the statistics, the numbers of help-seeker coming to Community Centers on Gambling Problem in women has increased over 5 times from 37 in 2009 to 191 in 2013 [9], although the number of women seeking help consistently low compared to the estimated number of women problem gamblers. Due to a strong stigma attached to problem gambling, women problem gamblers might be reluctant to seek help even though they experience the negative consequences of gambling in Korea [10]. Therefore, there are many women problem gamblers who are in need of, and would benefit from receiving professional help.
Many previous studies have reported that gambling behaviors and gambling etiology appear to be different between men and women problem gamblers [1112131415]. No single explanation can be applied to gender differences. In general, women gamblers tend to start gambling later in life, but progress to problem gambling more quickly than their male counterparts [1112] partly because they are more likely to run into problems, such as financial difficulties, sooner than male gamblers who tend to have a higher level of social support that helps sustain their life despite problem gambling [12]. The other reason for the fast progress to problem gambling may be related to the type of gambling. Women prefer machine gambling which is characterized by rapid speed play and high frequency of reinforcement and deteriorates loss of control faster than other types of gambling. The choice of gambling type seems to be gender-specific. Stark and colleagues [14] suggested that women problem gamblers may prefer chance/luckbased games, which are more addictive, whereas those of men are likely to be riskier games. Women gambler tend to engage in these games because this simple type of gambling relieves their stress and internal/emotional difficulties, and because they are perceived as offering an equal chance of winning/losing regardless of the player's social status. Female slot machine players' motivations to gamble are primarily to escape stress and for empowerment; in contrast, those of male gamblers are for excitement, challenge and competition [15].
Despite the increasing trend of women problem gamblers reported in official statistics, the literature on Korean women problem gamblers is scarce. Most of studies related to Korean women gamblers focus on gender differences in characteristics between men and women problem gamblers.
In order to effectively help women problem gamblers, in-depth knowledge is necessary to develop intervention programs for prevention, treatment, and recovery among women problem gamblers. To fill gaps in the current literature, this study was designed to explore the lived experiences of women problem gamblers. We aimed to: 1) describe the meaning of gambling to them; 2) explore how and why these women continue to gamble or stop gambling (e.g., gambling motivation); a nd 3) identify their needs and concerns.
METHODS
For the purpose of this study, it was deemed appropriate to use hermeneutics phenomenology which focuses on the subjective experience of individuals and groups. It is an attempt to unveil the world as experienced by the participant through their worldlife stories. Based on the premises that reduction is impossible and acceptance of endless interpretations, hermeneutics phenomenology puts an effort to get beneath the subjective experience and find the genuine objective nature of the things as realized by an individual [16]. The hermeneutics phenomenology approach was used to understand the common meanings and shared practices of gambling by women gamblers. It claims that humans understand and operate contextually, within a set of historical and temporal situations rendered explicit by interpretation through language. In-depth interviews were conducted to draw an everyday picture of these humans' lived experiences. By listening to the stories of these women gamblers' experiences, we can build a capacity to understand the meaning of gambling through the language used to express their views on life. We specifically focused on exploring the culture and uncovering the meaning of gambling behind the language they incorporated in telling their stories.
1. Participants
A total of 16 women problem gamblers were recruited using a snowball sampling technique with help from the K addiction care center in southern Kangwon Province, South Korea. The center established in 2001 as Korea's first gambling addiction care center provides healing support programs and counseling services for sufferers of gambling addiction. Participants in this study were all enrolled in the healing support program for women at the center. Sixteen women gamblers were interviewed: five of them have been quitted for less than 3 months, two of them have not gambled for more than one year, and nine were current problem gamblers. We decided to include all 16 women problem gamblers in this study so as to capture the whole experiences of women gamblers. Inclusion criteria were those who 1) are Korean women; 2) are self-identified problem gamblers (gambling is self-identified as problematic by individuals); and, 3) have lived as a "long-term visitor" in the casino area. "Long-term visitors" refer to a group of people who decided to stay in the casino area after losing everything to casino gambling. Most of them are heavily in debts having lost all of their fortune, credit, and existing social networks. They continue to live in the casino area on a temporary basis at a sauna house, motel, or rental place without acquiring residencies.
