Pathological Gambling

 

The perception of increased pathological and problem gambling is currently driving interest and concern among policymakers, treatment professionals, industry officials, gambling researchers, and the public. Data describing the extent of pathological and problem gambling are useful for many purposes, including planning public health services and medical services. We will discuss the prevalence of pathological and problem gamblers among the general U.S. population and specific subpopulations. As limited by the available data, the discussion is often framed in terms of the proportion of pathological and problem gamblers reported in studies of U.S. residents. Of particular concern is determining prevalence among reportedly vulnerable demographic groups, such as men, adolescents, the poor, the elderly, and minorities (including American Indians). We also attempt to examine trends in relation to the increased availability of legal gambling opportunities in the last decade. We will also make comparisons with the prevalence rates of alcohol and drug abusers, to help put the magnitude of excessive gambling and related problems into perspective.

Social and Economic Effects

The growth of legal gambling in the United States in recent decades has been fueled largely by increasing public acceptance of gambling as a form of recreation, and by the promise of substantial economic benefits and tax revenues for the communities in which the gambling occurs. There is no question that legalized gambling has brought economic benefits to some communities; just as there is no question that problem gambling has imposed economic and social costs. The important question, from a public policy perspective, is which is larger and by how much. Clearly, to address this and related policy issues, the economic and social costs of pathological gambling need to be considered in the context of the overall impact that gambling has on society.

The benefits are borne out in reports, for example, of increased employment and income, increased tax revenues, enhanced tourism and recreational opportunities, and rising property values. American Indian communities in particular, both on and off reservations, reportedly have realized positive social and economic effects from gambling "that far outweigh the negative"

Such costs include traffic congestion, demand for more public infrastructure or services (roads, schools, police, fire protection, etc.), environmental effects, displacement of local residents, increased crime, and pathological or problem gambling. To the extent that pathological gambling contributes to bankruptcy and bad debts, these increase the cost of credit throughout the economy. We use the term "costs" to include the negative consequences of pathological gambling for gamblers, their immediate social environments, and the larger community.

As we said, the fundamental policy question is whether the benefits or the costs are larger and by how much. This can in theory be determined with benefit-cost analysis. Complicating such analysis, however, is the fact that social and economic effects can be difficult to measure. This is especially true for intangible social costs, such as emotional pain and other losses experienced by family members of a pathological gambler, and the productivity losses of employees who are pathological or problem gamblers. Beneficial effects can also be difficult to measure and, as with costs, can vary in type and magnitude across time and gambling venues, as well as type of gambling (e.g., lotteries, land-based casinos, riverboat casinos, bingo, pari-mutuel gambling, offtrack betting, sports betting).


Ideally, the fundamental benefit-versus-cost question should be asked for each form of gambling and should take into consideration such economic factors as real costs versus economic transfers, tangible and intangible effects, direct and indirect effects, present and future values (i.e., discounting), and gains and losses experienced by different groups in various settings. Moreover, the costs and benefits of pathological gambling need to be considered in the context of the overall effects that gambling has on society. Unfortunately, the state of research into the benefits and costs of gambling generally, and into the costs of pathological gambling specifically, is not sufficiently advanced to allow definitive conclusions to be drawn.


Few reliable economic impact analyses or benefit-cost analyses have been done, and those that exist have focused on casino gambling. Consequently, we are not able to shed as much light on the costs of pathological gambling as we would have preferred.

Organization and Technology of Gambling

Most research on the causes of pathological gambling examines gamblers themselves—their family backgrounds, personality traits, experiences with gambling, attitudes about risk, motivations to gamble, and genetic attributes. Such research can lead to a better understanding of individual risk factors in pathological gambling and to better ways to predict and treat gambling problems. Another perspective examines changes in the social and technological environment surrounding gambling. From this perspective, we can ask whether changes in the organization of the gambling enterprise and technologies of gambling lead to more or fewer pathological or problem gamblers, or to new disorders associated with gambling. These are critical questions for developing sensible policies.


Most of the research on these questions is only indirectly related to pathological gambling. At the level of games and betting, there is considerable experimental research on the effects of game structure and game presentation on people's propensity to take risks or to make "nonrational" gambles. Papers have been authored about how, at the level of society, legalization has potentially affected the prevalence of gambling and pathological gambling. There also has been discussion, but not much empirical research, on how changes in the gambling industry have changed the social context of gambling. More recently, researchers and policymakers are debating whether the spread of computer-based (video or machine) gambling is changing the prevalence or nature of pathological gambling. Research has not established whether distinctive types of gambling organization and technology cause systematic changes in pathological gambling, but some of the research suggests such links may exist.

History

Much of what we know about the effects of earlier changes in the gambling industry and gambling technologies—such as the introduction of slot machines and the legalization of casinos in Nevada—comes from historical, biographical, and ethnographic narratives. This work suggests a close relationship between the social context and technology of gambling, gambling behavior, and social outcomes. For example, according to Barrett, the most significant early technological development in horse racing was the invention at the turn of the century of a wagering system and calculating machine called the Pari-Mutuel System. (The system survives today as "pari-mutuels.") The system allowed some bettors to improve their outcomes by predicting races more skillfully and/or by betting more wisely than most bettors, who underestimate the utility of betting on favorites compared with long. The system also gave rise to distinctive social roles (bookmaker, professional racetrack gambler, punter) and distinctive supporting technologies (e.g., the racing form).


Different domains of gambling have evolved distinctive cultures, norms, technologies, and social groups who have dominated gambling markets in their respective domains. For example, bingo has its callers and parlors and mainly women patrons. In general, "female" gambling domains are those in which gambling is likely to be less skill-based or to involve less social assertiveness than "male" domains. Kallick and colleagues (1979) noted that, in the United States, Jewish men were overrepresented at the racetracks and were also likely to have gambling problems. This demographic pattern, which is not as discernible in current studies, perhaps was related to the proximity of racetracks to Jewish communities. In any event, there developed among these men a subculture of the track and racing lore. Close social networks were formed among those who bet at the track or in offtrack venues; they would trade tips and loans.


Rosecrance (1986) and Zurcher (1970) have also provided accounts of the role of social groups in gambling. It is possible that the subculture of some gambling domains buffers the effects of pathological and problem gambling. For example, friends who gamble together may exert mutual social pressure to limit their gambling expenditures. Such social processes surrounding the technology of gambling have obvious implications for the advent of home gambling and machine games that may also encourage solo gambling.

Nature and Structure of Games

A large body of research suggests that today's gambling technologies and venues take advantage of people's normal responses to reward contingencies and to people's cognitive biases, perceptions of risk, and tendency to compartmentalize mental accounts of their expenditures. Some authors argue that gambling represents the purchase of an intangible leisure good, like purchasing a ticket to the movies. However, because gamblers no doubt expect, or hope for, something tangible (money), gambling might be less similar to viewing a movie than to shopping for a luxury watch or car. The value of the activity draws in part from the social desirability of obtaining a rare tangible good and in part from the drama or pleasure of the activity itself. Risk may be part of the pleasure. Gambling is influenced both by the actual risks and rewards of games and by how people imagine these risks and rewards.

Reward Contingencies

Most of the early experimental literature related to gambling focused on the tangible rewards in gambling and were derived from studies of learning through reinforcement and conditioning. Animal and human studies showed that behavior that is rewarded intermittently and randomly is likely to be repeated in the same situation and will be highly resistant to extinction (i.e., the behavior ceases only after many unrewarded trials). Thus, variable and multiple rewards in a gambling situation evoke more gambles and higher bets than single, consistent rewards do. Because most commercial games comprise intermittent rewards of varying magnitude, early learning research suggested that what it called compulsive gambling is a learned or conditioned behavior; however, since few gamblers become compulsive, intermittent and variable reward alone cannot explain problem or pathological gambling.


