The Chase: Predecessors and The Chase: Predecessors and Progress on Problem GamblingProgress on Problem Gambling

Henry R. Lesieur, Ph.D., Psy.D. Rhode Island Hospital Gambling Treatment Program

Providence, RI

Alberta Gaming Research Institute Annual Conference, Banff, Alberta, April 2008

hlesieur@lifespan.orghttp://www.gamblingtreatment.org

Major Questions to Major Questions to be Addressedbe Addressed

What was known about problem gambling before The Chase?

What broad socio-cultural patterns preceded the era of modern research?

What was occurring simultaneous to The Chase?

What research and social trends have occurred after The Chase?

Gambling in HistoryGambling in HistoryGambling has existed in most cultures

and in prehistory.Religion, law and play intermingled.Lots were used to determine the will of

the gods.Lots were cast to determine guilt or

innocence.

AstragalAstragal

Gambling as ProblematicGambling as Problematic Evidence that gambling was a problem for some existed

but there does not appear to be much social commentary on it. There are myths about heavy losses among the gods (Ancient India).

Ancient Egyptians outlawed gambling among the masses (slavery in the salt mines was a penalty for violation).

Nero and Caligula were notorious cheats and loaded dice were found in Pompeii.

Individual problem gambling was mixed in with cheating in the law.

Gambling as Problematic in Gambling as Problematic in North AmericaNorth America

In the year before I started doing gambling research, I searched through the Human Relations Area Files for gambling in North America.

For many tribes, gambling was ubiquitous, yet culturally controlled.

Stick DiceStick Dice

Social Controls among First Social Controls among First Nations PeopleNations People

The Mohave (along the Colorado River in Arizona, California & Nevada) made gambling a formalized, ritualized occasion. Gambling was instrumental to the ritual rather than affectively loaded.

Gros Ventre of Montana had no promissory principle. No debts were incurred.

Yakima in Washington State gambled with surplus property only. Family property was gambled only with spousal consent. Both heavy winners and heavy losers gained prestige. Losers were not stigmatized. Again, no promissory notes.

Gambling as Problematic Gambling as Problematic Among First Nations PeopleAmong First Nations People

Only in rare circumstances were gambling problems mentioned in the Human Relations Area Files.

Among the Mandan Indians of the upper Missouri River, the Yurok of Northern California, the Bella Coola of BC you could become the property of someone else after losing. Problems among family members and loss of children to slavery also occurred.

At least one case of suicide after gambling losses was documented among the Iroquois in 1639.

Characteristics of the Age Characteristics of the Age of Ignoranceof Ignorance

Some cultures implement controls that seem to work

Gambling losses were tied in with cheating in some cultures.

Some cultures outlawed gambling because of the association with cheating.

In spite of it all, problem gambling existed and cases were documented on an anecdotal basis.

Age of SinAge of SinGambling per se was equated with evilThe gambler was either an exploiter or

exploitedFocus on cheating, violating the law, and

corruptionThe player was viewed as a flawed victim

Skip to early 20Skip to early 20thth Century CenturyGambling and Gambling Devices: An

Educational Exposition Designed to Instruct the Youth to Avoid All Forms of Gambling

John Philip QuinnPublished in 1912

Quinn outlined the religious argument against gambling. He focused on crooked gambling devices

Three Stages of a Gambler’s Three Stages of a Gambler’s LifeLife

Three Stages of a Gambler’s LifeThree Stages of a Gambler’s Life

1. High hopes of pleasure. A life devoted to the ruin of his fellowmen. He “takes hold on hell.”

2. The Illusion is dispelled. He becomes a member of a villainous class.

3. He becomes a “fool of fortune … enslaved by his own degraded instincts.”

The Upward and Downward WayThe Upward and Downward Way

This continued:Sucker’s ProgressSucker’s Progress: An Informal : An Informal History of Gambling in America From History of Gambling in America From the Colonies to Canfieldthe Colonies to Canfield Herbert Asbury, 1938Herbert Asbury, 1938An “objective” history that is full of moralizing. For example, he An “objective” history that is full of moralizing. For example, he quotes a New York Herald article: “There is a small and select quotes a New York Herald article: “There is a small and select number of very splendid hells in this city where young men with number of very splendid hells in this city where young men with property are sent to perdition in no time.” From that point on he property are sent to perdition in no time.” From that point on he describes “gambling hells” in different parts of the US.describes “gambling hells” in different parts of the US.

