Problem gambling: Are all bets off?

Although gambling and its attendant problems have existed for thousands of years, only in the past two decades have they received much scrutiny as a treatable mental health condition. In 1980, pathological gambling (PG) was formally classified as a mental health disorder. Since then, the proliferation of casinos and the government-run lotto – as well as the ever-present jueteng and other numbers games plus the advent of Internet gambling – has made gambling increasingly accessible, furthering the need to identify and effectively treat PGs.

Gambling may be an innocuous social activity for most people. But for pathological gamblers, betting becomes a dominant and destructive force in life, providing thrilling highs and crushing lows. Huge debts may trigger tragic consequences, such as failed marriages, lost jobs, criminal behavior, substance abuse, depression, and even suicide.

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.

According to the US National Council on Problem Gambling, about 1 percent of American adults – nearly three million people – are pathological gamblers. Another two to three percent 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 or APA (see box).

Most compulsive gamblers are men, but the problem is growing among women. The poor and people with limited education, exposed to tempting visions of unattainable wealth are particularly susceptible. A biological predisposition could also be involved. Twin studies indicate that heredity may account for up to 35 percent of individual differences in susceptibility to gambling problems. Some research suggest 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 other personality disorders. In a survey of Gamblers Anonymous members, 22 percent reported panic attacks, 72 percent reported an episode of major depression, and 52 percent 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 PG. Although the APA 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 risk 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 the 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.

Helping Problem Gamblers

The treatment of compulsive gambling also resembles that for substance abuse as well as for impulse control. In recent years, researchers have developed various forms of treatment centered on counseling, medications, or group therapy. Most often, it is a multifaceted treatment program combining features from different treatment approaches.

The most common treatment for PG is Gamblers Anonymous (GA), which uses a 12-step, abstinence-based program of peer support derived from Alcoholic Anonymous. GA’s program includes admitting powerlessness over gambling, reading an autobiography of one’s gambling history to a peer group, and developing a plan to pay off debts and address legal issues.

Counseling may include cognitive therapy that aims to correct misguided thought common to pathological gamblers, such as belief that gambling will solve their financial problems or that they can control random events. Behavioral therapy, a related approach often combined with cognitive therapy, teaches gamblers tactics for combating their problem. For example, patients learn to relax when they encounter gambling opportunities, carry only small sums of money, make budgets, and assert themselves when peers encourage gambling.

Drug therapy 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 any treatment is almost certainly better than none, little is known about which treatments work best for which gamblers. There are a 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 term. 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 eight percent of members had achieved abstinence required by Gamblers Anonymous principles.

The Future: Needs And Proposal

The 1999 US National Gambling Impact Study Commission Report recommends more research on how to encourage compulsive gamblers to seek treatment and how to help their families. Like alcoholism and drug addiction, pathological gambling is a social problem that demands more than individual therapeutic solutions. Many countries in the world have councils on compulsive gambling and set aside some gambling revenues for treatment, prevention, and education. I propose that PAGCOR intensify its efforts to do the same.

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. It has also been 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.

All these are important because it is an unfortunate fact that pathological gamblers too often cannot afford to pay for their own treatment since they don’t seek help until they’ve exhausted practically all their own financial resources!