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
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
Compulsive Gambling 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
PROFILE OF MARYLAND GAMBLERS ANONYMOUS RESPONDENTS . . . . . 69
PROFILE OF MARYLAND GAM-ANON RESPONDENTS . . . . . . . . . . 72
REPORT OF THE COMPULSIVE GAMBLING HOTLINE. . . . . . . . . . 74
LIABILITY OF THE GAMING INDUSTRY FOR MARYLAND'S
PATHOLOGICAL GAMBLING PROBLEM . . . . . . . . . . . . . 78
BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . 81
APPENDICES
APPENDIX A: A WORD ON ROBERT A. YAFFEE, PH.D.. . . . . . . . 87
APPENDIX B: GAMBLERS ANONYMOUS SURVEY. . . . . . . . . . . . 89
Introduction. . . . . . . . . . . . . . . . . . . . . . 91
Methodology . . . . . . . . . . . . . . . . . . . . . . 92
Results . . . . . . . . . . . . . . . . . . . . . . . . 92
Discussion. . . . . . . . . . . . . . . . . . . . . . . 97
Tabulation of Survey Questions and Responses. . . . . . 100
APPENDIX C: GAM-ANON SURVEY. . . . . . . . . . . . . . . . . 112
Introduction. . . . . . . . . . . . . . . . . . . . . . 114
Methodology . . . . . . . . . . . . . . . . . . . . . . 115
Results . . . . . . . . . . . . . . . . . . . . . . . . 115
GamAnon Respondents' Requests for Help. . . . . . . . . 118
GamAnon Respondents' Messages for the Governor
and Legislators. . . . . . . . . . . . . . . . . . 119
Conclusions . . . . . . . . . . . . . . . . . . . . . . 120
Tabulation of Survey Conducted by the Task Force
on Gambling Addiction of Maryland
GamAnon Chapters . . . . . . . . . . . . . . . . . 120
APPENDIX D: COMPULSIVE GAMBLING HOTLINE (1-800-332-0402)
FY90 FINAL REPORT . . . . . . . . . . . . . . . . . . . 124
Background. . . . . . . . . . . . . . . . . . . . . . . 126
"Legitimate" Calls. . . . . . . . . . . . . . . . . . . 127
Lottery Calls -- U.S. and Maryland. . . . . . . . . . . 139
Public Relations Efforts. . . . . . . . . . . . . . . . 142
Legislative Activity. . . . . . . . . . . . . . . . . . 143
Summary . . . . . . . . . . . . . . . . . . . . . . . . 143
Representative Calls Received by the
Compulsive Gambling Hotline. . . . . . . . . . . . 146
Varied and Different Hotline Calls. . . . . . . . . . . 153
APPENDIX E: PROFILE OF PATHOLOGICAL GAMBLERS UNDERGOING
TREATMENT . . . . . . . . . . . . . . . . . . . . . . . 154
Research Objectives . . . . . . . . . . . . . . . . . . 156
Profile of the Pathological Gambler in Maryland . . . . 162
Demographic Characteristics of the Gambling Patient . . 164
Socio-Economic Characteristics of the
Gambling Patient . . . . . . . . . . . . . . . . . 165
History of Parental Abuse and Loss. . . . . . . . . . . 166
Personal History of Abuse and Consequences. . . . . . . 166
Crosstabulations of Variables
Related to the Severity Ratio. . . . . . . . . . . 169
A Model Explaining Seriousness
of the Gambling Problem. . . . . . . . . . . . . . 176
Co-addiction, Cross-addiction and General Therapy . . . 186
Substantive Recommendations . . . . . . . . . . . . . . 187
Methodological Recommendations. . . . . . . . . . . . . 189
Acknowledgements. . . . . . . . . . . . . . . . . . . . 191
APPENDIX F: SEVERITY OF COMPULSIVE GAMBLING AND CO-ADDICTION
IN MARYLAND . . . . . . . . . . . . . . . . . . . . . . 192
Background. . . . . . . . . . . . . . . . . . . . . . . 194
Problem Formulation . . . . . . . . . . . . . . . . . . 194
Patient Model . . . . . . . . . . . . . . . . . . . . . 197
Introduction to Gamblers Anonymous Models . . . . . . . 200
Ordinal Logit Model . . . . . . . . . . . . . . . . . . 201
Logistic Regression Model . . . . . . . . . . . . . . . 204
Conclusions . . . . . . . . . . . . . . . . . . . . . . 207
The Question of the Addictive Personality . . . . . . . 208
Acknowledgements. . . . . . . . . . . . . . . . . . . . 213
APPENDIX G: A REVIEW OF PREVALENCE ESTIMATES . . . . . . . . 214
Updating the Prevalence Estimate. . . . . . . . . . . . 216
Post-Stratification Weights . . . . . . . . . . . . . . 217
Our New Estimate. . . . . . . . . . . . . . . . . . . . 219
Concerns with Sparse Distributions. . . . . . . . . . . 219
Composite Estimates across States . . . . . . . . . . . 221
Conclusions . . . . . . . . . . . . . . . . . . . . . . 224
INTRODUCTION
Fact Sheet
Untreated pathological gambling costs Maryland billions of dollars, and
affects hundreds of thousands of lives
There are 50,000 pathological gamblers in Maryland
There are another 80,000 problem gamblers in Maryland
Pathological gamblers cost Maryland and its citizens about $1.5 billion
annually in lost work productivity and embezzled, stolen or otherwise
abused dollars
The total cumulative indebtedness of Maryland's pathological gamblers
exceeds $4 billion
Over 850,000 people in Maryland are affected by pathological gamblers
(i.e., 17 people for each gambler)Selected Comments of Survey Respondents
"We are on the verge of a real crisis in this country with the widespread
acceptance and dependence on gambling."
-- a GA survey respondent
"Gambling is a devastating disease, as overwhelming as cancer, but nobody
talks about it. People don't realize the many forms of gambling or how
insane the disease is. Some people can ruin their lives even on lottery
tickets or bingo. It isn't just Las Vegas or Atlantic City."
-- a GamAnon survey respondent
"Gambling is a terminal disease -- it is a family disease that
progressively kills each and every member of the family."
-- a GamAnon survey respondent
"We need more public awareness of gambling as an addiction, and financial
support for education and rehabilitation of those affected."
-- a GA survey respondent
"We need support services, family counseling, crisis intervention and
follow-up, social and mental health services."
-- a GamAnon survey respondent
"For me the gambling addiction was the strongest of my three addictions
-- alcoholism, drug addiction and compulsive gambling. The gambling
brought me to my knees and I questioned my sanity."
-- a GA survey respondent
"The damage that gamblers do spreads far wider than just the direct family
members. Much more white collar criminal activity goes on than is made
public. My own opinion is that the gambling illness is looked at as a
weakness as opposed to a sickness that can be treated."
-- a GA survey respondent
"Have as much advertising for treatment as they do for the state lottery."
-- a GA survey respondent
Establishment and Purpose of the Task Force
In December 1988, Lloyd Sokolow, Ph.D., then director of the
Alcohol and Drug Abuse Administration, became concerned that
compulsive gambling might constitute an under recognized health
problem in Maryland.
Dr. Sokolow invited about 15 people, ranging from researchers
and gambling treatment providers from private programs, to
legislators, reporters and lay people, all with some exposure to
compulsive gambling, to look into the situation in Maryland. Most
responded positively and enthusiastically. Others offered to help,
but could not commit themselves to what was expected to be six
months of monthly meetings.
