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An estimated 3-5% of all individuals who gamble will become compulsive gamblers. This "invisible addiction" can be financially and emotionally devastating to both the gambler and his/her family. This timely clinical manual explains why gambling is on the rise and the factors which distinguish recreational and compulsive gamblers. Mental health professionals will learn how to assess and treat compulsive gamblers using a variety of interventions: behavior therapy, inpatient treatment, family therapy, and 12-step programs.
The book contains black-and-white illustrations.
An Introduction to Gambling and Gambling Disorders.
Paradigms of Problem Gambling Behavior.
The Phenomenology of Gambling.
Etiologies and Maintenance of Gambling Disorders: A BriefReview.
Treatment for Pathological Gambling: Inpatient Programs andGamblers Anonymous.
A Multiphasic Model of Outpatient Treatment.
Working Strategies for Treatment Success: The Pragmatics of Therapyfor Abusive and Addicted Gamblers.
Assessment of Gambling and Gambling-Related PsychologicalDisturbances.
Chaos Theory, Gambling, and Addictions: Speculations on New Methodsof Nonlinear Treatment.
Family Systems Therapy: Treating the Patient and the System.
Epilogue: Considerations for Future Research andInterventions.
An Introduction to Gambling and Gambling Disorders
DIANNE* IS a 47-year-old physician. Despite a very successful practice in internal medicine, she is always "running out of money." Recently, she has begun to drink excessively and is often hung over during the morning medical rounds. Her only social life revolves around daily visits to a casino to play blackjack, a game that she believes she can eventually learn to beat. During the past two years, Dianne has lost over $87,000 while gambling, including $20,000 that she lost during a two-week junket to Las Vegas. Despite these losses, Dianne does not see her gambling as problematic. "The only problem I have is when I lose," she says matter-of-factly.
Bob, 25, is a part-time bartender and a graduate student in English. As part of his bartending chores, he channels illegal bets from bar patrons to his boss and his boss's associates. He simply writes down a patron's code name and wagered amount; at the end of each day, someone comes by to collect the sheet. He knows that his boss is heavily involved in underworld activities, but Bob has begun gambling himself. He already owes several thousand dollars to his boss's "business partner" for wagers on the recent collegiate basketball tournament finals. His boss tells him that he can "work off the debt" by agreeing to sell shipments of cocaine. Bob is desperate and, despite the danger, agrees to this arrangement. Although he would very much like to quit gambling, he admits that it is "tremendous fun" and that he constantly thinks about winning "the really big one that would let me break out of here."
Nate is a 16-year-old suburban high school student who buys lottery tickets from his older brother's friends. He has no consistent income, but he still manages to buy ten or more tickets each day, often at the inflated prices that accompany these secondhand transactions. He also bets liberally on sporting events and is usually heavily in debt. To finance these wagers, he often engages in "theft to order"-- soliciting a buyer for merchandise that is not yet stolen. Despite his young age, Nate has shoplifted thousands of dollars' worth of computers, audio equipment, cameras, and other high-ticket items. He would like to quit "wasting my money" because he knows he will eventually be caught. "I want to be a chemist someday," he notes. "I don't know too many chemists who have gone to good schools and have a shoplifting history." However, when he does not gamble, he becomes cranky, nervous, and agitated. For a while, he became interested in computers, but he quit because "I was developing an Internet addiction."
Dianne, Bob, and Nate share two things: (1) they have problems with gambling, and (2) their cases had poor outcomes. They were improperly diagnosed and treated by various mental health professionals. Their gambling problems were never addressed or appropriately treated. As a result, they experienced financial devastation, legal problems, elevated psychiatric symptoms, and, too often, complete personal disruption. One client almost succeeded in a serious suicidal attempt. We believe there was a strong probability that these clients' behaviors could have been changed by adequate and appropriate therapeutic interventions. Unfortunately, clinicians treating these cases knew almost nothing about problem gambling behavior.
The primary purpose of this book is to provide clinicians with an understanding of the variety of gambling disorders. Problematic gambling behavior is at epidemic proportions, and this growth will continue (Volberg, 1996; Volberg, Dickerson, Ladouceur, & Abbott, 1996). Available theory and research on gambling are often deficient (Gowen & Speyer, 1995; Griffiths, 1996b; McCormick, 1994; Murray, 1993). Furthermore, inadequate resources are now devoted to the prevention of problem gambling behaviors (Goodman, 1995; McCabe, 1992). We believe that this lack of prevention may incur massive social costs for future generations.
The goals of this book are modest. Our purpose is to highlight the problems, possible causes, and treatment options for people who exhibit excessive gambling-related behaviors. A book cannot make its readers into experts. This process occurs through training, supervision, scholarship, and experience. Nor do we attempt a comprehensive review of gambling literature, theory, or treatments. Instead, we present clinical strategies that have worked for our colleagues and for us. Few treatments in the gambling literature meet the rigid standards that would qualify them as "scientific." Far more research is needed.