One possibility is that additional aspects of gambling reward experiences are likely to result in habitual or problem gambling. For instance, people are likely to continue gambling when they are ahead and can gamble "with the house's money" It has also been shown that near-wins (e.g., the slot machine shows two apples and one pear) are particularly motivating (Skinner, 1953) for cognitive explanations of this effect). With some exceptions, this research has been conducted in hypothetical gambling situations or involved small amounts of money. A few studies report that pathological gamblers say they experienced a jackpot or winning streak early on, which is consistent with the laboratory research, although these studies lack baseline data. Perhaps every gambler remembers his or her first big win.

Cognitive Distortions

Research on the cognitive processes involved in judgment and choice has been fruitful in helping to elucidate gambling choices and preferences and, by extension, the kinds of technologies that may encourage habitual or excessive gambling. For example, several specific cognitive distortions have been noted as possible contributors to pathological and problem gambling, including: (1) the misunderstanding of the concepts of chance and randomness, (2) attitudinal and belief inertia, and (3) improper resetting of mental accounts. Each of these, discussed below, may contribute to biases in people's assessment of chance processes. Not surprisingly, many popular and profitable gambling products feature games that capitalize on biased judgments; many of these products are attractive to people even in the presence of very unlikely rewards. For example, many gamblers seem to think that multiple gambles give them ''more ways to win" even when the multiple gambles are actually disadvantageous to them. And many gamblers also believe independent, random events are somehow connected.


People generally have a strong need to impose order or meaning on random processes, and researchers have investigated whether people can generate random sequences of binary events (such as flipping a coin). Results show that they are often poor at both recognizing and creating such sequences, may impose too many alternations on a sequence, or may equate randomness with a balance of event frequencies. These tendencies contribute to the gambler's fallacy, which dictates that past losing events are less likely to occur in the future. For example, after several heads have appeared sequentially in the tossing of a coin, it is hard for many to resist the temptation to believe that the next toss will not be heads once again, even though the odds are still 50 percent heads versus 50 percent tails.

In addition to trying to identify predictable patterns in random sequences, people also try to control random outcomes. Langer (1975) refers to this effect as the illusion of control. Gamblers have a variety of methods for exerting their control in gambling situations. For example,  some gamblers believe they can influence the outcomes of a die roll by tossing it softly for a low number and hard when a high number is desired. Blackjack players will often switch to new tables after a streak of losses in order to change their luck. Other blackjack players would try to interfere with the shuffled order of cards by drawing an extra card that they would normally never draw. In this way, they believed they could break an unlucky predetermined pattern and put themselves on a winning streak.


The attempt to impose order on random sequences also relates to overestimating the importance of minimal skill involved in some types of gambling. This was described by Gilovich who claim that the "hot hand," apparent in basketball when a player's performance is perceived to be significantly better than expected, may be no more than a long sequence of randomly generated events. That is, players occasionally may perform better than expected simply due to chance, and to believe otherwise may be a cognitive distortion. However, playing basketball involves skill. So, although a successful string of free throws may be the result of chance, it is also possible that a player's shooting on a particular day may have been much more skillful than normal and due to little if any chance at all. As previously indicated, some forms of gambling (e.g., cards and track betting) involve both chance and limited skill. Cognitive distortions can occur when gamblers over-or underestimate the chance and the skill involved.

Other forms of gambling, such as slot machines, involve no skill at all but can nonetheless affect illusions of control. Griffiths (1994) asked those who gambled frequently and infrequently, "Is there any skill involved in playing the slot machine?" Those who gambled infrequently tended to say, "mostly chance," whereas frequent gamblers often said, "equal chance and skill.'' When asked, "How skillful do you think you are compared with the average person?" frequent gamblers thought they were often above average in skill, whereas infrequent gamblers said they were either below average or totally unskilled.


Gamblers favor lotteries featuring complex games; they fail to multiply probabilities and believe they are more likely to win these games than they really are. These perceptions may explain some of the attractions of slots, lotteries, and multiple-game video machines. Gamblers also favor long shots a bias that causes them to win less than they might otherwise in sports betting. Experience does not necessarily increase accuracy. With experience, many gamblers lose their fear of taking risks, place larger bets, and bet more on long shots.


Gamblers' reduced fear with experience may be associated with their tendency to create stories about events and anthropomorphize gambling objects. Gamblers imbue artifacts such as dice, roulette wheels, and slot machines with character, calling out bets as though these random (or uncontrollable) generators have a memory or can be influenced. More generally, gamblers desire, and think they can have, more influence than they actually do on random events. They choose lucky numbers, get strong hunches about future random events, value numbers they choose more than numbers they don't, think they can influence a dealer's shuffle, and bet more on their own hands than on others' hands. They develop retrospective stories about systematic turns of luck, resulting in the gambler's fallacy about past losses and a belief in winning streaks. They also remember wins and explain away losses and become more comfortable with risk and what they are "learning" as they make repeated gambles. The illusion of luck turning or of control increasing with experience encourages betting. Rachlin (1990) suggests that gamblers frame their games in strings, ending each string after a win. He claims people are especially attracted to large prizes because any win would more than eliminate losses.


Pathological gambling often involves chasing losses. This behavior is addressed by Rachlin , who argues that people who persist in gambling despite heavy losses do not adequately update their mental accounts. Normally, people keep track of their spending, winnings, and cash amounts mentally. He goes on to describe how gamblers may not reset their mental accounts often enough to recognize the full extent of their losses; that heavy gamblers temporarily discount losses more in long, negative strings than in short, positive strings. Negative strings can be evaluated positively in the mind of the gambler if losses are discounted. Furthermore, gamblers postpone their resetting as they continue to gamble, which can make negative strings falsely appear even more positive. This model of chasing losses can describe at least some of the cognitive distortion in pathological gambling.


Moreover, peoples' attitudes, beliefs, and opinions are remarkably resistant to change, even when confronted with overwhelming evidence to the contrary. This state of attitudinal and belief inertia is exacerbated by memories of past events. Some theorists have argued that people show evidence of a hindsight bias. After an outcome has occurred, people may claim that they "knew it all along" which may illustrate another form of omnipotence or an illusion of control. In addition, gamblers may have better recall for absolute wins than for relative net winnings—because they gamble frequently, they may win frequently, and some of their wins may be quite large. Nonetheless, those who gamble also lose frequently, and given the fact that the odds are against them, losses usually surpass wins by a considerable margin. Yet it is the wins, especially the big wins, that tend to be remembered, and loses tend to be discounted or forgotten.


An important question is whether electronic slots, video poker, and video lottery machines, all of which are spreading rapidly and involve chance-based betting, are more or less harmful than more traditional games, such as racetrack betting and playing poker and blackjack. There are arguments on both sides of this question, and empirical research has not settled the matter. In part the question depends on who gambles. Games that are part skill-based might attract particular groups, such as men, educated people, or people who desire control; such groups may be more or less prone to pathological gambling. On one hand, problem gambling could result from skill-based betting per se, if people's belief in their gambling skills encouraged them to hold misplaced illusions of control or respond overly to short-term streaks. On the other hand, skill-based gambling might be less likely to lead to pathological gambling than wagering in purely chance games. If wagering involves skill, then negative feedback (losses) could cause further study or rational adjustments in strategy. Game speed may be important. Skill-based betting may be experienced as slow or unexciting compared with most chance betting situations. Although the absence of time pressure tends to encourage betting in the laboratory, gambling without time pressures in real-world settings could be experienced as relaxing and might encourage gamblers to bet limited amounts to extend their play time.