The average age of participants was 59 years, ranging from 47 years to 67 years. The average years of education were 10.13 years, where majority (13 out of 16) were high school or middle school graduates. Eightout of the 16 participants were never married, three were divorced, one was widowed, and two were living with a male gambler. Two participants were married. Ten participants were originally from Seoul and six were from other cities. The duration of casino gambling ranged from 4 to 10 years, with an average of 7 years. The most common type of gambling was slot machine (14 out of 16)(Table 1).
2. Procedure
After receiving approval from the institutional review board at the first author's university (IRB No. 2013-11), the interviews were conducted from February through April 2013. Potential participants were contacted by the counselor who was in charge of the healing support program for women at the center. The counselor and the first author have been co-facilitating a special two-day healing camp once a year for the past three years. The first author explained to the counselor about the aims of this study and inclusion criteria of the participants. Once a potential participant expressed interests, the counselor called to schedule an interview, where they provided information about the nature of the study. Before the interview, participants were informed of the purpose and procedure of the study and their right to terminate the interview at any time if they felt uncomfortable. After the participant agreed to participate by signing the informed consent form, the first author conducted in-depth interviews, using the interview guide developed to capture their personal life before and after coming to the casino [17]. The interview guide consisted of the following questions: "Tell me about your typical day," "Recall your first visit to the casino and your days since then," and "Please share your experiences," "Look back in your life before coming here. What was your life like then?" "Currently, what kinds of support do you rely on?" and "Imagine your life 10 years from now. How would it look like?" The interview location was chosen by each participant; fourteen participants were interviewed at the counseling center, and two participants were interviewed in their workplace. The length of each interview varied between 1 and 2 hours. All participants were interviewed once except one participant who requested an additional interview to share more about her personal life. At the end of each interview, the participant wasasked to suggest or introduce someone who may fit the inclusion criteria of the study. The recruitment process was continued until the data met the saturation point, where no new information was emerging from the interviews.
3. Data analysis
Hermeneutic phenomenology avoids method for method's sake and does not have a step by step method or analytic requirements. The only guidelines are the recommendation for a dynamic interplay among research activities: commitment to an abiding concern, oriented stance toward the question, investigating the experience as it is lived, describing the phenomenon through writing and rewriting, and consideration of parts and whole [16].
After the first author transcribed all of the interviews verbatim in Korean, and compared them with audio files for integrity of the narratives, the analysis team began to meet. The analysis (interpretive) team consisted of three authors, the first author was a Korean qualitative researcher who had workedas an addiction professional for about 20 years, the second author was a Korean-American qualitative researcher who had worked in the addiction area of inquiry for about 10 years, and the lastauthor was an American expert in hermeneutics phenomenology for about 20 years. The first author had taken the 'Advanced Methods: Interpretive Phenomenology' graduate course for one semester opened by the last author in the PhD course at a school of nursing in the US.