We have attempted to remain impartial about the expansion of wagering opportunities, which is occurring at an almost logarithmic pace (Marvel, 1994; Moody, 1995). The expansion is propelled by economic, moral, and political decisions that are beyond the scope of this book. The Internet has carried the problem worldwide (Galston & Wasserman, 1996). We feel that it is vital for clinicians to concentrate on what they do best-- changing behavior. Discussions for which they are less prepared only distract from the seriousness of the clinical problem.
The word gamble has at least two important meanings. According to Cambridge International Dictionary (1999), its primary meaning is "to play games of chance for money or other reward." A secondary meaning is "to take a risk in order to gain an advantage." The etiology of the word gamble is unclear. It probably relates to the Old English word gamenian, meaning "to play," from which we derive the present-day word gambol (frolic) (Onions, 1966). It may also be distantly related to the Old French word gambet, which evolved into the current term gambit, meaning "a maneuver or action intended to gain an advantage." The irony is that people who develop a problem with gambling-related behaviors view their actions as gaining a financial advantage, while the rest of the world simply sees them wagering unsuccessfully.
Data indicate that most people in the world have gambled (Herman, 1967; Kusyszyn, 1972), even when gambling opportunities were scarcer than they are today (Lesieur, 1994). The great majority of people who gamble do not lose control of their behaviors. Like alcohol use, for most people, gambling is a pleasant pastime, a benign amusement. Yet, for a small subset of people, gambling is a serious behavioral disorder that is associated with depression, anxiety, substance abuse, theft, family disruption, and suicide. These people are labeled as "pathological gamblers" in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; APA, 1994). From a psychological perspective, they have failed at self-regulation (Baumeister, Heatherton, & Tice, 1994).
Griffiths (1996a) provides an excellent historical review of the concept of the pathological gambler. Its evolutionary nature is not unlike that of alcoholism. Most national surveys about gambling behavior have concluded that, in almost every culture, there are more gamblers than nongamblers. Furthermore, although most gamblers can control their gambling behavior, a small minority, probably 3% to 5%, will inevitably be labeled as suffering from pathological gambling. Some people in this group eventually seek clinical intervention, but knowledge of how to undertake successful treatment is still scant (Murray, 1993).
Despite its importance, the development of pathological gambling behavior is controversial and poorly understood (Brister & Brister, 1987; Griffiths, 1996a; Hollander & Wong, 1995). Clinical research regarding appropriate treatments of gambling disorders is scant, partly because of inattention and partly because of a lack of funding (Ladouceur, 1996). Society is slowly beginning to realize that, for an important minority of people, gambling can be as disruptive as any other addiction (Walters, 1994). This disruption affects individual gamblers, their families, and, often, their entire social systems (Hraba & Lee, 1995).
Some of the current alarmist headlines cast gambling as a new behavior, almost like a mutant virus that suddenly finds an environmental niche (e.g., Gallo, 1994). Coverage in the popular press frequently vacillates between condemning the apparent gambling "epidemic" as an intrinsic evil and praising the gaming industry for solving the economic problems of large urban areas and rural poor communities. Not surprisingly, the truth is far from both extremes. Gambling has been a ubiquitous phenomenon throughout history (Eisenbuch, 1977). Indeed, according to some authors, gambling is older than money itself (Kusyszyn, 1978). Although it is problematic for some people, its roots are deep in our past.
Gambling may actually predate history by many millions of years. Palmer and Palmer (2000), in an evolutionary behaviorist perspective, argue that analogues of human gambling can be found in the decision-making processes of animals trying to pass their genes on to future generations. They develop mating strategies that are beneficial and give them a reproductive advantage, compared with others of their species. Usually, these strategies involve mating with the strongest or most likely fertile partner that is available. Occasionally, though, animals "gamble" with their genetic lineage by mating with an atypical partner that has traits not usually classified as ideal. In a sense, they are gambling on a "long shot"; their mate has genetic characteristics that might be adaptable in conditions of marked environmental change. This "long-shot mating" may make genetic variability much more probable, enabling the species to adapt to dramatic new conditions that may suddenly emerge.
GAMBLING IN ANCIENT AND MEDIEVAL HISTORY
Regardless of their evolutionary roots, games of chance have been developed throughout human civilization. Early humans apparently used the process of chance to select individuals for certain tasks, provide entertainment, exchange property, or settle disputes (Kusyszyn, 1977). Car-tons made of bones, found in prehistoric caves, apparently represented the modern-day equivalent of dice. By the time of the ancient Egyptians, a popular game involved participants' guessing the number of fingers upheld by a priest or other important figure. Often, life or death decisions were based on the outcome of this simple, childhood game. The ancient Greeks developed similar games that were played with another primitive form of dice.
