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LETTER TO THE SECRETARY, DEPARTMENT OF HEALTH AND
MENTAL HYGIENE
December 31, 1990
The Honorable Adele Wilzak, Secretary
Department of Health and Mental Hygiene
201 West Preston Street
Baltimore, Maryland 21201
Dear Madam Secretary:
Enclosed is a copy of the Final Report of the Task
Force on Gambling Addiction in Maryland. On behalf of
the Task Force, we request your urgent review of its
findings and recommendations.
As charged, this report discusses the prevalence of
problem gambling in Maryland, its economic and social
costs to the citizens of the State, the current state of
responses to the problem, and the relationship between
pathological gambling and other psychiatric and addictive
disorders. The Task Force recommends specific steps to
better coordinate, add to and effectuate state, local and
private sector responses to this problem. It suggests
alternative funding resources to support and expand
gambling specific-programs.
The original research undertaken by this Task Force
indicates that the policy of treating addicted gamblers
under the same roof as other substance abusers may be
inappropriate. The study reveals that there is an
inverse relationship between severity of gambling
addiction and abuse of alcohol and other drugs. Although
gamblers report histories of substance abuse, those
individuals whose gambling addiction is most severe are
not currently abusing substances. Certain characteris-
tics make gambling addiction different from other sub-
stance abuse addictions, and we believe those differ-
ences cannot be adequately addressed solely by employing
the treatment model for traditional addictions.
This report strongly recommends that the network of
counselors and therapists at state-sponsored community
mental health centers and substance abuse treatment
programs be clinically trained to recognize and diagnose
problem gambling as a front-line approach, but refer such
patients for intensive gambling-specific treatment to
specialized programs and, possibly, then monitor the
necessary aftercare.
In addition, this report recommends the establish-
ment of a Legislative Advisory Commission on Gambling
Addiction and the creation of a new Office on Gambling
Addiction within the Department of Health and Mental
Hygiene to monitor the potential adverse health effects
of gambling on the citizens of the State and assist in
appropriate responses.
Although the Task Force is now officially terminat-
ed, the co-chairs and its individual members remain
committed to assist you in the execution of these
recommendations.
We thank the Secretary for the opportunity to
develop and present this report. If you have any
questions or need additional information, please do not
hesitate to contact us.
Sincerely yours,
Valerie C. Lorenz, Ph.D
Robert M. Politzer, Sc.D.
Co-Chairs
Maryland Task Force
on Gambling Addiction
TABLE OF CONTENTS
LETTER TO THE SECRETARY, DEPARTMENT OF HEALTH AND MENTAL
HYGIENE . . . . . . . . . . . . . . . . . . . . . . . . ii
TABLE OF CONTENTS . . . . . . . . . . . . . . . . . . . . . vi
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . 1
Fact Sheet. . . . . . . . . . . . . . . . . . . . . . . . 2
Selected Comments of Survey Respondents . . . . . . . . . 3
Establishment and Purpose of the Task Force . . . . . . . 4
Membership of the Task Force. . . . . . . . . . . . . . . 5
Acknowledgements. . . . . . . . . . . . . . . . . . . . . 7
Work of the Task Force. . . . . . . . . . . . . . . . . . 9
CONCLUSIONS AND RECOMMENDATIONS - SUMMARY. . . . . . . . . . 12
PATHOLOGICAL GAMBLING. . . . . . . . . . . . . . . . . . . . 19
Types of Gamblers . . . . . . . . . . . . . . . . . . . 21
Clinical Definition . . . . . . . . . . . . . . . . . . 24
The Stages of Pathological Gambling . . . . . . . . . . 25
Criminal Behavior . . . . . . . . . . . . . . . . . . . 28
Treatment and Recovery. . . . . . . . . . . . . . . . . 29
Public Health Impact. . . . . . . . . . . . . . . . . . 30
The Epidemiologic Model . . . . . . . . . . . . . . . . 31
HISTORY OF PATHOLOGICAL GAMBLING TREATMENT IN MARYLAND . . . 35
Legislation . . . . . . . . . . . . . . . . . . . . . . 36
Beginnings. . . . . . . . . . . . . . . . . . . . . . . 37
Johns Hopkins Center for Pathological Gambling. . . . . 38
Washington Center . . . . . . . . . . . . . . . . . . . 43
Taylor Manor Hospital . . . . . . . . . . . . . . . . . 44
Changing Point. . . . . . . . . . . . . . . . . . . . . 45
Epoch House . . . . . . . . . . . . . . . . . . . . . . 45
National Center for Pathological Gambling, Inc. . . . . 46
Maryland Council On Compulsive Gambling . . . . . . . . 47
Hotline . . . . . . . . . . . . . . . . . . . . . . . . 47
Further Developments. . . . . . . . . . . . . . . . . . 49
Current Treatment Options Elsewhere . . . . . . . . . . 51
PREVALENCE OF GAMBLING ADDICTION IN MARYLAND . . . . . . . . 54
ECONOMIC AND SOCIAL IMPACT OF GAMBLING ADDICTION . . . . . . 58
PROFILE OF MARYLAND PATHOLOGICAL GAMBLERS IN PROFESSIONAL
TREATMENT PROGRAMS. . . . . . . . . . . . . . . . . . . 62
The Nature of the Gambling Problem. . . . . . . . . . . 63
A Profile of the Maryland Pathological Gambling Patient:
1983-1989. . . . . . . . . . . . . . . . . . . . . 64
A Statistical Model of the Severity of the Gambling
Problem for Maryland Pathological Gambling
Patients: 1983-1989. . . . . . . . . . . . . . . . 66
Recommendations . . . . . . . . . . . . . . . . . . . . 68
HISTORY OF PATHOLOGICAL GAMBLING TREATMENT IN MARYLAND
Legislation
The 1978 session of the Maryland General Assembly enacted
House Bill 1311 for the purpose of providing a pilot project for
the treatment of pathological gamblers. On May 29, 1978, then
Governor Blair Lee signed the bill into law. Enrolled as Chapter
928 of the Acts of 1978 and codified as Article 43, Section 1K, the
law directs the Secretary of the Department of Health and Mental
Hygiene to establish as a pilot project a facility in a location
accessible to a major population center of the State, to provide
in-patient services, out-patient services and other forms of
prevention, treatment or rehabilitation services for the disorder
of pathological gambling.
Of major significance in the signing of House Bill 1311 is
that Maryland was the first state to recognize: (1) "compulsive
gambling is a serious social problem;" (2) "availability of
gambling increases the risk of becoming a compulsive gambler;" and
(3) "Maryland with its extensive legalized gambling has an
obligation to provide a program of treatment for those who become
addicted to gambling to the extent that it seriously disrupts lives
and families." Or to state the underlying moral premise simply --
we as citizens of a state are obliged to help treat the social ills
we help create.
When the referendum legalizing a State Lottery was approved in
1972, few citizens (including legislators) were aware of the
devastating consequences of this illness on pathological gamblers,
on their families, and on society.
The concept of the lottery was represented to the voters
largely as an easy way to get revenue to reduce taxes. Even the
label on the voting machines read: "An Act modifying the
prohibition against the authorization of lotteries by the General
Assembly in order to provide an exception for lotteries operated by
and for the benefit of the state" (emphasis supplied).
Some believed that the high-pressure advertising of the
Maryland State Lottery and its daily numbers "game" would create a
new type of gambler, in large numbers. The Federal Gambling
Commission's study of 1976 warned, "The gambling industry will grow
much faster than a community's ability to control it. The
regulated will dominate the regulators. . . . As the state and
others push gambling, they will create a market and a clientele to
support it. New gamblers will result and a certain percentage of
them will become sick, neurotic, pathological gamblers"
(Commission, 1976).
Anti-gambling lobbyists united to support legislation that
would at least treat those who were victimized by gambling.
Representatives of the Maryland Churches United, including Reverend
N. Ellsworth Bunce, Executive Director of the United Christian
Citizens, Inc., Clarence A. Canary, Chairman of the Legislative
Committee, and other local organizations spoke out for House Bill
1311, which was sponsored by Delegate Robert R. Neall. The bill
was approved by substantial majorities in both chambers of the
Maryland General Assembly.
Some of the nation's top experts came to testify in support of
the bill before both House and Senate committees. Dr. Robert L.
