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The Chase: Predecessors and Progress 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 [email protected] http://www.gamblingtreatment.org.

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The chase predecessors and progress on problem gambling

The Chase: Predecessors and Progress 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

[email protected]

http://www.gamblingtreatment.org


Major questions to be addressed
Major Questions to be 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 history
Gambling in History

  • Gambling 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.



Gambling as problematic
Gambling 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 north america
Gambling as Problematic in North 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.



Social controls among first nations people
Social Controls among First Nations 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 among first nations people
Gambling as Problematic Among 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 of ignorance
Characteristics of the Age of 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 sin
Age of Sin

  • Gambling per se was equated with evil

  • The gambler was either an exploiter or exploited

  • Focus on cheating, violating the law, and corruption

  • The player was viewed as a flawed victim


Skip to early 20 th century
Skip to early 20th Century

  • Gambling and Gambling Devices: An Educational Exposition Designed to Instruct the Youth to Avoid All Forms of Gambling

    John Philip Quinn

    Published in 1912

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



Three stages of a gambler s life1
Three 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 way
The Upward and Downward Way

The Upward Way

The Downward Way

to God and family

to prison and destitution


This continued:Sucker’s Progress: An Informal History of Gambling in America From the Colonies to CanfieldHerbert Asbury, 1938An “objective” history that is full of moralizing. For example, he quotes a New York Herald article: “There is a small and select 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 describes “gambling hells” in different parts of the US.


Continuation in late 20 th century ambivalence about sin and disease
Continuation in late 20th Century – Ambivalence 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 prior to the chase
Medicalization (prior to The Chase)

  • 1 – Psychoanalytic theorizing

    Freud; 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)






Provinces territories with legalized gambling 1975
Provinces & Territories with Legalized Gambling -- 1975

12

12

7

3

0

0

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


Provinces territories with legalized gambling 2005
Provinces & Territories with Legalized Gambling -- 2005

12

12

12

11

10

8

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


Gambling revenue statistics canada
Gambling Revenue – Statistics Canada

$12.4

$11.3

$9

$6.8

$2.7



Sociology of problem gambling prior to the chase basically a desert except for
Sociology of Problem Gambling prior to The ChaseBasically 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 deviance
Sociology of Deviance

  • Anti-medicalization

  • “Labeling Theory”

  • Symbolic Interaction and Phenomenology

  • Emphasis on Qualitative Research including participant observation and intensive interviews


Quitting gambling through gamblers anonymous
Quitting Gambling Through Gamblers Anonymous

  • University of Massachusetts -- Sociology

  • TV show and my ex-boss

  • GA meetings in Connecticut

  • Ph.D. thesis

  • Observations &

    Interviews


Compulsive gambler s spiral of options and involvement
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 crime

    3. Gambling = Organized Crime

    4. Nothing about route CGs take

    to Criminal Behavior



Methods used qualitative
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 chase
The Chase

  • Short-term chasing -- normal

  • CG = long-term chasing

  • Understanding CG view of

    the world: Action:

    Chasing; Finances; Family; Work;

    Gambling as Illegal activity; Crime

  • CG Spiral of Options and Involvement



Crime types among pathological gamblers
Crime Types Among Pathological Gamblers

  • Forgery, Fraud, Theft, Embezzlement

  • Tax violations (fraud & evasion)

  • Illegal Gambling operation

  • Less common: Burglary, Armed robbery, Drug Sales, Fencing Stolen Goods, Prostitution, Extortion


Cycles in the spiral of options and involvement
Cycles in the Spiral ofOptions and Involvement

1. Get Money

2. “Moving,” “Manipulating,”

or “Juggling” Money

3. Tightening of Resources

(Closure) and Need to

Make Moral Decision


Medicalization 1980
Medicalization -- 1980

  • American Psychiatric Association

  • Diagnostic and Statistical Manual of Mental Disorders, Third Edition

  • Lobbying 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
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 chart
Custer V Chart Custer, MD


Medical model continued dsm iii r dsm iv
Medical Model continued DSM-III-R & DSM-IV Custer, MD

  • 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 commencing in the 1980s and continuing
Significant Changes Commencing in the 1980s and Continuing Custer, MD

  • Development of measures (SOGS etc.)

  • Research on subgroups

  • Population studies

  • New Journal

  • Research and Programs Leapfrogged around the world


South oaks hospital sheila blume md
South Oaks Hospital & Custer, MD Sheila Blume, MD

  • Alcohol, Drug Abuse & Gambling

  • Gambling among mental patients

  • South Oaks Gambling Screen

  • Gambling Severity Index

  • Evaluation of inpatient gambling treatment program


Sogs translations 37 languages so far

Africaans Arabic Custer, MD

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

SOGS Translations 37 languages so far

Note: translations in Croatian and Slovenian in progress


Epidemiological surveys
Epidemiological Surveys Custer, MD

  • Only 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 with the following groups

General population studies Custer, MD

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

Surveys have been conducted with the following groups


Proliferation of measures only measures used by more than one researcher included
Proliferation of Measures Custer, MD(only measures used by more than one 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 measures only measures used by more than one researcher included
Outcome Measures Custer, MD(only measures used by more than one researcher included)

  • SOGS-3 month version

  • DSM-IV -- # criteria met

  • GSI – Gambling Severity Index (Lesieur & Blume)