The charge to the group, which met for the first time in
January 1989, was to help determine appropriate state responses or
policies, if, indeed, such responses were warranted.
Dr. Sokolow asked the Task Force to review the following
items:
1. A definition of the current compulsive gambling problem in
the State of Maryland;
2. The current state of responses to multiple problems in
prevention, treatment and law enforcement areas;
3. Goals needed to better organize, coordinate, add to, and
effectuate these responses;
4. The specific steps and conditions necessary to achieve
these goals;
5. Determination of funding resources to support and expand
gambling-specific programs;
6. The relationship between pathological gambling and other
psychiatric and addictive disorders;
7. Appropriate local, state, and private sector responsibility
with respect to these responses; and
8. Such matters which the Task Force might consider relevant
and appropriate to its mission.
Membership of the Task Force
Co-Chairs
Robert M. Politzer, Sc.D.
Director of Research
Washington Center for Pathological Gambling
3700 Berwyn House Road
College Park, MD 20740
301-443-5794 (workday);
301-345-6623 (Center)
Valerie C. Lorenz, Ph.D.
Executive Director National Center for Pathological Gambling, Inc.
651 Washington Blvd.
Baltimore, MD 21230
301-332-1111
Liaison
William B. Lowry, Jr.
Department of Health and Mental Hygiene, Alcohol & Drug Abuse Administration
201 W. Preston St.
Baltimore, MD 21201
301-225-6873
Secretary
Ralph B. Duane
Businessman and compulsive gambling peer counselor
Brookeville, MD
Psychiatric Consultant
Eugene M. Caffy, M.D.
Veterans Administration Board of Veterans Appeals
Bowie, MD
Statistical Consultant
Robert A. Yaffee, Ph.D.
Academic Computing Facility,
Courant Institute for Mathematical Sciences
New York University
Membership of the Task Force (continued)
Members
Clark J. Hudak, Jr., ACSW
Director, Washington Center for Pathological Gambling
College Park, MD
Christina R. Schauble, B.Sc.
Writer/Editor
Baltimore, MD
Joseph Ciarrocchi, Ph.D.
Director, Addictions Services
Taylor Manor Hospital
Ellicott City, MD
Alternate for J. Ciarrocchi:
Joanna Franklin, M.S., CAC
Taylor Manor Hospital
Richard Richardson
Maryland Council on Compulsive Gambling, Inc.
Baltimore, MD
Richard L. Feldman, LCSW
U. S. Probation Office
Baltimore, MD
Robert G. Goodman, B.Sc.
Glenwood Life Drug Treatment Center
Baltimore, Md
Thomas T. Truss, Ph.D.
Clinical Psychologist
Annapolis, MD
Judy Mulcahy
Community Member
Bel Air, MD
Special Volunteers
Barbara Turner
Maryland Gazette
Glen Burnie, MD
James Blumner, Esq.
Community Member
Baltimore, MD
Acknowledgements
Production of this report reflects the contributions and
personal efforts not only of members of the Task Force but also of
other persons and entities. The Task Force is pleased to
acknowledge their special efforts, recognizing that any errors in
this report are the responsibility of the Task Force itself. The
Task Force acknowledges --
For providing clinical and research data, the following
treatment center directors: Valerie C. Lorenz, Ph.D., National
Center for Pathological Gambling, Inc., Joseph C. Ciarrocchi,
Ph.D., Taylor Manor Hospital, and Clark J. Hudak, Jr., ACSW,
Washington Center for Pathological Gambling;
For cooperation in providing supplementary information about
their research design and findings: Rachel Volberg, Ph.D., and
Henry Steadman, Ph.D., of Policy Research Associates, Delmar, New
York;
For their cooperation in the surveys taken by the Task Force:
91 members of Gamblers Anonymous and 23 members of GamAnon;
For distributing, collecting and encoding data in the surveys
of Gamblers Anonymous and GamAnon members and for voluntarily
recording, editing and distributing the minutes of Task Force
meetings: Ralph B. Duane;
For his extensive analysis of the various data available to
the Task Force, his skills in bringing the "dry figures" to life,
and his donated time: Robert A. Yaffee, Ph.D.;
For their authorship of the principal sections of this report
and its appendices: Valerie C. Lorenz, Ph.D., Robert M. Politzer,
Sc.D, and Robert A. Yaffee, Ph.D.;
For their additional contributions to the writing of this
report: Christina R. Schauble and Joanna Franklin; and
For their review, editing and formatting of this report, using
WordPerfect 5.1 and DrawPerfect 1.0: James Blumner and Christina
R. Schauble.
Valerie Lorenz particularly acknowledges Helen Gonzalez,
Department of Social Work Research, Memorial Sloan-Kettering Cancer
Center for extra efforts in the survey of members of Gamblers
Anonymous; and Michele Todd, National Center for Pathological
Gambling, for secretarial support.
Robert A. Yaffee particularly acknowledges the following:
Professor Clifford C. Clogg, Pennsylvania State University
Sociology Department, and Editor of the Journal of the American
Statistical Association, for very helpful suggestions concerning
logit modeling.
Ralph B. Duane, for research assistance in the project
discussed in the chapter and appendix on pathological gambling and
co-addiction;
Edi Franceschini, Deputy Director of the Academic Computing
Facility of the Courant Institute of Mathematical Sciences of New
York University, for providing permission for this analysis to be
performed on the IBM 4341 mainframe;
Helen Gonzalez, Department of Social Work Research, Memorial
Sloan-Kettering Cancer Center, for research assistance on the
project discussed in the chapter and appendix on the Gamblers
Anonymous Study and Co-Addiction.
James Gray, for providing "out of town computer equipment"
with which much of the analysis of gamblers undergoing treatment
was written;
Bert Holland, a senior statistics consultant at the Academic
Computing Facility of the Courant Institute, for very constructive
suggestions of the work appearing in the appendix concerning
pathological gamblers undergoing treatment;
Mark Nicolich and Winthrop Munro, for their helpful comments
and criticism of the work appearing in the appendix concerning
pathological gamblers undergoing treatment; and
Yolanda Ramirez, Academic Computing Facility, Courant
Institute, for her entry of the Taylor Manor Data concerning
pathological gamblers undergoing treatment into machine readable
form on the IBM OS/MVS computers and for research assistance on the
severity of pathological gambling and co-addiction.
Work of the Task Force
The first meeting of the statewide Task Force on Compulsive
Gambling was held on January 17, 1989, at the Department of Health
and Mental Hygiene, 201 W. Preston Street, Baltimore. Members
spoke of the range of their knowledge and interest in the subject
of gambling addiction. Some of these Task Force members had been
part of the original professional counseling and research team a
decade earlier when Maryland established the nation's first
residential center for the treatment of compulsive gamblers. They,
and the other Task Force members, were aware that other states have
surpassed Maryland's efforts in responding to compulsive gambling
treatment needs.
Members were also aware that the National Institute of Mental
Health was funding an epidemiological study into the prevalence of
compulsive gambling in Maryland and four other states.
The membership of the Task Force realized they had a broad
subject area to study, encompassing the scope of the compulsive
gambling problem and its repercussions, analyzing what is being
done and what ought to be done, and recommending funding resources.
