A Word on
ROBERT A. YAFFEE, Ph.D.
Previous part of this document.
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
PROFILE OF MARYLAND GAMBLERS ANONYMOUS RESPONDENTS
Gamblers Anonymous is a fellowship of men and women who are
compulsive gamblers. Members share their experiences in an effort
to solve their problems and to help others in their recovery from
the gambling addiction. There are ten chapters in Maryland.
An anonymous survey was distributed at these meetings and 91
members participated (see Appendix B for a complete report with
statistics). It was found that these participants had been
gambling for many years, and that this gambling had resulted in
severe financial indebtedness, criminal and civil violations, and
familial histories of chemical dependencies or gambling addiction
dependencies. The survey showed that legal and illegal gambling
are pervasive throughout the state of Maryland.
Half the respondents listed casinos and horse racing as their
favorite forms of gambling, which was predictable in view of
Maryland's long history with horse racing, its proximity to
Atlantic City casinos, and the many charitable casinos in Prince
Georges County.
The survey showed an increasing prevalence of smaller games of
chance, substantiated by the number of lottery, poker machine,
bingo, slot machine, and tip jar addicts represented in the study.
One fourth of the participants of the study admitted that these
games were their first preference and a similar number stated these
games were the second preferred form of gambling. These addicts
appeared to be increasing throughout Gamblers Anonymous chapters.
They were most often female gamblers or lower-income, less educated
gamblers.
The younger ages and the lower educational level of the
respondents would also suggest that the profile of the compulsive
gambler has changed in the past two decades, from that of a
middle-aged, middle class white businessman to a more democratic
picture of male or female, of any age, religious preference, or
socio-economic level. The change of societal mores with respect to
gambling, as well as the availability and accessibility of
gambling, may account for this change in profile of the compulsive
gambler and the increase of compulsive gambling in the state of
Maryland.
Of concern is the number of illegal gambling addicts (poker
machines, 16%; sports, 11%; cards, 8%; and dice and tip jars, 1%
each), suggesting ineffective or possibly selective law
enforcement.
The direct effect of compulsive gambling upon Maryland's
economy is evident in that one-third of the respondents admitted
owing Maryland state taxes. Sixty-two per cent admitted to
committing crimes of a financial nature to support their gambling
addiction, such as stealing money, writing bad checks, or resorting
to forgery, embezzlement, mail fraud or similar crimes. Such
criminal acts, and related occurrences of incarceration or
probation, are similar to findings from other studies of gambling
addicts.
Of serious concern is the high incidence (80%) of civil
violations committed, most of which were automobile related. Their
speeding, reckless driving, number of accidents, parking
violations, and driving without insurance or proper tags or
license, makes the driving pattern of compulsive gamblers very
similar to that more often associated with drunk drivers, except
possibly worse. Also, 12% of the respondents considered committing
suicide using their automobile.
Another item of serious concern is the very high rate of
suicidal ideation. Fully two-thirds of the respondents had reached
the level of despair that they not only were considering suicide,
but also knew which method or weapon they intended to use to carry
out the suicide attempt. This strongly demonstrates the need for
well-trained professional care-givers to prevent such drastic
endeavors, particularly when compulsive gamblers can recover with
proper treatment.
This study alone raises serious policy implications for
lawmakers and state agency administrators. Certainly these policy
makers and administrators should, at the very least, consider
providing the funds to abate the social and economic costs of
compulsive gambling. The state should increase community awareness
and develop prevention programs in schools, businesses, and
industry, so that intervention can take place at earlier stages of
the illness.
It is known that pathological gamblers can recover from their
addiction. As with other addictive illnesses, pathological
gamblers and their families require financial support during the
recovery process. Because compulsive gambling addicts abuse money,
by the time they appear for treatment, most of them are seriously
ill, financially ruined, and often without a job or health
insurance. Funds will need to be allocated for those who lack the
ability to pay for treatment services, either inpatient or
outpatient, for themselves and for their family members, if they
are to recover.
Additionally, Maryland should seek to provide, throughout the
state, training for mental health counselors in dealing with
gambling addiction, so that addicts and their families, wherever
located, will have access to treatment resources close to their
homes. The legal system needs to be educated to identify these
addicts and develop referral resources for treatment, community
service and educational sessions.
PROFILE OF MARYLAND GAM-ANON RESPONDENTS
GamAnon is a self-help group for family and friends of the
compulsive gambler. Ideally, the number of members in a GamAnon
meeting would approximate those in the Gamblers Anonymous meeting.