Game Structure

The characteristics of game technologies, such as the number of gambles offered per time period, the physical and informational environment of games, game rules, speed of play, probabilistic structure, cost per play, and jackpot size, appear to affect gambling preferences and habits. For instance, repetitive and multiple interactive games can be created in which the gambler's illusions of increasing skill and premonitions of impending luck are encouraged through reward contingencies. These technology attributes, of course, are more easily manipulated by those who develop and offer games than are attributes of gamblers themselves. New computer-based video machines, in particular, can be programmed to emit the most empirically profitable stimuli and reward contingencies. Often today's machines and games are tested with customers in real gambling settings; those that pay off best are retained and those that customers tire of are discarded. Hence these products adapt to the marketplace, evolving to present more enticing gambling situations.


State lottery commissions have increasingly changed the structure of lotteries to take advantage of cognitive biases and responses to reward. A powerful phenomenon is people's attraction to bets featuring large rewards with small probabilities of winning as opposed to bets with smaller rewards and bigger probabilities of winning. In the 1990s, numerous front-page stories documented public zeal over multimillion-dollar jackpots with infinitesimal chances of winning. Cook and Clotfelter provided a thorough account, both theoretical and empirical, of the effect of odds and jackpots on lotto play. They note that the size of the market may influence lotto ticket sales and determine whether a long-odds game is feasible to implement in states like Delaware with relatively small populations. A time series analysis of Oregon's and Arizona's lotteries is one of the few quasi-experimental studies showing how these preferences interact with changes in technology. The authors showed that Oregon's lottery was modified five times and Arizona's four times from 1985 to 1991. Each modification resulted in lower odds of winning and/or a bigger jackpot. On one hand, reducing the odds was unrelated in either state to changes in betting, suggesting that people like low stakes and do not discriminate different odds or changes in the odds when the odds are small anyway. On the other hand, increasing the jackpot was strongly related to increased betting. Betting also increased when lotteries were drawn twice weekly instead of weekly, which could be explained either by increased opportunity to play or by reduced risk aversion with more familiarity. Sales trends suggested that ever-larger jackpots were required to sustain previous levels of play.


The time series study strongly suggests that gambling can be manipulated by lottery organizations through adjustments of lottery structure and rewards. However their study did not examine all aspects of the game environment. For instance, Oregon has added instant scratch-off numbers games, keno, video poker, sports betting, and the multistate Lotto American game. Both states border Nevada and California, which offer competing products. The behavior of the Oregon and Arizona lottery commissions suggests strongly that lottery organizations model one another in devising competitive market strategies; hence changes in the environment of gambling arise from interstate as well as intrastate competition. Advances in telecommunications and the spread of Internet-supported gambling suggest that gambling is becoming a global business, responsive to competitive pressures across the world.

"Stimulus" Context of Games

A dimension of games that has not received much research attention is the physical and informational environment in which games are presented. This environment includes such factors as informational variations in advertising and instructions, visual differences in the architecture of casinos, and what interface designers call the "form factor" of games (e.g., whether the slot machine has an arm or buttons, takes coins or reads plastic cards, and so forth). Advertising and other information affect what people know about gambling and how they think about it. For instance, lottery organizations publicize winners of big jackpots and use slogans that emphasize the pleasures of playing and winning. Casinos design their architecture to make customers feel as though they are visiting a fantastic, but legitimate world (along the lines of Disneyland); rooms, lighting, sound, and the array of game areas are meant to create feelings of welcome, excitement, comfort, and luxury.


Research on working memory and the consequences of cognitive load suggest that gambling situations with many distractions cause changes in how people make decisions and judgments. Generally, this research shows that multiple conflicting stimuli, multiple calls on attention, and noisy environments cause increases in cognitive load (effort of processing information and using working memory), which in turn cause people to process information using guesses and stereotypes and to respond more automatically to stimuli. Casinos, racetracks, and increasingly lines at multistate lottery venues feature crowds and crowd suspense and a celebratory atmosphere. Casinos have large rooms, lines of noisy machines, the sound of coins spilling into trays, flashing neon lights, multimedia presentations, loud announcements over the sound system, and the smells of food, perfume, and alcohol. This barrage of distracting stimuli is likely to induce high levels of cognitive load, which in turn could reduce introspection, increase the use of guessing in gambles, and more generally encourage thoughtless gambling.

Legalization and Social Influence

Legalization is assumed to dramatically change the organization and technology of gambling as new businesses enter the market. In the past few decades, researchers have examined the effects of changes in the legal status of gambling. In particular, the entry of legal gambling enterprises into a locale creates many new opportunities for the public to gamble easily and without stigma. Researchers interested in legalization have emphasized how legalization may have increased people's access to gambling by giving them closer proximity to gambling establishments and making gambling products and services more available.


It is not known whether increased access changes fundamental gambling patterns or switches gamblers from one venue to another. Hybels (1979) argued that related types of gambling (e.g., wagering related to horse racing) may be complementary, that is, when a new kind of gambling is introduced in a particular gambling domain, people gamble more. It has been noted that illegal and legal gambling can co-occur; they describe "line sellers," who sell (illegal) tickets on the basis of the display board at legal bingo games. There is conflicting evidence on whether new games displace other gambling or augment total gambling. It’s argued that the decline in racetrack attendance preceded the establishment of state lotteries and that racetrack attendance doesn't differ much between lottery and nonlottery states. However, the opening of offtrack betting venues in New York City hurt racetrack attendance. It has been found that opening a telephone betting service reduced racetrack attendance and betting overall. This evidence points to a tentative conclusion that, once people have had access to many gambling options, their gambling expenditures level off and are relatively fixed.


Legalization has been linked to pathological gambling. It has been reported that the percentage of pathological gamblers as a percentage of the total population was less than 0.5 percent of the population in states where gambling had been legal for less than 10 years, whereas it was 1.5 percent in states where gambling had been legal for more than 20 years. Two prevalence studies show increases in the number of pathological gambling before and after legalized gambling. However, some studies have failed to show that legalization results in increased pathological or problem gambling. Participation in a state lottery was associated with a greater involvement in general gambling, which is in turn connected with problem gambling.


Even when more pathological gamblers are concentrated in locations with more opportunities to gamble, the mechanisms behind this phenomenon are little understood. For example, legal gambling could increase the number of people who gamble at least a few times; if pathological gambling is some constant proportion of people who experiment with gambling, then the numbers of pathological gamblers will also increase. Another possibility is that legalization encourages people to gamble more frequently and to spend more money on gambling. This increased gambling activity could place more people at risk for developing gambling problems by increasing their comfort with games, their familiarity with gambling as entertainment, and their likelihood of socializing with other gamblers.


The spread of professional, legal gambling services (e.g., gambling offered by casino companies and government lottery agencies) over the past few decades has probably contributed to increases in public acceptance of gambling as recreation. It has been proposed that more middle-class parents consider gambling safe, family-oriented, and fun, and fewer worry about whether their teenagers gamble than they did in the past. These attitude changes could encourage more adolescents to experiment with adult forms of gambling.


Because legalization typically increases the advertising of gambling and the openness of people's gambling behavior, the public is increasingly exposed to gambling behavior. Research on social influence shows that people's behavior typically conforms to that of others in the situation, particularly when the behavior is public and unambiguous. Adults, as well as children and teenagers, are influenced by their peers. This conformity behavior occurs even in the presence of contradicting general values and prior learning. For example, children who are honest at home and have honest parents may cheat in school if their friends do. A reasonable hypothesis derived from this research is that, if people are exposed to settings in which people gamble, then behavioral norms (what most people in the situation actually do) will influence their gambling attitudes and behavior.


