William G. McCown

William A. Howatt

TreatingGamblingProblems

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To order, call 1-877-762-2974 or online at www.wiley.com/psychology.Also available from amazon.com, bn.com, and other fine booksellers.

Critical addiction treatment approaches—rightatyour fingertips.

Full of practical information on assessing, diagnosing, and treating addiction, the handy manuals inthe Wiley Series on Treating Addictions are invaluable tools for anyone who works with clientsexperiencing problems with addictions. The popular series format includes:• Quizzes, checklists, Don’t Forget and Research Frontiers boxes, dos and don’ts, etc.• Assessment scales, tables, and diagrams• Suggested resources such as self-help groups, residential and outpatient treatment programs,

support groups, and Web sites

Treating Drug Problems helps to bridge theserious gap between scientific research andpractice, pointing the way to a more promisingfuture in the treatment of drug problems. Thishighly practical resource offers up-to-the-minuteguidance on effectively diagnosing and treating thefull spectrum of common drug problems. It alsohighlights the importance of a biopsychosocialmodel in understanding and treating drugproblems and covers all of the major issues.

ISBN: 978-0-471-48483-7, Paper, 336 pp., April 2005, $37.95

Treating Alcohol Problems offers the latestevidence-based guidance on effectively diagnosingand treating the full spectrum of problems relatedto drinking. Bridging treatment approaches andscientific findings, this handy resource summarizesmethods proven to be successful. Written in a clearand accessible style, the text covers conceptualfoundations; identifying alcohol problems;assessment and treatment planning; treatmenttools, programs, and theories; and much more.

ISBN: 978-0-471-49432-4, Paper, 176 pp., April 2006, $34.95

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TreatingGamblingProblems

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Wiley Series on Treating AddictionSeries editors, Robert Holman Coombs and William A. Howatt

TREATING DRUG PROBLEMSAuthur W. Blume

TREATING ALCOHOL PROBLEMSFrederick Rotgers

and Beth Arburn Davis

TREATING GAMBLING PROBLEMSWilliam G. McCown

and William A. Howatt

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William G. McCown

William A. Howatt

TreatingGamblingProblems

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Copyright © 2007 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.Wiley Bicentennial Logo: Richard J. Pacifico

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in anyform or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise,except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, withouteither the prior written permission of the Publisher, or authorization through payment of the appro-priate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA01923, (978) 750-8400, fax (978) 646-8600 or on the web at www.copyright.com. Requests to thePublisher for permission should be addressed to the Permissions Department, John Wiley & Sons,Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online athttp://www.wiley.com/go/permissions.

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10 9 8 7 6 5 4 3 2 1

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In Memory of Bob Coombs, who unfortunately left us before

he saw the final product of this book. This is the third

book in the Wiley Addiction series, and we are proud

to be able to keep this series going in his memory.

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Acknowledgments xvii

Series Preface xix

Preface xxi

About the Authors xxiv

Chapter 1: Conceptual Foundations of Gambling DisordersIntroduction to Gambling 1

Definitions of Problem and Pathological Gambling 5

Definitional Distinctions 5

An Introduction to the Three Cs of Problem and Pathological Gambling 7

Myths versus Facts about Problem and Pathological Gambling 9

Transient versus Chronic Problems 11

Spontaneous Remission and Maturing Out 13

Clinical versus Nonclinical Populations: Why Some Gamblers Do Not Mature Out 14

Risk Factors for Gambling Disorders 16Exposure, History, Attitudes, and Expectancies 16Personality Variables 17

Blaszczynski’s Types 17Specific Contradictory Personality Variables 18

ix

CONTENTS

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x CONTENTS

Comorbid Psychiatric Disorders 20Biology and Genetic Factors 20Coexisting Addictive Disorders 22

Epidemiology of At-Risk Populations 22

Gender Differences 24

Gambling, the Family, and Multicultural Considerations 25

What the Future Holds for the Treatment of This Disorder 26

Where the Field Is Going 26

Summing Up 28

Key Terms 29

Recommended Reading 30

Chapter 2: Recognizing Gambling Disorders: Signs and SymptomsDevelopmental Stages in the Progression of Problem and Pathological Gambling Behaviors 33