One of the early uses of the printing press was to make specially marked playing cards. With the invention of movable type, developed in China fifteen hundred years before it appeared in Europe, entirely new games of chance and gambling opportunities were created. This tradition spread rapidly to the Arab world, where it remained despite antagonism from Islam. Professional bookmakers-- persons who collect and make wagers for a living-- arose during this period (King, 1969).
Games of chance were particularly popular in more advanced cultures, such as the early Jewish nations, where gambling was used in an attempt to link the physical and spiritual worlds. Early Hebrew scripture refers to this form of gambling as the "casting of lots"-- small, flattened stones that were tossed much like dice (Baly, 1978). The direction that these stones pointed out, once they hit a diagram or the bare earth, indicated the winner of the decision in question. Casting of lots was used in assigning land among tribes (Num. 2: 55; Josh. 18: 10), in the selection of men for expeditions or battles ( Judg. 1: 1-3; 20: 9), and even in the detection of guilty parties ( Josh. 7: 14; 1 Sam. 14: 40-42). The role of chance was also used in selecting the first Jewish king (1 Sam. 10: 20-21), and in determining the role of priests in temple worship (Luke 1: 5-9). According to scripture (Matt. 27: 35), Roman soldiers cast lots for the clothing of Jesus Christ during his execution.
The Roman civilization, especially during early Christian times and onward, seems to have been especially interested in gambling. Prior to this, Julius Caesar, in 49 B.C., is supposed to have cast lots to determine whether he should attack across the Rubicon and march on to Rome. He did, and the civil war with Pompeii then followed. The expression "The die is cast" (Alea iacta est), attributed to Caesar as head of his rebellious army, indicates the seriousness afforded to casting a die. Similarly, the expression "crossing the Rubicon" now indicates an irrevocable commitment.
In Rome, the Coliseum is a monument to how the ancients cherished the sport of chariot racing. A remnant of these competitions survives in our present-day sport of harness racing. (Wagering on horses ridden by jockeys seems to have been a later variation.) The Coliseum also provided the wagering public with opportunities to bet on the outcome of bloody gladiatorial conflicts.
The history of gambling indicates that it coexists quite well with monotheism. During the Dark Ages, games of chance were popular in Hebrew, Islamic, and Christian communities. This may seem to be contradictory to the traditions of the great religions, inasmuch as most sacred writings are, at best, ambivalent about gambling. Yet religion may foster wagering because it may encourage belief in luck (David, 1998), and few religious people or communities want to believe that life's misfortunes are due to their own inadequacies or are deserved. Belief in luck postulates that a force outside of Providence helps to shape our destinies (Curtain & Bernardo, 1997). While this may be psychologically necessary, it also may foster problem gambling. Social history repeatedly shows that wagering is much more common when people believe that luck is an important determinant of their behavior (O'Brien, 1998).
Not surprisingly, because of (or despite) religion, gambling flourished during most periods of Western history (Deutsch, 1990). Until the Crusades, gambling was probably as common in Islamic societies as it was in Christian Europe. Games of chance were everywhere in medieval life (Brenner, 1990). Peasants and Bedouins wagered on the weather, the yields of neighbors' crops, and the dates when babies would be born. Tribal or community festivals were especially celebrated with wagering (F. Rosenthal, 1997). Gambling was one of the few recreational and intellectual activities available, and almost every faction of society pursued it with vigor.
Following the Crusades, gambling became even more common in Europe. Most wagering was heartily proscribed by Islamic cultures as a "Christian vice" during this period (F. Rosenthal, 1997), but Europe's economic and political ascendancy witnessed the rise of the first independent bookmaker (Marx, 1952). Landed classes could place bets with someone other than their friends. Much of the early postal traffic involved correspondence regarding such bets. There is some evidence that ruinous debt acquisition from gambling became common during this period. Nobles wagered high stakes on animal fights, natural events, races of all sorts, and card games (Ashton, 1969).
Gambling among the artisan and peasant classes became more common only with the rise of surplus production (Chinn, 1991). Farmers with small excess could risk it all for the opportunity to receive much more than they ever could produce by themselves. The advent of a currency-based, rather than bartering-based, economic structure encouraged personal speculation. The lack of life opportunities afforded to people during this period added urgency to these wagers. By the time of the Renaissance, peasants and artisans frequently gambled in taverns, towns, and even in churches, with a zest that would shock even present-day observers. For many people, then as today, gambling was perceived as one of the only chances for bettering one's station in life. Superstition, irrationality, and the absence of education fostered these beliefs.
With the rise of capitalism and peasants' migration to cities, gambling became even more common (Geha, 1970). During this period, society witnessed its first large-scale problem of chronic gambling by many citizens. Alcoholism and gambling became common addictions during this period of social change. Working-class people often gambled much more than they could afford to lose. The results were predictably disastrous. Many people were incarcerated for debts incurred in games of chance. Such wagering was often fueled by cheap alcohol and fetid social conditions and fostered by professional bookmakers (Munting, 1996).