Exposure to gambling in others has been shown to be correlated with gambling or gambling problems. Those who gamble as adults (especially illegally) report that they were exposed to gambling as children. People who made illegal bets reported three times the amount of childhood exposure to gambling than those who did not gamble. College students who played the lottery were more likely than those who did not to report that they had friends and parents who gambled. However, biases in retrospective memory seriously compromise these survey results. That is, even if everyone has the same exposure, people who gamble would be much more likely to think about others' gambling, to create cognitive associations with gambling, and to remember their parents' and friends' gambling activities. Pathological gamblers may be more likely to remember their parents as having gambled heavily than others would, even if there were no real differences between the two sets of parents. In effect, unless retrospective surveys are very carefully designed and conducted, they cannot determine whether social influence through exposure plays a causal role in pathological gambling.


Another aspect of the social context of gambling that may influence people's propensity to develop problems with gambling is their practice of gambling in the company of friends or family. For instance, men who frequent the racetrack or who play poker together in the same group may develop (or reinforce) friendships around this activity. Many Americans used to invite one another to their homes for informal card games, sometimes limiting themselves to penny wagers. Elderly people and married women gambled with friends and family in bingo parlors or church basements; in some English communities, the bingo game was women's single opportunity to socialize outside the house. Many large casinos today are attractive to elderly people because they can attend with friends or family. Racetracks, casinos, and card rooms often feature restaurants and other spaces where people can meet. In England and Europe, there are exclusive gambling clubs where people can socialize with others in their social circle.


Two opposing hypotheses seem reasonable. On one hand, it is possible that gambling with friends or family (compared with gambling alone or in the presence of strangers) is unlikely to result in excessive gambling, at least in the short run. Pleasurable social interaction increases positive feelings. Although positive feelings increase people's perceived probability of winning, they also reduce betting, perhaps by increasing gamblers' happiness or reducing their boredom or loneliness. As well, social pressures from family and friends who are present may reduce gamblers' alcohol consumption or limit their expenditures. On the other hand, if friends and family gamble excessively, other members of these friendship and family groups could be led to do the same. Those who grow up in families in which family members gamble frequently, and those who have friends with gambling problems, could learn to use gambling as a response to stress, or perhaps to underestimate their gambling problems.

Effects of Changing Technology

Americans seem to love technology and the products and services made possible by technology. In 1995, people over 18 spent about 3,400 hours watching TV and videos, listening to the radio and recorded music, playing home video games, and reading printed books, newspapers, and magazines. Interaction with a home computer is fast approaching the popularity of these older technologies and activities. The first home computers were introduced as a hobbyist kit in 1975. Today, about 60 percent of all U.S. households own a personal computer. Computer technologies in homes, offices, and public places combine and increase the functionality of older technologies, providing new ways to use information and to communicate with others. None of the major changes in the organization of computing and in computing technology was foreseen even halfway in the century—the rise of high-technology industries, the shifts in office employment from clerical to technical labor, the popularity of electronic mail, the adoption of home computers, and the phenomenal spread of the Internet.


The organization and technology of gambling has changed no less dramatically and no less surprisingly in the past few decades. Some indicators of this change can be gleaned from analyses of gambling revenues and consumer spending.


Changes in the marketing of gambling may alter the demographics of gambling and pathological gambling. Gambling enterprises have traditionally attracted new or repeat customers through a variety of mechanisms, such as easy credit, low prices of entry (nickel slots; $1 lottery tickets), or ''comps" and "freebies" (free games, food, or drinks; reduced hotel costs; shows and other entertainment for nongambling family members). As gambling has become more acceptable as a business investment, popular marketing techniques have been applied to increase gambling sales and profits. Increasingly, businesses target particular market segments. For example, whereas racetracks traditionally attracted men and people who could or would take time off from work, casinos may offer baby-sitting facilities for parents and weekend package getaways for working people to reduce their effort and concerns about budget and time. Casinos also evaluate how to use floor space in relation to their market. For example, they may identify a market niche, such as elderly women who gamble $2 slots, and design safe places for these women to put their purses. Lotteries may attract gamblers who are female, minority, low income, or elderly because they are practically effort-free and do not require risky social behaviors or large investments.


During the period when legalization and the open marketing of gambling opened large new markets to gambling, technical advances in computing and telecommunications made possible the creation of new automated gambling devices and services, better casino security and policing against cheating, development of remote gambling services, consolidated operations across states and venues, and better collection and use of market data from such information sources as credit ratings, Internet hits, and membership (club card) records. The rapidly growing high-technology gambling industry suggests that future advances in multimedia, digitization, satellites, and the like will lead to many future technological changes in gambling.


Technological change is evident even in the traditional horse racing industry. A decade ago, competition with other forms of legal gambling threatened the owners of horses, training facilities, and racetracks with slimmer profits as new forms of gambling gave customers new entertainment options. New technology in the form of satellite wagering facilities or "betting parlors," simulcast races, and video poker machines that could run 48 hours a day may have saved some racetracks. Racetracks today offer new wagering options on chance-based games made possible by computers (e.g., picking the exact order of finishing or wagering that an even-numbered horse will win). New games such as picking the winner of six races can offer large payoffs with low probabilities of a win, approaches that increase profits and attract customers. Changes in computers and telecommunications are changing the way racing games are being distributed.


Wagering on horse races is now available to many people without leaving their homes. The Internet offers hundreds of web sites where people can bet on a variety of sports, including racing. A new effort by Television Video Games/On Demand Services joins television technology with racetrack products. It is not clear what effect these new gambling opportunities will have; for example, complexity in games can actually reduce risk-taking.


In evaluating the impact of technological change on pathological gambling, we cannot make predictions based on technical features alone. For instance, the telephone, TV, and the Internet are all technologies that have the potential to reduce the importance of physical distance as a constraint on gambling. They reduce the financial and behavior costs of getting information about gambling and increase people's gambling options. However, people could use both the telephone and the Internet, instead, to augment their traditional face-to-face communication for social contact. They could expand their number of friends and acquaintances and reduce the difficulty of coordinating interaction with them. Alternatively, because these technologies disproportionately reduce the costs of communication with geographically distant friends and acquaintances, they may lead to shifts in people's portfolios to more distant contacts. In addition, the Internet, through such things as interactive games and distribution lists, fosters communication among strangers. As a result, people who use these technologies heavily may have a smaller proportion of their total social contacts with family and close friends. Gambling via cable or satellite television and the Internet provides asocial entertainment and information that could compete with social contact as a way for people to spend their time.

Game Machines

Several writers have argued that playing computer-based game machines is more likely to lead to pathological gambling than other forms of gambling. Morgan and colleagues (1996) reported that video lottery gambling is the predominant type of gambling behavior engaged in by gamblers seeking treatment. Fisher and Griffiths (1995) argue that England's legal "fruit machines" (slots) are especially risky for adolescents. They claim that game machines, better than other technologies, can be designed and programmed to encourage frequent gambling. Gupta and Derevensky (1996) asked heavy and light video-game-playing children (ages 9-14) in Canada to complete a questionnaire and to play a computer blackjack game. The high-frequency video game players were more likely to report being regular gamblers. Heavy-playing boys also bet more on the blackjack tasks.

