Using Photovoice With Male Problematic Gamblers to Understand Their Lived Story on the Path to Recovery in South Korea

Illegal gambling has significantly affected individuals’ lives in South Korea, and it is difficult for problematic gamblers to recover despite the decreasing rate of problematic gambling. This study used photovoice to explore the life experiences and desires of seven male problematic gamblers in a rehabilitation center during their path to recovery in South Korea. Photovoice consisted of six sessions involving orientation, photo-taking and group discussions of photographs, and sharing of outcomes. Twelve subthemes emerged within four main themes predetermined by the participants: (a) my life after gambling, (b) what I have lost from gambling, (c) what would help my recovery, and (d) picturing myself recovered in the near future. Participants’ lives had completely changed after they started gambling; particularly, their personality had been negatively affected and their life became filled with mental suffering. Their financial well-being was compromised, their health worsened, and they lost the trust of other people and a sense of purpose in their lives. Despite these challenges, they made tremendous efforts to recover from gambling and pictured a recovered future. The lived narratives provide evidence that recovery from gambling problems is a long journey including recognition of the problem and development of personal strategies that are perceived as beneficial for their recovery and strengthening their motivation for change.

Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Original Research
Problematic gambling has become a significant issue across the world. Since the Korean government legalized Kangwon Land, the only casino resort for Koreans, in 2000 as a strategy for economic revitalization in the province of Kangwon, problematic gambling has been an important social issue (T. W. Lee, 2001). In South Korea, among adults aged 20 or older, an estimated 2.22 million are problematic gamblers (Korean National Gambling Control Commission, 2018). Although the prevalence of gambling participation in South Korea has been relatively low (Williams et al., 2013) and the proportion of problematic gamblers has been decreasing from 6.5% in 2006 to 5.3% in 2017 (Korean National Gambling Control Commission, 2018), the repercussions of illegal gambling and its market size are rapidly growing in South Korea. Furthermore, South Korea, where the internet is the one of the most advanced in the world, illegal online gambling has seriously affected the lives of citizens (Korean National Gambling Control Commission, 2019). In a study of more than 4,000 adults, Williams et al. (2013) reported that having more gambling facilities, gambling on the internet, male gender, mental health problems, sports betting, motivations for gambling, and lower income predicted problematic gambling in South Korea. Male gender is a risk factor for problematic gambling; according to Korean National Gambling Control Commission (2018), the share of male problematic gamblers is almost 3.8 times higher than their female counterparts (8.4% vs. 2.2%, respectively), in South Korea, indicating the significance of gambling problems for men.
It is widely known that problematic gambling negatively impacts quality of life Eby et al., 2016) and the life of the gambler's family (Chan et al., 2016;Dickson-Swift et al., 2005;Kalischuk et al., 2006;Kwan et al., 2020). In a qualitative study with gambling addicts in Korean (Chun et al., 2011), they experienced various harmful effects, including social and psychological problems, mainly in the areas of finance, employment, physical and mental health, interpersonal relations, and criminal and legal issues. Problematic gamblers tend to have psychological distress resulting from both consumer debt and debt-related problems (Oksanen et al., 2018). Compared with nonproblematic gamblers, they are more likely to have health risk behaviors, such as poor diet and low physical exercise, and thus have poor general health (Butler et al., 2020). Although stigma toward addictive gambling behaviors varies depending on gambling types, gambling behaviors are strongly stigmatized, thus creating distance toward gamblers (Peter et al., 2019) that can bring self-stigma and shame (Hing & Russell, 2017). Furthermore, previous studies found that relapse rates of problematic gambling were high (Oakes et al., 2012), indicating the importance of recovery. Gambling-related urges and cognition were associated with relapse in problematic gambling (Smith et al., 2015). Thygesen and Hodgins (2003) found that either cognitive or behavioral strategies, such as stimulus control, selfliberation, counterconditioning, and helping relationships, were the preferred strategies to avoid gambling relapse.
Previous studies qualitatively explored recovery experiences (K. M. Lee & Lee, 2019b) and stigmatized experiences of problematic gamblers in South Korea (K. M. Lee & Lee, 2019a). Although these studies have advanced our understanding of life experiences of problematic gamblers, the topics discussed were determined by the researchers, and we still know little about what problematic gamblers are really concerned about and need for recovery, from their perspectives. As a community-based participatory action research methodology, the photovoice method developed by Wang and Burris (1997) allows participants to identify and represent important issues through discussion of photographs, helping their voice reach policymakers. Given the benefits of using the photovoice methodology with individuals with addiction problems, photovoice was previously used with children of parents with addiction problems (Malka et al., 2018) and adolescents at risk of internet gaming addiction (Seok et al., 2018) in South Korea, as well as adults with alcohol dependence (Shortt et al., 2017) or people who use drugs (Padilla et al., 2019) in the United States. However, experiences of adults in the recovery process from problematic gambling using their own voice have not been understood. This photovoice methodology will help better understand the process of change using a strengths-based lens, not a deficit perspective. To address these gaps, this study explored the lived experiences of men who engaged in problematic gambling and their desire for recovery in South Korea using the photovoice methodology through group discussions and visual representations.

