With more and more Americans engaging in gambling activities, odds are high that psychiatrists may see patients who have some sort of gambling problem. What can be done about this problem, and how can these patients best be treated?
Is pathological gambling really that big a problem? Are its consequences widespread and serious enough to warrant not only a field of research and funding, but also treatment, third-party reimbursement and national awareness by psychiatry and the rest of the mental health profession? Only eight years ago, before working at the Gambling Treatment Program (U.S. Veterans Affairs Medical Center, Brecksville, Ohio), my answer might have been "no," primarily because I knew nothing about pathological gambling. Now, however, my answer is, without a doubt, "You bet!"
Epidemiology of Gambling
The third (and current) wave of gambling legalization in the United States started in 1964 when New Hampshire legalized the first state lottery since the 1890s; New York, New Jersey and Massachusetts were quick to follow. Currently, gambling is legal in every state except Utah and Hawaii; 37 states have lotteries and 28 have casinos; in Nevada alone there are over 400 casinos, and there are almost an equal number on Native American reservations (National Gambling Impact and Policy Commission [NGIPC], 1999). In 1973, state lotteries generated only $2 billion in revenue; by 1997, however, the total had reached $34 billion (NGIPC, 1999). In 1997, Americans waged a staggering $551 billion on legalized betting (National Research Council, 1999). To give you a sense of this figure, Americans spent less on music, movies, arcades, books and amusement parks combined (Castellani, 2000).
The consequence of all this legalized gambling is that the prevalence of pathological and problem gambling has increased significantly since 1963. Researchers conservatively estimate that 1.6% of the adult population meet criteria for pathological gambling and another 3.9% meet criteria for some type of gambling-related problem (NGIPC, 1999). The statistics for adolescents, although less reliable, are higher. The adolescent lifetime prevalence rate for pathological gambling is roughly 5%, and the combined prevalence rate for problem and pathological gambling is about 11.2% (NGIPC, 1999). Together, these figures add up to about 15.4 million Americans with a gambling problem (NGIPC, 1999).
Among adult gamblers, the populations most at risk include men, minorities, the working class and the elderly (NGIPC, 1999). The fact that men are at risk fits our American folklore. The archetypal image of "the gambler," as portrayed in movies, fiction and music, has always been male. This image has ranged from the charming and intelligent James Bond poker player, to the Humphrey Bogart gangster, to the Clint Eastwood cowboy "squaring the deal" in the Wild West.
While none of these images are necessarily real, they do hold sway, even among gamblers themselves. Nevertheless, the majority of people who enter your office, practice or treatment unit will not fit these stereotypical images. Women, for example, gamble for very different reasons than men (primarily to escape their problems) and are generally among the poor and working-class gamblers who go to the corner mini-mart to wager what little discretionary income they have (NGIPC, 1999). According to the NGIPC:
Lottery players with incomes below $10,000 spend more than any other income group, an estimated $597 per year. In addition, the lotteries rely on a small group of heavy players who are disproportionately poor, black, and have failed to complete a high school education.
This research does not begin to address how and why the elderly gamble. Think of the lonely, elderly woman living in a Florida retirement community and suffering from depression, who never mentions to you that she plays bingo day and night to cope with her life.
How Is Gambling Pathological?
So, what is it, exactly, that turns an otherwise harmless activity like gambling into a pathology? Like substance abuse, it is not the gambling itself that is the problem, as much as how and why people gamble (Castellani, 2000). When gambling becomes persistent, recurrent and maladaptive, it is on its way toward becoming a pathology, particularly when the consequences of gambling begin to have a profound negative effect on the person's life.
Henry Lesieur, Ph.D., in his classic study The Chase (1984), examined the process by which a person's relationship with gambling turns from play, to problem, to pathology. As Lesieur and others have documented (e.g., Abt et al., 1985), gambling provides most people with the opportunity for a brief period of escape-they can, for a while, forget about their troubles and have some fun. For some people, however, it becomes more than just fun. Gambling becomes a coping mechanism, a way of dealing with the world. For these people, gambling provides an opportunity to "be in action," "numb out" and escape their problems.
Eventually, however, their gambling becomes a dysfunctional coping mechanism. They get trapped in a vicious cycle of gambling to cope and coping to gamble. Now, not only are they suffering from the problems that started them gambling in the first place (e.g., impulsivity, emotional problems, unemployment), but they are also dealing with the negative consequences of their gambling (e.g., divorce, job loss, financial problems, strained relationships, increased emotional distress, legal troubles). This process leads people on an addictive and downward spiral toward disaster, which Lesieur (1984) called the chase.