The authors speculate that experience with video games, in which practice can improve performance, leads teenagers to have the illusion that gambling machine games are somehow solvable. Griffiths (1990) found that troubled teenagers (problem gamblers, those who had been charged with crimes) were likely to hang out in video arcades and to play fruit machines frequently. However, this study and others on the correlates of children's machine gambling are only suggestive of a causal link between playing game machines and pathological gambling, and reasonable alternative explanations exist. For example, background and personal factors leading British adolescents to get into trouble could also lead them to hang out in arcades, play slots, and also to have illusions of skill in their gambling and other areas of their lives.


If new game machines such as video poker machines can be tailored to their users, they might be able to deliver more effective reward contingencies. Such an effect could increase the probability of problem gambling. Kilby (1987) discussed an older rating system for casino players whereby records were kept of frequent patrons' conversions of currency to chips. Those who cashed in more money might be given more "comps" such as free food, drinks, or games. Today, plastic club cards used with game machines are a far more sophisticated version of the old system; they can record exactly how much a gambler is wagering on which types of games. In theory, these cards can track gambler preferences, wagers, and outcomes; future rewards and games can be "personalized" to those patterns. The cards also can be used to tally frequent gambler credits, encouraging loyalty to the casino or other venue.


Telecommunications technology also could be used in tailoring gambling to customer preferences and responses. Current gambling sites on the Internet require customers to provide their name, postal address, email address, social security number, and credit card information. Some sites require customers also to provide the name of the customer's mother's maiden name or other specific identifying information. Typically software has to be downloaded to the customer's machine as well; the customer's machine has a unique address that allows records to be kept over time about the use of that machine. Software can record gamblers' identity when they start a gambling session and passively log the time they spend gambling, the game they play, the time they spend logged into the Internet, the address that identifies the web pages they connect to, and in some cases the electronic mail addresses they exchange email with. Although current Internet gambling sites are fairly traditional in their design and have problems with slow response time and errors, the technology provides opportunity for much more sophisticated, adaptive applications in the future.

Home Gambling

Many scholars, technologists, and social critics debate how computer technologies, and the Internet in particular, are transforming economic and social life. It has been posited that home gambling and the Internet may attract adolescent gamblers, or cause people to get addicted to gambling and cut themselves off from normal social constraints on gambling, as they hunker alone over their terminals playing games in electronic casinos or betting with anonymous strangers through chat rooms. However, it could also be argued that gambling problems at home, whether via the Internet or some other telecommunications technology, will be rare. It has been claimed that the Internet actually offers people more and better entertainment and social opportunities by freeing them from the constraints of geography or isolation brought on by stigma, illness, or schedule.


There are at least two reasons why computer-based gambling at home should be studied further, using methodologies that can distinguish the effects of gambling at home from other factors.
One reason is that gambling at home may increase people's susceptibility to pathological gambling through the ease and frequency with which they can gamble. Another reason is that gambling at home may contribute to other personal problems. In particular, gambling at home is likely to increase passive leisure activity and solo gambling, and it may displace time spent on active, social interaction including social gambling excursions with others and table games at home.


Computer-based gambling at home may have effects similar to those of watching television. Empirical work suggests that television-watching reduces social interaction. At the individual level, social disengagement is associated with poor quality of life and diminished physical and psychological health. Time studies show that social interactions are among the most pleasant experiences people have. People who have close ties with local friends, neighbors, and family have available to them social support that seems to buffer them from life stresses. One study also shows that the social support that people get from distant acquaintances, friends, and family is less effective in buffering daily stress than the support they get from their local friends and neighbors. Compared with people who have little social contact in their lives, people with more social contact are physically healthier, mentally healthier, and happier.

Gambling at home also may encourage passive, sedentary activity, as watching television does. Recent epidemiological research has linked television-watching with reduced physical activity and diminished physical and mental health. Gambling by adolescents is correlated with watching television and other passive leisure-time activities.

Conclusions

Computers and telecommunications are changing the gambling industry, individuals' opportunities to gamble, and the social context of gambling. The effects of these technologies, especially of home gambling and the Internet, are highly uncertain. It pointed to the television as a technology that has caused Americans to withdraw from personal and civic relationships, to the detriment of the television watchers themselves and the community as a whole. However, even for the case of television, which has been around for years, we have only a weak causal chain, suggesting that television viewing reduces social involvement or activity which in turn reduces physical and psychological health. The chain for the case of gambling machines and home gambling is even weaker. Studies of the prevalence of pathological or problem gambling for different types of gambling do not generally control for extraneous factors, including survey questions, locale, and year in which the survey was done. Computer-based video machine gambling is new enough that it is not well represented even in the modest number of surveys that address the issue. Hence the impact of technology remains an important but open question. We do not know whether problem gamblers are more attracted to video or machine gambling than gamblers without problems, and we do not understand the mechanisms that account for the associations reported in the literature.


Research is needed that allows us to better understand the link between use of gambling technologies and subsequent changes in gambling disorders. By conducting natural experiments and prospective studies, preferably with national samples, it would be possible to estimate the extent to which conclusions from correlational cross-sectional studies are valid or widespread and to determine some of their limiting conditions. By differentiating social and asocial types of gambling, and by employing careful measures such as time diaries and assessments of the size and type of social circles that gamblers maintain, researchers would be able to test several of the plausible mechanisms by which use of technology may change vulnerability to pathological gambling.


Research on the organization and technology of gambling should be evaluated in the context of the sparse research on social and technological change more generally. Little empirical research exists even about the social effects of such important technologies as the television and the telephone. Laboratory studies on technology in gambling have tended to focus on the structure of gambles rather than gambling habits and social outcomes. These studies have led to important theories about the nature of betting, but their implications for technology and gambling problems have not been tested. Few if any gambling organizations would be willing to run public experiments on these issues, and even if they did, the link to pathological gambling would be difficult to trace. Field research on the organization and technology of gambling is rare, although there is a body of literature on the effects of legalization, most of which relies on cross-sectional surveys and self-reports of gambling behaviors. Since legalization is likely to change reporting along with the technology, markets, attitudes, and constraints of gambling, it is hard to draw conclusions about how a particular aspect of legalization is affecting people.


One way to study the effects of new technology or organization in natural settings is through natural experiments; natural experiments elicit data to which time series analyses can be applied. Another approach would be to conduct prospective, longitudinal studies of individuals. This approach has long been used in studies of health and disease. However, it is possible that little is to be gained from a dedicated longitudinal prospective study of pathological gambling, since only a tiny percentage of the sample is likely to develop a gambling problem. Still, it would seem feasible and worthwhile to add measures of gambling and related leisure activities and outcomes (e.g., debts) to other prospective longitudinal studies in health or mental health. Doing so would not only add valuable information about gambling over time, but would also provide important information about baseline date and comorbidity.

Even prospective studies can pose threats to valid causal claims. First, statistical controls may not adequately equate groups (e.g., gamblers and nongamblers) on other factors. Preexisting factors (ranging from cohort characteristics to biological stress) could cause people to be predisposed to gambling and as well to be attracted to a particular type of game or gambling setting. Second, unmeasured variables that change over time may induce both gambling of certain types and changes in outcomes such as problem gambling. Measuring gambling in relationship to how people spend their time and money more generally might be useful in understanding other factors that may be related to both normal, social gambling and problem gambling. Detailed studies using time and expenditure measures; measures of social network size, social activities, and stress; psychological measures of social support and physical and mental health could contribute to understanding of the relationships between problem gambling, how people use technology, time, and money, social interaction, and the size of social networks.