The Gambling Continuum 34

Recognizing Gambling Disorders 36

The Signs and Symptoms of Pathological Gambling 38Client Information 39Coexisting Addictive Disorder Screening 42Other Client Signs 47What Spouses or Others May Report 49Employers and Supervisors 50Traditional Psychological Assessment 51

Complicating Diagnostic Issues 56

Healthy versus Problematic Attitudes and Behaviors 59

Social Settings 60

Professional Collaboration, Accountability, and Responsibility in the Screening-Intake Process 60

Summing Up 62

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Contents xi

Key Terms 63

Recommended Reading 64

Chapter 3: Utilizing Optimal Professional ResourcesReferral Benefits and Disadvantages 68

Screening Reports, Documentation, and Responsibility 71

How to Develop a Professional Referral Network 72State and National Councils on Compulsive and Pathological Gambling 73

Gambling Hotlines 74Liaison with Gamblers Anonymous 75GamAnon 78

Psychiatrists and Emergency Facilities 78

Matching Clients with the Best Professional Options 79Referrals to Counselors under Contract in the Private Sector 80

Referral Do’s and Don’ts 81

Motivation Strategies and Techniques for Getting a Person to Professionals 83

Ambivalence 84Using Motivational Interviewing 85Avoiding Anger and Shame: The Rapid Demotivators 87Procrastination 88

Overcoming Client Obstacles 88Common Practical Obstacles 89The “Controlled Gambling Experiment” 90

Preventing and Dealing with Crisis Situations 91

Family and Concerned Others Involvement 93

Risk Management Strategies and Techniques to Protect Clients and Families 94

Suicide and Suicidal Ideation 94Six Step Model 96

Step 1: Define the Problem 96Step 2: Ensure the Person’s Safety 96Step 3: Provide Support 96

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xii CONTENTS

Step 4: Explore Options and Alternatives 97Step 5: Make a Plan 97Step 6: Get a Commitment 97

Risk Management Strategies and Techniques to Protect Counselors 101

Duty to Warn for Property Damage 101Referral Follow-Up and Cautionary Notes 103

Summing Up 103

Key Terms 104

Recommended Reading 104

Chapter 4: Developing an Effective Treatment PlanTherapeutic Benefits of Treatment 108

Initial Attrition 110

Telephone Contact and Crisis Intervention 112

Client Intake 113The Counselor’s Tasks During the Intake 115Questions That You Might Need to Ask Yourself 117Helpful Information Before the Intake 117Informed Consent and Limits of Confidentiality 118

HIPAA, Intake, and Client Records 123

Intake Do’s and Don’ts 124

Formal Assessment Processes 125

Assessment Measures and Instruments Commonly Used and Why They Are Useful 127

Diagnostic Processes and Determinations 128

Treatment Planning 129

Fees and Insurance Coverage 130Managed Care 131Filing for Insurance: The Practice of Responsible Client Billing 131Ethics of Insurance: Modeling Financial Responsibility for the Pathological Gambler 132

Family and Concerned Others Involvement 132

Recovery Contracts 134

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Contents xiii

Action Plans 135

Summing Up 138

Key Terms 138

Recommended Reading 139Resource for General Paperwork 139HIPAA 139Dual-Diagnoses Clients 140

Chapter 5: Recovery Theories, Programs, and ToolsAn Overview: What We Know from Other Addictions 143

Levels of Traditional Gambling Treatment 145Applying ASA Levels of Care To Gambling Treatment 146

Recovery Theories and Models 147The Disease Model 148The Alternative Model 149

Motivational Therapies 155

Social Interventions 156

Medical Treatments 157

Responsible Gambling 158

Teaching How Video Gambling Works 159

Family Therapy 160

Psychosocial Therapies 162Insight and Psychodynamic Therapies 163Grief Counseling 164