By the colorful time of Samuel Pepys, the famous diarist (b. 1633), Londoners were wagering on practically anything-- the outcome of the disastrous war with the Dutch, the mortality of the Plague, and even the damage estimates of the Great Fire of 1666. They were also wagering on who would make the life-threatening trip across the ocean to the New World (Ashton, 1969). Undoubtedly, they would have wagered on who would survive such an arduous journey had they any way of receiving accurate feedback.
GAMBLING IN NORTH AMERICA
When settlers arrived in the Americas, they had almost as many betting opportunities as in the Old World (Fenster, 1994). In the New World, gambling has a long and uneven history, not unlike that of Europe. Games of chance were common among the early colonists. The American Revolution was financed, in part, through lottery proceeds (Pavalko, 1999). Not surprisingly, Americans have long had a fascination with horse racing, and they adapted this sport to the frontier and rural environments. Wagering between local settlers or farmers was quite common in America during the eighteenth and nineteenth centuries. In many communities, as in pre-industrial Europe, few other leisure activities were available (Burnham, 1994). Native Americans of various tribes had long had friendly wagers, but the vigor with which the new arrivals gambled was often shocking to the indigenous peoples.
The American prohibition against gambling, from which we are now emerging, arose in the last quarter of the nineteenth century (Valverde, 1998). In part, this was a reaction to consistent illegal tampering of state-run lotteries and other games of chance. However, the gradual trend toward outlawing gambling of all types was also a response to the social mores and general prohibition sentiment of the United States during this period of early Modernism (Bergler, 1957). Most racetracks closed down, raising the ire of the newly wealthy, who regarded this "sport of kings" as part of their acquired cultural "heritage." State-run and private lotteries ceased. With the return of Fundamentalism to the American religious community, even card playing became socially unacceptable (Fenster, 1994).
Despite admirable intentions, gambling was never eliminated; it simply went underground (Livingston, 1974). Some evidence suggests that gambling actually increased during this period. It became the "bread and butter" of a variety of criminal societies. Most new immigrant and minority communities offered access to a variety of daily wagering opportunities. These included "punch boards" and "pull tabs," as well as early precursors to the pin-ball game. "Respectable" citizens found other wagering opportunities, mostly within their own social groups, and the newly expanding moneyed classes enjoyed the opulence associated with gambling in Europe, Cuba, or Mexico (O'Brien, 1998).
Gambling became immensely popular during another period of moral legislation-- Prohibition. Many "speakeasies" or clandestine bars or taverns had open gambling behind their closed doors. Persons who sold liquor were also able to take wagers (Pavalko, 1999). Many people who had never been in contact with gamblers soon found themselves in situations that made gambling not only respectable, but fashionable. Prohibition merely encouraged the appetite of a prosperous nation for additional forbidden activities. Outside of illegal restaurants and bars, both alcohol and gambling could be paid for by credit, usually with usurious interest rates.
Gambling declined during the Great Depression. However, this economic calamity became the next theater for its eventual expansion and explosion. The relegalization of gambling in the United States began in earnest in 1931 in Nevada, when Governor Frederick Balzar signed Assemblyman Phil Tobin's "Wide-open gambling" law. The law all but acknowledged that illegal gambling had been ongoing for years. Gambling had long been popular in Nevada and was hardly underground (Marx, 1952). This was especially true during Prohibition, which was expected to end shortly. Tobin's sentiment was simple and has been echoed repeatedly throughout this century: If gambling already exists unchecked, then why not regulate it and cash in on it for the good of everyone?
Tobin's actions were largely a concession to the economic realities of the Great Depression and to the downturn in mineral wealth that Nevada was experiencing (Lorenz, n.d.). However, Nevada had the forethought to capitalize on the new economic clout of the growing West Coast, with its comparatively looser moral structure. People had long traveled past the state line of Nevada to "sin." Tobin reasoned-- correctly or not-- that illegal gambling only encouraged additional criminal behavior. Unfortunately, open gambling made matters worse.
The history of gambling in America has been intimately connected with the rise of organized crime. Nevada proved an excellent opportunity for this relationship to continue. Many of the major casinos of the 1940s and 1950s were paid for by illegally obtained funding, such as drug money or pension funds from unions. Skimming from casinos was considered a part of appropriate business practice. Las Vegas, particularly, became a kind of ersatz capital for organized crime. However, most American and international patrons forgot this as they embraced the glamorous image that Las Vegas was promoting for itself. Organized crime remains intimately involved with both legal and quasi-legal gambling, despite the best attempts of regulators (Sternlieb & Hughs, 1985).
In 1963, the fiscally and morally conservative state of New Hampshire legalized the first statewide lottery. This was largely an attempt to prevent any increase in taxes. Slowly, other states followed. In 1998, 36 states had legalized lotteries, despite controversy regarding their economic impact and some evidence that legal lotteries disproportionately transfer wealth away from poorer communities. However, the rise in legal lotteries, with a variety of gaming opportunities, hastened the decline of the community institutions of "numbers' rackets." These petty wagering activities were connected with the results at local racetracks, and usually supported organized crime.