Unfortunately, this is not the case. While there are ten chapters
of Gamblers Anonymous in Maryland, there were only four chapters of
GamAnon at the time the Task Force survey was taken. Although 23
surveys were returned, data was compiled from only 18 GamAnon
respondents. (See Appendix C for a more complete description of
the GamAnon program and for the complete survey report with
statistics.)
All 18 GamAnon members were wives of compulsive gamblers, and
their ages mostly ranged from the 30s to the 50s. Ten of the
respondents were employed. One desperate wife worked three jobs at
a time. Working wives reported they became less productive at work
and had difficulty in their relationships with co-workers.
All respondents experienced numerous reactions, both
psychological (depression, bad nerves) and physical (headaches,
nausea, ulcers), as a result of living with an active compulsive
gambler. Several respondents were either threatened with eviction
or actually evicted, and others were either threatened or actually
had their utilities turned off. Five had severe suicidal thoughts,
and one did attempt to commit suicide. Others resorted to
committing illegal acts, such as writing bad checks, to support the
family. Those who sought help from mental health therapists,
doctors or lawyers said the help they received was ineffective, and
only two were referred to Gamblers Anonymous or GamAnon.
Fifteen members had children, ranging in age from infant to
mid-thirties. These respondents reported that their children also
suffered emotional or behavioral problems. Children were most
often either depressed and withdrawn, or angry and rebellious.
Almost all of those of school age had difficulty in school, such as
lower grades, failing or dropping out of school, or frequently
being late or absent. Several became active alcoholics or
developed other severe psychiatric disorders.
The data and messages from these respondents indicate that
they feel isolated and frustrated in their efforts to get help for
themselves and their families. They want the legislature and
governmental agencies to be more aggressive in community education,
in training of professionals, and in providing treatment for these
addicts and their families.
REPORT OF THE COMPULSIVE GAMBLING HOTLINE
The Maryland Department of Health and Mental Hygiene issued a
request for proposal in September 1987 for the establishment of a
24-hour Compulsive Gambling Hotline. A contract was awarded to the
National Center for Pathological Gambling, Inc., a not-for-profit
agency located in downtown Baltimore. The National Center
specializes in compulsive gambling treatment, research, education
and training. It has been operating the Hotline ever since. (See
Appendix D for a complete report.)
An intake form was developed to gather demographic data on the
caller and the compulsive gambler, including such information as
employment, health insurance, type of gambling, additional
problems, such as co-addiction, depression, and the potential for
suicide or criminal activity. Data on day and time of call, time
spent with the caller, nature of call, and how the caller learned
about the Hotline number are also collected.
A referral manual was developed, which lists Gamblers
Anonymous and GamAnon groups, Gamblers Anonymous contact persons,
and treatment providers who are trained and experienced in treating
compulsive gambling disorders. Referrals to self-help groups were
based on geographic location and next meeting date, as well as
nature of the problem. Referrals to professional providers were
based on nature of the problem, geographic location, urgency of the
problem, and ability to pay.
The Hotline is national in scope. It is staffed by National
Center clinical and administrative personnel, and volunteers.
Because of lack of funding for advertising, the Hotline number is
publicized through media interviews and public service
announcements, whenever possible.
Before February 1990, most calls were from compulsive gamblers
or family members, seeking assistance with the gambling problem.
Callers were given verbal information on compulsive gambling,
self-help groups such as Gamblers Anonymous and GamAnon, and
professional treatment providers. They were also sent a packet of
information. Referrals were made to self-help groups and
professional providers, whenever appropriate. Crisis calls, such
as suicidal threats or threats to commit a crime, occasionally
necessitated police intervention to transport the caller to a
nearby hospital.
At the present time, an increasing number of health providers
and employers are calling for information on treatment. Others
call to learn more about Hotline services, to give information for
use by Hotline staff, or to complain about gambling.
Approximately three-fourths of the calls were made during
regular working hours, although most serious or crisis calls come
in late at night or on weekends. Half the calls were made in
Maryland. Nearby areas, such as Washington, DC, Virginia,
Pennsylvania and New Jersey accounted for a major portion of
out-of-state calls. Baltimore City and Baltimore County generated
the largest number of calls within the state, followed by Harford
County, Montgomery County, and Prince Georges County.
During the first two contract periods (December 1, 1987
through June 30, 1989), 83% of the compulsive gamblers were males.
During the present contract period female compulsive gamblers
increased in numbers. Approximately two thirds of the compulsive
gamblers were employed (13% unemployed, 5% in jail), and only one
in four had health insurance covering mental health services.