Behavioral Therapies 164Cognitive and Cognitive-Behavioral Models 164

Existential and Spiritual Interventions 166

Holistic and Alternative Treatments 167

Financial Counseling 167

Support Groups 167

Internet Treatment 171

Formal Treatments 172Very Minimal Treatment 172

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xiv CONTENTS

Develop a Gambling Intervention Tool Box 172Workbook and Journaling Programs 173

Cultural Pathways of Recovery 175

Summing Up 176

Key Terms 176

Recommended Reading 177

Chapter 6: Continuing Care: When and How Should Clients Be DischargedRecovery—What Are the Goals? 181

Criteria for Exiting Clients from Supervised Treatment 183

Discharge Criteria For Different Problem Intensities 184Level 2 Gambling Problems and Mastery-Based Discharge: Using Cognitive Corrections 185

Level 3 Gambler Discharge or Step-Down Criteria 185

Discharge Criteria and Concerns during Various Stages of Recovery 186

Discharge and the Developmental Recovery Processes 188

Continuing Care Plan Procedures and Guidelines 189

Legal, Moral and Ethical Issues 192Proper and Improper Methods of Termination 193Abandonment 194

Assessing Community Resources 195

Organizing Recovery Supports Where Lacking 196

Styles of Recovery: Methods of Disease Management 197

Spheres of Recovery 199

Family and Concerned Others Involvement and Spheres of Recovery 200

Rates of Recovery and Failure 201

Summing Up 203

Key Terms 204

Recommended Reading 204

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Contents xv

Chapter 7: Posttreatment Recovery Management:Models and Protocols of Relapse PreventionRelapse Prevention 208

Models of Relapse Prevention 208Behavioral Models of Relapse Prevention 209Cognitive Models of Relapse Prevention 210Cognitive-Behavioral Models 210

Belief that relapses are inevitable. 211Belief that relapses are impossible. 211Belief that God intervenes to allow chance to favor people in need. 211Belief that all problems (finance, stress, etc.) need immediate solutions. 212

Belief that “What did not work in the past will suddenly start to work.” 212

An Integrated Model of Relapse Prevention 212Baumeister’s Model of Self-Regulation 212

Proactive Strategies for Preventing and Dealing with “Triggers” for Relapse 213

Cognitive Triggers 213Triggers in Cognitive Behavioral Therapy 215

Developing Relapse Prevention Plans 216

Common Themes in Relapse Prevention 219Emergence of Sadness and Subclinical Depression 219Sleep 220Modification of Social Networks 220Reduction in Other Addictive Substances 221Exercise 221

Monitoring and Negotiating Follow Up in Recovery 223Emergency Plans 224

Obstacles in Relapse Prevention: Emerging Difficulties 225Emergence of Psychiatric Disorders 225Emergence of Physical Problems 226Emergence of Couples and Family Problems 227

Community Linkage as Relapse Reversion Prevention 228Community-Based Vocational Counseling 228Academic Counseling 228

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xvi CONTENTS

Financial Counseling 229Pastoral Counseling 230Leisure Counseling 230Health Counseling 230

Telephone and Internet Follow Up 231

Family and Concerned Others Involvement during Posttreatment Recovery 232

Preventing Chronic Relapses 233Mindfulness 233

Summing Up 235

Key Terms 236

Recommended Reading 236

Chapter 8: New Beginnings: Moving Beyond the AddictionMoving Beyond 240

Recovery in Psychological and Mental Health Domains 241

Personality Changes 242

Psychotherapies 244Psychodynamic Therapy 244Narrative Psychotherapy 245Humanistic Psychotherapies 246

Increasing Positive Emotions and Happiness 248

Moral Development 250

Beyond Selfhood 251

Family Recovery 253

Vocational Recovery 255

Physical Health and Spirituality 257

Summing Up 258

Key Terms 259

Recommended Reading 259

References 261

Index 271

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xvii

Foremost, I want to acknowledge the contribution of my clients, from whom Ihave learned so much.I would like to personally thank Dr. Bill Howatt and also Lisa Gebo, the series

editor from John Wiley and Sons, who have been incredibly patient and sup-portive.

I would also like to thank Dr. Howatt’s assistant, Carolyn Hill, for her expert-ise in project management, editing, and organization. I understand she was adriving force in getting this book across the goal line.