Treatment of Pathological Gamblers

The treatments and interventions for pathological gambling that have been developed and reported in the literature are quite similar to methods of treating other disorders or addictions. Substantial progress has not been made in understanding the treatment of this disorder or the characteristics of those seeking help for it, nor is there research basis for matching clients to treatments. Most published investigations are case studies or studies with small samples of clients whose circumstances may not be generalizable to larger populations. Moreover, treatment approaches have not been subjected to rigorous and detailed empirical research. Given the lack of national attention to the treatment of pathological gambling, it is difficult to estimate the scope of intervention services available in the United States.


We begin with a discussion of the definition of treatment and challenges in treating such disorders as pathological gambling. We then discuss what is known about the characteristics of those who seek treatment for pathological gambling. We then turn to treatment models that have been applied for helping pathological gamblers, what is known about treatment effectiveness, whether treatment is warranted, and issues related to treatment availability, utilization, funding, and treatment providers in the United States. We also identify priorities for further research, including treatment effectiveness, cost-effectiveness, how patients should be matched to treatments, and prevention strategies.

Defining Treatment and Challenges to Treatment

We define treatment as: (1) activities directed at individuals for the purpose of reducing problems associated with problem or pathological gambling and (2) activities aimed at groups of individuals to prevent gambling problems from arising in the first place. Comprehensive treatments move through three stages: acute intervention, followed by rehabilitation, and ending with maintenance. These three stages can vary according to the philosophy of the providers, the settings in which treatment takes place, and the specific approaches employed. No systematic compilation of treatment services for pathological gambling has been made in the United States. Treatment is provided in many ways and in many settings, although outpatient treatment is probably the most common; no single treatment approach dominates the field. In fact, it appears to be common for approaches to be combined in most clinical settings. It is important, as well, to recognize that recovery from pathological gambling can take place without formal treatment. Such individuals have been classified by various descriptors, for example, so-called spontaneous recovery and natural recovery. Although the subject of natural recovery from psychoactive substances, such as alcohol and opiates, has received some attention in the professional literature, no such attention has been given to gambling.

Functionality of Addictive Behaviors

All addictions, by their nature, pose special problems to treatment providers. Like other purposive human behavior, addictive behaviors have adaptive or functional value, with the result that efforts to change these behaviors often fail.


Ambivalence is at the core of addiction. Those who are addicted and thinking about change want to free themselves from their addiction. At the same time, they crave the satisfactions that their addiction provides. As they become aware of the harm their addiction is doing, they begin to say that they want to quit. Of course, wishing or expressing a desire to quit a behavior is not the same as doing it. Despite the obvious harmful consequences, people in the throes of addiction cling to the part of the experience that they like: the part that was adaptive originally and may have even produced positive consequences, such as relief from painful emotions. The key to change comes when those addicted begin to realize that the costs of their addiction exceed the benefits, as when pathological gamblers identify gambling as a destructive agent in their life. It is at this point that addicted people often ask those who they trust to help them stop, and they take the first steps to seek professional help. This turning point is but the first step of a complex dynamic process, including the possibility that bouts of abstinence and relapse may occur for some time.


Preventing Relapse


A challenge in the treatment of pathological gambling is preventing relapse. For example, few people who stop using drugs remain abstinent thereafter. Many personal and environmental factors interact to influence the risk of relapse for any individual trying to recover from an addiction. Successful recovery also involves the development of new skills and lifestyle patterns that promote positive patterns of behavior. The integration of these behaviors into day-to-day activities is the essence of relapse preventio. Successful quitters substitute a variety of behavior patterns for their old drug-using lifestyle. For example, many take up some form of exercise. Spiritual conversions sustain others. In some patients, new behavior can become excessive, almost another addiction. We do not know whether the same substitute behaviors occur in pathological gamblers determined to quit.

Characteristics of Treatment Seekers

Understanding the characteristics of those who seek help for a given disorder can assist in developing effective treatments. As already noted, most clinical investigations in this field are case studies or studies with small samples of clients whose data may not be generalizable to larger populations. Thus, establishing an accurate profile of those seeking treatment is difficult. We can say a few things, however.

Demographics

Treatment seekers tend to be white middle-aged men, though more recent investigations suggest that admissions of women are increasing. The majority tend to be in their 30s and 40s and have graduated from high school and attended some college.

Gambling Severity

Most clinical studies indicate that, before pathological gamblers come in for treatment, they gamble either every day or every week. Little is known at this time about their preferences for types of gambling. One factor that may influence preference is proximity of certain games to gamblers; for example, one study showed that the preferred game of gamblers in Maryland was horse racing at Maryland tracks, and for Oregon clients, it was the video poker that is widely available there. Game availability does not simply translate to preference. Minnesota gamblers have been shown to prefer to gamble in casinos, which may be far from their homes, over purchasing lottery tickets, which can be bought almost everywhere in the state.

Legal and Financial Consequences

Although clients may be reluctant to fully disclose their legal entanglements, most clinical studies indicate that a sizable percentage reports having criminal charges pending as a result of engaging in illegal activity to fund their gambling or pay off their debts. Some reports indicate that from half to two-thirds of pathological gamblers have committed an illegal act to get money to gamble. Large debts, most often in the tens of thousands of dollars, are also part of the picture. One study reported that 10 percent of 128 gamblers ages 20 to 68 treated as outpatients at a gamblers' treatment clinic had debts in excess of $100,000.

Other Characteristics

Additional personal and social consequences reported by those seeking treatment include work absenteeism and lost productivity on the job, presumably because they either skip work in order to gamble or are involved in gambling-related activities while at work; and marital discord and family estrangement, due to the deception, lying, and stealing associated with their gambling.

Treatment Approaches and Effectiveness
Methods for treating pathological gambling include approaches that are psychoanalytic, psychodynamic, behavioral, cognitive, pharmacological, addiction-based and multimodal, and self-help. Often these approaches are combined to varying degrees in most treatment programs or counseling settings. The discussion below briefly describes each method and summarizes what is known from the empirical research about its effectiveness.


Psychoanalytic/Psychodynamic


Psychoanalysts seek to understand the basis of all human behaviors by considering the motivational forces that derive from unconscious mental processes. Psychodynamics refers to the ''science of the mind, its mental processes, and affective components that influence human behavior and motivations and how these potentially opposing forces of cognition and emotion are translated into behavior. During the first half of the twentieth century, psychoanalysts provided the first systematic attempts to understand and treat gamblers.


Psychoanalytic and psychodynamic treatment approaches have not been proven effective through evaluation research. They are briefly described here because they are the most common forms of treatment for pathological gambling at this time. These approaches are based on the principle that all human behavior has meaning and is functional. Even the most self-destructive behaviors can serve a defensive or adaptive purpose. This perspective suggests that pathological gambling is a symptom or expression of an underlying psychological condition. This approach takes the view that, although some individuals don't need to understand why they gamble in order to stop, there are many others whose lives do not improve with abstinence, which is experienced as futile and hopeless. They then develop a major depression, turn back to gambling, or seek out some other addictive or self-destructive behavior with which to distract themselves.


Psychoanalytic and psychodynamic therapy attempts to help pathological gamblers to understand the underlying source of their distress and confront it. Clinicians have considered psychodynamically oriented psychotherapy useful in treating some of the comorbid disorders and character pathology observed among pathological gamblers, perhaps especially the narcissistic and masochistic subtypes. Although several others have noted the value of psychodynamic treatment for addictive behaviors, there have been no controlled or randomized studies exploring the effectiveness of this approach for treating pathological gamblers.


