An Exploratory Study of Gambling Cross Addictions Mark Griffiths, Ph.D.
University of Plymouth
A growing body of empirical and theoretical research has concentrated on the overlaps a n d commonalities a m o n g chemical and non-chemical (behavioural) addictions. Pathological gambling has perhaps been the most widely researched behavioural addiction and some of this research has concerned the co-existing links between pathological gambling and alcohol/drug addiction in both the gambling substance abuser and the substance abusing gambler (i.e. cross addiction). This study was of an exploratory nature and attempted to gather information and data regarding gambling cross addictions in the U K . To achieve this, 456 letters were sent to all drug and alcohol helping agencies in England requesting such information. This yielded 210 returns (46% response rate). Results indicated that gambling cross addictions occur in both adults and adolescents and were almost exclusively a male condition. However, it must be noted only just over half of the responding agencies had encountered g a m b l i n g cross addiction and reasons for this are speculated. Results also indicated the existence of various cross addicted subgroups including an adolescent subgroup who were addicted to fruit machines and abused solvents. Future research ideas are also discussed.
INTRODUCTION
Since the 1980's, a growing body of empirical and theoretical research has concentrated on the overlaps and commonalities among
Reprint requests should be addressed to Dr. Mark Griffiths, Psychology Department, University of Plymouth, Drake Circus, Plymouth, UK, PL4 8AA. A more detailed version of this paper is available from the author on request.
Journal of Gambling Studies Vol. 10(4), Winter 1994 Q 1994 Human Sciences Press, Inc.
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chemical and non-chemical (behavioural) addictions (e.g., Miller, 1980; Levinson, Gernstein & Maloff, 1983; Orford, 1985; Marks, 1990). Pathological gambling has perhaps been the most widely researched behavioural addiction (i.e. an addictive activity which does not rely on the ingestion of a psychoactive drug) some of which has been concerned with the co-existence of alcohol/drug addiction with gambling addiction (and termed 'cross addiction'). An early study by Custer and Custer (1978) found that 8% of Gamblers Anonymous members were alcoholic and that a further 2 % were addicted to other drugs. Since this study, evidence for coexisting dependencies with pathological gambling have appeared with regularity. Ramirez, McCormick, Russo and Taber (1984) reported that 47 % of pathological gamblers attending at a Veteran's Administration medical centre met the criteria for alcohol and/or substance abuse at some point in their lives (with 39% meeting the criteria in the year prior t o admission). Ciarrocchi and Richardson (1989) reported that of those attending their gambling treatment centre, 34% were abusing alcohol, 6% drugs and 31% both. Studies by both Linden, Pope and Jonas (1986) using male GA members and Lesieur (1988) using female GA members both reported that 52% of their samples had abused alcohol and/or drugs at some point in their lives. Other studies by Dell, Ruzicka and Palisi (1981), Lesieur (1984) and McCormick, Russo, Ramirez and Taber (1984) have also reported links between pathological gambling and alcohol/drug addictions. In addition, some studies have reported the co-existence of gambling and sex addictions (Adkins, Rugle & Taber, 1985; Lesieur, 1988), and gambling and overeating addictions (Lesieur, 1988). There has been little research examining the co-existence of pathological gambling and alcohol/drug addictions using substance abusing populations. Although Haberman (1969) reported that 17 % of his 70 alcoholics under study admitted having "gambling difficulties" (p. 164) it was not until a study by Lesieur, Blume and Zoppa (1986) that more reliable figures were obtained. Lesieur and his colleagues reported that amongst 458 alcohol and drug addict inpatients, 9% were diagnosed as pathological gamblers with a further 10% showing signs of problematic gambling. A further study of 100 multiple substance abusers by Lesieur and Heineman (1988) reported 14% of the sample to be pathological gamblers with a further 14 % showing signs of pathological gambling. More recently, there has been further research highlighting the existence of cross addictions both in clinical
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surveys (Ciarrocchi, Kirschner, & Fallik, 1991) and clinical case studies (e.g. Blume, 1994). It is clear from the research outlined that more research is needed on the co-existing links between pathological gambling and alcohol/ drug addictions in both the gambling substance abuser and the substance abusing gambler. It is also the case that all the data on gambling cross addictions outlined above have been collected in the US. It is with this in mind that the present exploratory study was carried out.