We analyzed the data using the seven-stage team approach described by Diekelmann et al.[17]. The seven stages team approach of hermeneutics phenomenology involves both individual analyses and group analyses. Before the analysis started, we shared and acknowledged personal assumptions about gambling and women gamblers that could influence the whole team's interpretations. Unlike other phenomenological methodologies based on the methods of Husserl, hermeneutic phenomenology does not require researchers to bracket their own preconceptions or theories during the process. Instead, the research process includes the significance of the existing world and its meanings for the interpretive team. Recognizing assumptions made by the interpretive team has been described as the forward arc of the "hermeneutic circle" and the interpretation as the return arc―the "movement of uncovering" of the circle. Within the circular process, narratives are examined simultaneously with the emerging interpretation, never losing sight of each informant's particular story and context [18]. In stage 1, two bilingual (Korean and English) researchers read through all transcripts to gain an overall understanding of the narrative. One English-speaking researcher read through the one translated typical case to gain some understanding of the phenomenon. In stage 2, two bilingual researchers independently wrote an interpretive summaryand identified possible themes with supportive quotes in each case in English. The team met weekly for two months to discuss each case and arrive at a consensus of the interpretations, noting similarities and differences using textual evidence. Team consensus was achieved through debate, brainstorming and discussion. Stage 3 involved further analysis of succeeding interviews and, as new themes emerged, return to the previous interviews to compare for similarities and differences. In stage 4, the team identified relational themes that cut across many texts. Whenever conflicts arose among the various interpretations, the team would return to the original texts to check for congruity. In stage 5, the team identified a constitutive pattern, linking all of the related themes together in an interpretive pattern that described the common meaning of gambling in their lives. The stage 6, the first author conducted member-checking with five participants to verify whether the research findings captured the meaning that the participant sought to convey. One participant was unavailable. They replied and confirmed the themes as congruent with their experiences. Stage 7 included preparation of the final research report using sufficient excerpts from the texts to allow for validation of the findings by the reader.
RESULTS
One constitutive pattern was identified in the analysis: moving beyond addiction by recognizing the two faces of gambling in their lives. Four related themes emerged in the analysis: gambling as alluring; gambling as 'ugly'; living in contradictions; and moving beyond. These four themes are intertwined.
1. Gambling as alluring
This theme articulates the positive appeal and interest in gambling that the participants described as they consistently pursued gambling, from the beginning to the present. What they most appreciated about gambling was not gambling itself, but the effects that accompany it. Three subthemes were identified: relieving boredom and loneliness, enjoying the camaraderie of fellow gamblers, and seeking money: the illusion of hitting a "jackpot" or making living expenses.
1) Relieving boredom and loneliness
Gambling was an attractive option for them when they had time off from their hard work; boredom while between jobs was a common reason for engaging in gambling activities. Participants expressed regrets for getting into gambling-"if I had something to work on," "if I had continued working while gambling," or "if there had been time limits (for gambling), I would have not come this far." Gambling does not require any preparation or prior training. The following quote illustrated that the casino welcomed them with fun activities and it seemed to be a solution to them at first.
When I came here... it felt like walking into heaven... How great it was... Lights were flashing. Lot of snow... It was... it was... very good. Since then, I began to come here and started to lose money...Whenever I came here, it was great. Not only gambling... it was great to walk around here.(P11)
Boredom was related to feeling lonely. Most participants did not have partners (spouses) or children who they could count on for emotional support. When participants explained their own accounts of gambling, they lamented their pasts, using many if's: "if I had someone to take care of," "if I had someone who needed me," "if I had someone who welcomed me (at home), I wouldn't have clung to gambling." Sometimes, it was not lack of support but a lack of people to support. The next participant's statements revealed that they were looking for meaning in their lives, where they were needed by others.
After kids started to attend high school and college... I was waiting so long for them with dinner ready.... Eventually, they came in one by one, after a long time of waiting... 'Mom, I was late playing with friends. I already ate with friends... good night.' Once they got into their rooms, it was difficult to see their faces again. In front of the TV, lounging on the couch, I fell asleep until the next morning. In the past, I lived a diligent life because the kids needed my hands or because we needed money... after we achieved those goals, at some level, there was nothing that interested me. Now I am thinking back, I fell into gambling because I lost a place on which I could emotionally depend.(P16)
2) Enjoying the camaraderie of fellow gamblers
Camaraderie, perhaps developed while commiserating over their gambling-related situations, seems to play a role in their continuing gambling behaviors and in keeping them in the area as long-term visitors. They played, ate, and drank together. They also supported each other emotionally and financially, by loaning each other money when necessary. As in one participant's narrative, they expressed their preference for these social relations, 'I love living here, living here by and in itself! Even though I am losing money...'(P1)
These relationships have filled the void in their lives left by the family or friends they lost contact with both before and while gambling. They feel different from non-gambling women, cannot converse with "those people," given a lack of common experiences. Such social networks normalize their lives within the context of gambling when "no one accepted (them) in other places."