The psychoanalytic understanding of gambling problems rests on the foundation formulated by Freud (1928), who thought that it was not for money that the gambler gambled, but for the excitement. In fact, Freud speculated that some people gamble to lose. He thought this tendency was rooted in a need for self-punishment, to expiate guilt, and, for the male gambler, because of ambivalence toward the father. Bergler expanded on this concept of masochism, emphasizing the pathological gambler's rebellion against the authority of the parents and specifically the reality principle they represent.


A number of early psychoanalysts, dating back to Simmel in 1920, emphasized narcissistic fantasies and a sense of entitlement, pseudo-independence, and the need to deny feelings of smallness and helplessness. Other analysts described early parental deprivation, with the gambler then turning to Fate or to Lady Luck for the love, acceptance, and approval he or she had been denied. Several analysts  saw compulsive gambling as an attempt to ward off an impending depression. Boyd and Bolen (1970) viewed it as a manic defense against helplessness and depression secondary to loss. Still others have emphasized the eroticization of tension and fear, the central role of omnipotence, and problems identifying with parents. More recently, analysts have been investigating deficiencies in self-regulation as they pertain to gambling and other addictive.


The psychoanalytic literature provides individual case histories of gamblers treated. The only analyst to present information about a series of treated gamblers was Bergler (1958). In his account of 200 referrals, 80 appeared to be severe cases and, of those, 60 remained in treatment. A critique of his treatment appears in Rosenthal. According to Bergler, 45 were cured and 15 experienced symptom removal. By a cure, he meant not only that they stopped gambling, but also that they addressed core conflicts and gave up their pattern of self-destructiveness. There is no information on whether "cured" patients were followed-up after treatment.


There is a significant need, not only for randomized treatment outcome studies, but also for clinical vignettes and case histories that discuss what it is that clinicians who use these treatments actually do. It is necessary to deconstruct psychoanalytically and psychodynamically oriented interventions and techniques to see what specific components contribute to favorable treatment outcomes. And of course there are differences between one therapist and another with regard to their capacities for empathy, timing, tact, role-modeling, and support, which can complicate research on treatment effectiveness in general and psychodynamic treatment in particular.


Behavioral


Behavioral treatment methods actively seek to modify pathological gambling behavior on the basis of principles of classical conditioning or operant theory. Several variations of behavioral treatment methods are used today, often in combination. Aversion treatment consists of applying an unpleasant stimulus, such as a small electric shock, while the patient reads phrases that describe gambling behavior. During the procedure's final phrase, the patient reads about an alternative activity to gambling, such as returning home, but receives no shock. Imaginal desensitization consists of two steps. Patients first engage in a procedure to relax. Then they are asked to imagine a series of scenes related to gambling that they find arousing. They learn from this procedure to relax when they encounter opportunities to gamble, rather than to submit to their cravings. An extension of imaginal desensitization is in vivo exposure, in which relaxation techniques are applied while the patient is actually experiencing a gambling situation.


Behavioral counseling has been used in both individual and group treatment settings. Subjects receive reinforcement for desired gambling behaviors, such as gambling at a reduced level, betting less money, and so on. Specific treatment goals can be more formalized in the form of contingency contracting, in which specific aspects of behavior are rewarded or punished. Other behavioral techniques have been reported in the gambling treatment literature. Two of them, behavioral counseling, in which the gambler is given verbal reinforcement for desired outcome behaviors, and in vivo exposure, in which the gambler is exposed to gambling behaviors but is not allowed to gamble, are mentioned in the literature but have not been empirically tested.


Although behavioral treatment methods have been used and evaluated, such studies typically have had small sample sizes and no control groups. Case studies using various combinations of behavior treatments are. However, findings from these limited studies are not consistent enough to reach conclusions about treatment effectiveness. Early studies of effectiveness on behavioral forms of treatment for pathological gamblers focused on aversion treatment. The studies involved single patients and provided minimal evidence of treatment. Subsequent research on aversion treatment using electric shock for pathological gamblers had only slightly larger and produced equally questionable findings.
Larger outcome studies have been undertaken and provide more evidence for treatment effectiveness. In a study of 110 German pathological gamblers, it was described as a behavioral treatment that begins with an extensive assessment of the client's motivation for treatment, symptoms, the consequences of his or her gambling, and social competence. This assessment is followed by client training in emotional awareness, coping with negative emotions, and social and problem-solving skills. An uncontrolled evaluation of this approach revealed favorable treatment results.


The earlier studies compared imaginal desensitization with either aversion treatment or behavioral approaches. In a 1988 study, the effectiveness of imaginal desensitization was compared with imaginal relaxation (teaching the client general relaxation techniques). Although the early studies by this group had relatively small sample sizes, otherwise strong methodologies revealed that treatment techniques were successful at one month and also at one year following treatment.


Using a large sample and expanding the comparisons of behavioral approaches, randomly allocated 120 participants to one of four techniques: aversion treatment, imaginal desensitization, imaginal relaxation, or in vivo exposure. A total of 63 clients were recontacted two to nine years later, a 53 percent follow-up response rate. The group that received imaginal desensitization benefited more than those receiving the other three behavioral approaches when abstinence and controlled gambling were combined as the outcome variable. The authors defined controlled gambling as gambling in the absence of the subjective sense of impaired control and adverse financial consequences, based on self-rating and confirmation from a spouse or significant other. If just abstinence was considered, imaginal desensitization was equivalent to the other treatments' combined rate of abstinence (30 percent and 27 percent, respectively).


In a further investigation of this sample, it was found that the abstainers and controlled gamblers showed a significant reduction in arousal levels, anxiety, and depression during the follow-up period compared with those who could not control their gambling. Also of significance are the study's findings pertaining to the controlled gamblers. The pattern of gambling suggested that controlled gambling is not necessary a temporary response followed by a relapse to heavier gambling. Because the sample siz studies are relatively small and because only about half of the original sample was contacted for follow-up, although the long follow-up periods used were laudable, these results should be interpreted with caution.

Cognitive and Cognitive-Behavioral

Several clinicians and researchers have convincingly argued  that pathological and problem gamblers share irrational core beliefs about gambling risks, an illusion of control, biased evaluations of gambling outcomes, and a belief that gambling is a solution to their financial problems. Cognitive treatment aims to counteract underlying irrational beliefs and attitudes about gambling that are believed to initiate and maintain the undesirable behavior. Treatment typically involves teaching clients strategies to correct their erroneous thinking. Many, for example, do not understand the concepts of probability and randomness, believing that they can exert some control over whether they win or lose.


The effectiveness of cognitive treatments has received limited attention by researchers and, as for other studies of treatment success, most have small sample sizes and no control groups, from which little can therefore be concluded. However, a push for more comprehensive models to explain the origins of problem gambling has elicited investigations of the efficacy of combining cognitive and behavioral approaches. Investigations combining these treatments include case studies; small and uncontrolled studies, and controlled studies with larger samples. Combined cognitive-behavioral approaches have been successful for both adolescent problem gamblers and adult pathological gamblers. The Sylvain study (1997) is noteworthy in that it expanded the cognitive-behavior treatment to include a waiting-list control group. The study found that the cognitive-behavioral group improved vastly more than the control group. However, 11 of the original 40 individuals dropped out of the study and the follow-up data suffered from appreciable attrition.


Another cognitive-behavioral controlled investigation with a waiting-list control group was done by Echeburura and his colleagues (1994). They compared the effectiveness of cognitive and behavioral techniques in a Spanish sample of 64 men and women who met DSM-III-R criteria for pathological gambling. Participants were randomly assigned to one of four treatments: individual stimulus control and in vivo exposure with response prevention; group cognitive restructuring; a combination of the first two; and a waiting-list control group. At six-month follow-up, the outcome data indicated that the most favorable outcome was associated with the first two groups; these groups significantly outperformed the control group and reported therapeutic success rates,abstinence or 1 or 2 gambling episodes in which the amount gambled did not exceed the amount gambled in the week prior to treatment of 75 percent and 63 percent, respectively. However, the combined individual and group treatment condition showed significantly poorer results compared with the other treatment groups.