In 1978, casino gambling was legalized in New Jersey. This came at a midpoint of a long recession and general economic disaster in the area. After a rough financial start, it appears that this industry has stabilized. By 1979, more than $17 billion was legally gambled in the United States. Regulators in Atlantic City were initially more cautious in their support. For example, they did not legalize off-track wagering and sports gambling, as Las Vegas did. Missing little time, organized crime began exploiting this market. Illegal sports betting increased substantially, especially on the East Coast.
In 1988, the Federal Indian Gambling Regulatory Act legalized casino gambling on Native American land. By the end of the decade, Americans had wagered $247 billion legally, up 1,450% from the previous decade (Simurda, 1994), despite a severe economic downturn in Nevada and a major recession at the start of the decade. In 1995, this number had more than doubled to a record of $482 billion legally wagered (Schlichter & Valente, 1996).
By 1998, ten states had "general" casinos, and casinos were operating on Native American land in 24 states (Munting, 1996). Thirty-six states had lotteries, and six had legalized video poker or other noncasino electronic games. Pari-mutuel wagering-- usually on horses, but also on dogs and in Jai Alai frontons-- was available in some form in 34 states and was clearly tolerated in several more. Only two states, Utah and Hawaii, do not have some legalized form of gambling within their state borders. Even in these states, many bars, lounges, bowling alleys, truck stops, and restaurants have illegally run video games available for payoffs if the client is a "regular."
THE ELECTRONIC REVOLUTION AND GAMBLING
The electronic revolution brought on by the personal computer has had a substantial impact on types and perhaps on frequency of gambling. Initially, the computer gave gamblers in select events, such as horse races, an advantage over other betters. People with access to computer technology could employ multiple regression algorithms, which would give them a slight edge over other pundits. This advantage quickly declined when personal computers became more universal.
During the early 1980s, entrepreneurs with their own personal computers could establish their own bookmaking services, with bets placed anonymously. A humble Apple II or Commodore 64 could be programmed to answer telephone calls without human intervention. (The authors witnessed this process on several occasions and at several college campuses.) By the mid-1980s, it was not uncommon to find university students running such enterprises out of their dorm rooms or even via university computing facilities! Most major campuses had several "agents" who would set up accounts from credit cards, and credit wins or debit losses anonymously and automatically (Layden, 1995). Anecdotal accounts from people whom we now treat suggest that many of these entrepreneurs developed gambling-related problems themselves.
The wager of choice in the youth-oriented market of the 1980s was in the rapidly expanding sports betting market, especially for college and professional sports (Williams, 1999). This change from the traditional emphasis on horse racing was boosted in part by the proliferation of sports through cable television and satellite transmission. It became commonplace for local or network television sports commentators to discuss the gambling point spread-- a concession to the ubiquitousness of sports wagering. For a brief time, organized crime appeared slow to react to these changes; most traditional bookmakers were reticent to handle such unconventional "traffic." Again, this opened the door for students and other inventive techies to market a perceived vice to a new social niche. However, once organized crime saw the enormous profit potential, the "amateurs" were squeezed out, often by violent means.
During the 1980s, computer technology ushered in another revolution. The slot machine, invented in 1887 by Charles Fey, had made gambling popular for common, low-stakes players. The innards of the machine were previously composed of a variety of mechanical springs, wheels, and notches acting as stopping points for specific payoffs (O'Brien, 1998). Pull the lever and the slot reels turn, landing on a fairly random basis. By 1980, a microprocessor controlling these components stopped them randomly, within the limits of the payoff desired by the casino. This greatly reduced the cost of slot machines; expanded their availability, and allowed very rapid play.
Although slot machines brought in countless millions, they attracted only players who had few expectations. The "low stakes" slots were of little interest to serious players. The practical limitations on the physics of the pull-lever machines kept their potential combinations to usually fewer than 8,000-- hardly enough to allow them to pay out the huge dollar amounts that the public demanded.
Today, multimillion-dollar jackpots, available on "fruit machines" (Griffiths, 1994), have heightened interest in slot machine wagering. This change was made possible by additional innovations in computer technology (Daniels, 1994). By 1984, most slot machines were "virtual reels" (programmed images). Unlimited numbers of reels, each with an unlimited number of stops, were possible. Computer chips could be programmed to make jackpot payoffs much scarcer than previously, which made tremendous jackpots possible. This added interest to fruit gambling, a type of gambling behavior that may have its own potential problems. A new market of older, lower-stakes players began to be courted, and many of them lost control of their gambling behavior.
The cost of machines kept dropping, which helped both the legal and illegal marketers. The authors once saw an illegal homemade slot machine, constructed from an old computer and scraps from a defunct jukebox. This machine took in over a $1,000 a day from bar patrons but cost less than $400 to put together.