Study Setting and Participants
Our study participants were seven adults who were attending a short-term residential rehabilitation program that provides 4 weeks of psychosocial rehabilitation in the domains of cognition and behaviors, emotion, relationships and social, spirituality, and alternatives at the Korea Center on Gambling Problems (KCGP). KCGP was established in 2012 by the Revision of the National Gambling Control Commission Act (2012) and provides problematic gamblers and their families with information, support, and counseling for the prevention and treatment of problematic gambling in collaboration with local counseling agencies and hospitals. Inclusion criteria for the short-term residential rehabilitation program at the KCGP are (a) problematic gambling (scored more than 8 on the Canadian Problem Gambling Index; Ferris & Wynne, 2001); and (b) experiences of problematic gambling relapse within a year among those who received services at the regional centers of KCGP or private counseling agencies designated by the KCGP throughout South Korea. Fourteen regional centers of KCGP or private counseling agencies received information about this program and research and were asked to recommend participants who met the criteria. KCGP headquarters received applications from 10 voluntary clients. Of those, one declined participation before the program started and two dropped out right after the program started. Thus, we chose seven participants to understand their lived narratives of recovering from problematic gambling while attending the program. Although this sample might not be sufficient to understand the lives of problematic gamblers in South Korea, they were the first and only participants who used the shortterm residential rehabilitation program, which had just started in South Korea. While participating in the 4-week rehabilitation program, the participants reflected changes in their thoughts and experiences (e.g., motivation for stopping gambling, expectations for the future) through our participatory action research. Thus, we can benefit from the lessons they learned on their path to recovery from their lived experiences while participating in the program.
Our study participants' characteristics are presented in Table 1. All participants were male, and their ages ranged from 21 to 41 years old. Five were never married and the other two were divorced. Their highest education was university graduate, except one who reported earning a high school degree. All participants were currently not in the workforce. Their gambling periods ranged between 1 and 6 years, and their time since last gambling was between 1 and 3 months. Three had been hospitalized due to problematic gambling. All participants had engaged in online gambling, such as sports gambling, online casinos, and a lottery game known as ghost lag (Table 2).

Procedures
Six sessions of photovoice were held at the office where the rehabilitation programs are provided in June 2019. The first author, who has experience conducting many photovoice studies with diverse participants with disabilities and mental illness, facilitated the photovoice project. One research assistant who was a postdoctoral fellow in social work assisted with the project. Photovoice sessions consisted of the first session (orientation and group discussion to select themes), second to fifth sessions for photo-taking and group discussions about experiences related to the photos, and the last session for sharing photovoice outcomes with community stakeholders to increase awareness of problematic gamblers.
In the first session, the participants learned about the purpose and procedures of the photovoice study and their responsibility as participants (i.e., theme selection, phototaking, group discussion, etc.). After short icebreaking activities in which participants expressed their feelings about their current state using their selection of given pictures prepared by the research team, they started engagement in 1-hour group discussions to select a theme for the next session. Because all participants attended rehabilitation programs all day together, they appeared to feel relaxed about describing their experiences and feelings. Participants had openly shared their gambling experiences and desires for recovery (e.g., what made them start gambling, their life after gambling, what motivated them to attend rehabilitation, and their plan after completing the program). Of those topics, they determined the theme they would like to take pictures and talk about in depth using the photos. Once the theme was determined, all participants were asked to take several photos that express the feelings or experiences related to the selected theme and add a title that best illustrates their story.
Before the second session, they choose two or three key photos to share with the other participants, and photos were projected on a screen to be viewed by all participants. In the second session, all participants participated in a 2-hour group discussion in which each participant shared lived narratives reflected in the pictures they took and other participants shared common or unique experiences. At the end of the second session, they had a brief discussion to choose another theme for the next session. In some cases, discussions were held between participants on whether there was a better theme, even after the session, and an agreement was reached to finalize the topic.
The third to fifth sessions were conducted the same way and were completed in 4 weeks while they were attending the program. The last session was conducted a month later to celebrate their completion of program and share their pictures with narratives during the photovoice sessions and their reflections on study participation with others to increase awareness. We invited family members of the participants, center staff, and other center users who attended rehabilitation programs, and they also shared their feedback and thoughts on problematic gamblers whom they otherwise would have never known without learning about their photovoice experience.