Because of this gambling....it's been 10 years already. And you know, we are not like ...that kind of people... They are just homemakers and live a healthy life...... so... we got bored with that stuff. We cannot converse with those people.(P5)
3) Seeking money: the illusion of hitting a "jackpot" or making living expenses
The strongest and most enduring motivation of life in the casino town is the illusion of a possible big win. Their tiny hope for a jackpot is based on a gambler's fallacy: they have lost so much, so the odds of winning are getting better and it should happen at any time. They are holding on to hope that they could be the next lucky one, so that they can be lifted up from their miserable lives. They walk into the casino thinking "Who knows? Today may be the lucky day," only to end up with "of course not." The more miserable their reality is, the stronger the wish is.
If I had enough money to spend and if I were rich, I wouldn't have come here and... I would be well respected and live a comfortable life somewhere else... I do not have (anything). I do not have money... I am spending time here thinking 'who knows?'(P6)
While keeping the unrealistic dream or hope alive, some participants also use gambling as a means to sustain their present living. In reality, gambling is perceived as an easier job, compared to alternative jobs available to them, i.e., more physically-demanding, menial work. The challenge is to control their gambling behavior so they can stop gambling when they get some money in their hands. The following quote is a statement of a 66-year-old participant.
Actually, winning is... hard. But rent or the price for my medication ... So, to take care of them (expenses), I come up here (the casino). I can't take hard labor because of my age. (P11)
2. Gambling as 'ugly'
The theme of "Gambling as 'ugly'" is the other face of gambling. The participants perceived gradually that gambling is "ugly" because of losing what they had before and fearing for the future. Two related themes are 'Losing health, wealth, relationships, and the desire to live' and 'Fearingthe future: getting old, feeling ugly, and being stigmatized.'
1) Losing health, wealth, relationship, and the desire to live
When gambling becomes the top priority in their lives, it takes over their daily routine. They stay at the casino overnight, and then sleep the following day to regain their strength. They also feel pressure to forego eating in lieu of gambling and experience sleep problems due to an irregular sleep schedule. While they are gambling, most people smoke cigarettes and often, after a gambling night, drink alcohol both to release the intense stress generated from gambling and to aid in sleep. One participant describes a typical day when she gambles:
I go up (to the casino) around two or three o'clock and stay up all night. When they say 'Please leave...' at 6 a.m., then I leave. Then at dawn I go to drink a shot of soju... I mean, I cannot get to sleep that easily. So I go to the city and call up some familiar people and drink soju with them, then go home and sleep... On the following day, I can't come because my stamina (energy). The next day,(I think), 'ah... how could I go up, I need to go up (to the casino)' and then, I get to go up again.(P1)
As they continue to repeat this unhealthy lifestyle, the negative consequences accumulate, although losing health has not proven to be enough of a reason to quell the current life of gambling and leave the casino. Almost all of the participants reported dental problems to a certain degree:
As I lost (money), teeth were becoming loose. So (I) spent all night here, losing money...causing extreme nerves, headaches. Loose tooth came first. Then, teeth came off (from gum) one by one with their roots... but I didn't even notice they came off because I was so tired...(laughing) when I woke up one morning, a tooth was gone.(P4)
Obviously, losing money is the most problematic consequence of problem gambling.Continued gambling results in a significant loss of their assets.
As I continued to lose money... in my case, I do not owe to others because I snapped out of it from time to time... but I have no money left in my pocket... So, life becomes weary. (My) life could have been comfortable and elegant (laughing)... Like a beggar, I am spending my life assuming a life of a beggar.( P6)
The financial situation causes relationship problems for them. Most of them burned bridges because of owing money to their family and friends, having lied to them, and sometimes having "hurt others" in order to pay gambling debts. This participant lamented her loss.