At present, wagering opportunities for anyone with a credit card are only a telephone call away. The Internet proliferates with gambling sites, located in countries with liberal gambling laws or on Native American land (G. Johnson, 1996). Despite the attempts of legislators to curb these wagering possibilities, both offshore toll-free numbers and Internet gambling services seem likely to thrive in the foreseeable future (Impco, 1996). Abolishing or limiting the transmission of dollars over the Internet will not be easy. Even if such gambling were prohibited, it would undoubtedly continue to thrive with secretive numbers, not unlike the private bulletin boards that dominated cyberspace before the Internet. "Cyberbets" will be as easy to access as Internet pornography or bootlegged software.
Gambling is not new, but some persons have significant problems associated with gambling. How widespread and significant these problems are remains unknown, in part because of the difficulty in studying the phenomenon and in part because of scant attention afforded it by the scientific community.
The acquisition, development, and maintenance of pathological gambling are areas in continual dispute. One reason may be that pathological gambling was only recognized as a bona fide mental disorder in the Third Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III; APA, 1980). A second reason is the dearth of research. There are over 1,000 times as many articles on schizophrenia, which affects only one percent of the population, as there are on gambling disorders, which are at least three times as prevalent.
The data we have indicate that gambling is a major problem for a subset of persons. For example, Abbott and Volberb (1994) summarized major findings of a 1991 national survey of problem and pathological gambling among 4,053 adults in New Zealand, and compared these findings with those of epidemiological studies from the United States and Canada. Lifetime pathological gambling prevalence estimates ranged from 0.1% to 2.7%, and current estimates ranged from 0.6% to 1.2%. Shaffer and Hall (1996) estimated that about 1% of the adult population and 3% of the adolescent population have current chronic gambling problems.
Volberg (1996) examined the results of prevalence studies of problem and pathological gambling that have been carried out in 15 U.S. jurisdictions since 1980. Problem and pathological gamblers in the general population were significantly more likely than nongamblers to be male, under age 30, non-Caucasian, and unmarried. Furthermore, they started gambling at a significantly earlier age. There are critical challenges in conducting surveys of gambling and problem gambling in the general population, but this approach remains an important and cost-effective method for obtaining information about gambling that is unavailable from other sources.
Other researchers are less clear about the seriousness of the problem. The prevalence of pathological gambling refers to the percentage of cases of pathological gambling occurring in a community at a given time. When prevalence studies were conducted in different principalities throughout the world, none of them was found to conform to this definition of prevalence. The major error, in all but the most recent surveys conducted, has been identified as the use of questions that ask whether gambling-related problems have ever occurred rather than whether they are currently occurring. This error will lead to an overestimation of the prevalence of pathological gambling in society.
Perhaps the best generalizations regarding gambling in the United States can be made from the meta-analytic review by Shaffer and Hall (1996), which reached four conclusions:
Beyond mere numbers, researchers must pay attention to the severity of the problem afforded by gambling. It is clearly a social problem with a potentially vast impact. Blaszczynski and Silove (1997) provided evidence that pathological gamblers are at high risk for committing criminal offenses in order to maintain their habitual gambling behaviors. The average gambler who enters inpatient treatment is approximately $80,000 in debt and has lost almost everything he or she owns. Gambling problems correlate with substance abuse, depression, anxiety, suicide, antisocial behavior, joblessness, divorce, and family dysfunction (Vitaro et al., 1998. Not surprisingly, children of persons with gambling problems are at high risk for anxiety, somatization disorders, depression, substance abuse, low academic achievement, and personality disorders (Maurer, 1994).
Perhaps the most fear-inspiring aspect of gambling disorders is that they are increasing at an apparently rapid rate among the young (Winters, Stinchfield, & Kim, 1995). Indeed, one of the authors treated a nine-year-old child who gambled away not only lunch money, but also household furnishings and money stolen from his mother's purse. The object of the wagers usually was the outcome of pick-up basketball games played in inner-city playgrounds by older youths.
Prevalence studies support this. For example, Schaffer and Hall (1996) reviewed published and unpublished studies that estimate the prevalence of adolescent gambling problems in the United States. Data from more than 7,500 adolescents, aged 13 to 20 years, were included. In addition to comparing the conceptual and methodological differences among these studies, the article employed a meta-analytic strategy to synthesize prevalence estimates from the existing studies. This analysis revealed that, within a 95% confidence interval, between 9.9% and 14.2% of adolescents are at risk for developing or returning to serious gambling problems. Similarly, between 4.4% and 7.4% of adolescents exhibit seriously adverse compulsive or pathological patterns of gambling.
Although we have made frequent reference to problem gambling, we have not defined it yet. This is analogous to society's response to gambling as a disorder. Despite data to the contrary (e.g., Galdston, 1968), The American Psychiatric Association did not formally recognize pathological gambling as a genuine psychiatric disorder until 1980. Freud (1929/1950) had studied problem gambling, but he was rather pessimistic about its prognosis.