Ethical Considerations
The study procedures received approval from the institutional review board of Ewha Womans University, with which the principal investigator (corresponding author) is affiliated (201906-0022-01). All participants received an explanation of the study and provided both written and verbal consent a week prior to the study.

Data Analysis
Our data for analysis were photos submitted by the participants, transcripts of group discussions, and researchers' field notes. Group discussions were audio recorded and transcribed verbatim by an independent transcriber. The accuracy of the transcripts was checked and then the text was uploaded to ATLAS.ti software for data management. According to the six steps recommended by Braun and Clarke (2006), thematic analyses were conducted by the research team. First, we read the transcripts repeatedly to familiar ourselves with data. Second, we assigned open codes to each transcript that discussed each theme. Within each predetermined theme, we searched for subthemes by merging and grouping similar codes in each group discussion. Fourth, we reviewed subthemes to determine if the themes had sufficient data or the hierarchy was consistent across subthemes. Fifth, we defined and named themes that comprehensively captured experiences related to the themes. Finally, we presented our themes with quotes from the participants, using pseudonyms.

Results
Twelve subthemes related to problematic gamblers' feelings and experiences during their recovery journey emerged within four main themes predetermined by the participants: My Life After Gambling I found myself completely changed. All the participants said they felt dramatic changes after they started gambling because betting made them feel nervous and focus on only money. They perceived themselves as active, social, reliable, and hardworking as their original identity (before engaging with gambling), but they acknowledged that they became hypervigilant, aggressive, lazy, unsanitary, isolative, and unemotional after becoming addicted to gambling. Sunwoo mentioned that before gambling, he was resourceful and comfortable meeting with people, but now he doesn't have any plan for life and procrastinates. Similarly, Dongwoo showed a metaphor for his life: a rose that had blossomed but became withered (Figure 1). Most importantly, all participants said they realized that they lost their social role as a member in the community (e.g., workplace, social gatherings, etc.) after gambling. Sangmin mentioned that a lot of people knew his name before, but now they call him "gambler" and use swear words. He desperately "wanted to find my name again." They said they felt that their true identity was not there anymore.
My life feels like hell after gambling. All participants agreed that their life felt like "hell" after they became addicted to gambling. They got addicted to gambling because they were fascinated with the experience of making large amounts of money in a very short time compared to working. They felt so thrilled when they won and believed that gambling would make their life better and happy. One participant said he felt "like I'm in heaven when gambling and didn't know that it was actually in the hell at that time." However, gambling resulted in negative consequences for many aspects of life, such as relationships with family and friends, financial issues, and job status. Hoon, who was divorced because of gambling issues, mentioned that he felt so devastated when he was kicked out of his home and told by his daughter that she doesn't need a father anymore. Sunwoo mentioned that his life became meaningless and impoverished like garbage on a street, as shown in Figure 2.

What I Have Lost From Gambling
Financial well-being. Although their struggle with financial difficulty varied, all participants said they felt desperate and miserable because they ended up deep in debt that was not Note. I used to laugh a lot before I started gambling. But after gambling, I withered. I didn't feel any emotion and often felt down. I stayed home most of time, and I didn't even meet anyone. under control. They continued betting larger amounts to overcome gambling losses, and this made their debts continue to increase. Some participants continued to pay off their debt, whereas other participants gave up and declared bankruptcy. In addition to gambling debt, they lost their job because they could not concentrate on their work, which made their life financially challenging. All participants were struggling with financial problems and thus, it was difficult for them to pay their living expenses.
Health. All participants mentioned worsening health, which is the most important thing in their life. While they concentrated on gambling, they did not eat, sleep, or engage in any physical activities, so they became physically ill and their health deteriorated. Dongwoo had problems with his immune system and his skin broke out after he started gambling. Other participants had other physical pains, such as numb hands and neck pain because of overuse of a computer and mouse. Two participants also experienced stress that they could not control over gambling results. Sangmin had circular hair loss and Kangmin had liver-related problems because of gambling-related stress.
Trust in a relationship with people. Participants said they lost trust in their relationships with others, such as friends, relatives, and significant others. They often told lies to get money from others for gambling. However, they did not pay it back because they lost the money gambling and thus, they kept making excuses, which led to loss of trust. All participants mentioned that they deserved this loss of trust and disconnection from others and did not think that their relationships could recover. Particularly, two participants said they felt they lost everything when they lost the trust of family members who provided unconditional love and support toward them. They often lied about their gambling habits or financial problems to their family, and their family felt betrayed upon finding out where all the money had gone. They mentioned feeling they had "nothing left to lose" when their family gave up on them. Hoon, who has two children, expressed guilt toward his family when he lost all their money.