METHOD In March and April 1989 a total of 456 letters were sent to all drug and alcohol helping agencies in England (i.e. National Health Service and private addiction treatment units and clinics, self-help groups, drug and alcohol help lines, counselling services, youth agencies etc.) requesting information regarding cross addictions to gambling (i.e. information on individuals who were addicted to gambling and at least one other activity like drug taking, drinking etc.) The letter made no reference as to whether these behaviours occurred simultaneously or sequentially. All addresses were obtained from the Standing Conference On Drug Abuse National Directory (1987). The letter asked for no specific information leaving potential respondents the chance to write as much or as little as they felt necessary. Since funds were limited only one mailing was carried out with no follow up reminders. A total of 196 replies were received in addition to 14 letters "returned to sender" leaving a total of 246 potential respondents unaccounted for. Below is a breakdown of the replies received: 1. Letters (n = 142) and telephone calls (n = 8) providing information of varying amounts about cross addictions. 2. Letters which would/could not provide information about cross addictions (n = 7) because of "moral" and/or "professional" obligations to their clients. 3. Letters (n = 38) and telephone calls (n = 1) which provided no information regarding cross addictions but gave a follow up contact. These were only followed up if the person/ organization had not been contacted in the original mailing. (As a result of this process two follow up contacts were made in Scotland)
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4. Letters returned to sender (n = 14) because the organization had disbanded leaving no forwarding address.
RESULTS AND PRELIMINARY DISCUSSION Due to its qualitative nature much of the data reported in this results section cannot be reported without some kind of initial interpretation which would normally constitute inclusion in the discussion. A more general discussion will follow this section. O f the 150 replies yielding information, 53% (79 out of 150) reported they had encountered at least one case of gambling cross addiction whereas the remaining 47 % of respondents (71 out of 150) were of the view that gambling cross addiction did not exist or that they had not directly encountered it during their professional careers. This very small latter group constituted 2 % of the usable sample (3 out of 150) and reported they only knew of cases through third parties (e.g. partners of their clients) but had not seen it for themselves. One of the major arguments for the nonexistence of gambling cross addiction was that all an addict's energies go into one addiction. Statements putting forward this argument were abundant. Typical responses included the following (Note: places are county names, therefore individuals cannot be identified): "A drug addiction makes it necessary for (addicts) to spend most of their time and energy obtaining their drug of preference" (Drug Project Director,
Yorkshire). "In my own experience so far, serious addiction to one object or event usually does not leave room for a concurrent cross addiction" (Director of an Addic-
tion Trust, Norfolk). ~'It is unusual to see cross addictions to gambling since severe drug addicts have little money to gamble with" (Consultant Psychiatrist, London).
A few respondents said the reported non-existence might be due to other factors. For instance: "Although we have no records of cross addictions to gambling, this might not mean there are no such clients. It may be that we missed picking up such a vital point, but you have opened our curiosity. Hopefully this might make us more
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vigilant in picking up such things in the future" (Manager of a Substance Misuse Service, Lancashire). "We have not found instances of gambling and drug use. I should say, however, that this is not something we have been looking into so it remains a possibility that such cross addictions operate" (Drug Researcher, Scotland).
A number of respondents made the point that it may be possible for a person to have been addicted to both gambling and to have had an alcohol/drug addiction in their lives, but that it was unlikely that it happened concurrently. For instance: "People who use drugs heavily have little spare for other purposes although I wouldn't exclude the possibility that some people get heavily into gambling between bouts of heavy drug use" (Coordinator of a Drug Help Agency, Shropshire). "We occasionally notice that in the years prior to a client's drug problem he has had a phase of gambling addiction, but once he has moved onto drug abuse his time and money are totally committed to replenishing his drug supply" (Drug Team Leader, Warwickshire). "In a lot of cases, drug addicts are drinkers and gamblers too although they have not got enough money to support all three. In the case of drug addicts, the drug comes first" (Administrative Assistant, Drugs Advice Service, Cumbria).
