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Gambling is a strikingly ubiquitous human activity. For most people it constitutes a fairly casual pastime, amid a varied matrix of social and leisure pursuits. For some, however, gambling is anything but a casual activity: for the pathological gambler, gambling is preoccupying, consuming substantial time and money. The American Psychiatric Association regards pathological gambling as an impulsive disorder manifest as an addiction to gambling akin to alcohol or drug addiction. This entry briefly describes the salient characteristics of the pathological gambler and indicates the current prevalence of the disorder. Explanations for pathological gambling are reviewed along with comments on treatment and intervention.
Gambling Research Paper Outline
II. Pathological Gambling
A. Cognitive Bias
Gambling, in some form or another, is legally sanctioned in more than 90 countries worldwide and in 48 of the 50 states of the United States. In 1988, it was estimated that Americans legally wagered some $210 billion; by 1991, the estimated expenditure on gambling had soared by 50% to $304 billion. The proliferation of video lottery terminals and the establishment of casinos on Native American lands, consequent on passage of the federal Indian Gaming Regulation Act in 1988, are just the most recent manifestations of the progressive loosening of legislative restrictions on gambling. In this context, it is worth noting that in 1974, the total of legal wagers in the United States was $17 billion, a mere 5 % of the most recent expenditure estimates.
Other countries have increasingly adopted similarly supportive legislative postures and have shown similar expenditure trajectories. For example, government revenue from gambling in Australia rose from $168 million (Australian dollars) in 1972-1973 to $2.02 billion in 1992-1993. Indeed, some countries began relaxing strictures against gambling much earlier than the United States. Although the United Kingdom was slow to appreciate the fiscal possibilities of lottery gambling, the Gaming Act, which legalized gaming for profit, became law in 1968. Among other things, it allowed licenses to be granted for slot machine installations in cafes, leisure centers, or dedicated slot machine arcades, with access policed only by a voluntary code of conduct, devised by the British Amusement and Catering Trade Association (BACTA). The BACTA code prohibits those under 16 years of age from entering slot machine arcades. However, the code does not apply to seaside arcades, does not bind owners who are nor members of the association, and does not apply to nonarcade sites. Thus, while other European countries, Australia, and the states of the United States set the legal minimum age of access to slot machines at 18 or 21 years, the United Kingdom, in effect, exerts no legal restriction.
Not surprisingly, the legislative arrangements that govern gambling have implications for behavior. For example, whereas other countries are not without problems related to slot machine gambling, it would appear that the heavy involvement of young people is a particularly British phenomenon. In the United Kingdom, organizations such as Gamblers Anonymous (GA) report an increasingly large number of under-18 youths seeking help for excessive or uncontrolled slot machine use. In 1964, the typical British GA member was a 40- to 50-year-old horse race gambler; by 1986, approximately 50% of new members were slot machine players, half of these being adolescents.
Legislative relaxation in the United States has not only seen a massive increase in expenditure on gambling, it has also been associated with a substantial increase in participation. In 1974 in the United States, about 60% of the adult population was estimated to have participated in some form of gambling. By 1990, the figure had risen to just over 80%, and the most recent estimates, based on sampled states, suggest that the current lifetime participation rates may be even higher.
These figures are cited only as illustration. Nevertheless, they are broadly representative. With increasing legislative laissez-faire has come increased access and participation rates, as well as massively increased expenditure on gambling, not to mention, in many cases, vast increases in government revenues. In addition, where legislation and cultural values permit, gambling appears to be a prevalent activity among the young. For example, surveys show that between 3 % and 14% of British high school students are regular slot machine players. The figures for occasional use are more dramatic, with two thirds of British adolescents reporting use of gaming machines in arcades.
II. Pathological Gambling
While for most people gambling represents an occasional distraction, for the pathological gambler it is anything but. In contrast to the occasional or recreational gambler, the pathological gambler has lost control over his or her gambling behavior. Gambling has, for such an individual, reached the point of disrupting not only his or her life, but also the lives of close family members and friends. In 1980, the American Psychiatric Association (APA) formally recognized pathological gambling as a disorder of impulse control, similar in many ways to other addictions. Save for “chasing” losses, the criteria used for defining gambling as pathological were very much modeled on those used to define alcohol and drug abuse. Like the substance addict, the pathological gambler is consumed by gambling, and will beg, borrow, cheat, and steal to support their addiction. Like the substance addict, the pathological gambler often shows tolerance, needing to increase the size or the frequency of the bet to achieve the desired excitement or “high.” Similarly, withdrawal symptoms of disturbed mood and behavior are evident when gambling is curtailed. With regard to withdrawal, one study interrogated 222 pathological gamblers. Sixty-five percent reported at least one of the following: insomnia, headaches, upset stomach, loss of appetite, physical weakness, heart racing, muscle aches, breathing difficulties, sweating, and chills. Indeed, the pathological gamblers reported, if anything, more withdrawal symptoms than did substance-addicted control subjects. Finally, there are many instances of cross-addictions among pathological gamblers. Some studies have observed that as many as 50% of pathological gamblers had abused alcohol or drugs at some point in their lives.