Linda Chamberlain has remained a “like mind” for 15 years, but always amuch better clinician.

Reece Middleton, Janet Miller, and all of my friends at Louisiana Associationof Compulsive Gambling have been helpful in passing along wisdom.

The clients and staff at “Middle Pines” and “Gulf Coast” Addiction Centersdeserve special note for patience. Jim Z. set up and maintained the bulletin boardand Internet services described in several chapters. Thanks also, Ross Keiser.

“John” in South Carolina and “Ted” in Arkansas provided helpful criticismand extensive input from perspectives different from mine. I appreciate theirflexibility and hope that we all are richer.

Chris Johnson and Jay Bulot in the Department of Gerontology and Sociol-ogy at the University of Louisiana at Monroe have been friends of similar inter-est and furnished a great deal of advice and just plain enthusiasm. Joe McGahanhas just begun to teach me about social psychology and I am appreciative!Thanks as always to Sean Austin and Bob Abouee.

To Greg Stolcis and Gordie Flett—guys, you made me hang in there.Finally, to Louisiana: “Lache pas la patate.”

ACKNOWLEDGMENTS

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Most books on addiction are written for only 10 percent of those who deal withaddicted people—typically, for experts who specialize in addiction. By con-

trast, we designed the Wiley Series on Treating Addictions primarily for the other90 percent—the many health service providers and family members who, thoughnot addictionologists, regularly deal with those who suffer from various addic-tive disorders.

All volumes in this series define addiction as “an attachment to, or depend-ence upon, any substance, thing, person or idea so single-minded and intensethat virtually all other realities are ignored or given second place—and conse-quences, even lethal ones, are disregarded” (Mack, 2002).

Considering that over one’s lifetime more than one fourth (27 percent) of theentire population will suffer from a substance abuse problem (Kessler et al.,1994), many family members and all human services providers will, sooner orlater, be confronted with these problems. Unfortunately, few have received anytraining to prepare them for this challenging task.

Research is linking problem gambling behavior to a constellation of addictivedisorders, such as alcohol and drugs, at rates higher than the general nonprob-lem-gambling population. Two leading researchers in North America on prob-lem gambling (Korn and Shaffer, 2002 p. 171) reported that “Gambling is anemerging public health issue based on epidemiology, social costs, and quality oflife concerns.” The reality is that the prevalence of gambling problem behaviorshas been creeping up over the last 25 years, and the net result is that gamblinghas become a multibillion-dollar profit center for governments. No one knowsexactly how much revenue gamblers actually spend each year because much ofthe gambling that occurs is not regulated. What we do know is that gambling isa real social issue that is challenging governments and businesses to debateexactly what their social responsibilities are and what actions should be taken.While these debates roar on, people with problem gambling issues continue, andthere is a need for more professionals to take action. The goal of this book is to

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SERIES PREFACE

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xx SERIES PREFACE

provide professionals with a user-friendly resource that will move them frommerely identifying problem gambling to facilitating a process for people toreclaim control of their lives.

We are pleased to provide the thoughts of Dr. McCown, a professional in thetrenches working with clients, who has spent much time and research in discov-ering how professionals can help clients navigate through problem gambling. Inaddition to his impressive academic and professional background, we also wouldlike to acknowledge his tireless commitment to communities and organizationsin need of his expertise and skills through such casualties as Katrina andTsunami.

We believe you will find the information in this book invaluable for a clearerunderstanding and sensitivity to the personal, social, and cultural dynamics ofpeople living with gambling problems, and what one can do to assist themthrough the healing.

William A. Howatt, PhD, EdDSeries Editor

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PREFACE

This book was conceived by the late Dr. Robert Coombs and his associate, Dr. BillHowatt, as a practical guide for the treatment of disordered gambling. Bob real-

ized that many clients with problem and pathological gambling who receive treat-ment are unlikely to be treated by specialists, such as Certified AddictionsCounselors. For better or worse, most clients are now treated by counselors ortherapists in general mental health practices or by other helping professionals. Bobintended this book for professionals, whose primary population is not gambling,but who see the value and need to increase competencies in treating this popula-tion. As gambling problems become more common, this description will includemany more clinicians. In addition, this book will serve as an excellent reference formedical doctors, nurses, teachers, and other professionals who may cross this pop-ulation and who are looking for more insight as to options for treatment.