Continuation in late 20Continuation in late 20thth Century – Century – Ambivalence about sin and diseaseAmbivalence about sin and disease

National Coalition Against Legalized Gambling (US)

Arguments similar to those in the 19th and early 20th century but with the addition of an acceptance of the medical model.

See Suzanne Morton At Odds: Gambling and Canadians 1919-1969

Medicalization Medicalization (prior to The Chase)(prior to The Chase)

1 – Psychoanalytic theorizingFreud; Bergler (1958); and others

2 – Gamblers Anonymous (1957)3 – Robert L. Custer, MD (collected data

from VA hospital in Brecksville, Ohio) (1972)

4 – National Council on Compulsive Gambling (New York) (1972)

Bergler Psychology of GamblingBergler Psychology of Gambling

Number of States with Legal Number of States with Legal Gambling in the US – 1974Gambling in the US – 1974

41 36

13

1 1 20

10

20

30

40

50

LegalGambling

Lottery Casinos

ParimutuelMachines OTB

Number of States with Legal Number of States with Legal Gambling in the US – 2005Gambling in the US – 2005

48 43 41

3128 25

0

10

20

30

40

50

LegalGambling

Lottery Casinos

ParimutuelSlots/VLTs OTBs

Gross Win in Billions of Gross Win in Billions of Dollars 1974-2004 (US)Dollars 1974-2004 (US)

78.61 (2004)72.87 (2003)$65.3

$68.7 (2002) $61.4

$16.9

$39.9

$58.4

$50.9 $55.1

$34.7 $26.7

$23.5

$3.3

$0.00$10.00$20.00$30.00$40.00$50.00$60.00$70.00$80.00$90.00

1974

1987

1989

1991

1993

1995

1997

1999

2001

2003

Provinces & Territories with Provinces & Territories with Legalized Gambling -- 1975Legalized Gambling -- 1975

0.00

5.00

10.00

Legal

Gambling

Parimutuel

Lottery

Slots/V

LT

Casinos

OTB

12

7

12

0 03

All had Bingo and Lottery by 1975 Casinos: only Alberta (1975), Manitoba (1971) & Yukon (1800s)

Provinces & Territories with Provinces & Territories with Legalized Gambling -- 2005Legalized Gambling -- 2005

0.00

5.00

10.00

Legal

Gamblin

g

Parimutuel

Lottery

Slots/V

LT

Casinos

OTB

12 12 1210

11

8

Slots-all but NW & Yukon OTB-all but NFLD (has intertrack wagering)

Gambling Revenue – Gambling Revenue – Statistics CanadaStatistics Canada

$0.00

$2.00

$4.00

$6.00

$8.00

$10.00

$12.00

$14.00

1992 1997 2000 2002 2004

Billions

$2.7

$6.8

$11.3 $12.4

$9

Narragansett RacetrackNarragansett Racetrack

Sociology of Problem Gambling prior Sociology of Problem Gambling prior to The Chaseto The Chase

Basically a Desert except for:Basically a Desert except for:Edward Devereux Jr – Gambling and the

Social Structure – 1949 – a study of the numbers racket and racetrack – excessive gambling conflicts with the basic tenets of the Protestant ethic and has dysfunctional consequences for the social system

Sociology of DevianceSociology of Deviance

Anti-medicalization“Labeling Theory”Symbolic Interaction and

PhenomenologyEmphasis on Qualitative Research

including participant observation and intensive interviews

Quitting Gambling Through Gamblers Anonymous

University of Massachusetts -- SociologyTV show and my ex-bossGA meetings in ConnecticutPh.D. thesisObservations & Interviews