Custer, chief of Behavioral Science and Mental Health Services of
the Veterans Administration in Washington, D.C.; Msgr. Joseph A.
Dunne, Chaplain of the New York City Police Department and
President of the National Council on Compulsive Gambling; and
Irving Sachar, Executive Vice President of the same Council,
presented technical testimony for this program.
Beginnings
Following passage of the pathological gambling legislation,
Dr. Stanley Platman, then Assistant Secretary for Mental Health and
Addictions, Maryland State Department of Health and Mental Hygiene,
assigned Howard Silverman, then Deputy Director of the Drug Abuse
Administration, the responsibility of setting up this former
innovative program, at Silverman's request. Shortly thereafter,
Acting Governor Lee, in submitting his budget Maximum Agency
Request Ceiling to the various agencies, included $100,000 for the
pathological gambling program for fiscal year 1980.
Mr. Silverman conducted an extensive literature review and
began a dialogue with experts in the field. He attended Gambler's
Anonymous meetings and wrote to local and national foundations,
casinos and federal agencies in search of funding for research that
would be channeled to colleges and universities for stipends for
masters and doctoral level students. He went to New York to meet
with members of the National Council on Compulsive Gambling; he
went to Washington to meet with Veteran's Administration experts on
pathological gambling; and he visited the Miami Veterans
Administration Compulsive Gambling Center for in-patient and out-
patient clients. He located and arranged for the building to be
used for the Maryland pathological gambling program. He met with
the staff of United States Senator Harrison Williams and members of
the United States Senate Committee on Human Resources concerning
legislation to set up a National Commission on Pathological
Gambling and requested that they use Maryland as the pilot program
for the study. He then drafted the Request for Proposals (RFP) for
competitive bidders locally and nationally to run the new program
and personally arranged for a "blue ribbon" panel of four of the
top national experts to select the contractor.
In keeping with the legislative mandate, on August 27, 1979,
the Drug Abuse Administration, under Director Richard Hamilton,
advertised a Request for Proposal to implement House Bill 1311.
After a thorough review of four proposals submitted in response to
the advertised RFP, the Johns Hopkins University, School of Hygiene
and Public Health, was awarded the contract. The four key elements
in the Johns Hopkins proposal were:
1. The utilization of a cross-section of health and mental
health professionals on the staff, including recovering
pathological gamblers ("peer counselors") and spouses of
pathological gamblers with extensive counseling exper-
ience as members of Gamblers Anonymous or GamAnon.
2. The formation of counseling teams (one professional and
one peer counselor per team) for each client for purposes
of cross-training and effective service delivery.
3. The emphasis on group therapy as the primary modality.
4. The nearly total integration of service delivery and
program evaluation throughout all levels of the program
from its inception.
The contract, in the amount of $98,000, served to establish
the first pathological gambling treatment center in the United
States which was open to the general public. The program was
operated within the Department of Health Services Administration,
Johns Hopkins School of Hygiene and Public Health, Dr. Arthur
Bushel, Chairman.
Johns Hopkins Center for Pathological Gambling
The Johns Hopkins Center for Pathological Gambling, located on
the grounds of the Thomas Wilson Center, Pikesville, Maryland, was
officially opened with a ribbon cutting ceremony on October 24,
1979.
Director Robert M. Politzer, Sc.D., and then Clinical
Director, James S. Morrow, conducted an Orientation and Training
Seminar. Presenters at the seminar were psychiatrists and
psychologists from the Veterans Administration, members of Gamblers
Anonymous and GamAnon, representatives of the National Council on
Compulsive Gambling and faculty members of the University of
Maryland Counseling Department.
Subsequent to this training, counseling staff were recruited,
hired, and given additional training. The Johns Hopkins Center for
Pathological Gambling began accepting clients on November 12, 1979.
By this time, the Center had received 136 crisis calls. By January
7, 1980, less than 60 days after opening its doors, the program had
reached its assigned static capacity of 45 out-patient clients and
had seen its first two residential clients. The Center provided
services to 191 different clients the first year.
The program's therapeutic philosophy centered on the premise
that the most effective approach in treating the pathological
gambler consisted of a "team" of counselors; that is an individual
who has "been there" -- a recovering pathological gambler -- and a
credentialed counselor/therapist, knowledgeable in the areas of
therapeutic techniques and principles. This arrangement also
increased the recovering gambler's understanding of techniques of
therapeutic intervention and the credentialed counselor's awareness
of the unique needs of pathological gamblers.
This theoretical framework resulted in several first year
program accomplishments:
1. The Center brought together the collective expertise of
various fields to provide quality treatment and services
and to enhance the state of the art;
2. The Center served as a primary vehicle for dissemination
of information about pathological gambling to the
academic, legal, medical, clinical, and judicial arenas,
as well as to the population at large;
3. The recovering pathological gambler-therapists gained
valuable therapeutic knowledge and training;
4. The Center served as a stimulus and source of data for
much-needed research into the pathological gambling
disorder;
5. Pathological gamblers and their families negotiated
therapeutic long and short range goals, identified tasks
or actions needed to accomplish such goals and scored on
a regular basis the degree to which these goals were met.
In addition, the Center developed an ongoing Advisory Council
which included members of the National Council on Compulsive
Gambling, Gamblers Anonymous, and the State of Maryland, Department
of Health and Mental Hygiene. During the first year the Center was
exposed to the spectrum of publicity - averaging about ten calls
per week from the news media. Articles were written in all types
of media, ranging from local newspapers across the state, major
newspapers, such as the Washington Post, Los Angeles Times, New
York Times, to the major news weeklies such as Time, Newsweek, U.S.
News and World Report and Sports Illustrated. Taped and live
interviews were given with all types of media coverage ranging from
local to national TV and radio, and international stations in
Toronto, Ontario. Appearances were made on major television news
programs such as the Today Show, Phil Donahue and Good Morning
America.
Requests for residential stay in 1980 came from the
neighboring states of Pennsylvania, New Jersey, New York,
Washington, D.C., and from Connecticut, California, Colorado,
Michigan, Illinois, Louisiana, and North Carolina. Inquiries came
from attorneys defending pathological gamblers, employers of
pathological gamblers, mental health agencies requesting training
material, U.S. Marshall's offices responsible for incarcerated
pathological gamblers, and public officials sponsoring State
legislation for treatment programs for pathological gamblers. In
response to the last requests, representatives of the Center
testified at State legislative hearings.
By the end of the first year, it became apparent that the need
for ongoing service delivery was overwhelming, not only to
penetrate the existing backlog in Maryland, but also to assist
other states in initiating programs. Research was needed in order
to build upon the existing data base of information regarding the
development of the problem, the extent of pathological gambling in
society, and the degree of success achieved from alternate
treatment modes. It was with those objectives that the program
entered its second year.
The Center's second year was characterized by expansion into
new areas of treatment and training, and threat of extinction.
The pressures to reduce State expenditures left the Maryland
General Assembly prepared to cut the very appropriation it had
authorized just two years earlier. Persistent testimony that
described the Center's cost-effective treatment and national
recognition along with the testimony by Msgr. Dunne, resuscitated
the budget line item from the cutting room floor.
In addition to this rescue mission, Year Two was characterized
by the following:
1. The New Program for Incarcerated Pathological Gamblers.
The Johns Hopkins Center for Pathological Gambling added to its
list of pioneering efforts the country's first group therapy
program for incarcerated pathological gamblers. This project
consisted of group therapy sessions conducted by a counseling team
on a weekly basis. This particular program also included
transportation of inmates to the Center for the standard intake
procedure.
The response to these meetings as well as close examination of
the group process itself led to an evolution in the treatment of
incarcerated pathological gamblers.
In order to meet the unique needs of the incarcerated
pathological gamblers and maintain appropriate therapeutic tenor,
an innovative method or rearrangement of the existing procedures
had to be created. This new therapeutic process consisted of
sessions held at the Center's offices, followed by the regularly
scheduled Gamblers Anonymous meetings. This coupling of sessions
allowed clients accessibility to both the support of the
therapeutic milieu as well as the freedom to participate in
Gamblers Anonymous. Additionally, this integration allowed for a
stronger "bonding" of the clients to both the Center and Gamblers
Anonymous for future support upon their release from prison. This
program innovation was enthusiastically received by prison
officials as well as the inmates and the counseling staff.