When Bob first mentioned the concept of this book, I told him that it was agreat idea, but I protested that he could easily find a more qualified author. First,I was not a Certified Gambling Counselor. I had been forced to learn things thehard way, as a broadly trained psychologist, who gradually gained a backgroundin gambling, based on my background in addictions and perception of currentneed.

“Aha—So far, your qualifications are perfect.”Next, I objected that there were scores of more serious clinicians and schol-

ars than me. Certainly, he could find a more “reputable name” for this book. Hereiterated that this was not his goal. Instead, his hope was for a pragmatic,“hands-on” volume, to make the treatment of gamblers less formidable for thetypical nonspecialist clinician.

Bob had a way of being insistent about these things.I reminded Bob that my administrative and therapeutic mistakes, program-

matic errors, misdirection of resources, misunderstandings of clinical situations,and occasional franks misdiagnoses, could fill a small file.

“Great! What an opportunity to help others avoid your errors!”Bob was a bit of an optimist.

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xxii PREFACE

Dr. Howatt, the other Bill in this project, in his own persistent way similar toBob, would not let me out of this book. I was pretty much 90 percent done, thenthe pressures of life hit. In the throws of supporting a state crisis in Louisiana, anational crisis providing Arabic translation, and a book crisis trying to get a bookcomplete with no time and constant outside demands, the final caveat was thatI was expecting my first child. Dr. Howatt kindly agreed to help me finish thisbook and for that I am grateful.

As explained in the preface, this book follows the chapter guidelines and out-line suggested by Bob and Dr. Howatt. Chapter 1 is an overview of problem andpathological gambling, including definitions and a distinction between the twoterms. Counselors are often benefited by understanding group and individualrisk factors. Although there are risk factors associated with developing a gam-bling disorder, anyone with a sufficient reinforcement history can develop awagering problem. Recently, data have shown that gambling treatment works,something we could not claim perhaps five years ago.

Chapter 2 discusses the signs and symptoms of problem and pathologicalgambling. The paradox is that, although gambling is extraordinarily destructive,it is often hard to detect. Disordered gambling does not furnish definitive labo-ratory tests or even consistent reports from the neighbors about raucous behav-ior. However, there are numerous clues to the presence of gambling disordersthat a careful clinician may find. Structured interview questionnaires and screen-ing instruments may be helpful in detecting the presence of problem or patho-logical gambling.

Chapter 3 concerns the pragmatics of using and protecting scarce treatmentresources. The chapter opens with a practical problem that isolated cliniciansface: How can I find colleagues who can help me treat gamblers? For the isolatedclinician, this is a topic that is rarely addressed in the literature and was one thatBob Coombs often pointed out was critical for client and counselor well being.The chapter next covers a number of down-to-earth topics such as selecting theright professional for treatment, the “do’s and don’ts” of referrals, some concretestrategies for getting a person to a professional, advice about dealing with crisissituations, and risk-management strategies.

Chapter 4 involves some of the “nuts and bolts” of conducting an intake anddeveloping an effective treatment plan for people with gambling problems. Thechapter stresses that in order for a treatment plan to be truly effective, it mustbegin at intake. The chapter emphasizes that the intake interview should be moti-vational, and its purpose is to gather information. It also discusses problems withconfidentiality and compliance with the Heath Insurance Portability andAccountability Act (HIPAA). Admittedly, no one knows much about HIPAA asit involves treating clients with gambling disorders, but this discussion is a start,and I hope it generates awareness and dialogue.

Chapter 5 concerns treatment strategies for problem and pathological gamblers.This is not a “how to” chapter, such as you might find in a detailed manual-driven

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Preface xxiii

intervention. There are now several outstanding sources for these in the litera-ture, which are discussed in this chapter. Instead, we summarize various populartypes of treatment and discuss where to access more comprehensive resources.