My ordinary daily life and purpose of my life.
All the participants also lost aspects of ordinary life, such as going on trips with friends or family members, dating, or enjoying hobbies. They spent most of their time gambling and thus, they lost interest in their life other than gambling and didn't even eat and sleep. They lost precious time in their life, along with a sense of purpose and meaning of life, which used to give them direction. Thus, they mentioned that they couldn't imagine their future and feared that they might not have an ordinary life, as shown in Figure 3.

What Would Help My Recovery
Escaping from the past. Participants mentioned that they can recover from gambling addiction by escaping from the past. In the past, their life was filled with bad attitudes toward life, such as lies and bad behaviors. So, they have to stop those behaviors and attitudes and plan a new life. Particularly, Hoon wanted to discard their previous life and become a new person like the cicada, which spends most of its life as an underground nymph before hatching and emerging into the world, as shown in the Figure 4.
Healthy life patterns and environments. Three participants agreed that they desperately need new environments and regular activities to keep them away from the temptation of gambling and achieve recovery. For them, it was important to keep engaging in physical activities and developing their capacity (e.g., pursuing a professional degree, studying a foreign language, earning licenses for a career, etc.) to develop regular life patterns. Writing a diary for recovery, participating in a Gambling Anonymous (GA), and attending counseling sessions also helped them embrace environments that prevented gambling relapse.  My motivation to stop gambling. All the participants acknowledged that the most important thing for their recovery was their strong motivation to stop gambling. They knew that gambling addiction is too strong, making them to lose control and relapse. They mentioned that they often fight both instincts-to gamble and to stop gambling. Without willpower, they said they would never stop gambling. However, they knew that although they might try very hard to stop gambling, their willpower can disappear instantly. They mentioned that they have to change their life perspective toward money and build a positive purpose in life, which can strengthen their motivation for change.

Picturing Myself Recovered in the Near Future
Become hardworking. Two participants said they hoped to find their interests and work in a field where they feel accomplished when they recover. Some participants wanted to go back to their previous work, but other participants wanted to develop a new career, such as pursing postsecondary education or acquiring certificates with job skills. Ultimately, all participants hoped to pay off their gambling debt and achieve financial well-being. Dongwoo pictured paying off his debt and buying his own apartment, as shown in Figure 5.
Having control over my life. All the participants said they hoped to regain control over their life so they felt they could handle their life issues on their own. For example, they hoped to discipline themselves by reading a book or quitting alcohol and smoking-challenges they otherwise could not do. Several participants hoped to work as a peer counselor to help other gamblers recover from gambling issues, once they continuously maintained their control over their life.
Enjoying a peaceful life. Participants pictured themselves enjoying a peaceful life similar to other people. They hoped to live an ordinary life and feel happiness by exercising, having meals with family members, and taking walks. All partic-ipants currently had their cellphone or computers taken away to prevent gambling. They also hoped to feel comfortable with having cellphones and computers without any temptation to gamble.