2. Training Personnel of Community Mental Health Centers.
Staff members of the Johns Hopkins Center for Pathological Gambling
were invited to address the Board of Directors of People Acting to
Help (PATH), an umbrella organization for a network of mental
health agencies in the Philadelphia area. Their presentation
included information about the diagnosis, treatment and
rehabilitation of pathological gamblers and their families. Topics
covered included identification and differentiation between a
social and/or professional gambler, defining the team approach to
treatment and its rationale, and the significance of bailout as a
therapeutic issue.
This workshop was followed by a formal training request
from the same organization. Similar training programs were
presented locally to the staff of an alcoholism treatment center
(Pilot House) and to the counseling staff of a prison counseling
program (TRAP).
3. Gambling-specific Couples' Communication Workshop. The
Center developed and implemented a gambling-specific couples
communications workshop, based on the University of Minnesota
Couples' Communications Model. It consisted of 10 two-hour
sessions offered in the District of Columbia and Baltimore
metropolitan areas. Six couples participated in the workshop and
had expressed interest in a continuation or an advanced couples'
problem solving group. Once abstinence from gambling was achieved,
the pathological gamblers' marriages were still highly unstable.
This form of therapy could help prevent further relapses or
occurrences of the disorder in the family.
4. Increased Demand for Information by the Criminal Justice
System. The frequent court appearances by Center expert witnesses
resulted in commuted sentences, reduced sentences and ongoing
therapy, in addition to public, judicial, and legal education and
concomitant attitudinal changes.
5. Financial Independence. The establishment of the full-fee
for service residential program in order to meet the demand of non-
Maryland residents, increased from 5 percent of the Center's
revenues in Year One, to nearly one-third in Year Two. Such
revenues permitted an expansion of counseling staff and hours.
This allowed more clients access to treatment and also fostered
career positions rather than part-time appointments for staff.
Year Three constituted a time of rebuilding and fortifying
the program components. The literature on pathological gambling
was significantly expanded by staff presentations at the University
of Nevada's Fifth National Conference on Gambling and Risk Taking.
A major paper presented by Dr. Politzer estimated, for the first
time, the annual societal costs of pathological gambling and
compared such costs with leading illnesses such as heart disease,
cancer and alcoholism.
The Center continued to provide clinical training and
consultation to mental health agencies, such as with the State of
Connecticut, the second publicly supported treatment program.
Center staff continued to provide expert testimony. In addition,
the Center served as a field placement for graduate students of the
Johns Hopkins Medical Institutions. This led to a research project
submitted to the National Institute of Mental Health for support.
The development and testing of an impulsiveness/caution
psychometric instrument was initiated in conjunction with Dr. Alan
Zonderman of the Johns Hopkins University, Department of
Psychology. Treatment effectiveness assessments to date were
predominantly behavioral in nature (Goal Attainment Scale), with
the initiation of some follow-up psychometric testing. The
inclusion of a pathological gambling specific psychometric or
mental health status assessment would complement the behavior
information and thus form a comprehensive package.
A select group of valid and reliable psychometric tests
including the Minnesota Multiphasic Personality Inventory, and the
Impulsiveness-Caution Index was given to all new intakes starting
in early Spring, 1982. Intakes self-selected and thus fell into
two groups: an experimental group comprising those receiving
treatment, and a natural control group consisting of those not
receiving treatment. The development and validation of a
psychometric tool suitable for diagnostic use in pathological
gambling, represented an important first step in the study of
pathological gambling etiology and the acquisition of baseline data
for treatment effectiveness analysis. The initiation of a
prospective, regular program of initial testing also provided a
baseline for more rigorous treatment follow-up studies.
The Center's attempts to expand were consistently thwarted,
however, either due to lack of funding or possibly out of ignorance
about the problem. Applications for funding from private
foundations met without success. Businesses were also approached,
again without success.
Further, the Center in its third and fourth years sought to
increase its inpatient program so as to expand its financial base.
It continued to treat Maryland residents on an outpatient basis.
With a change in Department chairmanship at the School of Hygiene
came the issue of further sponsorship of a treatment facility.
Responding to this concern, the Drug Abuse Administration set out
to seek competitive bids for the continuation of the pathological
gambling treatment program in the fall of 1982.
The National Foundation for Study & Treatment of Pathological
Gambling, Inc., under the direction of Tor Meeland, Ph.D., was
awarded the contract beginning September 1983. This new
sponsorship was chosen because of differences in treatment
philosophy and organization between the Johns Hopkins Center's
administration and its medical advisor. Most importantly, the new
sponsorship was most convincing of its ability to reach financial
independence within one year.
Washington Center
Also in September 1983, two former officers of the defunct
Johns Hopkins Center for Pathological Gambling established the
Washington Center for Pathological Gambling. The former chief
clinical consultant, Clark J. Hudak, Jr., A.C.S.W., and the former
director, Dr. Politzer, located the Washington Center in College
Park, Maryland, minutes from the District of Columbia.
The Washington Center is a private non-profit organization
designed to provide treatment, research, and public education in
the area of pathological gambling. It is staffed by a multi-
disciplinary group of medical and mental health professionals with
extensive knowledge and experience in the treatment of pathological
gambling. The Washington Center offers a comprehensive program
including out-patient treatment, crisis intervention, legal and
financial counseling, vocational rehabilitation, professional
training, public education, and forensic evaluation and testimony.
Currently, the program is in full operation with Mr. Hudak as its
director since its inception. Dr. Politzer serves as Director of
Research.
Taylor Manor Hospital
The National Foundation for Study & Treatment of Pathological
Gambling, Inc., was formed as a non-profit health care corporation
in Texas in 1980, in order that "knowledgeable and concerned
professionals might address the individual and societal problems
caused by the aberrant behavior associated with pathological
gambling." The ultimate goal of the Foundation was to establish a
national or perhaps an international network of residential and
outpatient treatment facilities. Robert L. Custer, M.D., was
founder and Chairman of the Foundation.
In the Fall of 1982, the Foundation, under the administrative
leadership of Tor L. Meeland, Ph.D., had responded to a Request for
Proposal from the Drug and Alcohol Abuse Administration of the
Department of Health and Mental Hygiene. The Foundation was
awarded a grant in the amount of $60,000 to set up a treatment
program for compulsive gamblers and their families. Several of the
Johns Hopkins clinical staff members were hired by the Foundation
for its new program.
After considering several sites, the Foundation accepted an
offer from Taylor Manor Hospital, Ellicott City, to establish the
gambling treatment program on its grounds. Taylor Manor was a
small, independent, for-profit psychiatric hospital. The agreement
was that Foundation staff, consisting of administrator, researcher,
clinicians, three University of Maryland doctoral externs, and
support staff, would participate in the Taylor Manor payroll and
benefits programs, and use hospital clinical staff, buildings, and
supplies for the operation of the gambling treatment program. In
turn, all patients' fees would be collected by the hospital. This
program was started on September 1, 1983 and accepted its first
inpatient a month later.
The Taylor Manor Hospital Gambling Treatment Program provided
treatment and gambling related services both for outpatients and
inpatients, for gamblers as well as for family members and
concerned others.
Upon being admitted to the Taylor Manor Gambling Treatment
Program, the gambler was given a psychiatric and medical
evaluation. The length of stay ranged anywhere from two weeks to,
on occasion, six weeks. The average length of stay was anywhere
from 21 to 28 days. A multi-modal treatment plan was in place,
including a multi-disciplinary team of service providers.
For the first time, gamblers and their families were being
provided treatment services in Maryland from within a private
psychiatric hospital setting. Treatment services included
traditional group psychotherapy on a daily basis, individual
therapy and therapeutic recreation (including physical activity),
stress management, art therapy and family therapy. The clinical
treatment team consisted of a psychiatrist, clinical psychologist,
clinical social worker, in addition to addictions counselors,
activity therapists, and other counseling staff. Additional
services included forensic evaluation, for the compulsive gambler
who encountered legal or professional difficulties as a result of
the gambling disorder.