(I) lost all social connection ... when (I) gamble... everyone is disconnected. I didn't feel proud of myself, and kept goinginto a darker place, and lost all good people. That's the most difficult thing. I can earn money as long as I am physically healthy but I have lost all the good people... That's the hardest part. (crying) What I regret the most is having lost people who I didn't want to lose.(P9)
As they lost health, money, and social and family relationships, many participants' psychological well-being was threatened. Desperation, depression, and suicidal ideation were common feelings shared among the participants. There is often no hope for the future and life has lost its meaning. Having lost hope, some of them have lost a strong desire for life as one participants shared: "And when I lie down on the bed alone (sigh), I feel comfortable, and sometimes I wish I could stay asleep forever...sometimes (about to cry)."(P1)
2) Fearing the future: getting old, feeling ugly, and being stigmatized
The worst fear the participants shared was of becoming old women who loiter in the casino. Most of the participants described an old woman they saw in the casino as 'ugly' because she was unable to stop gambling even at such an old age. The future is "frightening" and "terrifying" thinking that they might "die while gambling."
I see old ladies who are in their 70s and 80s come here (the casino). Gosh... whenever I see them... like me, I shouldn't get to that point, not to that extreme.So ugly like that... She may have a lot of money, but gambling at that age (sigh)... it's ugly.(P5)
Participants were reluctant to leave the casino area because of the stigma against gamblers in the outside world. Fear of being branded or recognized as a 'gambler' by others who are not addicted to gambling, the so-called "society," is persistent even after they completely quit.
The reason that I cannot leave (the casino area)... is that I know people here and am very confident living here. If I go to Seoul, I must make friends again ... What if someone recognizes me? ... This is a character flaw. People from 'society,' normal people, would point fingers at me. I do not want to be treated that way... even if I'm not (gambling) anymore, I'm already branded... Someday I would think 'if they recognize me, they recognize me,' but I become timid, and stoop low. (P7)
3. Living in contradictions
Unfortunately, identifying the negative consequences of gambling is not always enough to initiate changes in their gambling behavior. They recognize the contradictions between what they say/know and what they feel/believe.
1) Sinking in the mire
They understand the nature of gambling and "one lucky day" is a misplaced hope in their life. They say that they cannot win money with gambling, and that they are addicted to gambling. Despite these insights into the nature of gambling and their acknowledgement of such an addiction, they are hesitant to quit gambling. This is partly because, deep inside, they also believe that 'one big win will solve all the problems at once.' Gambling is the only way out from a 'today' that is filled w ith problems. Thus, despite a clear and rational understanding of the negative consequences and nature of gambling, resolutions to change hardly surface as an option in their current lives. The gap between what they know and what they are actually doing, and the recognition of it, put them in despair. The following quote showed that a participant is sinking in the mire, while reciprocating back and forth between the alluring and ugly.
It's hard to leave, even though I know that ...ah (big sigh)... Because I lost so much money, ha (heavy sigh)... If a little bit of the money problems were solved...Only if I can take care of more urgent problems, I am saying it to myself, I should go, I should go... but nothing's resolved and instead... I am sinking into the mire even more.(P1)
4. Moving beyond
The theme of 'Moving beyond' emerged from the experiences of 7 former gamblers. Despite their realization of the connection between the place they live and gambling, there are no specific places to which they must return. They decided to stay in casino area as women gamblers living on without gambling. There are four sub themes: 'Thinking of ways to change', 'Facing the need to change', 'Caring for self and others', and 'Taking life as it is'.
1) Thinking of ways to change
The majority of the participants were contemplating changes in two ways: either moving their official address to the city in which the casino is located, or requesting permanent 'self-exclusion.' Self-exclusion is a program that enables a person to ban themselves from gambling venues voluntarily (i.e., access restriction from the casino). In order to minimize the negative consequences to the local community, the Korea's gambling laws allows local residents to only enter the casino once a month. Thus, changing their official residence would limit the number of casino entries to once a month. Requesting permanent self-exclusion to the casino means they would also be offered 4 weeks of psychotherapy and 6 months of support for rehabilitationfrom the K addiction care center, including a small amount for living expenses.