Compulsive gambling in Maryland is still not commonly recognized as
an illness, similar to, yet unlike, other forms of addictive
behavior. Compulsive gambling in Maryland involves both legal and
illegal forms of gambling. Although state law forbids gambling
absent a permissive local ordinance, and thus the state may be said
to have a policy against gambling, numerous counties have persuaded
the Legislature to grant exceptions. These counties have legalized
slot machines and casino nights. There is no uniform state policy.
Thus, the Task Force considered its role to collect and compile, as
well as to disseminate information to major decision-makers,
legislators, judges and the general public regarding these
inconsistencies and needs.
The Task Force continued to meet each month, alternating
meeting sites among the Health Department, the Washington Center
for Pathological Gambling in College Park, Taylor Manor Hospital in
Ellicott City, and The National Center for Pathological Gambling in
Baltimore, until May 1990, when the final report was in
preparation. During that time, it changed its official title to
"Task Force on Gambling Addiction," which it felt was more readily
understood than terms like pathological gambling or compulsive
gambling. The Task Force had no official standing other than as an
ad hoc advisory group to the Alcohol and Drug Abuse Administration.
Members volunteered their time and services.
Originally, the Task Force was anticipated to have a life
expectancy of six months. However, early on the members agreed to
identify the problem of gambling addiction in Maryland in terms of
demographics and statistics. They believed statistical analysis
should not only include estimates of numbers of addicted gamblers,
but also figures on how the community is affected by them --
a social and economic cost.
In order to obtain valid data, the Task Force agreed the only
realistic method available to them was to extrapolate from existing
data. This meant drawing a profile of the compulsive gambler
through the patient data and questionnaires used by the private
therapists. In addition, the National Center for Pathological
Gambling had records of telephone calls to its Compulsive Gambling
Hotline (1-800-332-0402).
The Task Force also agreed to obtain data from individual
members of the self-help groups Gamblers Anonymous and GamAnon.
(The groups themselves do not participate in or endorse such
surveys.) The Task Force developed two research surveys which
would fill in some of the gaps from the patient and telephone data.
The report of a pre-test of the survey with a limited number of GA
and GamAnon members revealed that the survey took four to ten
minutes to complete, was well-received, and generated interesting
comments. GA members were concerned about maintaining
confidentiality of participants. The Task Force agreed to proceed
with the survey, but destroy the questionnaires as soon as
statistical analysis was completed.
At the July 1989 meeting, the Task Force agreed to send all
patient data and survey data to Robert A. Yaffee, Ph.D., a
prominent computer and statistical analyst who has worked on other
research projects in the field of compulsive gambling. Dr. Yaffee
agreed to donate his time.
Compiling and coding the available information was a lengthy
process. The patient data had to be culled for information on
Maryland residents only. Some specificity of data were lost; for
instance, one treatment program used a range for income -- $15,000
to $20,000, and another used the actual amount, $17,250. Thus, to
be able to use the data, it was necessary to translate some of it
into broader terms. Data were available from almost 300 compulsive
gamblers. Similarly, coding and checking for accuracy of the
information from the nearly 100 GA surveys and the 23 GamAnon
surveys took many more hours than originally anticipated.
While Dr. Yaffee was developing a unique statistical approach
to the information, the National Institute of Mental Health/Volberg
prevalence study was completed and released. That information was
not only included in the Task Force study, but further expanded and
analyzed. The information gleaned from the different sources began
to outline a profile of a Maryland compulsive gambler which
sometimes confirmed and sometimes surprised the professional
therapists on the Task Force. For instance, it challenged the
concept of dual addiction. The most severely addicted pathological
gamblers were not concurrently abusing other substances; the
gambler who is embroiled is not engaging in escape through the
abuse of other substances.
Finally, the Task Force had hoped to hold a public hearing in
order to have community input, so that compulsive gamblers and
their victims could tell their stories and that gaming interests,
such as the state lottery, racing industry and bingo parlors, could
present their views of gambling. However, the Task Force had no
budget in order to arrange such a hearing. Task Force members
concurred that such a hearing, and more study, is needed.
The following conclusions and recommendations are made by the
Task Force on Gambling Addiction.
CONCLUSIONS AND RECOMMENDATIONS - SUMMARY
CONCLUSION 1: The Task Force recognizes that the problem of
gambling addiction is on a disturbing rise in Maryland. The
prevalence of pathological gambling is conservatively 1.5 percent
of the adult population or about 50,000 addicted gamblers. These
figures represent a near doubling of the estimated prevalence in
the mid-1970s. An additional 2.5 percent or 80,000 people are
problem gamblers. Although Marylanders suffer from other health
problems, such as alcohol abuse, intravenous drug abuse and AIDS,
public policy at the federal, state and local levels has addressed
these latter issues. In contrast, solutions to the problem of the
present rise in gambling addiction have not kept pace with the
increased availability of legalized gambling or the increased
legitimization of previously illegal forms of gambling and their
subsequent promotion.
RECOMMENDATION 1: The State Legislature, the State
Department of Health and Mental Hygiene, and the gambling
industry should work together to address the adverse
effects of gambling addiction on the citizens of the
State. In 1978 the State of Maryland, in House Bill
1311, recognized the social responsibility to help those
who are suffering from gambling addictions. The Task
Force recommends that the State of Maryland re-acknow-
ledge its social and economic commitment to this task.
CONCLUSION 2a: Most pathological gamblers note that as teenagers
they were exposed to an addicted person as their role model.
Recent data on treatment of addicted gamblers reveal that gambling
onset is beginning at an earlier age.
CONCLUSION 2b: Although no substance is ingested by the addicted
gambler, a substance is nevertheless abused -- money. Since the
acquisition of gambling funds involves the manipulation of many
individuals, the abuse of money for gambling renders many citizens
victims of this disorder.
CONCLUSION 2c: Since the substance abused by the addicted gambler
is money, over many years, gambling addiction is the most expensive
addiction per addict known to society, costing Maryland citizens
approximately $1.5 billion annually. Although addicted gamblers
have had histories of stress-related disorders which have been
costly to treat, gambling addiction is a purely psychological
disorder for which appropriate treatment is relatively inexpensive
and which does not require extensive medical intervention. Since
no substance is ingested, addicted gamblers can maintain their
addiction for long periods without discovery. This "silent"
addiction is a severe burden to work productivity as the gambler
pursues gambling and obtaining money at the expense of gainful
employment. Thus, appropriate intervention for the primary and
secondary prevention of gambling addiction is inherently cost-
effective.
RECOMMENDATION 2: Health education of elementary and
high school students currently includes significant
information on alcohol abuse and other illicit drug
abuse; it should also include gambling addiction. The
State Department of Health and Mental Hygiene should work
with the Department of Education, the school districts
and their superintendents to include in the curriculum in
appropriate grades information about the disorder, its
early detection and its prevention.
CONCLUSION 3: The study of gamblers attending Gamblers Anonymous
revealed that the common notion that many gamblers abuse alcohol at
the same time they are gambling, is not accurate. Those
individuals suffering currently from gambling addiction and who
report an alcohol abuse problem have previously learned to cope
with their alcohol abuse -- perhaps they have already sought
treatment. Moreover, addicted gamblers in treatment show a similar
negative relationship with drug abuse. Although some elements of
treatment for traditional addictions apply to gambling addiction,
the treatment model for traditional addictions is insufficient for
treating pathological gambling. Therefore, addictions counselors
and other therapists whose patient populations comprise substance
abusers as well as patients with gambling addiction cannot rely
solely on the traditional substance abuse treatment model as an
analog for gambling addiction. Furthermore, referrals of patients
with gambling problems to drug or alcohol treatment programs when
they do not have a drug or alcohol problem might be analogous to
putting a cast on an arm when the patient has a broken leg. It is
a disservice to the patient, the community, and the health
profession to send a compulsive gambler or family member to a
mental health treatment provider not specifically trained in
treating this very complex psychiatric disorder.