The most current definition of "pathological gambling" appears in DSM-IV, published in 1990. The American Psychiatric Association defines pathological gambling as a progressive psychological disorder characterized by emotional dependence, loss of control, and accompanying negative consequences in the gamblers' school, social, or vocational life. Other common names for pathological gambling are compulsive gambling and addictive gambling.
More specifically, in DSM-IV, Pathological Gambling (312.31) is defined as an Axis I disorder of persistent and recurrent maladaptive behaviors. To receive the diagnosis, the patient must demonstrate five of the following:
The sole exclusion criterion is that gambling behavior is not due to bipolar disorders.
The argument concerning whether gambling is an "addiction" is unnecessarily controversial and at times defies common sense (Kusyszyn, 1980). For example, several years ago, a popular advice columnist ran an article from a physician stating that gambling "could not possibly" be addictive. By definition, according to this person, actions such as gambling, shoplifting, and excessive sexual behaviors do not involve substance ingestion and therefore are not addictions. Instead, the physician argued, they are usually manifestations of manic depressive illness. (Interestingly, mania is an exclusion diagnosis for gambling disorders. If this were true, then gambling patients would almost all be controlled with lithium, which is not the case.)
Unfortunately, this is an outmoded yet still popular view. In part, the DSM-IV supports it. Gambling is not classified as an addictive disorder because the latter term is reserved for behaviors associated with specific abused substances. Instead, it is characterized as a disorder of impulse control. Gambling is placed in the same category as fire setting, hair pulling, and explosive temperament, rather than alcohol abuse and cocaine use, despite the fact that the dynamics of gambling include preoccupation, loss of control, tolerance, withdrawal, and other aspects that make it indistinguishable from a classic addiction (Lesieur, 1989).
Our bias in this volume will become more obvious throughout, but we choose to be explicit here. We believe that this pseudo-distinction between chemical ingestion and behaviors not directly caused by chemical ingestion, as a criterion for addiction, conflicts with current definitions of the concept of addiction. For example, L'Abate's (1994) definition, which has been highly instrumental in influencing the World Health Organization, defines addiction as involving compulsive use of a substance over time, despite suffering social and/ or health consequences; an overwhelming preoccupation with obtaining sufficient supply; and a relaxation after use. Peele (1990), a persistent critic of many aspects of addiction treatment and diagnoses, defines addiction as a preoccupation with one person or activity as the sole potentially desirable reinforcer.
Our philosophy is that there is no real distinction between disorders classified in the DSM-IV as substance abuse disorders and many of those classified as disorders of impulse control. Gambling, simply, is one of many nonpharmacological addictions. Others include workaholism, Internet addiction, and incessant watching of rock videos. Hundreds of others could be named.
The DSM-IV (1994) notes the first symptom of Pathological Gambling as follows:
is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping, or planning the next venture, or thinking of ways to get money with which to gamble). (p. 618)
The example-- preoccupation with past experiences-- implies that pathological gamblers, like drug addicts, are seeking to recreate a prior sensation. It is our experience that gamblers are preoccupied with future expectations, not past experiences. That is part of what differentiates pathological gambling from drug addictions. Gamblers are addicted to fantasy and "what if." They are generally more consumed with imagining the next big win than reliving a past success.
Difficulty in understanding the concept of a nonpharmacological addiction has been pronounced, especially among biologically oriented researchers, who lean toward a simplistic view of biological processes. J. Johnson and McCown (1993) have noted that there was once an overwhelming sentiment that each substance of abuse involved only one specific neurotransmitter. For example, LSD binds to serotonergic receptors and therefore has its properties because it more efficiently mimics natural neurotransmitters. Because there was not a specific gambling receptor, the behavior was denied the label "addictive."
Allied to this sentiment was a strong but highly erroneous belief that drugs that did not produce gross symptoms of physical withdrawal were not addictive, in any but a trivial "psychological state" (White, 1998). Indeed, great distinction was made between drugs that were "genuinely physically addictive" and those that were only "psychologically addictive," primarily because they had strong reinforcing properties. The comparative clean bill of health afforded cocaine in the 1970s illustrates how disastrous such thinking was to public health.
Since that myopic period, there has been ample evidence that the body may be addicted to behaviors through its own neurochemical and neurohormonal processes. This will be discussed in detail in later chapters. We do not believe that it is helpful for either researchers or clinicians to draw a distinction between disorders that are supposedly chemically based and those that are not. Addiction has common features, regardless of whether a specific substance is involved. Table 1.1 illustrates the commonalities of so-called "addictions" and nonpharmacological behaviors that have an addictive quality.
Apply the concept of addiction to the following case study to see how it applies to excessive gambling.