2) Facing the need to change
The process of getting to the point of contemplating changes is not linear but spiral. Only seven people included in this study were able to come to this point while the otherswere still working toward it. Every decision comes with regrets and reluctance to give up, going back and forth between what they know and what they feel. The following statement describes the process one participant went through before she reached the final stage of change after an event that led to a reality check.
I saw an old and haggard-looking woman walking around and asking (for money from strangers, saying) 'I don't have bus fare. Please spare some money.' Ah,(I was thinking) 'I would be exactly the same person. People would point fingers at me... I should quit before I become like her.(P7)
Some of them found that they had already become the one they despise. That became a moment of clarity about what they had become because of gambling.
One day I got to the point that I asked kids who were passing by "you, how much do you have? Give me that"...Later on that day when I got home, I beat my chest with my hands. That's another reason that I decided to quit (gambling). 'This is not it. You have gone too far.'(P5)
The commonly shared factors that affected a change at this stage were: religion (being spiritual); receiving emotional support from family members (either by keeping family ties or mending broken family relationships); and being financially free from gambling debts.
3) Caring for self and others
Once moved out of the daily cycle of gambling, these former gamblers felt as if they were experiencing everything for the first time. Time became a precious and limited commodity for them.
This moment may never come back again so I need to work hard. I didn't know how precious the time was. I didn't feel its preciousness in the past. Now, I deeply feel how precious it is and lament how fast a day passes by. In the past, I was thinking that 'as long as I have money...'(P2)
After a long period of neglect, health becomes an immediate concern. In order to recover their health, the participants now try to maintain a regular exercise regimen, get regular and sufficient sleep, develop health routines, and start to pay attention to a healthy diet, which involves purposeful thinking and intentional efforts.
I am making efforts to live a normal life. And (I'm) so happy. Ah, to lead a normal life... that is, not drinking or taking sleep aids to forget everything, normally waking up at 8 sharp, drinking coffee. Like other women, (I am) cleaning up the room, massaging my face, and sitting down to read the Bible and pray. And then walking around the neighborhood... ah, this is living (laughing).(P5)
Some of them began to look for meaning in life through helping others in the community around the casino. This gives them self-confidence.
I just plan to stay here (a Catholic church) for now. It is not like I have a family to see in Seoul... the situation here is inadequate. I have a prayer group I need to lead. Everyone is old so I need to take care (of them). I also prepare meals for kids (from multi-cultural families)... It is rewarding.(P14)
4) Taking as it is
The characteristic feature in this stage is accepting the present, the past, and who they are. The participants who no longer gamble showed a considerable decrease in expressing self-reproach, self-loathing, and feelings of regret and guilt. Instead, they were proud of themselves for making an effort; patting their own shoulders for their accomplishments. "Ah... I did crazy things...That's it. No regrets though. I am grateful that I finally realized it now. Thanking and praying. I am still praying and giving thanks for this moment."(P15)
5. Constitutive Pattern: Moving beyond addiction by recognizing the two faces of gambling in their lives
Female gamblers first had positive experiences in the beginning of their gambling (Theme 1: Gambling as alluring). The meaning of gambling for them was a way to cope with the feelings of loneliness and isolation. These women could relieve boredom and loneliness through gambling in the beginning stage of gambling. The participants showed commonalities in characteristics. Many of them were either never married or divorced and did not have family members who need their help. Having met in the casino, they shared emotional supports as they would do with their family members. Also, most of them had a hope that they might be able to live a different life if they hit a jackpot. While they dream of a jackpot that would transform their current life, they are experiencing adverse consequences of gambling.