Limitations of Current Research
While the chase can be described as an addictive and downward spiral, its circular movement is by no means constrained to a linear stage theory of addiction; nor are the differences between social, problem and pathological gambling discrete. There are no data to suggest that once someone is diagnosed with pathological gambling, they remain a pathological gambler forever. In fact, research done by Blaszczynski et al. (1991) indicates that many individuals diagnosed with pathological gambling return to some level of controlled gambling even after treatment. This suggests that, while for some people pathological gambling may be chronic and progressive, it is not that way for everyone-which leads to the next point.
While the chase paradigm suggests that pathological gambling is an addiction, current research does not entirely support this view. In fact, while pathological gambling's diagnostic nomenclature has been successively rewritten to read like an addiction, it is actually catalogued in the DSM (and has been since 1980) as an impulse disorder (Lesieur and Rosenthal, as cited in Castellani, 2000). As such, the essential feature of pathological gambling is the individual's failure to resist the impulse, drive or temptation to gamble, despite negative consequences.
Recommendations for Treatment
Psychiatrists need to adopt a systems approach to their treatment of patients. Even a cursory review of the literature reveals that pathological gambling is a rather complex and heterogeneous disorder. There are many different subgroupings under the general headings of problem and pathological gambling (which can be broken down in terms of gender, ethnicity, age, type of gambling and level of severity). The disorder itself, in terms of etiology, is also multiply determined, including 1) neuropsychological and cognitive impairment; 2) problems with impulsivity and risk-taking behavior; 3) emotional and relational difficulties; and 4) issues related to gender and socioeconomic status. In order to provide the best treatment possible, psychiatrists need to conceptualize pathological gambling as a multiply determined disorder that is complex in its pathogenesis and diagnostic features and equally complex in its negative outcomes.
Given the lack of information about pathological gambling, it is a strong possibility that you may be treating someone right now who has a gambling problem. This is particularly important to note, since problem and pathological gambling appear to have a high comorbidity with other addictive and emotional disorders, not to mention physical problems, such as hypertension and poor physical well-being.
Psychiatrists should obtain one of the two main screening tools used for pathological gambling: the South Oaks Gambling Screen and the Gamblers Anonymous Twenty Questions. While these two screening tools tend to overestimate the severity of gambling, they are useful. For more information, contact the National Council on Problem Gambling: (202)547-9206; hotline (800)522-4700; or visit their Web sitewww.ncpgambling.org.
Because the term
is a simplistic diagnostic heading for what is, in actuality, a complex and heterogeneous disorder, psychiatrists should tailor their treatment to the particular needs of their patients. For example, a middle-aged, middle-class, Asian-American female who gambles to cope with boredom and depression is not the same as a young, white, professional-class male who has lost his wife, house and job, and who is $75,000 in debt because he is addicted to day-trading.
Because treatment tends to be individually focused, most family members of pathological gamblers never receive the care they need. Nevertheless, when families, friends and significant others are included in current statistics, the number of people suffering from the negative consequences of pathological and problem gambling can double (Castellani, 2000). (For more information, please see Behind the 8-Ball: A Guide for Families of Gamblers [Simon and Schuster, 1992].)
You can help prevent pathological gambling by bringing a public health perspective to your work. As recommended by the NGIPC (1999), more emphasis needs to be placed on education and prevention. Psychiatrists can assist this process by not only examining how pathological and problem gambling are distributed throughout their treatment populations but also by writing articles for the local paper, giving presentations at churches and social clubs, educating colleagues and insurance companies, and doing evening TV-news interviews.
For information regarding treatment facilities, local experts and self-help groups, contact the National Council on Problem Gambling; for an exhaustive review of the literature, contact the National Gambling Impact Study Commission at www.ngisc.gov, read the Journal of Gambling Studies or get a copy of Pathological Gambling: A Critical Review at www.nap.edu. It is important that psychiatry takes a lead in addressing this problem; the lives of those for whom we care are at stake.
Abt V, Smith JF, Christiansen EM (1985), The Business of Risk: Commercial Gambling in Mainstream America. Lawrence, Kan.: University Press of Kansas.
Blaszczynski A, McConaghy N, Frankova A (1991), Control versus abstinence in the treatment of pathological gambling: a two to nine year follow-up. Br J Addict 86(3):299-306.
Castellani B (2000), Pathological Gambling: The Making of a Medical Problem. Albany, N.Y.: State University of New York Press.
Lesieur HR (1984), The Chase: Career of the Compulsive Gambler. Cambridge, Mass.: Schenkman Publishing Co.
NGIPC (1999), Final Report. The National Gambling Impact Study Commission. Washington, D.C.: NGIPC.
National Research Council (1999), Pathological Gambling: A Critical Review. Washington, D.C.: National Academy Press.