Chapter 6 highlights continuing care for people with a gambling problem. Ithighlights the stages of recovery and how various treatments may be appropri-ate for each stage. Successful discharge planning is able to use family and com-munity resources and to organize resources where they are not available. Ethicalconcerns involving discharge are discussed in this chapter.

Chapter 7 emphasizes posttreatment recovery management. Since manyinstances of gambling disorders are considered potentially chronic, they willneed to be managed throughout long periods, perhaps life. Clients will need todevelop proactive strategies for preventing and dealing with “triggers” forrelapses. This includes developing relapse prevention plans appropriate for dif-ferent stages of treatment. Other resources include those in the community andfamily, as well as pastoral counseling.

Finally, Chapter 8 discusses what the client’s life can be like after gamblingrecovery. This includes the possibility that he or she can live a richer, fuller lifethan otherwise imagined. Each recovered gambler’s life is different and the pos-itive direction cannot be measured in advance. However, almost invariably, whenpeople change, they report that their lives have a real and deeper meaning. Thischapter is brief because there is not one single path to a posttreatment lifestyle.Some clients find that they are able to use the emptiness of their time spent gam-bling in a constructive and positive manner. Others simply prefer to forget thatperiod and move on.

All of the clinical vignettes are true stories. Identifying information has beenremoved through a two-part process to preserve anonymity.

The volume deliberately excludes a few popular topics. Notably, these includeprevention, although some of the suggested resources are very helpful concern-ing this topic. It also excludes treatment of adolescent and elderly gamblers.Adolescent treatment usually requires additional training, and it is unlikely thata clinician can develop minimal competence without more extensive supervision.Furthermore, it is still unlikely that adult generalist mental health counselors andpractitioners will be referred adolescent gambling cases. Regarding elderly, theirtreatment needs are usually so diverse and complex that they also demand spe-cially trained practitioners.

Bill McCown, PhD

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ABOUT THE AUTHORS

William A. Howatt, PhD., EdD., has more than 18 years experience as an addic-tion counselor. He is an internationally acclaimed alcohol and drug addictionsspecialist, gambling addictions specialist, registered professional counselor, reg-istered social worker who has also completed post doctoral work in addictionstudies at UCLA School of Medicine. He is a faculty member of Nova ScotiaCommunity College where he teaches in the addiction counselor program forthe School of Health and Human Services. He is author of numerous booksincluding The Addiction Counselor’s Desk Reference and is coeditor of theTreating Addictions Series (both published by Wiley).

William G. McCown, PhD., is a clinical psychologist with over 20 years of addic-tion-treatment experience. He combines appreciation of traditional approachesto treatment with a commitment to evidence-based methods. An internationalconsultant, he pioneered one of the first Internet-based treatments for disor-dered gambling. He is presently Associate Professor at the University ofLouisiana at Monroe, where he carries on an active research program.

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TRUTH OR FICTION QU

IZ

1

Introduction to GamblingGambling is the attempt to win something on the outcome of a game or eventthat depends on chance or luck. The purpose of this chapter is to educate pro-fessionals and clinicians about pathological and problem gambling. Gambling isnot inherently pathological, immoral, or associated with any psychological prob-lems. An overwhelming majority of people who choose to wager do so in mod-eration and without evident problems. There is no evidence that this majority isat any risk of developing the problems described in this chapter and throughoutthis book.

After reading this chapter, you should be able to answer the followingquestions:

1. Gambling is a new addiction that first appeared in the twentieth cen-tury. True or False?

2. Gambling is primarily a compulsion, like perfectionism or excessivehand washing. True or False?

3. Problem gambling and pathological gambling are two separate anddistinct disorders. True or False?

4. Most people with gambling problems lose control every single timethey gamble. True or False?

5. Clinical difficulties involving gambling seem to be increasing. True orFalse?

6. True pathological gamblers develop problems regardless of wageringopportunities. True or False?

7. The treatment of pathological gambling is identical to that of otheraddictions. True or False?

Answers on p. 31.