The following criteria are currently recommended by the APA as being characteristic. A diagnosis of pathological gambling is registered if an individual meets five or more of these criteria, with the proviso that the behavior is not better accounted for by a manic episode. A person may meet the criteria if he or she:
- 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)
- Needs to gamble with increasing amounts of money in order to achieve the desired excitement
- Has repeated unsuccessful efforts to control, cut back, or stop gambling
- Is restless or irritable when attempting to cut down or stop gambling
- Gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression)
- After losing money gambling, often returns another day to get even (“chasing” one’s losses)
- Lies to family members, therapist, or others to conceal the extent of involvement with gambling
- Has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling
- Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling
- Relies on others to provide money to relieve a desperate financial situation caused by gambling
III. Prevalence of Gambling
Prevalence is the measure of the rate of a given phenomenon, such as pathological gambling, in a given population at a given time. Accordingly, the examples of prevalence rates cited here will necessarily be parochial. Although there are reasons for suspecting that the rates have increased in recent years, the data are circumstantial. As yet, there are no published reports of repeat prevalence surveys conducted on the same population. Nevertheless, there are clear trends apparent in research findings. Consider, for example, surveys of slot machine gambling among British high school students; in general, higher rates of pathological gambling appear in more recent surveys. Similarly, an escalation in pathological gambling can be inferred from the increase in treatment-seeking behavior. Consider the example of Holland and its alcohol and drug treatment centers. The number of individuals seeking treatment for gambling-related problems at these centers has increased strikingly over time. While only 10 individuals sought information or treatment in 198.5, 400 did so in 1986, 1200 in 1987, and 3883 in 1991.
The only national survey in the United States was conducted in 1974. The authors concluded that 1.1 million Americans were probable pathological gamblers. More recently, researchers have relied for data on state-based prevalence surveys. Those carried out since 1990 report prevalence rates ranging from 1.4 to 2.8%. Surveys of gambling behaviors in Canadian provinces yield, if anything, slightly lower prevalence rates, but much depends on the definition of what constitutes pathological. One of the problems with the survey research is variation in the criteria used to define pathological gambling. For example, if one adheres to a strict definition of pathological gambling, the Canadian provincial rates range from 0.8 to 1.7%. However, if one relaxes the definition to include problem gamblers who possess almost, but not quite, a sufficient number of the defining characteristics to qualify as pathological gamblers, the prevalence rates range from 2.7% in Saskatchewan to 8.6% in Ontario. Other countries are gradually beginning to survey their populations. Rates of pathological gambling in regions of Spain currently run at about 1.7%. In Australia, a partial national survey revealed pathological gambling rates of 1.2%, an identical figure to that which emerged from the recent national survey in New Zealand. Some appreciation of what these figures mean in social problem terms can be obtained by extrapolating from the case of New Zealand. A prevalence rate of 1.2 % implies that there are approximately 27,500 pathological gamblers in New Zealand. If we assume an overall current prevalence rate of 2 % in the United States, a reasonable assumption given recent individual state estimates, and an age structure similar to New Zealand, we can calculate that there are more than 3 million pathological gamblers in the United States.
There are reasons for suspecting, however, that the prevalence rates revealed by many of these surveys are, if anything, underestimates. We have already alluded to the matter of the criteria used to identify pathological gambling; someone may have severe problems with gambling, yet fall just short of pathological status. Secondly, most of the prevalence surveys have relied on telephone data collection techniques. Such an approach has obvious pitfalls. Pathological gamblers may be underrepresented as they are more likely to have their telephones cut off periodically for nonpayment of bills, or to be too poor to possess telephones. Furthermore, telephone surveys have notoriously high nonresponse and refusal rates; pathological gamblers are less likely to be at home to telephone enquiries and, if they are, more likely to be reticent in the face of enquiries about gambling. This would again lead to pathological gamblers being undersampled. Problems also arise from unsampled groups, such as those in institutional care. Studies of patients in alcohol and drug treatment centers reveal prevalence rates of pathological gambling of 9 to 15 %. The exclusion of such individuals from surveys of pathological gambling will consequently lead to underestimates of prevalence. There is also emerging evidence of relatively high rates of pathological gambling among adolescents. For example, recent surveys among high school age individuals in Canada registered pathological gambling prevalence rates of about 3 %. Most general telephone surveys necessarily exclude adolescents and are, as a result, likely to yield prevalence estimates lower than the true figure.