RECOMMENDATION 3a: The Department of Health and Mental
Hygiene should require that all therapists and certified
addictions counselors in state-certified community mental
health centers and state-certified substance abuse
treatment programs receive, as a condition of
certification and licensure, comprehensive training in
gambling addiction. Both conventional training programs
leading to certification and continuing education
programs for practitioners should include this training.
At a minimum, the training should include a definition of
the problem of pathological gambling, an explanation of
the unique interaction of addicted gamblers and their
gambling environment, an understanding of the
victimization of family and community, and a thorough
knowledge of appropriate referral sources -- including
the self-help groups of Gamblers Anonymous and GamAnon.
A multi-disciplinary team of experts in gambling and
gambling addiction with direct experience with problem
gamblers in the clinical setting should administer this
training.
RECOMMENDATION 3b: The Department of Health and Mental
Hygiene should create a network of mental health pro-
viders and programs that can effectively address gambling
addiction by recognizing problem gamblers, referring them
to specialized centers for intensive treatment directed
towards gambling addiction, and monitoring their ongoing
aftercare.
RECOMMENDATION 3c: The State Legislature should mandate
that the Department of Health and Mental Hygiene
establish a separate Office on Gambling Addiction, with
its own director, staff, goals, and budget, independent
of the Alcohol and Drug Abuse Administration. This
office would serve as a central focus to monitor the
proliferation of gambling in the state and its potential
health effects, oversee and direct establishment and
certification of gambling treatment programs, develop
educational programs for the certification of
practitioners, and conduct research and evaluation.
RECOMMENDATION 3d: The Maryland Legislature should
create a permanent State Advisory Commission on Gambling
Addiction to appropriately advise the Department of
Health and Mental Hygiene on the establishment of the
proposed Office on Gambling Addiction, and on other
matters relating to the potential adverse health effects
of gambling. This Commission should include members of
the Legislature, Department of Health and Mental Hygiene,
the Office of the State Attorney General, law
enforcement, the different gambling industry components,
the gambling treatment programs, religious groups, and
public educators, among others. This Commission should
meet at least quarterly and should receive an
appropriation from the Legislature.
RECOMMENDATION 3e: In order that citizens of Maryland
who suffer from gambling addiction may receive proper
treatment at bona fide gambling addiction treatment
programs, the Department of Health and Mental Hygiene,
working together with the Commissioner of Insurance and
the independent third party payors, should cooperate in
making available, as part of standard health insurance
packages, provision for the treatment of pathological
gambling. Such benefits should be at least comparable to
those provided for other addictive behaviors and mental
health problems, and should allow for treatment on an
inpatient and outpatient basis.
RECOMMENDATION 3f: The Department of Health and Mental
Hygiene should work with the State Legislature to
establish a fund to pay for treatment for those problem
gamblers and their families who have limited or no health
insurance and lack the means to pay for treatment. The
Department of Health and Mental Hygiene, Office on
Gambling Addiction, would dispense these funds on a case-
by-case basis to compulsive gambling treatment programs
providing treatment to these patients and/or their
families. Programs would be held fiscally accountable.
Addicted gamblers in recovery would be required to repay
these funds, in whole or in part, as a part of their
treatment/restitution plan.
RECOMMENDATION 3g: Gambling addiction produces signifi-
cant losses to worker productivity. Because it can serve
as a role model to private employers, the Department of
Health and Mental Hygiene should initiate an intervention
program specific to gambling addiction for its own
employees. In addition, the permanent State Advisory
Commission on Gambling Addiction should supplement the
efforts of the Department of Health and Mental Hygiene by
pursuing all potential public and private funding sources
for prevention, treatment and research to reduce loss of
work productivity.
CONCLUSION 4a: The extent of the public health problem of gambling
addiction only begins with the addicted gambler. Unlike other
addictions, problem gambling can only be sustained by the continued
bilking of many companies and individuals over long periods of
time. Thus the network of victims of this disorder progressively
encompasses family, friends, clients, employers, banks, insurance
companies, credit card companies, and social welfare systems.
Intervention at the secondary level must be directed at the
continued victimization.
CONCLUSION 4b: The study of members of Gamblers Anonymous revealed
that those pathological gamblers whose gambling debt relative to
their income was highest, tend to abstain from alcohol, tend to
gamble in casinos, tend to seek public assistance, and report that
they considered or attempted suicide. Thus, addicted casino
gamblers cost society not only in the amount of money they obtain
from friends, family and others, far in excess of their own
resources, but also in social costs when they turn to public
assistance or attempt to take their own lives.
RECOMMENDATION 4a: The Department of Health and Mental
Hygiene should work with the State Advisory Commission on
Gambling Addiction to persuade the legislature to impose
greater restrictions on credit and lending; in particu-
lar, betting on credit should not be extended to any type
of gambling, including bingo, casinos, horse racing,
lottery, slot machines, and other forms of gambling.
RECOMMENDATION 4b: The Departments of Health and Mental
Hygiene and Human Resources should promote public
education and prevention programs to stem the continued
victimization of spouse and family. Courses on marital
relationships, effective communication, family relation-
ships, assertiveness training and household budgeting are
appropriate in educating about gambling addiction.
RECOMMENDATION 4c: The Department of Health and Mental
Hygiene, through its Office on Gambling Addiction, should
initiate public service announcements and other adver-
tisements with warnings about gambling addiction at all
legal gambling establishments including, but not limited
to, bingo halls, charitable casinos, lottery vendors,
race tracks, establishments with slot machines, and buses
that transport Marylanders to casinos in Atlantic City.
RECOMMENDATION 4d: The State Legislature should require
lottery, racetracks, bingo parlors, and any other forms
of gambling entities that advertise in Maryland or
promote its games, to spend five percent, or an alternate
percentage, of its advertising on caution messages, e.g.
"Bet with your head, not over it" or "Help is available
for those with a gambling addiction" or "Social gambling
is fun for most, but for those who cannot gamble in
moderation, it may be devastating." (This is similar to
the public relations work that the liquor industry uses
in its advertising.)
CONCLUSION 5a: Further analysis of the prevalence of problem
gambling in Maryland revealed a significant problem among non-
whites in Baltimore City, Baltimore County, and Prince Georges
County. It is clear from the treatment data, the Hotline data, and
the results of the Gamblers Anonymous survey of the Task Force that
the limited treatment now available is not reaching the non-white
community.
CONCLUSION 5b: Other data reveal that female problem gamblers also
are not being reached.
RECOMMENDATION 5: The Department of Health and Mental
Hygiene, with the assistance of the State Advisory
Commission on Gambling Addiction, should establish a
network of care providers for the treatment of minority
and female problem gamblers. Care providers in existing
community mental health centers, pastoral counselling
centers, domestic violence centers, and community based
organizations that already treat chemical dependency and
other health problems should be adequately trained to
recognize problem gambling, especially in non-whites and
women. Counselors and therapists as well as local
community workers should be recruited and trained to
diagnose and refer minority and female patients with
gambling problems to treatment centers. Existing
treatment programs for problem gambling within the state
should be approached to organize and establish cross-
cultural training programs for therapists and counselors.