CHAPTER 1

Conceptual Foundationsof Gambling Disorders

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2 TREATING GAMBLING PROBLEMS

However, in North America, approximately between 2 and 6 percent of thepopulation has, or has had, gambling-related problems. Estimates vary accord-ing to the research methodology used. For example, researchers find differentestimates depending on what time frame and frequency gambling is assessed(e.g., within the last month, within the last year, within a lifetime). Findings alsoare influenced by where they are obtained. For example, proximity to a gamblingvenue possibly contributes to the risk for developing a problem. However, thismay be changing with the onset of additional wagering options, including thoseavailable on the Internet and growth in casinos across North America.

Although the behaviors involved in disordered gambling do not involve a spe-cific substance of abuse, they facilitate a syndrome that is similar to the classicalchemical, or other, addictions. Similarities include compulsion, loss of control,and continued use despite negative consequences. These are the “Three Cs ofaddiction” (Blume, 2005), and they are detailed in a later section. For peoplewith a gambling dysfunction, the dependence, craving, and disruption to theirlives are often as severe as in any addiction. What is confusing to family and oth-ers is that gambling does not involve a specific substance; consequently, theaddiction to gambling seems (to them) less legitimate and understandable.

Not everyone with a gambling disorder demonstrates the stereotype of pro-gressively severe impairments. In the world of gambling, what walks like a duckand quacks like a duck—may not be a duck at all. It is relevant to understandthat, just because a person appears to meet the criteria of being a pathological orproblem gambler, it does not always prove to be true. Some show patterns of peri-odic difficulties that may or may not be related to external events, such as lifestressors; others “mature out,” gradually curtailing destructive gambling overmonths or years. The reasons for these varied patterns are not well understood.Still, others show more abrupt spontaneous remission that occurs when disor-dered gambling problems disappear without informal or formal treatment. Thefrequency of spontaneous remission is unknown, as are its definitive mechanisms.

Certain cultural, economic, racial, and ethnic groups may be at higher risk fordeveloping gambling problems. The specific pathways for developing a gamblingdisorder are not necessarily the same in diverse groups or in any two people.Rather, gambling disorders may represent a common outcome or destinationfrom a variety of different pathways.

The need for this book comes from the fact that many general therapists,counselors, and other mental health professionals now are encountering, or willsoon encounter, someone with a gambling problem. Yet, gambling and gamblingproblems are not new. On the contrary, people have been gambling sincerecorded history, presumably even earlier. Betting on horses began almost assoon as these animals were domesticated. Ancient Chinese and Egyptian textsindicate that gambling was common, though excessive gambling was a concern.The Biblical book of Judges (Chapter 14) highlights the role that gamblingplayed at ancient feasts and weddings, when Sampson apparently tried to pro-

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Conceptual Foundations of Gambling Disorders 3

voke warfare by wagering on who could solve a riddle (The Holy Bible). Manyhistorical accounts discuss various forms of wagering that existed in Europe dur-ing the Dark Ages and during the Renaissance. During the sixteenth and seven-teenth centuries, some of the seminal advances in the mathematics of probabilityand statistics were based on attempts to understand and capitalize on the oddsafforded to gamblers.

In North America, the popularity of gambling has followed various periodsof expansion that some observers have labeled waves. Undoubtedly, historiansdisagree about these exact time frames, and it is our belief that gambling expan-sion never completely ceased, even during its least popular periods. Someaccounts suggest that the first wave began with colonization, where colonistsgambled heavily, with the possible exception of the Puritans. Later, Scotch-Irishimmigrants probably wagered even more frequently, primarily to fight thetedium of frontier life. The first race track was established on Long Island morethan one hundred years before the Declaration of Independence. Playing the lot-tery became a voluntary tax and form of civic pride, as well as a universal formof amusement. All of the 13 original colonies had some form of lottery.