Gamblers with adequate health insurance tended to have full time
jobs, while those with very restricted health policies, such as
health maintenance organizations (HMOs), or no health insurance at
all, tended to be under-employed or unemployed.
The data suggested that full-time employed and those with
adequate health insurance tend to prefer gambling at casinos
(Atlantic City and Prince Georges County), at race tracks (horses),
or on sports, and typically were white males. The under-employed
or unemployed and those without adequate mental health insurance
tended to gamble on lotteries, video poker machines, and bingo.
These forms of gambling require a smaller initial outlay of money
and are generally found close to one's home or office. More female
compulsive gamblers were represented in the latter group, as were
blacks and younger gamblers.
Ethnic and minority groups continue to be under-represented,
in spite of increased promotion of the Hotline number by the media.
While there was an increase of calls from blacks in Baltimore, this
pattern was not reflected across the state.
Review of Hotline calls and data have resulted in some
unanticipated findings. Video poker machines, which are illegal,
were found to be pervasive in the state of Maryland. Sports
betting, also illegal, was active in all parts of the state. Tip
jars and pull tabs appear more often in the western part of the
state. Some bingo parlors were accused of questionable business
practices.
Casinos were legalized in Prince Georges County as a means of
fund raising for local groups. Some of these casinos were
extending credit to gamblers and were cashing checks in
denominations up to $1,000. Allegations of skimming were made.
Callers also alleged that the games were run by outsiders from New
York and New Jersey, rather than by members of the firehalls or
veterans associations, and that dealers were paid rather than
volunteers.
Employers most often called to complain about employees losing
entire paychecks gambling on video poker machines in nearby
restaurants or bars.
Two incidents occurred which resulted in a sudden and dramatic
increase of calls. First, a Massachusetts bank erroneously
programmed the Hotline number into their credit line information,
resulting in over 300 calls within one week. Through the efforts
of the Baltimore Police Department, FBI, and AT&T and C&P security,
the source of calls was identified and the error was corrected.
Second, in February 1990 the Maryland State Lottery began
publishing the Hotline number on lottery tickets. This resulted in
an increase of calls from an average of 100 a month, to over 3,000
per month. The vast majority of these calls sought information on
winning lottery numbers, size of prize, where to cash in tickets,
and how to play the game. While Hotline staffers guessed at the
age and ethnicity of these callers, it was apparent that blacks and
females comprised a majority of the callers. Also, probably as
many as one-half of these calls were from all parts of the country,
including Alaska, Hawaii, and the Cayman Islands. (This strongly
suggests that non-Marylanders play the Maryland lotteries.)
As of July 1990, in spite of the nuisance of requests for
information on lottery games and winning numbers, the placement of
the Hotline number on lottery tickets has resulted in a steady
increase of calls about compulsive gambling, averaging 100 per
month.
The Hotline is a valuable service to citizens of Maryland.
The Department of Health and Mental Hygiene, State Lottery and
legislature need to realize that, and support the Hotline
financially. The most recent three-year contract between the
Department of Health and Mental Hygiene and the National Center for
Pathological Gambling was for $66,000. Expenses are anticipated at
be approximately $400,000. Staffing costs may be reduced somewhat
as a result of an agreement between U.S. Probation and Parole and
the National Center to refer their clients to serve court ordered
community service by assisting with the Hotline. However,
volunteers are not adequate substitutes for professionally trained
therapists.
LIABILITY OF THE GAMING INDUSTRY FOR MARYLAND'S PATHOLOGICAL
GAMBLING PROBLEM
Although on the surface pathological gambling appears to be a
purely psychological disorder, in that no substance is ingested, in
contrast to alcohol or drugs, pathological gamblers do abuse a
substance -- money. Paradoxically, it is not the effect of the
actual gambling on the addict, but the addict's actions to obtain
the abused substance, that is the major component of the public
health problem. In order to obtain money to support gambling,
pathological gamblers victimize those whom they are dependent upon
for money and those who are dependent upon them for money
(DSM-III-R, 1987; Lesieur, 1984; 1987; Lorenz, 1989). This
prolonged victimization, which entails lying to and manipulating
family and community members to obtain control of money, is the
root of the public health problem. Furthermore, as implied above,
policies that attempt to restrict the agent (gambling action), by
drawing attention away from more productive treatment strategies,
may actually contribute to the public health problem.
It is estimated that each pathological gambler affects 10 to
17 individuals, including spouse, children, extended family,
employer, employees, clients, consumers, patients, creditors, and
insurance agencies (Lesieur, 1984). In this respect, pathological
gambling may be advantageously compared to two other public health
problems whose victimizing effects reach well beyond the addict.