CONCLUSION 6: The examination of patient data collected by the
treatment programs in Maryland revealed that information is lost
when data are not comparably compiled.
RECOMMENDATION 6: The Task Force agrees that patients
would be better served if a uniform instrument were
available for research purposes. The Office on Gambling
Addiction, with assistance from the State Advisory
Commission on Gambling Addiction, should develop a
uniform patient data collection instrument for use by
treatment programs throughout the state. This uniform
coding should be required of all state-supported gambling
treatment programs.
PATHOLOGICAL GAMBLING
Compulsive gambling is the layman's term for "pathological
gambling." Twenty years ago compulsive gamblers attending
Gamblers Anonymous (GA) typically were white, middle aged, middle-
class men (Livingston, 1974, Custer, 1977). Today a compulsive
gambler may be a teenager or a retired senior citizen, male or
female, a businessman, blue collar or white collar worker, military
member, student or housewife, of any level of socioeconomic status,
highly educated or illiterate, of any racial or ethnic group, or of
any religious inclination. In short, many groups are represented
in Gamblers Anonymous.
Compulsive gamblers in the past most often were casino,
racetrack or sports bettors, with more than an occasional stock,
options, or commodities gambler. Currently, however, trends
identify younger and older compulsive gamblers, and more women,
underemployed, and lower socioeconomic status level players, many
of whom are addicted to either poker machines, lotteries, bingo, or
a combination of these forms, such as poker machines and the
lottery (Lorenz, 1984). In Maryland, which recently legalized slot
machines in some jurisdictions, the first slot machine addict was
reported a few months later. Slot machine addicts also appear to
be more common among military personnel stationed in Maryland.
For some as yet unknown reason casino, racetrack and sports
bettors appear to be able to maintain their gambling behavior for
many years at a controlled level, before eventually succumbing to
the chronic and progressive urges to gamble which lead to loss of
control and fully established mental illness.
This final stage may be the last two to five years of the
illness, marked by repeated attempts to stop gambling, illegal acts
to support the addiction and to pay off debts, attendance and
dropping out of Gamblers Anonymous, and "bottoming out"
financially, physically, and emotionally. One possible explanation
of this ability to "stay in action" longer may be the gambler's
greater access to money; however, this is not yet supported by
strong data.
Slot machine, poker machine, lottery and bingo addicts tend to
"bottom out" in less time than other types of gamblers, usually
within two to three years of starting to gamble on this particular
gambling activity. A possible reason for this may be attributed to
this latter group having less money from the onset. It takes
money, after all, to support the gambling addiction. Another
possibility may be that slot machine, poker machine and bingo
addicts resort to these forms of gambling more as a means of
avoiding painful issues in their lives, rather than in the hopes of
winning large sums of money with which to solve their problems.
However, regardless of the form of gambling or length of time
involved, the legal and financial problems, medical and mental
health complications, and impact on the gambler, family member,
employer or community, makes pathological gambling a devastating,
costly illness -- but one which is treatable and preventable
(Lorenz, 1988, 1989; Lorenz & Yaffee, 1986, 1988, 1989).
Types of Gamblers
In confronting the problem of compulsive gambling, it is
important to be able to differentiate between types of gamblers.
Basically, there are four types of gamblers. Most frequent is the
Social Gambler, who gambles for recreation or diversion from
everyday stresses. Losses are viewed as entertainment, and
gambling does not interfere with normal family, social or voca-
tional interests, with the gambler's physical or emotional health,
or with the gambler's sense of values. Should the gambling
interfere, the social gambler will limit the gambling in terms of
frequency, time and money wagered, or turn to an activity which
causes fewer problems and is more rewarding.
Examples of social gambling are betting on a Super Bowl game,
a weekly poker game, or buying a daily lottery ticket. Frequency
and amount are not the issue; rather, it is the gambler's reason
for gambling and his or her ability to control the gambling that
distinguishes among the types of gamblers.
The Professional Gambler views gambling as a business, earning
his livelihood from gambling. The gambling is disciplined and
controlled, with losses being carefully studied to minimize their
recurrence. Wins, too, are carefully analyzed in order to increase
the profit margin. The professional gambler does not seek to avoid
emotional pain through gambling.
Some examples of professional gamblers are stock brokers,
professional card players, such as "Amarillo Slim" and Kenny
Huston, and dealers in gambling houses. These are persons who
often gamble with other people's money, who may be staked by
supporters, and who would not use the second mortgage on their own
home to support the gambling or the industry. Nevertheless, the
professional gambler is often at risk of losing control of his
gambling and becoming a compulsive gambler.
The Criminal Gambler gambles to make money, even if this
includes cheating or swindling, alone or in conspiracy with others.
Losses are usually blamed on others and cheating is justified.
Losing or cheating does not result in feeling guilty or remorseful;
rather, it increases the criminal gambler's tendency to blame
others for his misfortune and to seek revenge.
This type of individual develops problems early on in life
with physical and sexual aggressiveness, poor school performance,
truancy, lack of acceptable social skills, an inability to sustain
close personal relationships, association with fringe groups, and
a history of poor work performance.
The criminal gambler is usually well known to juvenile
authorities and law enforcement agencies, being a "client" of these
systems generally starting in childhood or adolescence, being in
and out of foster homes and juvenile detention centers. Gambling
is only one of his many socially unacceptable or illegal
activities.
From a clinical perspective, this person most often may be
diagnosed as suffering from Anti-Social Personality Disorder and
may be labelled as a sociopath. Bookies and loan sharks often fall
into this category. Recent data support the belief that some
sociopaths may also become addicted to gambling.
The Pathological Gambler can be described as an individual who
is above average in intelligence, honest, energetic, competitive,
creative, athletic, hard working and motivated to achieve -- a
citizen with a solid set of values concerning law and order,
health, family, job and country.
Typically the pathological gambler is reared in a family
environment in which there is a strong emphasis on money. Almost
always there is a parental history of pathological gambling,
alcoholism, or some other form of serious emotional disorder. The
gambler's childhood is marked throughout with inconsistent
parenting and discipline, and with a history of physical and/or
verbal abuse. There is also a very strong emphasis on the
importance of money in these families.
There are other forms of family dysfunction, such as an
emotionally distant father and an "overly emotional" mother,
parental separation through death or divorce, or an early sibling
death. Emotional deprivations and losses are not addressed, and
the gambler fails to go through the natural grieving stages to
recover from these traumas.
A history of being sexually abused or molested occurs
frequently among male and female pathological gambles. Sexual
abuse for them is an issue rarely addressed and even more rarely
resolved. Data suggest that males suffered sexual abuse more often
by persons outside the family, while females incurred sexual abuse
more often by family members.
The Pathological Gambler is emotionally damaged. He or she
grows up emotionally immature, a "loner" with poor self-image,
lacking in self-confidence and self-esteem, easily bored, and with
a low level of frustration tolerance. Many are painfully shy and
fear close emotional relationships.
There is virtually always a history of additional painful,
frightening or anger-provoking events during later stages of
development. These are traumas which are unresolved and which
continue to trouble the individual, often leaving the person in a
state of dysphoria and vulnerability (Jacobs, 1987; Taber, 1987).
Traumatic military experiences compound the pathological gambler's
problems.
