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(This article was first printed in the March 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)
Gambling has become increasingly legitimate and socially acceptable. Most states have legalized it in some form, and it’s one of the nation’s fastest-growing industries, already attracting more customers than baseball or movies. Credit requirements have been relaxed and facilities are more accessible. Gambling expenditures have more than doubled since 1975. One in two adults bought a lottery ticket and nearly a third visited a casino in 2003. States depend on lotteries to fill their treasuries, and casinos are the main source of revenue on some Native American reservations. Technological advances continually supply easier and more enticing ways to play; the latest is the Internet. Inevitably, out-of-control gambling is on the rise. It’s now recognized as a psychiatric disorder and a challenge for mental health treatment.
Compulsive gamblers are constantly thinking about past bets, planning the next one, and finding the money to support the habit. They increase the size of their wagers and struggle to quit or cut back. Unable to tolerate losing, they immediately try to recoup. They gamble when they are disappointed or frustrated; neglect their families; lose jobs, careers, and marriages to the habit; sell personal property, borrow, beg, lie, steal, and write bad checks to finance gambling or pay their debts. Often they are repeatedly bailed out by their families. The American Insurance Institute has called gambling the main cause of white-collar crime.
According to the National Council on Problem Gambling, about 1% of American adults — nearly 3 million people — are pathological gamblers. Another 2%–3% have less serious but still significant problems, and as many as 15 million are at risk, with at least two of the symptoms described by the American Psychiatric Association (see box).
Definition of pathological gamblingPathological gambling involves five or more of the following:
Adapted from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 1994. |
Most compulsive gamblers are men, but the problem is growing among women. African Americans have a higher rate of compulsive gambling than whites, and the rate is about twice the average among those living within 50 miles of a casino. The poor and people with limited education, exposed to tempting visions of unattainable wealth, are particularly susceptible.
Experts often distinguish gambling for action from gambling to escape. Action gamblers, highly competitive and easily bored, tend to take unnecessary risks and make impulsive decisions. They often prefer poker and blackjack, horse races, professional and college sports, and stock market speculation — where they can exercise some skill, or at least the appearance of skill. Escape gamblers are more likely to play passive games of pure chance — slot machines, bingo, and lotteries. They are often depressed or anxious and use gambling to numb or cheer themselves.
A biological predisposition could be involved. Twin studies indicate that heredity may account for up to 35% of individual differences in susceptibility to gambling problems. Some research suggests that pathological gamblers have abnormal activity in areas of the frontal lobes that are centers of judgment and decision-making. But gambling problems cannot be reduced to genetics or neurochemistry. Biological research is still scarce, and the results have to be corrected for the presence of other psychiatric disorders.
Such disorders are common. Compulsive gamblers have high rates of depression, mania, alcohol and drug abuse, and some personality disorders. In a survey of Gamblers Anonymous members, 22% reported panic attacks, 72% reported an episode of major depression, and 52% reported alcohol abuse. As in all such situations, it’s difficult to distinguish between causes and effects. The results of irrational betting while intoxicated lead to more drinking. Gambling losses cause depression, which leads to more gambling. Eventually, whatever the origin of the problem, the pattern becomes self-perpetuating.
It’s a pattern typical of addiction, and that’s how most experts now regard pathological gambling. Although the American Psychiatric Association formally classifies it as an impulse control disorder, the description closely parallels alcoholism and drug dependence. The thrill of the wager corresponds to intoxication. Increasing the size of bets corresponds to tolerance and taking more than intended. The restlessness and irritability of abstaining gamblers are a kind of withdrawal reaction. The bailout — a loan or gift to pay debts in return for a promise to quit — corresponds to detoxification without further treatment. The origin of the word “addict” fits this picture; it’s an ancient Roman term referring to persons legally enslaved for defaulting on debts.
The treatment of compulsive gambling also resembles substance abuse treatment. Widely used methods include psychodynamic therapy, 12-step groups, motivational interviewing, and cognitive behavioral therapies, often in combination.
Psychodynamic therapists regard the gambling compulsion as a symptom or expression of an underlying psychological condition, often one with roots in childhood. The therapist tries to help the patient understand and confront this problem. One psychodynamic theory is that gamblers want to lose in order to punish themselves for guilty feelings. Other analysts have treated compulsive gambling as an attempt to ward off depression or as the result of narcissistic feelings of omnipotence.
Gamblers Anonymous, a 12-step group modeled on Alcoholics Anonymous, provides the most widely used treatment in the United States. Costing practically nothing and available everywhere (there are more than 1,000 chapters), it’s routinely recommended by professional therapists. Members acknowledge that they are powerless over the habit and try to heal themselves with the help of other group members and trust in a higher power. In confessional meetings, members tell stories of their addiction and confront the consequences of their behavior. They are asked to admit their failures, make amends to persons they have harmed, and carry the message to others. Sponsors (experienced members serving as mentors) offer advice and support.
Motivational interviewing is aimed at promoting readiness to change — and a commitment to treatment — by exploring and resolving mixed feelings. Avoiding aggressive confrontation, argument, labeling, blaming, and direct persuasion, the interviewer supplies empathy and advice, while helping compulsive gamblers define their goals. The emphasis is on promoting freedom of choice and encouraging confidence in the ability to change.