Compulsive Gambler’s Spiral of Options and Involvement

Criminology – Missing Information in the Research Literature

1. Gambling as deviant behavior – Nothing about CGs in articles or textbooks

2. Gambling as crime3. Gambling = Organized Crime 4. Nothing about route CGs take to Criminal Behavior

The Chase Book CoverThe Chase Book Cover

Methods Used (Qualitative) Attended Gamblers Anonymous meetings CT,

RI, MA & prisons (non-participant observation) Intensive semi-structured, open-ended

interviews (tape recorded) with– CGs (all white males)– Wives– Bookmakers– Loan sharks– Regular gamblers I knew from gas station– prisoners

The ChaseShort-term chasing -- normalCG = long-term chasingUnderstanding CG view of the world: Action: Chasing; Finances; Family; Work; Gambling as Illegal activity; Crime CG Spiral of Options and Involvement

SpiralSpiral

Crime Types Among Crime Types Among Pathological GamblersPathological Gamblers

Forgery, Fraud, Theft, EmbezzlementTax violations (fraud & evasion)Illegal Gambling operationLess common: Burglary, Armed robbery,

Drug Sales, Fencing Stolen Goods, Prostitution, Extortion

Cycles in the Spiral ofCycles in the Spiral ofOptions and InvolvementOptions and Involvement

1. Get Money 2. “Moving,” “Manipulating,” or “Juggling” Money3. Tightening of Resources (Closure) and Need to Make Moral Decision

Medicalization -- 1980Medicalization -- 1980American Psychiatric AssociationDiagnostic and Statistical Manual of

Mental Disorders, Third EditionLobbying occurred (e.g. gay community

and the removal of homosexuality as a mental disorder in 1973; the removal of sexual orientation disturbance in 1980; and total removal in 1987).

American Psychiatric Association DSM-III and Robert L. Custer, MD

Brecksville VA Hospital – 1972 Custer conducted research on the patients Custer lobbied the American Psychiatric

Association (DSM-III 1980) Pathological Gambling included under

“Disorders of Impulse Control, NEC” along with kleptomania, pyromania, intermittent explosive disorder and trichotillomania

Custer V ChartCuster V Chart

Medical Model continued DSM-III-R & DSM-IV

Critique of DSM-III (sexist & ignorance of criminals with gambling problems)

Generated DSM-III-R questionnaire

DSM-IV with Richard Rosenthal, MD– Survey of people in treatment (alcohol & gambling)– Used non-problem gambling alcoholics as controls

Significant Changes Significant Changes Commencing in the 1980s Commencing in the 1980s

and Continuingand ContinuingDevelopment of measures (SOGS etc.)Research on subgroups Population studiesNew Journal Research and Programs Leapfrogged

around the world

South Oaks Hospital & Sheila Blume, MD

Alcohol, Drug Abuse & GamblingGambling among mental patientsSouth Oaks Gambling ScreenGambling Severity IndexEvaluation of inpatient gambling

treatment program

SOGS Translations SOGS Translations 37 languages so far37 languages so far

Africaans Arabic Cambodian Chinese Czech Danish Dutch English Farsi Estonian Finnish French German Greek Hindi Hmong Icelandic Italian

Japanese Laotian Maori Norwegian Polish Polynesian Portuguese Russian Sesotho Somali Spanish Swedish Tagalog Thai Turkish Urdu Vietnamese Xhosa Zulu

Note: translations in Croatian and Slovenian in progress

Epidemiological SurveysEpidemiological SurveysOnly one existed worldwide, US in 1974

(this happened when I was doing research for The Chase)

Since then, numerous surveys have been conducted by a wide range of highly skilled researchers initially following the medical model and gradually widening the focus to broader perspectives

Surveys have been conducted Surveys have been conducted with the following groupswith the following groups

General population studies

College/University students

Substance abusers Psychiatric patients Patients in general

practice Gaming Patrons

College Athletes College Sports officials Prisoners Youth Incarcerated youth Gaming employees Minority groups Older adults Special populations

Proliferation of Measures Proliferation of Measures (only measures used by more than one (only measures used by more than one

researcher included)researcher included) SOGS SOGS-R – Volberg & Abbott SOGS-RA – Stinchfield & Winters NODS – NORC Diagnostic Screen CPGI – Canadian Problem Gambling Index Eight Screen – Sullivan (New Zealand) DIS – Diagnostic Interview Schedule DIGS – Diagnostic Inventory of Gambling Severity –