One year later, the Alcohol and Drug Abuse Administration
considered the arrangement between the Foundation and Taylor Manor
Hospital inappropriate for receiving state funds, and the grant was
terminated after the end of the contract year. Faced with this
loss of income, the administrator of the Taylor Manor Hospital
terminated the contractual relationship with the Foundation
administrative and research staff, while renewing contractual
agreements with clinical team members. This gambling treatment
program continues to operate to this date, primarily as an
inpatient program, although it now has been absorbed into the
Addictions Program, headed by psychologist Joseph Ciarrocchi.
In October 1984, Dr. Custer's Foundation, with the support of
private funds and an additional $12,000 from the Alcohol and Drug
Abuse Administration for the transition period, established a
residential treatment program in downtown Baltimore. This program
provided both inpatient and outpatient care, until it was forced to
close due to lack of funding in February 1986.
Changing Point
In 1985, the DHMH saw the need to make treatment services more
available to state residents, particularly those needing to use
public transportation. Changing Point, a private residential
treatment program for alcoholics associated with Taylor Manor
Hospital, began the administration of a $40,000 grant from the
Department of Health and Mental Hygiene. A core function of the
Changing Point administration of the grant was ongoing training.
Training was provided for two days a month, every month, to mental
health care providers, probation officers, and EAP officers from
business and industry. Changing Point maintained the grant for a
period of 16 months. The Alcohol and Drug Abuse Administration
advised the gambling treatment community that because of the
dramatically growing cocaine addiction problem, and severely
limited resources, the decision was made to fund a cocaine
treatment program and end the subsidy of gambling treatment.
Epoch House
Indigent state residents were assigned to Epoch House Drug
Counseling Center services in Catonsville. It was the state's
contention that indigent compulsive gamblers could seek counseling
for their gambling disorder at this drug treatment program, since
it was the state's belief that "50 - 70% of compulsive gamblers are
co-addicted." The state also mandated at this time, through the
Office of Education and Training for Addiction Services (OETAS), a
gambling training module for all addiction counselors beginning the
OETAS training program. This program was terminated in 1988.
In the meantime, the Foundation's residential treatment
program in downtown Baltimore was struggling to overcome financial
obstacles, in large part due to resistance by third party insurers,
such as Blue Cross/Blue Shield of Maryland, to reimburse claims for
treatment of compulsive gambling, and the lack of further state
funding. Richard Weikart, the Foundation's new Executive Director,
sought to overcome this obstacle through state certification of the
gambling treatment program. He was informed by Howard Silverman of
the Alcohol and Drug Abuse Administration that the ADAA would
assist in this goal if certain guidelines, similar to those of
alcohol rehabilitation centers, were met.
Efforts at complying with the written proposal for this were
underway when the Foundation was forced to close its doors, because
of lack of funds, in February 1986. Since then the Foundation has
existed in name only, and no longer operates any treatment
programs. Dr. Custer, its founder, died in August 1990.
National Center for Pathological Gambling, Inc.
In order to prevent confusion about financial or clinical
responsibilities, Valerie C. Lorenz, Ph.D., the former director of
the Foundation gambling treatment program, established the National
Center for Pathological Gambling, Inc. This 501(c)(3) agency's
goals are to disseminate information about compulsive gambling, to
conduct ongoing research, to train mental health providers in
diagnosing and treating compulsive gambling, and to provide the
actual treatment for these gambling addicts and their family
members. The clinical files of both the original Johns Hopkins
program and of the Foundation program were turned over to Dr.
Lorenz and the National Center for safekeeping and further clinical
or research use, if necessary.
The National Center continued the Foundation's efforts at
certification for a compulsive gambling treatment program, and in
April 1986 presented a lengthy protocol in compliance with Alcohol
and Drug Abuse Administration guidelines. The proposal for
certification was denied several months later on the basis that the
State of Maryland had no applicable laws for certification of a
gambling treatment program. The Department of Health and Mental
Hygiene and the Alcohol and Drug Abuse Administration have taken no
further action to develop such laws.
Initial efforts of National Center staff were spent on
research and education, and to provide continuity of care to former
Foundation clients. However, as requests for clinical services
increased, the National Center expanded its clinical program.
Conceptually, it followed the original Johns Hopkins model, that of
non-psychiatric hospital setting, and the comprehensive team
approach. However, it differed from both Johns Hopkins and the
Taylor Manor program in that the emphasis is on individual therapy
instead of group therapy. It further has implemented a short term
intensive therapy model, with emphasis on resolving grief and
trauma issues, family therapy, communication and coping skills,
resolution of financial, work and legal obstacles, and relapse
prevention.
The National Center is currently building a residential
treatment center in downtown Baltimore. This new building is
funded, in part, by the City of Baltimore ($10,000) and the State
Legislature ($100,000), will be named Harbour Center, and will
serve as a model for subsequent facilities to be implemented by the
National Center.
Maryland Council On Compulsive Gambling
In September, 1986, Dr. Custer, the founder of the Foundation,
served as clinical director of the Taylor Manor Hospital Gambling
Treatment Program. He, these staff members, staff from Changing
Point, and several other Taylor Manor associates formed the
Maryland Council on Compulsive Gambling. This Council is a
not-for-profit educational agency, an affiliate of the National
Council on Compulsive Gambling, located in New York City. Although
the Maryland Council meets regularly, it is lacking in funding. It
must be noted that the establishment of the Maryland Council by
Taylor Manor staff, to the exclusion of compulsive gambling
treatment providers outside of the Taylor Manor network, led to a
political and professional schism (Schauble, 1989). Attempts are
now in progress to overcome this schism.
Compulsive Gambling Hotline
In the fall of 1987 the Addictions Services Administration
(formerly the Alcohol and Drug Abuse Administration) of the
Department of Health and Mental Hygiene issued a request for
proposal for the establishment of a 24-hour compulsive gambling
Hotline. Several proposals were submitted, and the winning grant
was awarded to the National Center in the amount of $7,038. These
funds were to be used to set up the Hotline by December 1, 1987,
until the end of the fiscal year, June 1988.
The purpose of the Hotline was to provide information on
compulsive gambling, make referrals to professional providers and
self-help groups, and provide crisis counseling services. Although
originally the Hotline was promoted only within the state of
Maryland, the Hotline was a national service. The National Center
recognized that Hotline calls could serve as a valuable source of
information on compulsive gambling within the state of Maryland and
the country. The National Center thus developed an intake
procedure to maximize collection on caller data. Thus callers
routinely are asked for demographics such as age, sex, race, ZIP
code of the caller and the gambling addict; time, date, and length
of call; nature of the call, and if other problem areas exist, such
as alcohol or drug abuse, or depression and potential suicide;
source of income and health insurance, type of gambling, and to
whom the caller was referred. (See related Appendix D for Hotline
Intake Form and Hotline report.)
During the first contract period, the Hotline received 651
appropriate calls, and a fairly large percentage of wrong numbers
and hang-ups. Presently hang-ups and wrong numbers represent only
a very small percentage of calls.
In the summer of 1988 the Alcohol and Drug abuse
Administration issued another Request for Proposal for the Hotline,
for $7,500. The National Center was the only agency which
responded to the RFP, and was awarded the contract. During the
second contract period the ADAA granted permission to promote the
Hotline nationally, which resulted in a slight increase in phone
calls. The National Center also had the Hotline number listed in
all Yellow Page directories in the State of Maryland.
The contract period was extended for another year, with ADAA
allocating $10,000 for the fiscal year, in spite of repeated
communication to the Department of Health and Mental Hygiene and
the Alcohol and Drug Abuse Administration that operating costs of
the Hotline were approximately $90,000. The National Center
accepted the grant as a means of continuing to collect data from
callers. It had become apparent to National Center staff that
through Hotline calls different types of compulsive gamblers, such
as lottery addicts and poker machine addicts, could be identified.
It was also possible to locate areas of the state which had a
preponderance of illegal gambling, such as Washington and Frederick
Counties, which have tip jars, and Baltimore County with its
illegal card clubs.
In the meantime, the House Appropriations Committee of the
state legislature, under the leadership of Delegate Timothy Maloney
of Prince Georges County and Delegate "Pete" Rawlings of Baltimore
City, was concerned about the operational costs of the Maryland
State Lottery and its potential negative effects on the citizens of
Maryland. After numerous hearings, the Appropriations Committee
ordered the State Lottery to print a warning message and the
Hotline number on lottery tickets and promotional materials. This
was started in February 1990.