Gambling, and winning, give the pathological gambler a sense
of action and excitement, a sense of confidence and accomplishment.
Money and winning are seen as a means of gaining in esteem,
attention and power; thus, gambling provides the pathological
gambler with the opportunity to avoid facing pain and the harsh
realities and discomforts of life.
Through gambling, reinforced by wins and attention from
others, the gambler develops irrational patterns of thinking
(Gaboury & Ladouceur, 1987). He is convinced of his superior
gambling skills and luck. As this delusional thinking becomes more
fully developed, the thought processes become marked by denial,
rationalizations, self-deceptions, magical thinking and obsessive
thoughts of gambling. The gambler fails to realize that he has
lost control of his gambling and is unable to resist the urges to
gamble. He seeks immediate gratification, without regard for the
consequences (DSM IV). He does not view his bets as risky, and
experiences less anxiety while gambling than do social gamblers
(Kuly and Jacobs, 1988).
For the purposes of this report, the Problem Gambler is a
person whose gambling is no longer a recreational pastime or
leisure activity. His gambling exceeds his planned limits in time
spent, money lost or both. Gambling has passed beyond casual
involvement. The Problem Gambler is at risk of becoming a
Pathological Gambler.
Clinical Definition
Pathological gambling was categorized in 1979 by the American
Psychiatric Association in its Diagnostic and Statistical Manual of
Mental Disorders, Third Edition (DSM-III) under Impulse Control
Disorder, Section 312.31. It was updated in the DSM III, Revised,
1985, and has again been revised for the DSM IV.
Essential features of pathological gambling in the DSM IIIR
are "a chronic and progressive failure to resist impulses to gamble
and gambling behavior that compromises, disrupts, or damages
personal, family, or vocational pursuits. The gambling
preoccupation, urge, and activity increase during periods of
stress. Problems that arise as a result of the gambling lead to an
intensification of the gambling behavior. Characteristic problems
include extensive indebtedness and consequent default on debts and
other financial responsibilities, disrupted family relationships,
inattention to work, and financially motivated illegal activities
to pay for gambling" (DSM III-R, 324-325).
As with other addictions, compulsive gambling follows a
pattern of progression:
1) Developing a tolerance toward gambling -- that is, gambling
longer, more often, and with larger amounts of money in order to
obtain that same level of excitement or "high."
2) Developing an intolerance for losing -- the "high" becomes
an intolerable "low" as losses occur, resulting in periods of
"chasing" losses, making reckless bets with larger amounts of money
to recoup losses.
3) Preoccupation with gambling cravings -- gambling becomes
an obsession, every waking hour of each day. The strong cravings
or urges to return to gambling are reinforced by interpersonal
conflict or emotional needs, to feel good and to avoid depression,
and by environmental press.
4) Disregard for consequences of gambling or illegal activi-
ties to support the gambling -- the pathological gambler is
suffering from a psychiatric disorder, which, by definition, makes
it impossible for him to think logically, rationally, and
sequentially while involved in gambling. In his distorted views of
the world, illegal activities committed to obtain funds to support
the addiction are seen as "temporary loans" to be replaced by the
next win or as the only option available in his desperate state.
Just as nicotine addicts, alcoholics, drug addicts, and people
with eating disorders ignore the medical effects of their
addiction, so do compulsive gamblers fail to consider seriously the
consequences of their actions regarding family or employer, or
their illegal activities committed to obtain funds to continue the
addiction or to resolve a desperate financial situation.
5) Withdrawal symptoms -- which most often result in head-
aches, stomach problems, sleep difficulties, and depression.
6) Slips and relapses -- most often after interpersonal
conflicts, a constant need for money, or a desire to be a "normal"
gambler again.
7) Cross-addiction -- most often becoming workaholic, or
developing excessive eating, smoking or coffee habits.
The Stages of Pathological Gambling
Another view of the development of pathological gambling might
be described as developing in three phases -- the Winning Phase,
the Losing Phase and the Chasing Phase. Each phase may last from
a few times of gambling to gambling for several years.
The Winning Phase starts when the casual, social gambler
realizes that gambling can become a fast-action, exciting experi-
ence. He gambles carefully, studies the horses, teams, cards or
numbers, and wins fairly frequently. The gambling is fun, is
usually a social activity engaged in with a friend or two, and is
a means of relaxing and getting away from daily pressures of work
and family.
This phase is usually ended by repeated wins or a "big win,"
a win of money equivalent to several times one's weekly income, or
more. These wins generate in the potential pathological gambler a
false sense of optimism concerning luck and skill in gambling.
Winning provides a sense of accomplishment: it is a boost to low
self-esteem. It gives the pathological gambler new status,
confidence, a sense of control and power.
The Losing Phase is generally marked by increased gambling and
losses. Although the gambler has experienced a big win, or several
big wins, or even a series of smaller wins, he will also eventually
experience losses. These losses are very disturbing to the
pathological gambler. It is not only a loss of money, but also an
upset to a fragile sense of self-esteem. What had been fun is now
very uncomfortable, making him feel anxious and depressed. Thus he
immediately returns to gambling to rid himself of these feelings.
He needs to gamble more often and with larger amounts to regain the
previous level of action and excitement.
This stage is associated with attempts to hide the gambling,
with lies about absences from home, about income not received, and
missing monies, mail, and other ploys. Money is lacking and bills
are late in being paid. The gambler may borrow from friends or
colleagues hoping thereby to prevent a spouse or other family
members from discovering gambling losses.
Personality changes occur such as becoming restless,
irritable, defensive and argumentative. The gambler becomes more
despondent, feeling guilty about his behavior towards others and
angry with himself.
Repeated evidence of money missing and bills not paid on time
result in increased arguments. He desperately wants his family to
stop harassing him and berating him. Promises of abstinence are
made.
The family is convinced that intentions to stop gambling are
sincere and will provide the money to pay back loans and past-due
bills. Unfortunately, this "bail-out" more often than not will
become the first of many bail-outs, both financially and emotion-
ally, by covering up for the gambler, through lies and other
deceptions. The spouse or other family member may themselves
become co-dependent or enablers of this illness.
Promises of abstinence are well-intentioned but short-lived.
As new pressures occur, as financial problems increase, the urge to
gamble becomes stronger. The return to gambling is not with a $2
bet or one lottery ticket, but rather at the level where the
gambling was left off previously. The gambling accelerates -- as
do losses. The gambler becomes desperate, and starts "chasing"
losses, gambling large amounts, recklessly, wagering with all
available funds on a long-shot. Thus begins the Chasing Phase.
All thoughts are on gambling, constantly -- which team to
play, how much to bet, how to pay off bills, how to get to the
phone or track, to the action, how to block out discomforts and
pressures.
The gambler borrows until all borrowing options are used up.
Checking or savings accounts have long been depleted. Credit cards
are overdrawn. Cash value on life insurance policies is spent.
Loans from banks and financial institutions are no longer possible,
and whatever could have been sold was, in fact, sold long ago.
He knows of only one way to escape from what many gamblers
describe as "living in a gray zone, a fog." He needs one more big
win -- a win that rides on the next bet, if only he can get the
money to make it. He is convinced he will win. He "borrows" --
most often first from the family, then from his employer or
elsewhere. Most gamblers start their "borrowing" by writing bad
checks, forging a loan application, or using another's credit card.