Three respondents highlighted the fact that they knew their clients liked to gamble but it was at non-addictive levels. Fourteen percent of respondents who reported no existence of gambling cross addiction (10 out of 71) additionally mentioned that they had encountered other cross addictions. Some typical admissions include: "Some of our individuals certainly abuse multiple substances--alcohol and heroin for example" (Drug Researcher, Scotland). "We certainly come across poly abuse e.g., the amphetamine user who when supplies are short turns to alcohol--but not to gambling" (Drug Help Line Project Worker, Bedfordshire).
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"If you had chosen the connection between nicotine and either alcohol or opiate addiction (rather than gambling), it would have been a different matter. Two small samples I did at former places of work both had 90 % cross addiction" (Clinical Psychologist, Berkshire). As reported above, 53% of the respondents (79 out of 150) reported at least one case of gambling cross addiction although 65 % of these (51 out of 79) gave no specific incidence figures--only rough impressionistic estimates. Using these estimates it would appear that reports of more than nominal gambling cross addiction (i.e. those reports which would seem to indicate at least 10% of people encountered are cross addicts) account for 26.5% of cases (21 out of 79; see Table 1), however, this may not be the "true picture." There were a number of reasons why respondents did not give exact details, the primary reason being that such information was not kept or collated. Other respondents gave no reason or rationale for their rough estimates while still other respondents gave reasons of a more idiosyncratic nature (e.g. trying to decide what behaviours constitute bona fide addictions and cross addictions). 35% of respondents (28 out of 79) gave specific statistics of the incidence of gambling cross addiction. This low figure was probably due to the low incidence rates involved i.e. there were so few cases that these were either remembered well or specifically recorded because of their 'novelty.' O f the 28 specific replies, 57 % reported having encountered only one gambling cross addict in their careers (16 out of 28) with 36% reporting under ten cases (10 out of 28). However, a few of the incidences in this latter group were current annual figures rather than total cases ever recorded. Table 2 shows the main types of gambling cross addiction. Although 'drugs' could technically include alcohol, solvents, amphetamines etc., it is assumed that respondents reporting 'drug' addictions meant opiate addictions (e.g. heroin) although this of course may be a false assumption and may also include various stimulants (e.g. cocaine) and hallucinogens (e.g. LSD). Allowing for this assumption, results show that 'alcohol/gambling' cross addictions were the most frequently reported by the respondents (42%), followed by ~drugs/ gambling (20 % ), 'solvents/fruit machines' (10.5 % ), 'alcohol and drugs/ gambling' (7 %) and 'amphetamines/gambling' (3.5 %). This type of profile appeared to correspond with the more detailed replies from the
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Table 1 Gambling Cross Additions and Type in Treatment Establishments by Region Where Incidence is Presumed to be at Least I0% Treatment Establishment
Geographical Location
Incidence of Gambling Cross Additions
Main Types of Cross Additions
01
I.R.
Buckinghamshire
"quite a few"
alcohol/gambling
02
H
Devon
8-10 per year
alcohol/gambling
03
I.R.
Devon
04
S.H.
Hampshire
05
I.R.
Hertfordshire
06
I.R.
Hertfordshire
07
I.R.
Lancashire
08 09
I.R. I.R.
London London
"increasing numbers" "quite a few" ~'a high number" "quite a few" "quite common" "very common" approx. 10%
solvents/fruit machines drugs/fruit machines
t0
I.R.
London
nine (currently)
drugs/gambling
11
I.R.
London
seven (10%)
drugs/gambling
12
S.H.
London
"quite common"
heroin/gambling
13
I.R.
Northumbria
H I.R.
Nottinghamshire Shropshire
16
I.R.
Surrey
17
I, R.
Surrey
18
I.R.
Surrey
19
I.R.