As their live revolved around gambling they lost their health as well as their wealth. They tend to linger around the casino area even after squandering all their fortune. Because of gambling problems, they were rejected by family or relatives or got divorced. The more they were addicted to gambling, the more they feared for their future. The nature of the fear is loneliness: becoming an ugly old lady and dying alone. This was when they started to recognize the negative aspects of gambling. Although they recognized the reality that gambling cannot be profitable, they also kept speculating. At this stage, the health condition of women gamblers had deteriorated and most of them experienced depression and suicidal ideation.
This is when women gamblers started to think about ways to stop gambling based on the information given by the addiction care center. Nonetheless, they were able to request self-exclusion to start their journey to recovery only after they faced a critical or devastating incident that required they change in their gambling behaviors. Seven participants from this study arrived at this stage and were working to get back to their life that was once lost due to gambling by taking care of their health and helping others. Living in the casino area, they had a community where they were not lonely or isolated. Having recognized the two faces of gambling, they let go of regrets from their past and fear for their unknown future and accepted their present life as it is.
DISCUSSION
For the study a group of long-term women visitors in the casino town in South Korea were interviewed. The first theme, "gambling as alluring," covers what initially entices and sustains involvement in gambling among participants. Gambling is a common choice for women who have experienced problem gambling to escape from loneliness and boredom in their lives, to fill in a psychological and emotional void, and to gain a sense of community. In the end, gambling provides meager earnings to sustain their lives. Popular gambling motivational themes for men, such as gambling for competition, challenge, and excitement, were not reported by the participants in this study. Instead, the findings of this study supported the findings of gender-specific motivation to gamble from many previous studies [1214]. Women gamblers in this study used gambling as a way to avoid stress, to relieve boredom, or to escape from feeling lonely.
Soon after they were attracted to the positive effects of gambling, they also recognized the negative aspects of gambling. Basically, they knew the fact that they cannot win big money by gambling yet continued to gamble to make money; they also acknowledged the fact that they should leave the casino area to quit gambling, yet stated that they could not survive in any other places. The incongruence that participants recognize between what they know and what they do becomes unbearable and they are disappointed with themselves. It is important to intervene to make them aware of their contradictions [19]. Thus, a motivational interviewing approach may be effective for helping women gamblers to face the contradictions and ambivalence in their thinking. The goal of motivational interviewing is to facilitate the transition toward behavior change by resolving ambivalence (contradictory thoughts) about change. By recognizing and verbalizing ambivalence, clients can explore the two different "sides" they are dealing with, which can help them work through it [20]. For the women who remained at the stage of 'living in contradiction', journaling also could be a therapeutic tool by providing insight into their gambling through reflective and intellectual process [21].
The theme "moving beyond" explores the process of recovery. Both the type of support and the timing of that support are critical. Instrumental support may enable gambling activities, while emotional support will decrease participation in gambling [22]. In previous literature, family encouragement and continuous acceptance seemed to have an effect on former gamblers only after the gamblers decided to quit [23]. Likewise, the participants who were successful in changing their gambling behavior tended to keep their ties with family or friends outside of the gambling circle, which suggests the positive effect of social support outside the gambling community in the recovery process. Interestingly, the way they related to family differs from those in other studies in western cultures. While women with substance use problems expressed anger toward their estranged family members in other culture [24], Korean women with gambling problems in this study showed guilt and longing for their family, which has also been seen in Korean women alcoholics [25]. Although this study didn't explore the origin of these feeling, we speculate that these may reflect internalized gender role norms the same as the results of Kim's study [25]. In other words, they may have internalized the traditional gender norms, e.g., "wise-mother, good-wife," and then despaired as they found themselves not fulfilling them.
Men often start the road to recovery when family takes a strong stand by refusing to provide instrumental support or enabling behaviors [23], or when spousal support is critical to their recovery [26]. Women problem gamblers often attempt to quit for protection of an important relationship such as marriage [27]. However, most of the participants were not in a marriage, or when they were, their relationship with their spouse was neither close nor supportive. The critical incidents that turned them toward recovery came when they encountered the 'ugly' face of gambling. With a lack of spousal support in the process, the importance of one's own insight is seems to be more critical and essential in recovery. The motive for recovery (quitting gambling) among men was mostly "family." This may be due to cultural expectations for women: If women has gambling problem, they were divorced rather than supported and encouraged for recovery [11]. Two divorced from participants in this study are included in this case.