  • G-SAS – Gambling System Rating Scale (Kim)

  • PG-YBOCS -- Hollinger



Journals since jgb
Journals since JGB Custer, MD

  • 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 gambling
Research from the UK on Youth Gambling Custer, MD

  • 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 recovery
Pathways to Recovery Custer, MD

  • 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 modalities
Treatment Modalities Custer, MD

  • Imaginal Desensitization

  • Controlled Gambling

  • Cognitive Behavioral therapy

  • Self-help manuals

  • Motivational Interviewing

  • Brief therapies

  • Variety of medications


Robert ladouceur s research irrational thinking and gambling
Robert Ladouceur’s research; Irrational 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 problem gamblers
Thinking Errors Among Problem Gamblers Gambling

  • 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 treatment
Cognitive Treatment Gambling

  • Ladouceur & Colleagues (2001)

  • A focus on randomness is very effective when compared to controls

  • Erroneous beliefs about chance, luck, skill and randomness were challenged

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


Attitude and cognition inventories
Attitude and Cognition Inventories Gambling

  • Cognitions

  • GBQ (Gamblers’ Belief Questionnaire)

  • Attitudes

  • GAS – Kassinove

  • Combine attitude & cognitions

  • GABS – Breen & Zuckerman


Alex blaszczynski s research 1980s to the 2000s

PG & Imaginal Desensitization Gambling

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

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


Blaszczynski nower pathways model 1
Blaszczynski & Nower Pathways Model --1 Gambling

  • Normal Problem Gambler

    -- Low Severity

    -- Secondary Substance Dependence

    -- Secondary Depression

    -- Secondary Anxiety

    -- Irrational Cognitive Beliefs


Blaszczynski nower pathways model 2
Blaszczynski & Nower Pathways Model -- 2 Gambling

  • Emotionally Disturbed Gambler

    -- Moderate Severity

    -- Premorbid Substance Dependence

    -- Premorbid Depression

    -- Premorbid Anxiety

    -- Avoidance & Passive aggressive coping

    -- Escape using Dissociation


Blaszczynski nower pathways model 3
Blaszczynski & Nower GamblingPathways 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 model korn shaffer 1999
Public Health Model GamblingKorn & 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 Gambling

Continuum of Problems

Healthy Gambling

Unhealthy Gambling

In Treatment

Gambling w/ Severe Adverse Consequences

Gambling w/ Some Adverse Consequences

No Gambling

Gambling w/ No Adverse Consequences


Public health model 2 korn shaffer
Public Health Model - 2 GamblingKorn & Shaffer

  • Public Health Action Plan

  • Prevent gambling-related problems via public awareness, early identification & treatment

  • Promote informed and balanced attitudes towards gambling via knowledge, responsible choices and community participation

  • Protect vulnerable groups from harm (harm reduction focus)


Gambling choices and guidelines roger svendsen tom griffin 1993
Gambling Choices and Guidelines Gambling– 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 manuals
Self-Help Manuals Gambling

  • 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 change prochaska diclemente
Stages of Change GamblingProchaska & DiClemente

  • Precontemplation-- Resisting Change

  • Contemplation -- Change is Needed

  • Preparation -- Readying for Change

  • Action -- Time to change

  • Maintenance -- Continue Change

  • Relapse -- What did person learn?

  • Termination – Change has occurred


Pathways to recovery1
Pathways to Recovery Gambling

  • General Population Surveys

  • Rate 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
Pathways to Recovery 2 Gambling

  • 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 1
Natural Recovery 1 Gambling

  • 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 2
Natural Recovery 2 Gambling

  • Jeff Marotta

  • Why 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 Gambling: Lessons from Longitudinal Studies:D.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 T2

Source: La Revue Canadiene de Psychiatrie, 53, 1, Jan 2008


Comments on stability progression
Comments on Stability & Progression Longitudinal Studies:

  • 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 west simpson 2007
Prevention Research (Willams, West & Simpson, 2007) Longitudinal Studies:

  • 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 physiological studies
Medical Model Redux: Physiological Studies Longitudinal 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 2
Medical Model Redux -- 2 Longitudinal Studies:

  • Gamblers Anonymous which assumes a disease model is an effective adjunct to therapy.


Moral model redux
Moral Model Redux Longitudinal Studies:

  • Anti-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 game larry braidfoot 1985
Gambling: A Deadly Game Longitudinal Studies:Larry 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 growth locations

1957 – one chapter Longitudinal Studies:

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

Gamblers Anonymous Growth & Locations



Social controls that seemed to work among some first nations people
Social Controls that Seemed to Work Among Some First Nations People

  • Gambling without Credit

  • Instrumental (formalized) rather than Affective gambling

  • No house takeout


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



Questions about slot machines
Questions about Slot Machines need for research

  • 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 needed
Effectiveness Studies Needed need for research

  • Studies of Financial Counseling/Advise

  • Studies 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? need for research

  • 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 information
For further information need for research

Henry R. Lesieur, Ph.D., Psy.D.

Rhode Island Gambling Treatment Program

Department of Psychiatry

235 Plain Street, Suite 501

Providence, RI 02905

Tel: (401) 277-0721

E-mail: [email protected]

http://www.gamblingtreatment.org


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