Surrey
20 21
I.R. H
Sussex Yorkshire
"quite common" "many" '`quite common" "many" (out of 300 + ) 'fairly common" "a sizeable number" ~very common" "a fair number"
alcohol/gambling
14 15
48/225 (21.3 %)
solvents/fruit machines alcohol/gambling alcohol/gambling * */gambling alcohol/gambling
alcohol/gambling amphets/fruit machines drugs/gambling not specified alcohol/gambling alcohol/gambling solvents/fruit machines alcohol/fruit machines
H = Hospital, I.R. = Independent Rehabillitation and S.H. = Self Help **alcohol, drugs, tranquilizers & overeating
respondents. Although gambling type was not specifically asked for in the letter requesting information, it should be noted that those agencies reporting gambling type noted that the problem concerned fruit machines. From a number of the replies it seems there were two groups of gambling cross addicts differentiated by age and type of gambling, with
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OF GAMBLING
STUDIES
Table 2 M a i n Types of Gambling Cross Addictions as Reported by Respondents (n = 79) Type of Cross Addiction
n
Alcohol/gambling* Drugs/gambling* * Solvents/fruit machine gambling Alcohol & drugs/gambling Amphetamines/gambling* * * Tranquillizers/gambling Overeating/gambling C annabis/gambling Computer games/gambling Caffeine/gambling Exercise/gambling
36 17 09 06 03 02 02 01 01 01 01
Not Specific
13
Total
86****
*Includes 3 fruit machines **Includes 4 fruit machine gambling ***Includes 1 fruit machine gambling ****Some respondents gave more than one answer
an increasing awareness that young gamblers can be just as problematic as their older counterparts: '7 see gambling chiefly in two client groups, fruit machine problems with young drug users (under 18) and betting in alcohol users" (Director of a Drugs Advice Service, Sussex). 'Cross addicts who gamble tend to be male from social classes 4 and 5, often with criminal records who tend to have severe drinking problems to the point of physical dependence~ (Consultant Psychiatrist, Nottinghamshire). "One particular sub-group came to mind which consisted of fairly young adolescents who seem to get caught up in a cycle of gambling on fruit machines and solvent abuse" (Clinical Psychologist, Addiction Centre, Kent).
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"Of the 225 appointments booked, 21.3 % werefor gambling . . . Most of the clients were fairly young (15-25 age group) and fruit machines was the main form in which the gambling presented. (Clinical Psychologist, Addiction
Unit, Yorkshire). "The only addicts I personally encounter are younger clients who frequent amusement arcades awaiting friends and dealers" (Drug Counsellor, Hum-
berside). Reasons for the links between gambling and other addictive activities were only touched upon by a few respondents, however, those who did give reasons had interesting hypotheses: '7 suspect there is a cultural element . . . The pub and the bookies tend to be fairly close together. In a sense this is acknowledged legally, as gambling was outlawed from public houses in 1948 and prior to that, had serious restrictions placed upon it" (Consultant Psychiatrist, Addiction Clinic, Devon). "I feel that situational forces also come into play in so much that pubs are also centresfor gambling and amusement arcades are centres, at least in (this town), for youth culture drug dealing" (Director of a Drugs Advice Service,
Sussex). "My suspicion is that this is largely due to the social and cultural milieu that the person was circulating in, where gambling was predominant . . . These were men in their mid-30's to mid-50's. In most cases, the drinking pre-dated the gambling episodes, and in all the cases I can think of, the gambling and drinking were in the individual's family history" (Co-ordinator of a Drug
Outreach Project, London). "Most of my referrals (for solvent abuse and fruit machine addiction) are quite young i.e. 12 to 15years o l d . . . ~ The interest displayed by theseyoungsters is usually flirtation initiated by curiosity and peer pressure" (Solvent Abuse
Counsellor, Lancashire). "One area of concern is ethnic groups. The oriental~eastern cultures have a very clear link with gambling and narcotics and one only has to look at the facts concerning Soho in London in the sixties" (Co-ordinator of a Drug Project,
Buckinghamshire).
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Typical reasons put forward by respondents as to the psychological motivations behind their client's addictive behaviour problems: "In character many (cross addicts) are searching for instant fun or an immediate resolution of stress, and it is often the impulsive quality that presents a barrier to treatment" (Consultant Psychiatrist, Yorkshire). "Following counselling, the root cause (of his opiate and fruit machine addiction) turned out to be his inability to communicate or mix socially, hence the need to play the machines to avoid feeling foolish and to dissipate feelings of loneliness" (Drug Project Worker, Yorkshire). "(Those fruit machine addicts who abuse solvents) are clearly seen to have inadequate personalities, are low achievers with little or no self-esteem, usually from difficult home circumstances" (Solvent Abuse Counsellor, Lancashire ) . "My client's problems while causing him enormous difficulties are secondary to his long term social and emotional deprivation" (Co-ordinator of a Drug and Alcohol Advice Centre, Oxfordshire).