Behavioral therapists concentrate on eliminating the incentives for gambling and the external conditions and internal states that stimulate the urge to gamble. The incentives — reinforcements or rewards — include the thrill of the game, the exhilaration of winning, escape or distraction from everyday problems, and avoiding the shame of losing. Payoffs in gambling come occasionally and largely at random. Psychological experiments show that behavior sporadically rewarded is particularly difficult to eliminate even when the rewards are withdrawn — one reason for the development of addiction. At the same time, the sights, sounds, and physical sensations and even moods and feelings associated with gambling begin to provoke an almost automatic response that leads to more gambling.
To unlearn this conditioned learning, patients identify, record, and try to avoid situations and feelings that provoke the urge to gamble. They may be taught to distance themselves from gambling spots, specialize in a particular kind of betting, set aside money not to be gambled, or do something practical with winnings, such as making mortgage payments. Some gamblers have themselves put on a list to be banned from casinos. In imaginal desensitization, gamblers contemplate betting scenarios while remaining physically relaxed instead of submitting to the craving. In covert sensitization, they are guided through scenarios in which, say, they are discovered embezzling by an employer or threatened by a loan shark.
Meanwhile, cognitive therapy may change their thinking. The aim is to clarify and alter underlying ideas about the world, the self, and the future — delusions of control, superstitions about chance and fate, selective recall of winnings, belief in special skill. Cognitive therapists teach compulsive gamblers to regard gambling as an expensive form of entertainment rather than a moneymaking venture.
In the family of a compulsive gambler, unpaid bills, constant argument, and chronic lying create anxiety, distrust, and conflict. Couples or family therapy may help, and family members can also get help for themselves through the mutual aid group Gam-Anon, which is modeled on Al-Anon.
Medication is not used much in the treatment of problem gambling, and there are few controlled or long-term studies of its effectiveness. In a couple of studies, the opiate antagonist naltrexone has been found to reduce gambling urges. Because of parallels between gambling and compulsive behavior, some have suggested the use of selective serotonin reuptake inhibitors (Prozac and related drugs). But antidepressants and other drugs are prescribed to gamblers mainly for associated mood disorders.
Although some treatment is almost certainly better than none, little is known about which treatments work best for which gamblers. There are few randomized controlled trials. Behavioral and cognitive therapies, which have been studied most carefully, seem to be effective for some, at least in the short run. One study found that motivational interviewing plus a mailed self-help workbook was more effective than the workbook alone or assignment to a waiting list. The advantage persisted for six months, but no longer.
Gamblers Anonymous, like Alcoholics Anonymous, has undoubtedly transformed some lives, but the dropout rate is high, and it’s not clear how much the confessional meetings help the general run of people with gambling problems. In one study, only 8% of members had achieved abstinence for a year or more. Besides, many gamblers want to return to controlled betting instead of the abstinence required by Gamblers Anonymous principles.
The 1999 National Gambling Impact Study Commission report recommends more research on how to encourage compulsive gamblers to seek treatment and how to help their families. The Commission also calls for more study of the connections between gambling, mood disorders, and alcoholism; the effects of gambling on bankruptcy, suicide, divorce, and crime rates; and the problems created by electronic and Internet gambling.
Like alcoholism and drug addiction, pathological gambling is a social problem that demands more than individual therapeutic solutions. Most states have councils on compulsive gambling and set aside some gambling revenues for treatment, prevention, and education. Many authorities now believe stricter regulations are needed, especially on marketing, promotion, credit availability, and access by adolescents. Some high schools have introduced programs in which adolescents are warned about manipulation by the gaming industry and educated about legal issues, myths of chance and probability, and ways to recognize when gambling is out of control.
The National Gambling Impact Study Commission’s report recommended more public awareness, education, and prevention programs for both adolescents and adults. The Commission suggested that legal gambling facilities be required to state a policy on the problem of pathological gambling and train their management and staff to recognize and discourage it.
Specialized gambling counselors are certified through the National Gambling Counselor Certification Board and the American Academy of Health Care Providers in the Addictive Disorders, but payment is not always covered by insurers and health maintenance organizations. Pathological gambling was not officially listed as a psychiatric disorder until the 1980s, and some think that more 20 years later, it has not gained the public and professional recognition it deserves.
National Council on Problem Gambling
202-547-9204
Confidential National Helpline
800-522-4700 (toll free)
www.ncpgambling.org
Gamblers Anonymous
213-386-8789
www.GamblersAnonymous.org
Gam-Anon
718-352-1671
www.gam-anon.org
Institute for Problem Gambling
www.gamblingproblem.net
ReferencesCommittee on the Social and Economic Impact of Pathological Gambling, National Research Council. Pathological Gambling: A Critical Review. National Academy Press, 1999. Ladouceur R, et al. Understanding and Treating the Pathological Gambler. John Wiley & Sons, 2002. National Gambling Impact Study Commission. Final Report. US Government Printing Office, 1999. http://govinfo.library.unt.edu/ngisc/index.html Raylu N, et al. “Pathological Gambling: A Comprehensive Review,” Clinical Psychology Review (Sept. 2002): Vol. 22, No. 7, pp. 1009–61. |
(This article was first printed in the March 2004 issue of the Harvard Mental Health Letter. For more information or to order, please go to www.health.harvard.edu/mental.)
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