He may "borrow" once, or he may "borrow" many times. There is
no intention to injure anyone but rather, in the gambler's confused
state of mind at this time, there is only the thought, "the next
bet will come in, and all will be well." If the next bet does not
come in, he will have to "borrow" again. He "knows" it is his turn
to win; after all, he has done so before, many times. And the wins
have been for very substantial sums.
He can't think clearly or concentrate. He is filled with a
tremendous sense of anger, guilt, and anxiety. He works harder,
but accomplishes less. He has become alienated from his spouse,
family, friends and fellow employees. He feels isolated and alone.
He may start drinking.
The gambler at this point in the development of the mental
illness is also quite ill, physically (Adkins, 1988; Lorenz &
Yaffee, 1987). He may briefly consider seeing a doctor, but that
would cost money -- money which he needs for gambling.
He suffers physically from multiple somatic complaints. His
head hurts constantly. He cannot eat, and often goes two or three
days without food. His stomach feels like it is tied in knots, he
is constipated or suffers from frequent diarrhea. His chest hurts,
as does his lower back and his upper back. He may break out in a
rash or other form of dermatitis. His breathing becomes difficult.
He cannot sleep soundly, and often finds himself awake all night,
suffering from increasing nightmares. At times his fingers or
hands feel numb or he cannot lift his leg. He has no more energy.
This formerly honest, intelligent person now has only a very
weakened intellectual understanding between right and wrong, of
appreciating the consequences of his behavior, of considering that
others are being hurt by his actions. But he does know that when
that urge to gamble comes upon him, he is virtually powerless. He
is unable to fight off that urge.
Some believe the only way out of the desperation and turmoil
is to commit suicide. Research studies on compulsive gamblers
indicate that almost 25% have attempted suicide (Custer & Custer,
1987). Others have felt incredibly relieved after being arrested.
The long, desperate struggle is over.
Finally the gambler "hits bottom." Some may need to be
hospitalized, either for depression, suicidal ideation, or any of
the physical complications resulting from years of stress, anxiety,
abuse, neglect or malnutrition. Others need to be removed from the
environment to prevent further illegal activities. Withdrawal
symptoms similar to those of alcohol or drug withdrawal may occur.
It is only after a period of abstinence that the compulsive
gambler begins to recognize the irrationality of his behavior. It
is not uncommon to hear a compulsive gambler in treatment utter
over and over again, "I can't believe I did this, I can't believe
I did this." Or, "My head kept racing, everything was so fast."
Or, "My children are teenagers! I remember them as toddlers."
Unfortunately, the first "bottom" may not be the only one.
Gamblers may experience several bottoms, with the financial bottom
usually being the first. They may remain abstinent for a period of
time, repay debts and other financial obligations, but eventually
the hopes of "being normal", of being able to gamble responsibly
again, will lead them back to the poker table, track, bookie,
lottery vendor, or other form of action.
As family or job related stress or money pressures once again
build up, the ability to think clearly diminishes. Problem solving
skills and communication skills are still poor, and resources are
fewer. The one-time slip ("to prove to myself I'm normal") becomes
a relapse. Without treatment, not even the fear of a parole
violation will suffice to intercept the gambling addiction. An
outside intervention is necessary to break the destructive pattern.
Criminal Behavior
Crimes committed by compulsive gamblers vary, but typically
are non-violent crimes such as writing bad checks (against
insufficient funds, against a closed account, on a spouse's
account), floating or kiting checks, forgery, fraud, embezzlement,
failure to file IRS returns, submitting false financial statements
to obtain loans, or other thefts by deception.
With the democratization of gambling and compulsive gambling,
current trends indicate that all types of non-violent crimes are
committed by compulsive gamblers during the desperate Chasing
Phase, depending on the individual's circumstances. An attorney,
for instance, may embezzle a million dollars from clients' trust
accounts, a juvenile may steal from a parent's wallet, a housewife
may shoplift or forge a husband's name on a credit application, a
plumber may falsify invoices, or a businessman may fail to file
income tax returns (Brown, 1987; Lorenz, 1984).
As the compulsive gambling population becomes more diverse, it
is anticipated so will the types of crimes. Several cases of bank
robbery have been reported, although in almost all instances the
weapon was nonfunctional -- a plastic or wooden gun, or a gun
without bullets or a firing pin (Lorenz, 1987).
Others may resort to pimping, selling drugs, or prostitution
(Lesieur, 1987) or hustling (Livingston, 1974). These numbers are
small. Sports bettors may become bookmakers to support their own
addiction.
Some will go to jail, where they continue to gamble. Incar-
ceration will not cure this mental illness, and no professional
gambling treatment is available within any state, local, or federal
penal institution.
Treatment and Recovery
Pathological gambling is a treatable mental disorder. For
those gamblers who are in serious distress, inpatient treatment may
be indicated. For gamblers who are not suicidal or uncontrollably
committing crimes to support their addiction, but who nevertheless
are in serious distress or who may be under time constraints,
intensive short-term therapy on an outpatient basis appears ideal.
Both are followed with outpatient aftercare.
For others, less intensive therapy is sufficient. For all, a
combination of individual and group therapy is recommended.
Abstinence from gambling during therapy is essential for
recovery. Restitution is an integral aspect of treatment, and
commitment to the Gamblers Anonymous program is vital.
The first year of abstinence is the most difficult for the
gambler and for the family. In treatment, emphasis generally is
first on resolving financial and legal conflicts. Rebuilding
family cohesiveness, including developing more effective communi-
cations patterns, establishing trust, and rebuilding intimate
relationships, is difficult, especially without the assistance of
professional help, yet it is necessary to insure recovery.
Different types of treatment have been tried, such as
long-term psychoanalysis, paradoxical intention, behavior modifi-
cation, flooding, and electroshock therapy, or other aversive
therapy, with poor results.
Incarceration, too, has been found to have little beneficial
effect on overcoming this illness. Gambling in prison is
common-place; thus incarceration merely changes the location of the
gambling site and the medium of exchange. The compulsive gambler
in prison gambles for food, goods or services instead of money
(Jarvis, 1988). The illness itself is perpetuated.
Current evidence points to the effectiveness of a mix of
psychodynamic, behavior, cognitive and rational-emotive therapy,
with a mix of professional therapists and trained peer counselors,
for the gambler and immediate family members. Gamblers respond
well to therapy in a supportive, open environment, and tend to
become defensive and resistant in a locked, psychiatric setting.
A common difficulty with obtaining professional care, however,
is the gambler's inability to pay for services rendered. Mental
health insurance coverage is inadequate in most instances, and in
other cases the gambler may have neither a job nor insurance.
Some, who are employed and who may have at least some health
insurance, cannot take the time off from work without losing their
pay, thus increasing the already severe financial pressures.
Others lack the funds or means of transportation to go to a center
where treatment may be offered.
Public Health Impact
Lawmakers throughout the nation face the question of whether
to legislate state lotteries and other forms of gambling, while
opponents argue that legalized gambling has done more harm than
good (Indiana Citizens Against Legalizing Gambling, 1985; New
Mexico Coalition Against Gambling, 1989). In 1986, state lotteries
supplanted casino gambling as the largest American gambling
industry, a feat just accomplished by casinos over horse racing in
1979 (Christiansen, 1987). Legislators in several states have
looked to physicians, mental health professionals, epidemiologists,
and public health analysts for the answers when they seek to
determine the public health risks of legalized gambling (Politzer
& Morrow, 1981; ICALG, 1985; NMCAG, 1989). One of the consequences
of this increased exposure to gambling is the creation of a whole
new group of problem or pathological gamblers (NMCAG, 1989).