Discussion
In this study, we attempted to understand problematic gamblers' experiences and their journey to recovery using photovoice methods. Our study participants acknowledged that their life had completely changed after gambling. Their personality had been negatively affected and their social identity disappeared. Their life was filled with miserableness and mental suffering. Particularly, their identity completely changed after they started gambling and they felt stigmatized when labeled as "gamblers," as consistently reported in previous studies (Chun et al., 2011;Hing et al., 2016). Recovering from gambling is the process of reshaping their self-identity connected to society from the addicted and helpless "gambler identity" (Reith & Dobbie, 2012). Their recognition of self-change due to gambling and their desire to regain their original identity could give them motivation to initiate recovery.
Our participants reported that they lost significant amounts of money and thus, their financial well-being was compromised. Our study results are consistent with previous findings that bankruptcy was among the most severe harms for both gamblers and affected others (Li et al., 2017). In our study, loss of money accelerated their loss of health and even their social life. Because gambling-related debt problems result in psychosocial difficulties (Swanton & Gainsbury, 2020) and socially affected their nongambling family and communities (Downs & Woolrych, 2010), participants in our study lost the trust that is essential in social relationships and even ordinary daily life. As our participants shared, reminding themselves of negative consequences and loss of gambling is a pervasively used strategy among gamblers (Rodda, Bagot, et al., 2018).
Our study participants made efforts to recover and perceived significant strategies that may facilitate their recovery, which shows their perceived position in this recovery process. Such findings are consistent with findings that once problematic gamblers recognize the problem, they have an impetus for recovery, either by externally directed or selfdirected pathways (Vasiliadis & Thomas, 2018). In our study, they needed to gain control through healthy life patterns and safe environments to help them successfully manage gambling urges and manage external environments, indicating the need for externally directed strategies for recovery. Particularly, environmental control is known to be significant factor to impose a boundary or stop gambling in the context of internet-mediated gambling, in which our participants had engaged (Siemens & Kopp, 2011). On the other hand, they also acknowledged that they had to abandon their past life patterns and behaviors that often made them relapse. Most importantly, their motivation for change is essential to preventing gambling relapse. Although informal support from family and friends can be an important resource to change their gambling problems (Bond et al., 2016), the gamblers perceived themselves as the primary agent of their recovery process.
Although our study participants were in a rehabilitation program, they pictured a future in which they had recovered from gambling. Similar to what has been found in previous studies (Pickering et al., 2020), this "recovered" future was not limited to not engaging in gambling behaviors and managing gambling urges, but it meant enjoying a flourishing life, such as working hard at a workplace, spending peaceful times with their families and significant others, and having control over their life. It is consistent with previous study findings that the meaning of recovery to problematic gamblers can be further extended to various dimensions of psychosocial well-being beyond financial stability (Pickering et al., 2020).
This study's findings fit into a model (Gavriel-Fried & Lev-El, 2018) that conceptualizes recovery capital in a range of domains (i.e., human, community, cultural, social, and financial) that are needed in the gambler's recovery process. Particularly, the current findings suggest the need to develop interventions that stimulate cognitive changes by identifying loss resulting from gambling behavior, which can help gamblers recognize the problem and initiate recovery. Motivational interviewing, which was found to be efficacious for reduction in gambling in the short term (Yakovenko et al., 2015), can be applicable to problematic gamblers to strengthen motivation for change. This study also shows that a variety of behavior change strategies are needed to help quit problematic gambling. Problematic gamblers' change strategies are complex and thus, tailored interventions should be developed for those individuals considering their recovery stage .

Recommendations
Future research may overcome the limitations of the current study. First, our study sample size was small and may not be sufficient to generalize findings to the lives of all problematic gamblers in South Korea. Our study sample was in a short-term residential rehabilitation center and thus, their experiences may provide lessons to other populations with gambling problems who are served through rehabilitation programs. Second, our study sample had diverse demographic characteristics in terms of age and marital status. These factors could affect their struggle and motivation for stopping gambling. Future studies could examine how their trajectory varies depending on those individual factors. Third, our study sample was male, and female gamblers' experiences should be examined in future studies. Fourth, our study sample had engaged in illegal online gambling and had varying severity of gambling problems that may have differently affected their life. Finally, future studies could focus on longitudinal changes in terms of cognitive and behavioral aspects while they received rehabilitation.

Conclusion
The narratives shared by problematic gamblers in this photovoice study provide evidence that recovery from gambling problems is a long journey beginning from recognition of the problem and moving toward constantly developing their own strategies that are perceived as beneficial for their recovery and strengthening their motivation for change. This study highlights the role of clinicians in enhancing gamblers; motivation for change and building a long-term plan for their recovered life in the future. Problematic gamblers could achieve recovery not only by suppressing the urge to gamble and preventing relapse, but also by regaining their identity and ordinary daily lives that were lost to gambling.

Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported by a grant of the Korea Center on Gambling Problems

Ethical Approval
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was approved by the ethics committee of Ehwa University (ewha-201906-0022-01).