The first such warning on the back of lottery tickets met with
criticism from the Appropriations Committee, because the print was
too small to be readily legible. However, this warning did result
in an increase of calls from lottery addicts.
A second printing resulted in an avalanche of calls. The
warning label this time was printed at the end of a paragraph of
claims information about the lottery. The notice then reads:
"Compulsive gambling is a treatable illness. For assistance call
1-800-332-0402." Callers believe that they are calling for
assistance with claims, winning numbers, how to play the game, etc.
Calls increased from less than 100 per month to over 3,000 per
month.
An unanticipated finding of these calls is that many callers
inquiring about the Maryland state lottery reside throughout the
United States as far away as Hawaii and Alaska and in Canada. Due
to the tremendous increase in telephone and administrative costs,
the Alcohol and Drug Abuse Administration allocated an additional
$9,000 for the remainder of the Hotline contract period.
In July 1990, the ADAA contracted with the National Center to
continue operating the Hotline for three years. A grant of $66,000
was allotted for this three-year period. Cost to operate the
Hotline currently are over $100,000 per year. In the meantime, the
National Center is pursuing other options for financial support,
such as from operating costs of the state lottery's advertising
budget and private foundations.
Further Developments
Further interest in combating compulsive gambling came from
legislators who introduced bills in support of compulsive gambling
treatment, education and research; however, these bills invariably
were voted down in committee. The most recent of these bills was
Senate Bill 188, introduced by Senator Howard Denis, for one
percent of lottery net revenues for compulsive gambling assistance.
The Department of Health and Mental Hygiene testified against this
bill, per administrative instructions, because the source of funds
was designated. It is the administration's position that monies
for such purposes should come from the General Fund.
In December 1988, newly hired Director of the Alcohol and Drug
Abuse Administration, Dr. Lloyd Sokolow, contacted Dr. Lorenz of
the National Center for assistance in convening a Task Force to
determine the social and economic impact of compulsive gambling on
the state of Maryland. This Task Force was convened in January
1989. Its members represented the four treatment or education
programs, Gamblers Anonymous and GamAnon, private providers, and
members from the community at large. The Task Force met monthly
for 18 months, at its own expense. This report stems from ideas
discussed and projects undertaken as a result of those Task Force
meetings.
In the fall of 1989, Delegate Gerald Curran introduced House
Bill 264, to create a state debt (bond) in the amount of $200,000
for construction of the National Center's new residential treatment
facility, Harbour Center, to be located in downtown Baltimore.
This bill was amended (for $100,000) and was passed by the House
and Senate. Governor Schaefer signed the bill into law on May 29,
1990. In the meantime the National Center had applied for and was
approved for a $10,000 Neighborhood Improvement Program grant from
the City of Baltimore. The National Center was also approved for
a $200,000 low interest loan through the Maryland Housing
Redevelopment Program; however, during the final application
process, the loan was jeopardized when the Maryland Historic Trust
mandated the preservation of existing storefronts, with their large
glass windows. Compliance with this mandate would have compromised
the desired patient milieu, security of confidential files, and
protection of the residential patients. Baltimore City Department
of Housing and Community Development and the Maryland Department of
Public Works are attempting to reach an agreement on this loan to
prevent further delays in construction. Construction of this
facility began in June 1990 and completion is expected in February
1991, barring further unanticipated complications.
Harbour Center is the treatment program of the National
Center. Its unique residential program is expected to serve as a
prototype for future programs in the United States. This model
will have major advantages for financially struggling patients:
(1) reduced cost; (2) travel convenience; (3) greater treatment
options; (4) the only Gamblers Anonymous and GamAnon in downtown
Baltimore; and (5) the first Rational Recovery program in
Baltimore. It will continue the work of other Maryland gambling
treatment programs of educating and training future mental health
professionals. A byproduct of these treatment options and the
Hotline is that the National Center will have access to a large and
ongoing population of compulsive gamblers and family members who
may be called upon to participate in future research activities.
In summary, the only funds expended by the state of Maryland
for education about compulsive gambling and treatment resources are
the funds presently allocated to the National Center for operating
the compulsive gambling Hotline. Funds allocated by the City of
Baltimore and the State of Maryland in 1990 were designated for
construction of the National Center's new facility. No funds have
been allocated for treatment since 1985, although the state and
counties continue to legalize new forms of gambling, such as the
stadium lotteries, bingo parlors, slot machines, and charitable
casinos. Other forms of gambling, such as Off-Track Betting
parlors and video poker machines, are being considered by the
legislature. Hopefully, the administration and the legislature
will be more cognizant of the social and economic costs of
compulsive gambling, and will be more supportive to their
compulsive gambling constituents and their victims in the future.
As the compulsive gambling population continues to increase in
Maryland, it will be of primary importance that third party
insurers include compulsive gambling in their health benefits.
Further, it is essential that policy makers and the Department of
Health and Mental Hygiene recognize the seriousness of this
disorder and provide adequate funds necessary for education and
prevention programs, research, training of mental health
professionals, and treatment for compulsive gamblers and their
family members. Without such support compulsive gambling will
clearly live up to predictions as being "the mental health epidemic
of the decade."
Current Treatment Options Elsewhere
Treatment options for the compulsive gambler are limited. The
most available is that of Gamblers Anonymous. Gamblers Anonymous
is a fellowship of recovering compulsive gamblers who follow a
12-step program of recovery similar to that of Alcoholics
Anonymous.
Started in 1957, Gamblers Anonymous has grown to over 800
chapters in the United States. Gamblers Anonymous is also located
in nearly twenty foreign countries, including Argentina, Australia,
England, Germany and Israel.
Professional treatment varies in its treatment stratagems and
effectiveness. Most inpatient gambling treatment programs are
components of alcohol or addiction units of psychiatric hospitals.
The availability of family therapy and after-care varies with each
setting.
State-sponsored gambling treatment programs most often are
limited to outpatient counseling for the gambler and family. New
York, New Jersey, Connecticut, Massachusetts, Ohio and Iowa have
allocated funds for gambling education and treatment. Iowa
allocated $1.5 million of its lottery proceeds to compulsive
gambling programs and training of mental health workers in 1989.
New York spent $750,000.
The first professional gambling treatment program was
established in the Brecksville Veterans Administration Medical
Center in 1972. Located outside of Cleveland, it provides
inpatient care for active duty military members and veterans. The
success rate is high, when inpatient therapy is supported with
outpatient therapy and regular attendance at Gamblers Anonymous.
It drops when treatment recommendations are not followed. Recent
VA budget cuts forced this Center to shorten its program to three
weeks and to reduce its staff size.
Outpatient programs are located in VA Medical Centers in
Brooklyn; Miami, Miramara, and Tampa, Florida; Lyons, and East
Orange, New Jersey; Loma Linda, California; Reno; Washington, D.C.;
and White River, Oregon. Some of these centers also provide
inpatient services for compulsive gamblers, when additional
criteria are met.
Inpatient treatment for active duty military members operate
without official sanction at two U.S. Navy Hospitals. A program
started at an Air Force base was terminated when the principal
provider was transferred. There are no programs within any of the
Army installations or hospitals. Most typically, active duty
members suffering from compulsive gambling are transferred to other
duty stations or court-martialed, or terminated through
administrative discharge. Military bases in Maryland rarely allow
for the active duty member to receive treatment.
Ironically, the US Army has promoted gambling more than any
other branch of the Armed Forces (Farinella, 1987). To combat the
spread of compulsive gambling among military members and their
dependents, the US House and Senate Armed Services Committees
directed the Department of Defense to study this problem in the
military (Air Force Times, 1988), with a view towards providing
treatment for these afflicted members. Representative Benjamin
Cardin from Maryland initiated this Congressional inquiry.
Findings of the DOD report are inconsistent with experiences of
military psychiatrists (Department of Army Psychologist Conference,
1990) and civilian providers in Maryland and elsewhere.
The South Oaks Hospital gambling treatment program
(Amityville, New York), which was started in 1981, has had a
successful history of treating compulsive gamblers. Based on the
medical model, it has long been an advocate of family therapy and
it conducts ongoing research into this disorder.
The State of Iowa has been the most aggressive state in
providing treatment for compulsive gamblers and their families. It
sponsored the training and hiring of counselors to work in a dozen
community mental health centers throughout the state. Funds for
this were allocated from state lottery proceeds.