This young woman was introduced to casino gambling through her boyfriend and pursued it vigorously after her boyfriend broke off their relationship. She stated that playing slot machines made her think less about her boyfriend and provided for her a thrill that was otherwise missing in her life. Rena lived about 100 miles from a casino. Initially, during the week, she confined herself to a local version of video poker, with limited stakes and no immediate paybacks. Although she spent most of her spare time in the video poker arcades, this was not enough stimulation. She moved to another state where a variety of gambling opportunities were available on casino-based boats. Although she had a well paying job as a pharmacist, she supplemented her income with prostitution or theft. She sought treatment-- only after being arrested for theft-- and was initially successful with abstinence from gambling behaviors. During her initial phases of abstinence, she was angry, depressed, and highly sensitive to stimuli similar to gambling objects, and she drank heavily. She described this period-- lasting about three weeks-- as her "withdrawal."
Following the death of her mother, she began playing video poker in earnest, and then branched out to other slot games. She dropped out of treatment after informing the therapist that she was going to move to another area of the country where "there's more action in the casinos." By this time she had lost her pharmacist's license and was living in a cheap motel. Her primary means of support was work as a prostitute in an escort agency.
Apart from the use of any specific substance, Rena's behavior is indistinguishable from that of any alcoholic or drug user whom we have treated.
The present authors might disagree about a number of ideas regarding the etiology and treatment of gambling behaviors, but we are unified in the sentiment that gambling can be pathological and still have dynamics identical to those of pharmacologically mediated addictions. The attempt by the writers of DSM-IV to place nonpharmacological addictions in a separate class is both scientifically inaccurate and therapeutically inadequate for the client or patient. It has often resulted in clients' being denied reimbursement by third parties for what are, in many cases, life-threatening disorders. This is particularly true for patheological gamblers who are one of the highest risk groups for suicide.
This book will not make anyone an expert in the treatment of gambling disorders. As we stated previously, only experience and supervision will succeed in this area. We do not expect all experts in the field of gambling to agree with our treatments or beliefs. At heart, we are eclectic-- we do what works. We employ techniques as diverse as Gamblers Anonymous, aversion therapy, desensitization, family therapy, and other forms of treatment inspired by the new field of chaos theory.
We argue that a scientific eclecticism is necessary as well as desirable. For years, practitioners were taught that the word eclectic had somewhat nasty connotations, and that true therapists should understand something from one orientation and stick to it. In other words, the behavior in question was forced into the theoretical mold of the practitioner. Perhaps the relatively unsuccessful state of psychotherapy exemplifies the effect of forcing people into therapeutic or theoretical systems.
Our bias is reversed. We believe that because human behavior is infinitely complex, it is often necessary to view it from several different vantages (Bütz, Chamberlain, & McCown, 1997). The same behavior can and should be viewed from psychodynamic, biological, behavioral, and cognitive perspectives. Theories regarding gambling and chronic gamblers are not true or false; they are simply useful or not, depending on whether they help or hinder the therapeutic goals at hand. Rather than use the term eclecticism, we prefer the one popularized by William James and John Dewey: pragmatism. Consequently, a view expressed in this volume will be that a grand theory of gambling disorders is perhaps as impossible as a grand theory of human behavior. Just as we see light sometimes as waves and sometimes as particles, we will see gambling, variably, as a learned disorder, a family pathology, a psychodynamic need to fail, and a deficit in learned behavior. The overriding principle is that theoretical flexibility is necessary if the client is to receive the needed treatment.
Does this mean that we abandon empiricism in favor of an unverifiable mishmash of "anything goes?" No. Experimental paradigms will frequently be used throughout this volume to suggest the origin, maintenance, and dynamics of problem gambling. Often, though, these will be simply heuristic. No model, laboratory, or other source can predict more than half the behavior it specifies in advance. We construct our models by operationalizing them to specific behaviors that we feel are relatively predictable-- another evidence of the immense task of the behavioral scientist and practitioner.
For those who read further, this approach will translate into a frustrating lack of solid rules. Is gambling a symptom of a deeper disorder? Sometimes yes and sometimes no. Can people with problem gambling ever return to social gambling? Sometimes yes and sometimes no. Is gambling a function of opportunity? Of personality? Of deviancy? Of psychopathologies? Yes and no. It depends on the client and the level of behavior that is examined. There is no guru, no single method, and no ultimate teacher. Finally, there is no substitution for both clinical experience and multifaceted theoretical exposure. We do not pretend to synthesize the relatively minute literature on problem gambling, but we hope to present enough of it to enable clinicians to become more critical thinkers. Our fondest hopes are that this guck, our stew-without-a-recipe, raises questions more than it provides answers, and that it will soon be obsolete, having been supplanted by more and better research, more refined theories, and better clinical methods.
*Each case presented herein has identifying details removed. Case material was peer-reviewed to ensure adequate confidentiality. Chapters were peer-reviewed for both clinical relevance and scientific accuracy. Thanks are due to Dr. Ross Keiser, who coordinated these reviews, as well as to the anonymous reviewers, whose comments were greatly appreciated.