DISCUSSION
Since this study was of an exploratory nature in which no specific information was asked for, it is perhaps unsurprising that the range of information given was varied and at times somewhat anecdotal. However, m a n y of these anecdotes and assertions were duplicated and confirmed by other responding agencies providing reasonable evidence for the widespread prevalence - albeit minor-- of gambling cross addictions. It should also be pointed out that the data from this study were collected some years ago and that it is possible that the situation has changed, but this is probably unlikely. Accepting the study's limitations, results indicate that gambling cross addictions amongst people with drug problems exist and thus confirm the findings of Lesieur, Blume and Zoppa (1986). However, it must be added that only just over half the responding agencies had encountered it. Prevalence levels of gambling cross addiction were hard to estimate although approximately a quarter of the responding agencies gave levels (assumed by
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the author) of at least 10% which is similar to the figures of 9% and 14% reported by Lesieur et al (1986) and Lesieur and Heineman (1988) respectively. It was clear from the results that most of the agencies that did not acknowledge the existence of gambling cross addiction argued it was because a drug addict's finances and time could not simultaneously be stretched over more than one addiction. Since cross-addiction has no universally accepted definition bar some vague notion of dual/multiple addiction within an individual, it may be that cross addiction to some of the agencies reporting its non-existence meant simultaneous drug and gambling addiction co-existence whereas for others who responded it may have meant an individual going from one addiction (say heroin) to another (say gambling) but not actually occurring concurrently. Alternatively (as a few agencies reported), it may just be because gambling cross addiction was not specifically looked for. These observations highlight the need for strict and widely available operational definitions of what cross addiction constitutes and perhaps more importantly what it does not constitute. It also highlights the need for more records to be kept by the helping agencies. However, it should be noted that other cross addictions (i.e. dual/multiple drug users but non gamblers) were additionally reported by 14% of the respondents not reporting gambling cross addiction. It is perhaps worth noting that some behaviours reported as being "addictive" by some agencies may not be perceived by others (including other agencies and the general public) as bona fide addictions because they do not involve the ingestion of a drug (e.g. overeating addictions), are legally prescribed (e.g. benzodiazepines) or are commonplace and socially acceptable (e.g. nicotine). These observations lead to the conclusion that not only should the term "cross addiction" be adequately defined but that the term "addiction" itself should have practical operational definitions for research purposes. This is perhaps the fault of the author for not being explicit as to the information required. Although there is no precise breakdown of cross addiction by sex, it is clear from the information received that for nearly all of those agencies referring to specific instances and/or case studies, the gamblers were almost always male. The only female cross addiction mentioned in replies from the agencies were non gambling ones involving nicotine and benzodiazepines. Cross addictions involving
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gambling and alcohol were the most widely reported (see Table 2); although given the comparable social histories of these two activities (outlined in the previous section by some of the respondents), it is perhaps unsurprising that they should co-exist among some people. The data suggested that alcoholics who also had a gambling addiction gambled on horse racing, whereas other gambling cross addicts tended to gamble on fruit machines. The latter was particularly noted amongst adolescents and young adults. Such a suggestion that particular types of gamblers (e.g. horse race gamblers, fruit machine gamblers etc). tend to abuse particular substances requires more substantial empirical support. However, it is interesting that a number of agencies reporting instances of gambling cross addiction should independently report the co-existence of fruit machine playing and solvent abuse amongst adolescents (9 out of 79). This is a little documented phenomenon and would make an interesting area of potential