The State of Massachusetts is also strongly committed to
address the problems caused by compulsive gambling. The Harvard
Medical School has opened an outpatient program at Mt. Auburn
Hospital and the Massachusetts Council of Compulsive Gambling holds
annual conferences in an effort to educate the community at large
and to network with other health professionals.
New York State's legislature has responded by funding several
outpatient programs, a hotline and by placing warnings at race
tracks and on state lottery promotional materials and tickets.
The Ohio State Lottery recently began a Compulsive Gambling
Advocacy program, and spends money on advertising, such as on
tractor-trailer trucks and on billboards. Its goals are to expand
the lottery's commitment to combatting compulsive gambling.
The Minnesota Legislature recently appropriated $600,000
($300,000 in fiscal year 1990 plus $300,000 in fiscal year 1991) to
implement a compulsive gambling treatment program which will
include inpatient and out-patient treatment and rehabilitation
services, plus research studies.
The Maryland Task Force on Gambling Addiction is hopeful that
the State of Maryland will review its commitment to combating the
social, economic and health impact of compulsive gambling within
its own state.
PREVALENCE OF GAMBLING ADDICTION IN MARYLAND
There are several significant public health issues facing the
Nation and the State of Maryland. Recently, the federal Department
of Health and Human Services awarded the State of Maryland nearly
$1 million to reduce the lists of people waiting for drug abuse
treatment at the various programs in the State. This investment is
a testimony to this public health problem. In addition, the State
is also investing in drunk driving prevention initiatives to stem
the impact of alcohol abuse and alcoholism on deaths on the
highways. Alcohol abuse and other substance abuse cost the Nation
over $180 billion annually. According to national estimates, about
10 percent of the adult population have alcohol problems and an
additional 1 percent abuse other drugs.
Several studies of the prevalence of pathological gambling
have been commissioned over the past 15 years. The most reliable
estimate is as old as the National Commission in 1976 which
estimated pathological gambling at slightly less than 1 percent of
the adult population. This estimate was the most conservative of
estimates recorded at that time. More recently, the National
Institute of Mental Health sponsored a prevalence study of
pathological gambling for New York, New Jersey, California, Iowa,
and Maryland. The results of telephone interviews using the South
Oaks Gambling Screen produced reliable and comparable estimates of
prevalence for these states. Approximately 1.5 percent of the
adult population were classified as pathological gamblers and an
additional 2.5 percent problem gamblers. This translates into
approximately 50,000 pathological gamblers in Maryland with an
additional 80,000 problem gamblers. (See Appendix G for a review
of this study.)
This percentage for the state of Maryland, when compared to
the state estimate for 1976 (by extrapolating the national
estimate), reveals that prevalence has nearly doubled in the state.
This estimate of doubling is also conservative because the gambling
industry in Maryland has always exceeded the national norm.
Moreover, the instrument for assessing pathological gambling
prevalence and the administration over the telephone are far less
precise methods than have been administered in the assessment of
prevalence of other disorders. Particularly for pathological
gambling when illegal activities are present, the lack of
corroborating information from family members enhances the
probability of denial. This type of addictive behavior is not as
readily countable as other addictions in which substances are
ingested and intoxication is more readily discernable and
measurable.
Except for alcohol, the prevalence of pathological gambling
exceeds that of any abused substance. Moreover, data indicate that
alcohol consumption and illicit drug use by teens are on the
decline whereas the prevalence of problem gambling, especially
among teenagers and young adults, is on the increase. The overall
involvement in gambling of the state's citizenry is more intense.
The state has witnessed a dramatic increase in various types of
legalized gambling in recent years with the advent of the state
lottery and charitable casino nights in two counties, slot machines
on the Eastern Shore, and bingo parlors. It should be mentioned
that the proliferation of illegal gambling contributes to the
growing numbers of addicted gamblers, and this component is
virtually impossible to measure. It is apparent that ongoing
surveillance of the incidence of problem gambling in Maryland is a
first step consistent with the information most recently collected
on comparative prevalence.
With huge jackpots creating instant millionaires and the
proliferation of games that tell players immediately whether they
have won, state-operated lotteries have become the most popular
form of legal gambling in the nation (Christiansen, 1987). This
access to the action of gambling - the agent - has increased
dramatically. Epidemiologically, it can be said that this industry
expansion is likely to have contributed to production of
pathological gamblers.
A review of the literature produces evidence that the
prevalence of pathological gambling has increased in the last
fifteen years along with the proliferation of legalized gambling.
In 1974, 61 percent of the U.S. adult population gambled, with more
than $17 billion wagered legally (Commission, 1976). In 1986,
$166.7 billion was wagered (Christiansen, 1987), which is almost a
950 percent increase. Gambling is legal in almost all 50 States.
A study in 1975 of the prevalence estimated that about 0.77 percent
of the adult population could be classified as pathological
gamblers (Commission, 1976), while more recent estimates place it
at a conservative 1.5 percent (Volberg, 1989). Although both of
these prevalence estimates were derived from methods with reported
limitations, it is evident that the prevalence of pathological
gambling has doubled during a period of increased access to
legalized gambling and significant growth in the legal wagering of
Americans.
In some states such as Massachusetts, gambling is a leading
$6 billion industry. According to conservative estimates by law
enforcement officials, three to five times more is bet illegally on
sports events and betting with bookmakers (Rose and Lorenz, 1988).
In recent years, nearly all states have endorsed some form of
lottery or other legalized gambling. For those states with
lotteries, like Maryland, revenues from this endeavor have
consistently increased (Christiansen, 1987). However, no one has
been able to measure the growth of illegal gambling and its impact.
Nevertheless, a natural reaction -- or "quick fix" -- strategy
would be to oppose the legalization of gambling, thus reducing or
eliminating that component of access to the agent (Indiana Citizens
Against Legalized Gambling, 1985).
These authors agree that strategies aimed at reducing the
quantity of or access to the agent by susceptible hosts can reduce
the incidence of consequent compulsive gambling. However, we argue
that such an approach is insufficient to reduce the precursive risk
factors. A complete, balanced use of the epidemiologic model is
necessary to reveal strategies for combatting compulsive gambling.
ECONOMIC AND SOCIAL IMPACT OF GAMBLING ADDICTION
Prevalence estimates are the first step in estimating the
impact of problem gambling on society. Traditionally, the National
Center for Health Statistics has measured the annual economic costs
of illnesses and diseases. In the mid 1980s, a national study was
commissioned to measure the economic impact of alcohol and other
substance abuse using the conventional methodology but altering it
to comply with the social cost estimates that are unique to mental
health problems.
Economic costs of illness and diseases are divided into direct
and indirect costs (Rice, Hodgson & Kopstein, 1985). Direct costs
are those dollars lost to gambling as well as those spent by
society for prevention (both primary and secondary), detection, and
treatment. Indirect costs are defined as those resulting from lost
productivity, measured as income foregone, and are divided into two
components, productivity lost due to morbidity and mortality.
The costs of pathological gambling have been estimated earlier
(Politzer, Morrow & Leavy, 1981). The indirect costs include those
dollars obtained by the pathological gambler legally or illegally
for gambling and related activities as well as the cost of lost
productivity. Since much of pathological gamblers' working hours
are channeled toward gambling (for example, they are either at the
casino, or on the phone, or studying the racing form, but not
working), lost productivity can be a serious economic cost. Among
the direct costs for pathological gambling, those dollars set aside
for treatment are negligible to date. Only a few treatment
programs (52) exist and their funding is marginal, consequently the
services vary greatly (National Council on Compulsive Gambling,
1989).
We have updated the total cost estimate from $20,000 per
pathological gambler per year in 1980 to about $30,000 in 1988
dollars. The total cost estimate is a function of the productivity
loss on the part of the gambler in one year, and the total
resources gambled in one year (Politzer et al, 1981). When these
components are corrected for inflation, the 1988 estimate is
conservatively increased to $30,000 per year($41,826.29 in 1998
dollars). So for the conservative 1.5 percent or 2.7 million pathological
gamblers (180 million adults; DOC, 1988), at an average cost of $30,000,
pathological gambling cost society about $80 billion in 1988 ($111.54
billion in 1998). For Maryland, if it is typical of the national profile,
pathological gamblers cost its citizens about $1.5 billion in 1988
($2.09 billion in 1998), ceteris paribus.