Pharmacological

Pharmacotherapy is a relatively new approach to the treatment of pathological gambling. There are only a few studies and reports in the literature. In 1980, just prior to the introduction of DSM-III, Moskowitz described the treatment of three compulsive gamblers with lithium carbonate. Significant abstinence was achieved in all three cases, with improvement documented by long-term follow-up. However, two of the three were clearly manic depressive, and the third had a bipolar spectrum disorder. Twelve years later, Hollander et al. described the treatment of a single patient with clomipramine. When the patient entered the study, she had been gambling consistently 2 to 3 times per week for the previous 6.5 years, although she had periods of abstinence in the past. The study's design was double-blind, placebo controlled, 10 weeks to each phase. She was minimally improved on the placebo, then became abstinent on the medication and didn't gamble for the duration of the trial. Except for a relapse at week 17, she remained abstinent on open maintenance for an additional seven months. Significant in her personality were compulsive features, including perfectionism and hoarding, and a history of social phobia, all of which respond well to such drugs as clomipramine.


Rosenthal (1997) discussed indications for using medication in the treatment of pathological gamblers. Although some patients experience withdrawal symptoms, including prominent physical symptoms, (Wray and Dickerson, 1981; Meyer, 1989; Rosenthal and Lesieur, 1992), they do not need to be medicated. Also, some gamblers report frequent and intense cravings. Rosenthal (1997) reviewed several approaches to a pharmacotherapy of cravings. One of the most promising involves agents that block the excitement or pleasure of the addictive drug. The best known of these blocking agents is naltrexone, an opioid antagonist used in the treatment of alcoholism. It has also been used in treating those addicted to cocaine and heroin. The effectiveness of the drug in treating pathological gamblers is currently being investigated under controlled conditions by Suck-Won Kim at the University of Minnesota (Kim, 1998).


However, medication is useful only if the patient takes it. It is estimated that, 50 percent of all patients don't take the medications their doctors give them. Greenstein et al. (1981) found that fewer than 10 percent of patients who began naltrexone treatment for opioid dependence were still taking it after two months. For pathological gamblers, compliance is an issue because they are often ambivalent about giving up their gambling or altering long-standing patterns of coping, no matter how ineffective. When they stop gambling, they often feel something has being taken away from them.

Addiction-based and Multimodal

This category of treatments, which has a relatively long tradition, includes a broad range of techniques used by inpatient and outpatient programs. The first gambling inpatient program, which started in 1972 at the Brecksville, Ohio, Veterans Administration hospital, was based on a preexisting program for alcoholics. Similarities with substance abuse programs continue and include the use of recovering gamblers as peer counselors, an emphasis on Gamblers Anonymous and other 12-step meetings, and an educational component about addiction, including relapse prevention, personal communication to the committee, 1998). This latter component focuses on how to avoid high-risk situations, being able to identify specific gambling triggers, and developing problem-solving skills for dealing with urges or cravings. McCormick believes that pathological gamblers are deficient in the number of coping skills they have available and in their ability to flexibly choose the skill most appropriate to the stressful, or potentially relapse-triggering, situations they face. In a comparison with no-gambling substance abusers, he found that substance abusers with a gambling problem utilize significantly more avoidance and impulsive coping styles.


There are other therapeutic components commonly employed by addiction-based programs. One is autobiography. Patients write a history of their gambling problem incorporated into a narrative of the significant events in their life, and then read it to the therapy group. Feedback focuses on the role gambling has played in the person's life, as well as how his or her behavior and perceptions contributed to the development of the problem. The reading of one's autobiography is often a very emotional experience, and many view it both as a rite of passage in the treatment program and as a turning point in their recovery.


Joint or family therapy is another therapeutic component of addiction-based treatment. This element is important when dealing with pathological gamblers, because families are often loath to forgive the gambler. Clinical wisdom suggests that it is not until after the individual has stopped gambling that the anger of family members begins to surface. This may be so because gambling can be easy to hide and the financial and interpersonal damage can be swift; those close to the gambler remain distrustful and hold on to their anger to protect themselves. Franklin and Thomas (1989) note that the return of the gambler into the family is often met with resentment and resistance. The spouse and children often are depressed and have problems of their own that are in need of therapy. Alternatively, because the gambling offers intermittent rewards, family members may be angry that the patient has stopped gambling.


Another key aspect of the addiction-based approach is after-care planning. This may include identification of a support system, continuing involvement in Gamblers Anonymous, relapse prevention strategies, a budget and plan for financial restitution, a plan for addressing legal issues, ongoing individual or group therapy, family therapy, and medication.
Some of the multimodal approaches have been evaluated for long-term effectiveness. Hudac and colleagues (1989) assessed 26 male gamblers four years after they were treated. Of the 26, 8 were abstinent and the others showed less gambling compared with the period prior to treatment. However, the gamblers contacted at the four-year follow-up represented only about one-third of the original treatment sample of 99 pathological gamblers. Schwartz and Linder found that, after two years following inpatient treatment with a client-centered approach, 13 of 25 assessed clients remained abstinent, 33 original subjects were not contacted.

Self-Help

Gambler's Anonymous

Gamblers Anonymous (GA) is believed to be the most commonly used of all approaches to deal with pathological gambling, and it is routinely included in multimodal strategies. The data suggest that relapse rates tend to be quite high for participants. Stewart and Brown (1988) found that total abstinence was reported by only 8 percent of members surveyed one year after their first attendance and by 7 percent at two years. When those who continued to gamble were compared with those who dropped out of Gamblers Anonymous, Brown found that dropouts were more likely to perceive that they had less of a gambling problem, found themselves in personality clashes with the members who did attend, and reported that Gamblers Anonymous was too rigid in its abstinence-only policy. Other researchers have examined the role of Gamblers Anonymous in maintaining abstinence. Taber and colleagues found that 74 percent of abstinent gamblers in their sample attended at least three meetings in the prior month, compared with only 42 percent of those who continued to gamble.


The therapeutic effectiveness of Gamblers Anonymous has also been explored with respect to participation by the gambler's spouse. Johnson and Nora found that there was a trend for higher abstinence rates for gamblers whose spouses were present at meetings compared with gamblers whose spouses did not attend. Although not statistically significant, the results revealed that 20 out of 44 gamblers whose spouses were present at meetings stopped gambling for at least four years, compared with 13 out of 46 gamblers whose spouses did not participate. In sum, Gamblers Anonymous may be increasing in popularity, but whether participating in meetings makes a significant and lasting impact is still not known.

Diagnostic criteria for 312.31 Pathological Gambling 
 

A. Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: 

(1) is preoccupied with gambling (e.g., preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) 
(2) needs to gamble with increasing amounts of money in order to achieve the desired excitement 
(3) has repeated unsuccessful efforts to control, cut back, or stop gambling 
(4) is restless or irritable when attempting to cut down or stop gambling 
(5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) 
(6) after losing money gambling, often returns another day to get even ("chasing" one's losses) 
(7) lies to family members, therapist, or others to conceal the extent of involvement with gambling 
(8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling 
(9) has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 
(10) relies on others to provide money to relieve a desperate financial situation caused by gambling 

B. The gambling behavior is not better accounted for by a Manic Episode.

 

 

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