Finally, individual surveys in the United States usually show that pathological gambling prevalence rates are higher among those with low levels of education, as well as being higher among males, young adults, and nonwhites. It is worth noting that young adults and nonwhites tend to be underrepresented in treatment programs. Thus, treatment may not be reaching many of those who need it most.
IV. Explanations of Gambling
Early attempts to account for pathological gambling relied either on psychodynamic metaphor or on a strict application of reinforcement theory. From a psychodynamic perspective, gambling was regarded as an attempt to resolve conflicts with parental figures through symbolic contests with a surrogate. Pathological gambling reflected an unconscious desire to lose such contests, thus appeasing the parental figures. Reinforcement theory regarded gambling as a learned response to intermittent schedules of financial reinforcement. Pathological gambling, from this perspective, was the result of repeated exposure to these powerful schedules. Neither provide a satisfactory answer. While psychodynamic explanations are couched in a manner that renders empirical examination extremely difficult, strict reinforcement theory, with its emphasis on purely financial contingencies, gives improper regard to other motivating agencies and to intraindividual factors.
Other, recent theoretical models of pathological gambling are much more multifactorial in character, and, although retaining variable financial reinforcement schedules as part of the explanatory matrix, have incorporated a range of other factors. Most prominent among these are cognitive bias, personal disposition, and arousal.
A. Cognitive Bias
One of the most influential contributions to a cognitive psychology of gambling has been the work of Ellen Langer on the illusion of control. The illusion of control is defined as an expectancy of personal success inappropriately higher than the objective probability would warrant. In an elegant series of laboratory studies, Langer demonstrated that subjects’ appropriate orientations toward chance events could be altered by a range of manipulations. For example, subjects who cut cards against a nervous competitor bet more than when playing against a confident competitor. Subjects would pitch the sale price of a lottery ticket that they had chosen themselves at a higher price than they would a ticket chosen for them. Subjects given the opportunity to practice a novel game of chance would bet more than those denied such an opportunity. Finally, subjects led to believe that they were particularly successful during the early trials of a coin-tossing task rated themselves as significantly better predictors of outcomes than subjects led to believe they performed poorly in the early stages of the task.
In summary, if devices conventionally characteristic of skill situations are introduced into chance situations, individuals will inappropriately shift their expectations of success to levels better than chance. For example, provision of “feature” buttons which control aspects of slot machine behavior may enhance beliefs that skill is relevant to this form of gambling. Studies of gamblers in naturalistic settings yield confirmatory data. Regular gamblers frequently deny the importance of chance factors in their chosen pursuit, erroneously believing that they have devised a winning system. They display flexible attributions in that success is attributed to their own skill, whereas external factors such as bad luck or fluke circumstances are invoked to account for losses.
It is also clear that individuals vary in the degree to which they generally attribute outcomes to internal factors, such as skill, or to external factors, such as luck. Thus, some individuals may be more likely to adopt a skill or control perspective in essentially chance situations. There is certainly evidence from studies of slot machine players that an internal locus of control may be particularly characteristic of young pathological slot machine gamblers.
Aside from orientations regarding the locus of control, other personality factors have been implicated as predisposing a person to pathological gambling. Given the variety of personality questionnaires that have been deployed and the variations in the populations studied, it is perhaps hardly surprising that not all studies point in the same direction. Nevertheless, some consistent themes can be discerned. Sensation-seeking, impulsivity, and lack of concern for others emerge as characteristic of pathological gamblers in a number of studies.
Results from studies that have measured a disposition toward sensation-seeking have yielded equivocal results. However, perhaps sensation-seeking is best regarded in the context of prevailing levels of stimulation. Evidence seems to indicate that pathological gamblers, apart from their gambling, endure a lifestyle noticeably low in stimulation, and many report relief from boredom as a major motivating force. Accordingly, to the extent that sensation-seeking is implicated in pathological gambling, it is perhaps less as a personality trait, and more as a response to characteristically low levels of stimulation and arousal.