This cost estimate is considered conservative because we have
not included costs such as suicide attempts, family neglect, and
incarceration or other health problems resulting from pathological
gambling. Recent estimates of the costs of alcoholism, substance
abuse, and mental illnesses (DHHS, 1987) account for such social
cost components as crime, social welfare programs, and property
damage from motor vehicle accidents. We have maintained a
conservative approach to estimating the cost of pathological
gambling to facilitate cost comparisons by component with physical
illnesses and diseases.
Most recently, alcohol abuse and alcoholism was estimated to
cost society nearly $120 billion in 1988 ($167.31 billion in
1998 dollars) and an additional $60 billion ($83.65 billion in
1998 dollars), ceteris paribus, was estimated for other substance abuse.
These figures rank among the highest of any illness or disease in
1988.
All addictive disorders manifest their costs in lost
productivity and employment as well as the economic and emotional
destruction of the family unit. With pathological gambling, lost
productivity is particularly costly. Alcoholics and substance
abusers can ingest their respective substances and then return to
the work setting. Although partially impaired, the substance
abuser is physically present at work. The addicted gambler can be
present at work, but if engaged in gambling must either be on the
telephone, at the job site figuring his betting strategy instead of
working, attempt to borrow funds from fellow employees or others,
or he must leave to attend the gambling activity.
Finally, it must be emphasized that although a substance is
not ingested, a substance is abused -- money. Obtaining alcohol is
relatively inexpensive compared to obtaining money to gamble.
Pathological gamblers tap their own resources and deplete those
available to their own families. They then engage in acquiring
dollars from many different sources. Anywhere from 10 to 17
individuals may be affected by a single pathological gambler
(Lesieur, 1984). Their addictive behavior requires that they
obtain money from any and all available sources. Therefore,
pathological gambling becomes a cost borne by the victims, family,
friends, and employers of the addicted gamblers.
How serious a cumulative direct economic cost was incurred by
pathological gamblers in Maryland is partly estimable from the Task
Force survey of GA members in the state. From 1984 through 1989,
the average indebtedness of the compulsive gambler undergoing
treatment was $71,853. The cumulative indebtedness of these
patients over this five year interval was $9,772,000, almost
$10 million. The average amount of accumulated gambling debt for
the Gamblers' Anonymous member by the time he sought help was
computed to be $83,336. The aggregate financial debt incurred can
be roughly estimated by multiplying the prevalence of the patho-
logical gambling problem in 1988 by this average amount of gambling
debt per gambler. The population of Maryland in 1988 was
4,621,733. Approximately 74.5 percent of this population
(3,441,805) was 18 years and older. If we are to accept 1.5
percent of this population as consisting of pathological gamblers
(Volberg, 1989), then there would be 51,627 to 52,599 pathological
gamblers in Maryland during 1989. Given the weighted average
indebtedness of $75,262 of gamblers in treatment and gamblers in
self-help groups, the direct economic cost due to gambling on the
part of these individuals would be roughly within the range of
$3,885,551,274 to $3,988,810,738 in 1988. In 1998 dollars
the magnitude of this debt would be between $5,417,273,029.39
and $5,561,238,369.16. The magnitude of this accumulated debt is an
indicator of the size of the economic burden on a segment of society.
The social cost of the pathological gambling stems partly from
civil and criminal offenses perpetrated by those afflicted. Sixty-
one and one-half percent of the GA members admitted to having
committed illegal acts as a result of their gambling. More than
three-quarters (80.2%) indicated that they had committed some sort
of civil offense due to their gambling. More than a quarter (28%)
of them had become delinquent in paying their Maryland taxes.
Approximately a quarter of them (25.3%) admitted to having been
involved in auto accidents during the worst of their gambling. To
be sure, almost half (47.3%) of the GA members reported speeding
while heavily gambling. Many of these individuals seem to become
more hurried, more accident prone, and more risk-taking during
their heavier gambling activity.
That the gambling exacts a harsher toll on society may be
surmised by a review of the number and types of criminal offenses
that are associated with this addiction. About one-third of the GA
members report writing bad checks at times of heavy gambling.
Thirty-seven percent indicate that they have stolen money during
this time as well, and 3.3 percent say that they have been involved
in a burglary; a fifth of the GA members recount at least one
incidence of forgery. Families suffer as GA members undergo
foreclosure or eviction, fall behind in their child support
payments, sustain auto accidents, or wind up being charged with a
criminal offense at times of heavy gambling. Yet criminal damage
to the social fabric does not explain all of the suffering or
economic cost that is wrought by this pathology.
The damage inflicted on the institution of the family and the
obligations of parenthood may be overbearing, as indicated by
research in recent years. Shame, concealment and guilt were
followed by breakdowns in communication, trust, and support. Anger
and resentment were found among the negative emotions that emerged
on the part of the spouse. The sexual relationship between the
couples suffered. Parental obligations were also neglected.
Fifty-nine percent of the couples had considered separating.
Thirty-three percent of the couples, in fact, separated but have
since reconciled. The series of stressful events were found to be
associated with depression and strains that were accompanied by
numerous psychosomatic difficulties, including ulcers, cardiac and
gastrointestinal problems. The institution of the family and its
social-psychological health were found to have been seriously
impaired (Lorenz & Yaffee, 1987, 1988, 1989).
PROFILE OF MARYLAND PATHOLOGICAL GAMBLERS IN PROFESSIONAL
TREATMENT PROGRAMS
A profile of socio-demographic background, parental role
models, psychological attributes, financial situation and legal
problems of the patient population was undertaken from an analysis
of 246 patients in the three Maryland treatment centers between
1983 and 1989. The Washington Center for Pathological Gambling,
Taylor Manor Hospital, and the National Center for Pathological
Gambling, Inc., provided data in such a way that the anonymity and
confidentiality of their patients were secured. From this subject
pool, the distribution of gambling preferences of these patients
was examined. The analysis of these patients concludes with
statistical models of significant and substantial influences on the
severity of the gambling problem.
The Nature of the Gambling Problem
Most (84%, n=180) of the patients began their gambling
between the ages of 10 and 30 years of age. Less than 8 percent
began gambling before the age of 10 and less than 8 percent began
it after the age of 30.
A plurality of these patients (30.6%, n=144) reported that the
racetrack was their most favored type of gambling. Slightly more
than a fifth of these respondents indicated that poker machines
were their most favorite form. Casino was favored by 16 percent.
Many gamblers had more than one preference in betting.
Foremost among the second most preferred type of gambling was
the lottery/numbers. Traditionally, numbers playing has rarely
been reported in Maryland. Almost 36 percent of the patients
maintained that the lottery was therefore their second most favored
type of gambling. After the lottery, casino gambling dominated the
second most preferred type of gambling. Cards ranked third among
the second gambling preference. Tables I and II in the Patient
Profile, Appendix E, give the precise breakdown of these preference
distributions.
The depth of the gambling debt provides an indication of the
severity of the gambling problem and an indication of its direct
social cost. Approximately forty-eight percent (n=136) of these
individuals owe less than $20,000. About 25 percent of them owe
between $10,000 and $50,000. Another quarter of them owe more than
$50,000. About 12 percent owe more than $100,000 in gambling debt.
The average gambling debt for these patients was $71,853. The
total gambling debt for all of these patients was $9,772,000. Even
though this debt is spread over five to six years, the direct
financial cost to society approximates $1,628,666 per year just for
those under treatment.
The severity of the gambling problem can be indicated by the
ratio of the gambling debt to the annual income of the gambler.
High ratios, greater than one, suggest a serious problem whereas
ratios of less than one suggest more remediable severity. Fifty-
seven percent (n=100) of the patients owed one-half or less than
one-half of their annual income. Seventy-three percent of the
gamblers owed less than, or as much as, their annual income.
Another twelve percent owed between one and two times their annual
income. Fifteen percent owed more than twice what they make each
year. This ratio indicates a distribution of psychological burden
upon these patients.