Winters, Specker & Stinchfield DSM-IV-J -- Fisher

Outcome MeasuresOutcome Measures(only measures used by more than one (only measures used by more than one

researcher included)researcher included)SOGS-3 month version DSM-IV -- # criteria metGSI – Gambling Severity Index (Lesieur

& Blume)G-SAS – Gambling System Rating Scale

(Kim)PG-YBOCS -- Hollinger

JGB (1985) & JGS (1990)JGB (1985) & JGS (1990)

Journals since JGBJournals since JGB The Wager (1996) – not a journal but provides

summaries of research Gaming Research and Review Journal

(primarily casino & regulatory) (1994) Gaming Law Review (1997) eGambling (2000) Journal of Gambling

Issues (Dec 2004) – based in Ontario International Gambling Studies (2001) – Based

in Australia

Research from the UK on Youth Research from the UK on Youth GamblingGambling

Mark Griffiths – studies of fruit machine gambling among youth (methods varied)

Sue Fisher – field research among youth playing fruit machines in Seaside towns in UK

Raised prospect that gambling problems may reach into very young groups

Mantle taken up by Derevensky (& later Gupta) at McGill

Pathways to Pathways to RecoveryRecovery

Before GA -- Psychoanalytic Psychotherapy and a few drug trials

1957 -- Gamblers Anonymous 1972 -- VA Brecksville (addictions model along

with GA) 1979 -- Connecticut Gambling Treatment Some case studies of medication use

New modalities emerged

Treatment ModalitiesTreatment Modalities

Imaginal DesensitizationControlled GamblingCognitive Behavioral therapySelf-help manualsMotivational InterviewingBrief therapiesVariety of medications

Robert Ladouceur’s research; Robert Ladouceur’s research; Irrational Thinking and GamblingIrrational Thinking and Gambling

“thinking aloud method” (1986) Irrational thinking among more frequent gamblers Talking to the machine (“This machine is making

me mad on purpose.”) Statements implying nonrandom events influence

outcome (“I won three times in a row, I’m going to win again.”)

Referring to luck: (“I’m lucky today. I should buy a lottery ticket.”)

Thinking Errors Among Thinking Errors Among Problem GamblersProblem Gamblers

Gambler’s Fallacy (streaks & the machine or I’m “overdue”)

Personification of the Machine Illusions of Control (Langer Experiment) Present Random Event explains Past Random

Event (Gambler’s Fallacy in reverse) Biased Evaluation of Outcome (random events are

the cause of failure; success reflects skill) Entrapment (bus-stop analogy)

Cognitive TreatmentCognitive TreatmentLadouceur & Colleagues (2001)A focus on randomness is very effective

when compared to controlsErroneous beliefs about chance, luck,

skill and randomness were challenged

Petry – CBT > GA alone ; both better than either alone

Attitude and Attitude and Cognition InventoriesCognition Inventories

CognitionsGBQ (Gamblers’ Belief Questionnaire)AttitudesGAS – KassinoveCombine attitude & cognitionsGABS – Breen & Zuckerman

Alex Blaszczynski’s research Alex Blaszczynski’s research (1980s to the 2000s)(1980s to the 2000s)

PG & Imaginal Desensitization

PG & Controlled Gambling

PG & Impulsivity PG & ASPD PG & Criminal

Behavior

PG & Sensation Seeking PG & Anxiety and

Depression PG & Documented

Suicides His critiques of the

Medical Model His model of the etiology

of pathological gambling

Blaszczynski & Nower Blaszczynski & Nower Pathways Model --1Pathways Model --1

Normal Problem Gambler -- Low Severity -- Secondary Substance Dependence -- Secondary Depression -- Secondary Anxiety -- Irrational Cognitive Beliefs

Blaszczynski & Nower Blaszczynski & Nower Pathways Model -- 2Pathways Model -- 2

Emotionally Disturbed Gambler -- Moderate Severity -- Premorbid Substance Dependence -- Premorbid Depression -- Premorbid Anxiety -- Avoidance & Passive aggressive coping -- Escape using Dissociation