During Prohibition, the attempts to hold down alcohol consumption
by prohibition of the agent (the alcohol itself) resulted in an
unparalleled period of organized criminality whose effects yet
linger. More recently, our nation's ongoing attempts to stem
illicit drug use and trafficking have failed to stem an enormous
demand for such drugs and, in some experts' opinions, may
contribute to the murderous anarchy infecting many American cities.
In order to devise effective strategies to reduce the public
health risks of pathological gambling, a balanced deployment of the
epidemiologic model is essential. Judicious use of the model is
indicated because neither accessibility to gambling nor the
psychodynamics of the gambler is the major contributor to the
public health problem of pathological gambling.
In the opinion of this Task Force, the key to dealing with the
public health problem of pathological gambling lies in the
environmental factor that addresses access to money. Very simply,
the gambler must obtain a substance which is common to us all --
money -- in order to procure the "action" of gambling, legal or
illegal. Thus, to appreciably reduce the risk of the health
problem of pathological gambling -- victimization of those in
contact with the pathological gambler -- we must employ strategies
aimed at the interaction between the gambler and this part of his
environment.
There is a risk that the gambling industry, particularly
lottery commissions, will tend to view health professionals
interested in pathological gambling as "the enemy." Health
professionals involved in treating gambling addiction hope to avoid
the pitfalls encountered by their colleagues in the substance abuse
arena. It is likely the gambling industry will be defensive and
resistant unless it can be demonstrated what this Task Force finds
to be: that the environment (family and culture) and the emotional
development of individuals who gamble are the significant
contributors to gambling addiction. Nevertheless, increasing
access to gambling does contribute to an increase in the problem.
To date, the evidence points to multiple contributing factors in
the etiology of gambling addiction: genetic or biological,
social/familial, personality characteristics, histories of
unresolved losses or traumas, environmental stimuli, as well as
access to an availability of gambling, money, and credit. Each
factor is as important as the other and a concentration on any one
will not eliminate or reduce the prevalence of this disorder.
Thus, a multi-pronged approach to prevention and treatment is
necessary: prevention programs in schools; spiritual group and
rational recovery programs; education of community, business, and
industry; training of mental health and substance abuse personnel;
treatment in specialized gambling addiction treatment centers;
prison reform with halfway houses for rehabilitation instead of
incarceration; improved comprehensive health insurance; and
identification of multiple sources of funding for prevention and
treatment. Other states, including West Virginia, are moving to
offer coverage for all kinds of mental health care in insurance
policies, not just inpatient hospitalization. Greater emphasis
should be placed on out-patient, half-way house and residential
care in Maryland.
In addition, creative measures need to be discovered to
support gambling addiction treatment, such as: earmarked dollars
from the General Fund, using unclaimed Lottery tickets and
unclaimed earnings from horse racing, using Lottery operating
advertising funds, taxing bingo parlors and other gambling
industries, and surcharges. Some of these sources may require
legislative acts.
Hopefully, gambling officials will assist in developing useful
strategies, including improving the family environment, shoring up
the mental health status of individuals, and perhaps even limiting
access to credit for individuals at risk.
In order to reduce the social cost and risk of pathological
gambling, we need to fully understand the relationships between the
potential gambling addict and the environment. The first step in
that direction is to recognize that the problem exists. The second
step is to do something about the problem. This Task Force is
committed to that endeavor.
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APPENDIX A
A Word on
ROBERT A. YAFFEE, Ph.D.
Robert A. Yaffee, Ph.D., is the statistical con-
sultant to the Task Force on Gambling Addiction in
Maryland. Dr. Yaffee is currently a research consul-
tant at the Academic Computing Facility of New York
University's Courant Institute of Mathematical Scienc-
es. He received his Ph.D. from the Graduate Faculty of
the New School for Social Research. He has taught
courses on PL/C, statistical packages, advanced statis-
tics and empirical research.
He served as a statistician on National Institute
of Mental Health AIDS grants in the Department of
Social Work Research at Memorial Sloan-Kettering Cancer
Center during 1988. The following year he became an
Associate Research Scientist in the Division of Socio-
medical Sciences at Columbia University's School of
Public Health, where he worked with a team of scien-
tists involved in research on the influence of illicit
drugs on psychological and physical health.
In recent years, he has served as an expert wit-
ness, lectured on advanced statistics, and coauthored
several articles on gambling addiction with Dr. Valerie
C. Lorenz.
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