Many classic card games followed the Mississippi River up from New Orleans,blending French and Creole influences into the New World. These includedpoker, which had firmly developed a variety of different rules by the 1840s. Themystique of this game contributed to the American folklore of the prewar ante-bellum South and period of Western expansion. The gentleman’s game of crapsalso originated in Europe and became popular in New Orleans, partly becauseit resisted fixing. Fixing displayed an ugly side to the romanticized notions ofriverboat and frontier gambling. Violent sharks, thugs, and cons often attemptedto rig whatever games were available. The solution for these players was oftenquick, vigilante justice.

Slaves may have turned to gambling as one of the few amusements that theycould afford and conceal. Unfortunately, little is known about the folk gamblingculture that developed during these conditions of oppression. Following theAmerican Civil War, gambling popularity increased until the United States pub-lic became disgusted with recurrent lottery and race track corruption, beginninga period of rapid legal restrictions. This abruptly ended the first wave of NorthAmerican gambling.

Some argue that the next wave of gambling in the United States, perhapsfrom the 1890s to the early part of the 1900s, was tied in part to advances in gam-bling technology. At the race track, the set starting gate and, particularly the toteboard (or parimutuel machine), reduced the appearance of corruption. Tote boardsfeature odds that are constantly being updated. The public is basically bettingagainst itself, with players trying to outsmart each other as they might in the stockexchange. No longer were odds set by various bookmakers, who were corrupt andmight fix a race. Instead, all the money bet at a track was pooled together anddivided according to odds set by the crowd’s ever-changing choices. In the United

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4 TREATING GAMBLING PROBLEMS

States, this type of wagering smacked of the populism that a growing democracyliked. This led to the perception of fairness, though with many notorious exceptionsand attempts to defraud the public, which continue on through today.

The mechanical slot machine, called the fruit machine in Britain, or one-armedbandit in some circles, was another innovation spawned from a renewed interestin legalized gambling. Invented in 1895 by Charles Fey, a locksmith and machin-ist in San Francisco, these amusement devices proved immensely popular andbecame a backbone of legal casinos in Nevada and later New Jersey and else-where. Nevada legalized most forms of gambling in 1931. The potential prof-itability of slot machines for the player increased when the mechanical reel wasreplaced with increasingly sophisticated electric and electronic variations. Thiseventually resorted in enormous revenue for slot machine owners, since so manymore patrons played them, often for hours at a time.

The third wave began after the 1930s in the United States with the return ofbingo and parimutuel betting, and on into the 1960s with the renewed popular-

ization of state lotteries. Atlantic City saw gamblingas a cure for a moribund economy and opened casi-nos in the late 1970s. This trend was followed withriverboat gambling, ostensibly for its romantic,quixotic appeal and attempt to restore rustbelt cityeconomies. Native American casinos, often fallingunder less stringent regulation, became immenselypopular and circumvented state law. Only two states,Utah and Hawaii, presently do not have some legal-ized form of gambling; however, this is now over-shadowed by the ability to access Internet and cableor satellite television wagering.

In Canada, all gambling was made illegal by theCanadian Criminal Code of 1892. Still, there aremany very colorful accounts of frontier gamblers thatrival those on the Mississippi. Canadian gamblingnever really went away. It just moved down the blockor out to the frontier. In 1969, the federal govern-ment began reducing its involvement with gambling,turning over regulation to provinces and territories,which accepted the expansion at varying paces. In1985, provinces were allowed to oversee video slotmachines and video lottery terminals. These havebecome immensely popular, very lucrative, and thereis concern regarding their potential for causing

excessive gambling problems.Some form of legally sanctioned gambling is now available in all ten provinces,

with casino gambling now available in many provinces as well.

IMAGINE THAT!

The odds of being struck by lightningare 1 in 240,000. With slot machines,the odds of winning the top prize atmaximum coin play ranges from 1 in4,096 up to 1 in 33,554,000.

Source: British Columbia Partnership for Responsible Gambling (2004).

IMAGINE THAT!

The profits from government gamingoperations are almost $13 billionnationally, but the costs of gamblingaddictions are not known. Some ofthese could be quantified, includingmedical care, policing, courts, pris-ons, social assistance, and businesslosses. However, no simple dollar fig-ure can measure the devastation tothe lives of those affected by patho-logical gambling.

Source: Canada Safety Council(2006).

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