Blaszczynski & Nower Blaszczynski & Nower Pathways Model-- 3Pathways Model-- 3

Biologically Base Impulsive Gambler -- Impulsive & Attention Deficits -- High Severity of Gambling Problems -- Substance Dependence -- High Suicidal -- High Irritability -- Low Tolerance for Boredom -- Sensation Seeking; High Criminality -- Poor interpersonal relationships -- Early age of onset; rapid increase of problems -- Binge Gambling

Public Health ModelPublic Health ModelKorn & Shaffer (1999)Korn & Shaffer (1999)

Views gambling problems as occurring along a continuum

Looks at health, social & economic costs and benefits

Emphasizes prevention and harm reduction

Levels of Gambling

No Gamblin

g

Gambling w/ No

Adverse Conseque

nces

Gambling w/ Some Adverse

Consequences

Gambling w/ Severe Adverse

Consequences

Continuum of Problems

Healthy Gambling

Unhealthy Gambling

In Treatme

nt

Public Health Model - 2Public Health Model - 2Korn & ShafferKorn & Shaffer

Public Health Action Plan1. Prevent gambling-related problems via public

awareness, early identification & treatment 2. Promote informed and balanced attitudes

towards gambling via knowledge, responsible choices and community participation

3. Protect vulnerable groups from harm (harm reduction focus)

Gambling Choices and GuidelinesGambling Choices and Guidelines – – Roger Svendsen & Tom Griffin (1993)Roger Svendsen & Tom Griffin (1993) Gambling is a source of recreation with risk Gambling is a matter of choice and not essential for

having a good time Low-Risk Gambling is social, limited, and with

predetermined loss limits There are times when people should not gamble There are high-risk situations when gambling

should be avoided What to do if you know someone has a problem Self-test and resources for help

Self-Help ManualsSelf-Help Manuals Note: Mark Dickerson initiated this for problem

gambling. They have developed to include: Self-assessment Gambling Diary Goal Setting Triggers/High Risk Situations Gambling Cognitions Alternatives to Gambling Resources for further help (GA/treatment)

Stages of ChangeProchaska & DiClemente

Precontemplation-- Resisting ChangeContemplation -- Change is NeededPreparation -- Readying for ChangeAction -- Time to changeMaintenance -- Continue ChangeRelapse -- What did person learn?Termination – Change has occurred

Pathways to Recovery

General Population SurveysRate of Lifetime PG > Rate of Past

Year PG by 36-46% WHY?Hypothesis 1 – They received Treatment

and no longer have problems – evidence doesn’t support this

Pathways to Recovery 2

Hypothesis 2 – Problems with the Measures Used

Hypothesis 3 – Denial (not willing to acknowledge current problem) – there is some support for this

Hypothesis 4 – Natural Recovery – some support for this

Natural Recovery 1Natural Recovery 1 Hodgins & el-Guebaly -- Naturally recovered gamblers had less severe

problems -- No difference in rate of co-morbid conditions

Marotta – Naturally recovered gamblers less severe problems than treatment seekers Less Likely to have co-morbid conditions Less likely to be video machine players

Natural Recovery 2Natural Recovery 2Jeff MarottaWhy not seek treatment?-- no Identification with CG image-- did not want abstinence

How did they change? Numerous strategies but more likely to weigh pros & cons as motive to quit

Stability & Progression of Disordered Stability & Progression of Disordered Gambling: Lessons from Longitudinal Gambling: Lessons from Longitudinal Studies:Studies: D.LaPlante, S.Nelson, R.LaBrie & H ShafferD.LaPlante, S.Nelson, R.LaBrie & H Shaffer

Reviewed 5 prospective studies of gambling behavior among non-treatment samples

Excluded treatment samples Looked at Level 1, 2 & 3 gamblers at T1 &

followed them to T2 No evidence that individuals progress Most improved over time; no evidence that

individuals worsen from T1 to T2Source: La Revue Canadiene de Psychiatrie, 53, 1, Jan 2008

Comments on Stability & Comments on Stability & ProgressionProgression

They excluded treatment samples from which the model of progression was generated.

No control for regression to the mean. Not all individuals are followed up in these studies.

Some cannot be located or refuse to participate in the follow-up. Are those not followed like those who are followed?