Several theoretical models have been proposed to explain
problem gambling including the medical or disease model (Blume,
1987), the social learning model (Brown, 1987), directive state
theory (McCormick, 1987), economic theory (Eadington, 1987), and
biological theory (Carlton & Manowitz, 1987). All have significant
limitations. The medical model, which locates the source of
deviant behavior within the individual, tends to be the dominant
theoretical approach that guides our present knowledge (Blume,
1987). However, it is limited in that it focuses only on the agent
or condition and virtually ignores the influence of environmental
factors. Although social learning theory touches upon the
opportunities afforded gamblers by their occupation, leisure
habits, and other features of lifestyle, environmental factors are
not at its central focus. Economic, directive state, and
biological theories also focus primarily on observations of
pathological gamblers to explain the phenomenon.
The Epidemiologic Model
The epidemiologic model may be instructive in analyzing
alternative strategies to reducing the health risk of pathological
gambling. In applying the model to pathological gambling, the host
is the gambler, the agent is the action of gambling, and the
societal environment in this instance, is comprised of three
sectors: family, community, and culture. The three components of
the model interact in varied combinations to affect the incidence
of pathological gambling, as depicted below.
Agent -- The Gambling Action
The agent is usually described as a substance or entity that
is consciously ingested, unintentionally internalized, or directly
linked to the change in health status of the host or victim.
Recent publicity has focused on such ingestible agents as choles-
terol, alcohol, illicit drugs, anabolic steroids, and tobacco.
National attention has also focused on the human immunodeficiency
virus. The abusive care-giver and a weapon in the hands of a
perpetrator could also be considered agents.
For pathological gambling, no substance is ingested, and,
unlike victims of abuse or violent crimes, gamblers exert some
influence over their interaction with the gambling environment.
Pathological gambling has been described as a purely psychological
disorder (Custer & Milt, 1984).
Gambling action is the product of wagering on the ambiguous
outcome of an event. This ambiguity creates the level of excite-
ment and entertainment. The level of excitement, repetition of
events, and extent of postponement of the outcome contribute to the
height of action and consequently are the factors that contribute
to risk of addiction. The degree of involvement and the setting
also contribute to the excitement level. For example, horse racing
at the track is viewed as more exciting than horses off track by
some gamblers (Commission, 1976). Anticipation of the experience
also demands attention and affords an escape from the problems of
daily routine (McCormick, 1987).
Host -- The Gambler
The host is usually described as the individual manifesting a
detectable change in health status, such as the alcoholic, the
HIV-infected person, a person with coronary heart disease, an
abused child, a substance abuser, a victim of a crime, a lung
cancer patient, an anabolic steroid user. A closer look at the
dynamics of the gambling disorder displayed by the gambler who
manifests the pathological state reveals other competitive risk
factors. In labeling pathological gambling as an impulse disorder,
psychiatrists have characterized the host as immature, highly
stressed, and depressed (Custer, 1984; Jacobs, 1986). Hence, an
underlying psychological imbalance is a necessary risk factor for
a potential host to manifest the disorder after obtaining the
gambling "action." Experts have stated that the mental health
status of the gambler is a significant predisposing risk factor to
manifesting the disorder (Taber, McCormick & Ramirez, 1987).
Addicted gamblers are loners with low frustration tolerance, easily
bored, fear criticism and rejection, who demand immediate
gratification and relief, and have low self-esteem and self-image
(Lorenz, 1989).
Recent biological findings suggest that pathological gamblers
suffer from an addiction like alcoholism. In a study of 22
subjects, it was found that 12 were driven by the need for the
thrill which stimulated an under-active noradrenalin-ergic system
(Roy & Linnoila, 1989). Some "extreme" gamblers were found to have
basic flaws in applying otherwise useful habits of everyday
decision-making and displayed difficulty in controlling impulses.
Other researchers state that gamblers are victims of beliefs that
lead them to overlook the laws of probability (Wagenaar, 1989).
Environment - The Family
The family structure of compulsive gamblers can be considered
an environmental risk factor. For example, those families which
permit their dominant and unlimited control of family finances are
at increased risk of perpetuating the disorder (Custer, 1984).
Dysfunctional family development also can be viewed as an
environmental risk factor. Pathological gamblers are typically
reared with strict but inconsistent discipline, in families which
place a strong emphasis on money or materialistic possessions
(Politzer & Morrow, 1980). Psychosocial histories indicate that
addicted gamblers have experienced several psychological or
physical traumas which have not been resolved (Taber, McCormick &
Ramirez, 1987).
Researchers are uncertain as to why at-risk individuals choose
gambling as their addiction as opposed to other behaviors. They do
report, however, that these individuals not only have histories of
parental absence or emotional deprivation, but they also have a
familial history of gambling addiction, alcoholism or other
psychiatric disorder (Ciarrocchi & Richardson, 1989). The addicted
gambler is a victim of verbal, physical, or sexual abuse, or some
combination (Lorenz & Yaffee, 1986; Ciarrocchi & Richardson, 1989).
The gambling usually begins with imitation learning, perhaps
copying a hero figure in adolescence, but more commonly learning
from one's own social peers (Brown, 1987). Gamblers are inherently
competitive and good with figures.
Environment - The Culture, Work, Leisure
The glamorizing and acceptance of gambling would represent a
factor of the general societal environment or culture. The
publicizing of lottery winners reflects this popularity. Other
environmental factors such as work and leisure time activities play
a role in the incidence and prevalence of pathological gambling.
Experts report that addicted gamblers are often dissatisfied with
their current employment (Hudak, Varahese & Politzer, 1989). In
addition, credit policies have increased access to money. In
essence, credit implies permission to spend someone else's money
today to be repaid with interest in the future. This easier access
to money places the impulsive, "relief-seeker" with a preoccupation
for material wealth at even greater risk.
Researchers argue that the Protestant work ethic, a basic
social tenet of our culture, is critically eroded when a government
or a citizenry encourages profit or gain through chance rather than
through work (Commission, 1976). It seems that we live for the
moment and, unlike our forbearers, are quite willing to consume our
wealth in immediate gratification. Currently, we save far smaller
percentages of our income than we did in the past, even when
discounting for inflation (DOC, 1988). Workers are consumers even
in leisure when leisure should be escape to genuine opportunities
for creative play. Institutional leisure has reduced our
opportunities for genuine creative play. We rely on television to
provide the creativity. We pay to be spectators and permit others
to determine the opportunities for escape. Consequently, it
appears that contemporary man is perpetually bored, dissatisfied,
and looking for safe risks. These changes in culture have fostered
an environment conducive to gambling and, for some, gambling
addiction (Abt et al., 1985).
Other investigators report that the stress of employment,
coupled with child-rearing and household responsibilities felt by
married women who have recently entered the labor force could
explain, in part, the increase in the prevalence of alcohol and
other substance abuse among women (DHHS, 1987). Such an explana-
tion could also underscore the increase in the number of female
pathological gamblers. One researcher found that female patho-
logical gamblers, unlike their male counterparts, gamble for
escape and relief from life's troubles (Lesieur, 1988).
In short, family dysfunction, life experiences, personality
characteristics, biochemical imbalance, work dissatisfaction,
social mores, and the prevalence of gambling all contribute to the
development and increase of pathological gambling.
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