While caution is appropriate, given the bias toward male subjects in research, impulsivity and a lack of concern for others emerge from a number of studies of pathological gamblers. Pathological gamblers score high on a range of questionnaires devised to measure disregard for others, lack of empathy, inability to form and sustain relationships, attraction to risk and danger, and preference for immediate stimulation regardless of the consequences. Further evidence on impulsivity emerges from electroencephalographic studies. Drawing on the theory that brain hemispheric dysregulation is related to poor impulse control, hemispheric activation was measured in response to simple verbal versus nonverbal tasks. Pathological gamblers showed a pattern of activation dissimilar to normal control subjects, but similar in many ways to children with attention deficit disorder. Probably the major behavioral characteristic of such children is impulsivity. It has been speculated that at the neurochemical level, poor control of impulses may reflect a deficit in a particular brain neurotransmitting substance, serotonin. There is some recent evidence in line with this speculation. A serotonergic probe was used to measure the degree of activity of the serotonin system in pathological gamblers and matched control subjects. The pathological gamblers showed hypoactivity relative to the controls. It would appear that pathological gambling may share common neurochemical features with other behavioral disturbances characterized by poor impulse control.
A number of recent theories propose an important role for arousal in pathological gambling theories. Such theories add arousal, as a reinforcer on a fixed-interval schedule, to the more commonly hypothesized variable financial schedule to explain what sustains pathological gambling. Indeed, it has been argued that arousal as a reinforcer may be the most important determinant of loss of control. From this perspective, then, arousal in combination with irregular financial schedules is regarded as the driving force behind pathological gambling.
Early laboratory investigations of heart rate as an index of arousal suggested that gambling was not particularly provocative. However, the ecological validity of these studies has been questioned. Tellingly, a key study found only modest increases in heart rate among students and regular gamblers in the context of a laboratory casino. For the regular gamblers in a real casino, however, substantial increases in heart rate accompanied gambling. Furthermore, the magnitude of the increase was related to the size of the wager. In subsequent studies, reliable increases in cardiovascular activity has been observed during slot machine play and horse race gambling.
Nevertheless, there is still no strong evidence that individual variation in arousal underlies pathological gambling; that is, there is no evidence that pathological gamblers are any more aroused by gambling than recreational gamblers. Furthermore, a recent study comparing pathological and recreational slot machine gamblers suggested that it might be baseline levels of arousal that are discriminating, and not the magnitude of the increase provoked by gambling; pathological slot machine gamblers tended to register low baseline arousal levels.
V. Treatment of Gambling
A variety of treatments have been applied to pathological gambling, but have not, on the whole, been subject to systematic and controlled evaluation. Because, for many, GA is the main or only recourse available, it is unfortunate that its mixture of disclosure and social support has received so little formal evaluation. In a study of 232 GA attenders in Scotland, 8% were abstinent at the 1-year follow-up; by the 2-year follow-up, 7% remained abstinent. The addition of behavior therapy to the usual GA provisions seemed to produce better results; in one study in the United States that used this combination, 54% reported gambling less than they did before treatment. This latter study raises an, as yet, unresolved issue: the appropriate outcome measure. Whereas earlier studies championed complete abstinence, there has been a shift toward moderated gambling as the preferred treatment outcome. Moderated gambling is not necessarily, as critics claim, associated with an increased probability of a return to pathological gambling. There is even evidence that intermittent relapses from complete abstinence can occur without gambling returning to pathological proportions.
A number of earlier studies applied behavioral techniques to the treatment of pathological gambling. The underlying assumption of the behavioral approach is that pathological gambling constitutes a learned response to schedules of intermittent reinforcement by money and arousal. The most common treatment procedures have been aversive conditioning and covert sensitization. In the former, unpleasant, but not painful, electric shocks are administered while individuals engage in gambling behavior. In the latter, aversive imagery is substituted for the electric shocks; the gambler is guided through a sequence of imagined gambling scenes characterized by unpleasant physical (e.g., nausea) or social (e.g., discovered gambling by spouse) consequences.
The application of both of these techniques has produced encouraging outcomes, with up to 40 to 50% of pathological gamblers reporting either complete abstinence or that gambling is under control at follow-up. Nevertheless, caution is warranted. None of the behavioral treatment studies to date has included proper control conditions, many have treated very small numbers of gamblers, and the follow-up period has often been of limited and insufficient duration.
More recently, cognitive therapies have been tried. These are based on the assumption that faulty and erroneous cognitions are important determinants of pathological gambling. The aim of therapy is to replace dysfunctional cognitions with adaptive and rationale thinking. While there are fewer data available, cognitive therapies would seem to produce outcomes not wholly dissimilar to more purely behavioral approaches; that is, about 40 to 50% of pathological gamblers derive benefit from the therapy.