Medical/addictive model on the other hand is based in what criminologists call “the warden’s fallacy.” (i.e. The people “out there” are like the people we see “in here.”)

Prevention Research (Willams, Prevention Research (Willams, West & Simpson, 2007)West & Simpson, 2007)

Limited data exist on effectiveness Research needs to focus on behavioral change Current programs are too small to make an

impact (e.g. information/awareness campaigns are too shot-term and too restricted)

Effective prevention programs are likely to inconvenience gamblers without problems and are likely to reduce revenues (e.g. restriction on locations of venues and on concurrent use of alcohol and tobacco in gaming facilities)

Medical Model Redux: Medical Model Redux: Physiological StudiesPhysiological Studies

Gambling appears to operate similar to other pleasurable behaviors

PET scans; Functional MRIs validate this Frontal lobe impairment found (higher rate of

ADD & ADHD among PGs) PG & Dopamine activity among Parkinson’s

patients Pharmacotherapy with SSRIs, opioid agonists,

and mood stabilizers show some efficacy

Medical Model Redux -- 2Medical Model Redux -- 2Gamblers Anonymous which assumes a

disease model is an effective adjunct to therapy.

Moral Model ReduxMoral Model ReduxAnti-gambling proponents typically focus

on zero access rather than harm reduction strategies

GA is spiritually based; as such it takes a zero tolerance approach to gambling. In spite of this, GA is growing.

Gambling: A Deadly GameLarry Braidfoot, 1985Larry Braidfoot, 1985

The religious, moral model, continues in a different form as exemplified in this book.

Compulsive gamblers are seen as victims of an immoral industry that should not exist.

His conclusion: “These individuals represent a harvest of shame for not only the …

gambling industry but also for those of us who as citizens have allowed this nightmare to develop.”

Gamblers Anonymous Gamblers Anonymous Growth & LocationsGrowth & Locations

1957 – one chapter 1960 – 16 chapters 1970 – 130 chapters 1983 – 524 chapters

in 14 countries 2008 – 2922 chapters

in 48 countries 1733 chapter in US

2008 – 1189 chapters outside of US including

304 in Canada 196 in UK 128 in Australia 101 in Argentina

The Age of Ignorance may yet The Age of Ignorance may yet have some lessons for the 21have some lessons for the 21stst

CenturyCentury

Social Controls that Seemed to Social Controls that Seemed to Work Among Some First Work Among Some First

Nations PeopleNations PeopleGambling without Credit Instrumental (formalized) rather than

Affective gamblingNo house takeout

As a Clinician I would like to As a Clinician I would like to make some observations make some observations on the need for researchon the need for research

Impact of problem gambling on children (some survey & anecdotal research exists)

Research on outreach to and treatment of minorities Parameters for the effectiveness of self-exclusion

and other pre- & post-treatment prevention programs

Educating the general public about randomness and irrational thinking

Safe@PlaySafe@Play Slots Tutorial Slots Tutorial

Questions about Slot MachinesQuestions about Slot Machines

Are they the “most addicting form of gambling”

If not, what is it about slots that causes some people trouble quickly (Breen research)

What percent of total revenue comes from problem gamblers? (“how much do you spend” needs to be changed to reflect net expenditure) – current estimates range from 25-33%

Effectiveness Studies Effectiveness Studies NeededNeeded

Studies of Financial Counseling/AdviseStudies of education and treatment of

spouses, parents and others (or if treatment needed)

Studies of education or treatment of children (or if treatment needed)

Clinical Research Needed?Clinical Research Needed? Research Based Protocols for dual diagnosis

e.g. PG & SUD; PG & GAD; PG & PTSD Empirically Based Decision Trees for Self-help;

Minimal Intervention; Individual Therapy; Group Therapy; Combined

Partial Hospital? Inpatient Programs?

For further informationFor further information

Henry R. Lesieur, Ph.D., Psy.D.Rhode Island Gambling Treatment Program

Department of Psychiatry235 Plain Street, Suite 501

Providence, RI 02905Tel: (401) 277-0721

E-mail: hlesieur@lifespan.orghttp://www.gamblingtreatment.org