2. 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 hlesieur@lifespan.org http://www.gamblingtreatment.org

3. 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?

4. 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.

5. Astragal

6. 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.

7. 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.

8. Stick Dice

9. 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.

10. 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.

11. 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.

12. 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

13. Skip to early 20 th 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

14. Three Stages of a Gambler’s Life

15. 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.”

16. The Upward and Downward Way

17. Sucker’s Progress: An Informal History of Gambling in America From the Colonies to Canfield Herbert Asbury, 1938 An “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. This continued: Sucker’s Progress: An Informal History of Gambling in America From the Colonies to Canfield Herbert Asbury, 1938 An “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.

18. Continuation in late 20 th Century – Ambivalence about sin and disease National Coalition Against Legalized Gambling (US) Arguments similar to those in the 19 th and early 20 th century but with the addition of an acceptance of the medical model. See Suzanne Morton At Odds: Gambling and Canadians 1919-1969

19. 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)

20. Bergler Psychology of Gambling

21. Number of States with Legal Gambling in the US – 1974 Parimutuel Machines OTB

22. Number of States with Legal Gambling in the US – 2005 Parimutuel Slots/VLTsOTBs

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

24. Provinces & Territories with Legalized Gambling -- 1975 12 7 00 3 All had Bingo and Lottery by 1975 Casinos: only Alberta (1975), Manitoba (1971) & Yukon (1800s)

25. Provinces & Territories with Legalized Gambling -- 2005 12 10 11 8 Slots-all but NW & Yukon OTB-all but NFLD (has intertrack wagering)

26. Gambling Revenue – Statistics Canada $2.7 $6.8 $11.3 $12.4 $9

27. Narragansett Racetrack

28. Sociology of Problem Gambling prior to The Chase 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

29. Sociology of Deviance Anti-medicalization “Labeling Theory” Symbolic Interaction and Phenomenology Emphasis on Qualitative Research including participant observation and intensive interviews

30. Quitting Gambling Through Gamblers Anonymous University of Massachusetts -- Sociology TV show and my ex-boss GA meetings in Connecticut Ph.D. thesis Observations & Interviews

31. 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

32. The Chase Book Cover

33. 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

34. 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

35. Spiral

36. 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

37. Cycles in the Spiral of Options and Involvement 1. Get Money 2. “Moving,” “Manipulating,” or “Juggling” Money 3. Tightening of Resources (Closure) and Need to Make Moral Decision

38. 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).

39. 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

40. Custer V Chart

41. 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

42. Significant Changes Commencing in the 1980s and Continuing Development of measures (SOGS etc.) Research on subgroups Population studies New Journal Research and Programs Leapfrogged around the world

43. South Oaks Hospital & Sheila Blume, MD Alcohol, Drug Abuse & Gambling Gambling among mental patients South Oaks Gambling Screen Gambling Severity Index Evaluation of inpatient gambling treatment program

44. SOGS Translations 37 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

45. Epidemiological Surveys 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

46. Surveys have been conducted with 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

47. Proliferation of Measures (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

48. Outcome Measures (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

49. JGB (1985) & JGS (1990)

50. Journals 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

51. Research from the UK on Youth Gambling 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

52. Pathways to Recovery 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

53. Treatment Modalities Imaginal Desensitization Controlled Gambling Cognitive Behavioral therapy Self-help manuals Motivational Interviewing Brief therapies Variety of medications

54. 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.”)

55. Thinking Errors Among Problem 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)

56. Cognitive Treatment 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

57. Attitude and Cognition Inventories Cognitions GBQ (Gamblers’ Belief Questionnaire) Attitudes GAS – Kassinove Combine attitude & cognitions GABS – Breen & Zuckerman

58. Alex Blaszczynski’s research (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

59. Blaszczynski & Nower Pathways Model --1 Normal Problem Gambler -- Low Severity -- Secondary Substance Dependence -- Secondary Depression -- Secondary Anxiety -- Irrational Cognitive Beliefs

60. Blaszczynski & Nower Pathways Model -- 2 Emotionally Disturbed Gambler -- Moderate Severity -- Premorbid Substance Dependence -- Premorbid Depression -- Premorbid Anxiety -- Avoidance & Passive aggressive coping -- Escape using Dissociation

61. Blaszczynski & Nower Pathways 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

62. Public Health Model Korn & Shaffer (1999) Views gambling problems as occurring along a continuum Looks at health, social & economic costs and benefits Emphasizes prevention and harm reduction

63. Levels of Gambling No Gambling Gambling w/ No Adverse Consequences Gambling w/ Some Adverse Consequences Gambling w/ Severe Adverse Consequences Continuum of Problems Healthy GamblingUnhealthy Gambling In Treatment

64. Public Health Model - 2 Korn & Shaffer Public Health Action Plan 1. 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)

65. Gambling Choices and Guidelines – 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

66. Self-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)

67. Stages of Change Prochaska & 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

68. Pathways to Recovery 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

69. 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

70. Natural 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

71. Natural Recovery 2 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

72. 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

73. Comments on Stability & Progression 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.”)

74. Prevention Research (Willams, 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)

75. Medical Model Redux: Physiological 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

76. Medical Model Redux -- 2 Gamblers Anonymous which assumes a disease model is an effective adjunct to therapy.

77. Moral Model Redux 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.

78. Larry Braidfoot, 1985 Gambling: A Deadly Game 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.”

79. Gamblers Anonymous Growth & 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

80. The Age of Ignorance may yet have some lessons for the 21 st Century

81. Social Controls that Seemed to Work Among Some First Nations People Gambling without Credit Instrumental (formalized) rather than Affective gambling No house takeout

82. 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

83. Safe@PlaySafe@Play Slots Tutorial Safe@Play

84. Questions 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%

85. Effectiveness Studies Needed 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)

86. 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?

87. For further information 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: hlesieur@lifespan.org http://www.gamblingtreatment.org