Of the various behavioral and cognitive approaches that have been applied, currently the most promising is imaginal desensitization. In contrast to covert sensitization described earlier, imaginal desensitization promotes images in which the gambler is no longer excited by gambling and no longer thinks of it as a way of dealing with tension, stress, and boredom. Participants practice relaxation along with imaging four scheduled scenes. In the one published controlled treatment outcome study, imaginal desensitization was compared with aversive therapy. Whereas only 2 out of 10 of aversive therapy participants reported that they were abstinent from gambling at 1-year follow-up, 7 out of the 10 imaginal desensitization participants did so.
As gambling has become more accessible, so the casualties have increased. While the development of effective treatment is very much in the early stages, the need is pressing. It is clear that our general understanding of pathological gambling is improving, and, accordingly, more recent therapeutic initiatives are being informed by more sophisticated theory. However, in this context, we would do well to pay more heed to the models of behavior change being deployed elsewhere. Most relevant are the therapeutic models being applied to changing unhealthy behaviors, such as cigarette smoking and poor dietary habits. In particular, the stages-of-change model, described first in 1984 by Prochaska and Di Clemente, is worth close consideration.
The stages-of-change model has, as its starting point, a keen appreciation that people differ in their willingness to consider or to adopt behavioral changes. Furthermore, the process of change contains a series of stages through which individuals progress, reflecting the temporal dimension in which behavior change occurs. A stages-of-change model may be particularly applicable to changing gambling behavior in that it describes both the nature of change and the strategies most likely to facilitate change. Five stages of change are identified. The first stage is known as precontemplation. Here, no or only occasional thought is given to changing behavior. The next stage is known as contemplation, in which the individual begins to consider changing his or her behavior. However, contemplation does not guarantee action, and individuals can still slip back to the precontemplation stage. Nevertheless, contemplation may lead to active consideration, which is the necessary launching pad for behavioral change. These stages of active consideration and achievement of behavioral change are the planning and action stages. The final stage is one of consolidation and maintenance of behavioral change. From this perspective, intervention is about moving individuals from one stage to the next, from precontemplation to contemplation, from contemplation to active consideration, and so on. Thus, it is important that the therapist appreciates what stage the individual is at and also that different sorts of intervention are called for, dependent on stage. A number of researchers have identified phases in the career of a pathological gambler. At the very least, it has been argued, it is important to distinguish between acquisition and maintenance. Nevertheless, there has been, as yet, no systematic attempt to exploit a stages model in treating pathological gamblers.
Preventive strategies have received limited attention, although there are encouraging preliminary results from a high school-based program in Quebec. However, given the evidence implicating early initiation into gambling in the development of pathological gambling and the high prevalence rates of pathological gambling among adolescents in many countries, substantially greater energies should be devoted to developing and evaluating preventive strategies.
It is clear that relaxation of legislative strictures and easing of access are associated with increased gambling. This is evident both in the numbers gambling and the monies wagered. It is almost certain that such changes have consequences for the numbers who gamble pathologically.
While substantial progress has been made, the study of gambling has still to yield a definitive account of the mechanisms that lead some individuals to pathological gambling. A variety of factors are undoubtedly involved. It is also likely that these various factors assume a different importance during progression from acquisition to maintenance, that is, from induction to addiction. For example, at the induction stage, positive cultural attitudes toward gambling, legislative laissez-faire, and early age of initiation all undoubtedly increase risk. Subsequently, compelling schedules of monetary reinforcement, the consistently arousing nature of gambling in the context of an otherwise unfulfilling and unstimulating lifestyle, a tendency to presume control when it is chance that operates, and a personality high on impulsivity and low on social concern, are all likely to be significant factors. Nevertheless, this is merely the bare bones of a theory, and, aside from the proposed role of hemispheric dysregulation and serotonergic deficits in impulsivity, we are without any account of the mechanisms operating at a neurobiological level. Given that pathological gambling may not be phenomenally distinct from other addictive behaviors, it is perhaps to the neurobiology of other, more fully studied addictions that gambling researchers should look for clues.
Both behavior and cognitive treatment techniques have been applied to pathological gamblers with some success. However, there is a dearth of properly controlled therapeutic trials. In addition, the treatment of pathological gambling could well benefit from adopting the therapeutic models that have been used successfully in other areas of behavior change. In particular, much could be gained from adopting a model that appreciates stages of change. Furthermore, more attention needs to be paid to preventive strategies. Given the prevalence rates of pathology gambling in young people, it is imperative that effective school-based preventive programs are developed. Finally, there may be a need to consider selective legislative intervention. Many of the substantial numbers of young people in the United Kingdom who fall afoul of slot machines could be helped by effective treatment regimes. However, simple legislative reform, restricting access to those 18 years or older, would undoubtedly yield more immediate and cost-effective dividends.
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