Part of the burden borne by these patients comes from the
extent of legal problems incurred by their gambling. Approximately
20 percent (n=153) of the patients indicated that they had pending
legal problems. To make matters worse, more than a quarter of
those surveyed (28.7%, n=94) reported having no insurance coverage
for treatment. Almost one-third of these respondents lacked solid
insurance coverage for treatment of this disorder.
A Profile of the Maryland Pathological
Gambling Patient: 1983-1989
The demographic characteristics of the compulsive gambling
patient at the time of this analysis included age, race, sex,
family composition, and marital status. For the most part, these
patients were married, middle-aged, male, caucasians, and from a
family with two brothers or sisters. Eighty-five percent (n=246)
of the patients were male. Eighty-six percent (n=217) were white,
12 percent were black and the remainder were Asians, Hispanics, and
others. Almost 59 percent (n=241) were married. Seventeen percent
were divorced and 12 percent were single. About seven percent were
widowed, while a little more than three percent were separated.
Almost three-fourths of the patients come from families with three
or fewer siblings.
In socioeconomic characteristics, the patients are, for the
most part, fully-employed, working in clerical positions or sales
with at least a high-school education, and earning less than
$30,000 a year. More than 80 percent report being fully-employed,
less than three percent partly-employed, and 13 percent report
being unemployed. About 44 percent (n=229) were working in
clerical or sales jobs, 37.6 percent indicate working in management
or executive positions, and 13.5 percent relate working in the
professions; less than five percent say that they are in business
and less than one percent maintain that they are housewives or
students. More than half had completed twelve years of schooling
while about a quarter dropped out of high school. Nevertheless,
twelve percent had two or more years of college, while nearly six
percent had gone to graduate school. Approximately 27 percent
(n=229) reported earning $10,000 or less, while another 21.8
percent earn between $11,000 and $20,000. An additional 27 percent
earn between $20,000 and $30,000. About 13 percent earn incomes in
the $30,000 and $40,000 range, while 12 percent state that they
earn more than $40,000 per year. In general, these patients are
largely employed, working-class persons, with low to middle
incomes, and with a high-school level education.
In a substantial portion of cases, the father had a problem
with alcohol or gambling. Also, in a surprising percentage of
cases, the mother had passed away before the patient was 18 years
of age. About thirty-seven percent (n=75) of the fathers were said
to have had an alcohol problem. Almost 24 percent (n=170) of the
fathers were reported to have had a gambling problem at one time or
another. In 50.3 percent (n=169) of the patients, the mother had
died before the patient had turned 18 years old. Roughly four-
tenths of the patients had been subjected to physical or sexual
abuse in earlier years. This history may be indicative of an
inadequate role model, early loss of parental support and guidance,
and abuse.
Substantial portions of the gambling patient population had a
history of or suffered (at the time of the survey) from other
addictive disorders. More than one-fourth (26.7 percent, n=187)
have had or do have a drug problem, while more than one-half (50.8
percent, n=187) have had or do have an alcohol problem. More than
one-quarter of these patients (25.7 percent, n=167) have attempted
suicide. Forty-eight percent (n=173) have been outpatients before,
while more than one-fifth (22.1 percent, n=172) have been
inpatients before.
More than one-fifth (20.3 percent, n=153) had pending legal
problems and about 13 percent (13.2 percent, n=174) found
themselves in jail or prison. One might postulate from this the
existence of an addictive personality. A more careful analysis
later will show that such an inference from these frequencies can
be misleading.
A Statistical Model of the Severity of the Gambling Problem
for Maryland Pathological Gambling Patients: 1983-1989
Using powerful and robust statistical techniques (ordinal
logit model and logistic regression), we found that a number of
significant phenomena were found to be associated with the severity
of the gambling problem. Whether the patient was or had been
physically or sexually abused, the level of the patient's
education, whether the mother died before the patient was 18 years
of age, and whether the patient has or had a drug problem were
variables that were found to be significantly related to the
severity of the gambling problem.
Most of the variables were positively related to the severity
of the gambling problem. If the mother of the patient had died
before the patient was 18 years old, then it was more likely that
the patient would have a more severe gambling problem. If the
patient had been subjected to physical or sexual abuse, he was more
likely to have a more severe gambling problem. If the patient was
a high school graduate, he was more likely to have a more severe
gambling problem. However, if the individual had or had had a drug
problem, he was less likely to have a more severe gambling problem.
All of these relationships were significant.
In magnitude of association, the early demise of the mother
was the most powerful. Past or present physical or sexual abuse
appeared to have the second greatest influence; and the past or
present drug problem was the third strongest association with the
severity of the gambling problem. The weakest linkage was with
education. The powerful model developed allows us to correctly
predict for 78 percent of the patients how severe the gambling
problem will be.
These findings are not difficult to explain. With a high
degree of confidence, we have been able to formulate some of the
possible influences worsening the impulse control disorder of
compulsive gambling. Early abuse and loss of maternal love and
support may predispose these patients to put themselves and their
livelihood at risk and reinforce the need for "making it big" on
the next bet. Drugs, past or present, are negatively related to
the severity of the gambling problem. The more severe the gambling
problem, the greater the need for clarity and control, and the
greater the aversion for drugs. The more the education, the more
the patient is likely to have funds with which to gamble. It is
interesting to note that a past or present alcohol problem is not
significantly related to the severity of the gambling problem among
these patients. But these explanations have implications for
policy also.
There is new evidence to call into question the theory of the
addictive personality, advanced by Durand Jacobs (1986). When we
refer to alcohol or drug abuse in our statistical model, our
measures here are of past or present abuse. From our analysis, we
see no statistically significant relationship between the severity
of the gambling problem and either past or present alcohol abuse.
We also find that the relationship between drug abuse and severity
of the gambling problem is a negative one. The more severe the
gambling problem, the less severe the drug abuse, either past or
present. The corresponding predisposition to various and sundry
addictions comes under a shadow of doubt.
Is it possible that the negative relationship between the drug
and the gambling relates to past drug abuse and not current drug
abuse? If it does, then it is possible that one gets over one
addiction as one becomes addicted to something else. If this be
so, then the theory may still hold. But it is not simultaneous or
co-addiction that is the problem; under those circumstances, it is
serial or sequential addiction that poses the problem for the
addictive personality.
But how does this relate to policy? If there is no
relationship between alcoholism and severity of pathological
gambling among the patients, then sending a gambler to an alcohol
rehabilitation facility would be a waste of resources. Similarly,
sending a gambler to a drug rehabilitation facility would possibly
miss the nub of the problem. It could even worsen matters. What
successfully treats one kind of illness might be inappropriate for
another. Although we will explore this matter further in our
analysis of Gamblers Anonymous members, it would appear that one
would be safer to enroll compulsive gamblers in a treatment program
specially designed to treat their unique problems, than to refer
compulsive gamblers to an alcohol, drug, or general addictions
program.
Recommendations
However much we have learned about the pathological gambler in
treatment, we would have learned more if a standard questionnaire
had been in use. See Appendix E for discussion of some problems
encountered for want of uniformity in data collection. Our initial
and most basic recommendation for treatment programs is that a
uniform questionnaire be constructed by a state commission and
administered by all treatment programs in the State of Maryland.
Administration of this questionnaire should be required by
Department policy for all gambling treatment programs receiving
state aid. This questionnaire would have the identical questions,
with the same number and types of answer categories for each
question. Such standardization would make merging the data files
and the items on the questionnaires easy when the State needs
information on the treatment programs. The State of Maryland would
save much money in collecting its data this way.
Each question in the uniform questionnaire should deal with
one idea alone. Combining concepts in one question confounds their
analysis. Each question should be constructed in such a way that
the answer categories for each question are collectively exhaustive
and mutually exclusive. This question construction would allow for
sophisticated statistical analysis. Failure to comply with this
requirement could seriously hamper analysis.
If at all possible, there would be multiple indicators for
theoretical constructs that are to be tested. At least one
indicator for each dimension of the construct should be included.
The scaling of the answer categories should be, whenever possible,
in seven point scales: from agree very strongly, agree strongly,
agree, unsure, disagree, disagree strongly, and disagree very
strongly.
Beyond the recommendation for a uniform questionnaire, we
believe further inquiry is needed into the relationship of
pathological gambling to addictive drug or alcohol abuse. In
particular, whether pathological gambling and drug abuse occur
serially or in the form of co-addiction requires study. The answer
may have profound consequences for treatment.
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