The recovery process focuses on self-care, altruistic motivations, and spiritual engagement. These were common feature of seven former gamblers who entered the recovery process. This finding was reaffirmed that benefits of recovery include improved physical health and spiritual practices [28]. When the participants quit gambling, they re-focused on their own well-being by taking care of their bodies and minds. Religion also seemed to play a significant role in their daily lives. Pursuing a spiritual life distanced them from the worldliness of life's components, e.g., money, winning, and gambling, and helped them find that their life had a purpose for a higher will. Helping others and contributing to the community helped them to deal with their gambling problems [23]. Likewise, the participants found meaning in life and felt rewarded when their work mattered to someone else's life. On the other hand, nine current gamblers have been stuck at the stage of "living in contradiction" and were gradually "sinking in the mire."
Participants stayed in the casino area because of the social support, or camaraderie, they found among fellow women gamblers whether they still gambled or not. Thus, the initial motivations for gambling (loneliness and isolation) became a reason to stay in the area. This may suggest a professionally guided selfhelp group as an effective intervention modality for this population. Participation in such a group may satisfy the need for social support and a feeling of belonging, as well as move the recovery process forward through group-based therapeutic factors [29]. In the case of the participants in this study, the former and the current gamblers attended the guided self-help group regularly at the K addiction care center. The participants said that the group gave them a sense of belonging and at the same time confidence and desire to change.
Constitutive pattern in this study is moving beyond addiction by recognizing the two faces of gambling in their lives. It tells that the first step to resolve the problem of women gamblers is to recognize contradiction and ambivalence about gambling. This step takes a long period of time going to back and forth, it is the key protective factors to be with them exploring their recovery capital. At this time, it is important to take care for their belonging needs and fear of loneliness so as to ensure stable journey. Fear was a common theme shared by the participants. However, the fear that grew out of previous experienceshas given rise to a fear for the future in the face of critical incidents among the former gamblers. For instance, they are fearful of being stuck in the casino area, and of continuing to gamble even in their late adulthood. Some participants had the so-called "hitting the bottom" experiences that may have led them toward the path to recovery. It may be possible that, the current gamblers may have not yet experienced a critical incident or could not have gained an insight from it to change their gambling behavior. Further studies are needed to identify major keys to recovery among these women.
Although this study offers in-depth insights, the study findings should be interpreted with caution for several reasons. First is the sampling limitation. This study explored gambling issues among women gamblers who stayed in the casino area even after they had lost all their fortunes, thus excluding women problem gamblers who may not be staying in the casino area, or those who may engage in other forms of gambling. Second, the study results may not be applicable to women problem gamblers in other cultural contexts. Despite the limitations, this is one of the first efforts aimed at understanding problem gambling from the perspectives of women gamblers in South Korea.
CONCLUSION
This study explored the meaning of gambling through the stories of woman problem gamblers who were living around the casino area. We were able to find out how and why these women continue to gamble or stop gambling, and identified their needs and concerns. These results can help in designing culturally appropriate and gender- specific intervention programs for women problem gamblers in South Korea. Loneliness and isolation play a critical role in gambling experiences of women gamblers in Korea. That is, gambling motivation, effects gained from gambling, the reason for change of gambling behavior, and the reason why to stay in the casino area are all associated with escaping from loneliness. In other words, they are motivated to gamble in order to escape from loneliness, to stop gambling for fear of having lonely life when older, and to stay in the casino area so as not to be alone. This is in contrast with men who pursue gambling for challenge and excitement. Intervention programs should focus on the underlying motivations for wanting to gamble, exploration of the contradictions, and both mental and physical self- care to recover from multiple losses due to gambling problems.
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