study. It is known that fruit machine playing is a common activity in adolescence that can in some cases reach addictive levels (Griffiths, 1989; 1991), but there is little evidence in the literature to date to suggest addicted fruit machine addicts abuse either alcohol, solvents and/or other drugs. This study clearly indicates that adolescents as well as adults can become cross addicts. A n u m b e r of reasons for the link between fruit machines and solvent abuse and drugs could be speculated. It could be that the arcade subculture in some way "promotes" deviant activities and is thus utilized by drug dealers. With regards to solvents, it could just be that they are relatively easy to obtain in comparison with other drugs (i.e. they are legally available to b u y ) - - a t least at the time of the study. Alternatively, it could be characteristics of the individuals themselves. The sparse anecdotal accounts from the responding agencies reporting fruit machine addiction/solvent abuse appeared to suggest that at a psychological level, addictions were related to social deprivation and isolation, a lack of self esteem, a lack of communication skills and difficult home circumstances. All of these hypotheses require further support. A further line of research could be based on the observation by one respondent that in his experience cross addicted males abused alcohol prior to their gambling problems whereas in women the gambling pre-dated the drinking. Reasons for why this should be the case are unclear but nevertheless should be investigated. M o r e research is
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also n e e d e d into gambling cross addictions a m o n g s t ethnic minorities. It could well be that different cultural forces are at work in relation to their addictive b e h a v i o u r than n o n minorities. T o the author's knowledge this is the first study to examine g a m b l i n g cross addiction in the U K and as such the data (although a d m i t t e d l y sparse and somewhat anecdotal) are of existential value. M u c h of the data reported here are inconclusive and m u c h research needs to be done to confirm or disconfirm the suggestions raised. H o w e v e r , cross addiction clearly exists and studies such as this d e m o n s t r a t e there is a need to educate addiction workers to ask about gambling. REFERENCES Adkins, B.J., Rugle, L.J. & Taber, J.I. (1985, November). A note on sexual addiction among compulsive gamblers. Paper presented at the First National Conference on Gambling Behavior of the National Council on Compulsive Gambling, New York. Blume, S.B. (1994). Pathological gambling and switching addictions: Report of a case. Journal of Gambling Studies, 10, 87-96. Ciarrocchi, j . & Richardson, R. (1989). Profile of compulsive gamblers in treatment: Update and comparisons. Journal of Gambling Behavior, 5, 53-65. C iarrocchi, J., Kirschner, N.M. & Fallik, F. (1991). Personality dimensions of male pathological gamblers, alcoholics and dually addicted gamblers. Journal of Gambling Studies, 7, 133-141. Custer, R.L. & Custer, L.F. (1978, December). Characteristics of the recovering compulsive gambler: A survey of 150 members of Gamblers Anonymous. Paper presented at the Fourth Annum Conference on Gambling, Reno, Nevada. Dell, L.J., Ruzicka, M.F. & Palisi, A.T. (1981). Personality and other factors associated with gambling addictions. International Journal of the Addictions, 16, 149-156. Griffiths, M.D. (1989). Gambling in children and adolescents. Journal of Gambling Behavior, 5, 6683. Griffiths, M.D. (1991). Amusement machine playing in childhood and adolescence: A comparative analysis of video games and fruit machines. Journal of Adolescence, 14, 53-73. Haberman, P.W. (1969). Drinking and other self indulgences: Compliments or counter attractions? The International Journal of the Addictions, 4, 157-167. Lesieur, H.R. (1984). The chase: The career of the compulsive gambler. Cambridge, MA: Schenkman Books. Lesieur, H.R. (1988). The female pathological gambler. In W.R. Eadington (Ed.), Gambling &udies." Proceedings of the 7th International Conference on Gambling and Risk Taking. Reno, Nevada: University of Nevada press. Lesieur, H.R., Blume, S.B., & Zoppa, R.M. (1986). Alcoholism, drug abuse and gambling. Alcoholism: Clinical and ExDen'mental Research, 10, 33-38. Lesieur, H.R. & Heineman, M. (1988). Pathological gambling among youthful multiple substance abusers in a therapeutic community. British Journal of Addiction, 83, 765-771. Levinson, P.K., Gernstein, D.R. & Maloff, D.R. (Eds.)(1983). Commonalties in substance abase and habitual behavior. Lexington, Mass.: Lexington Books. Linden, R.D., Pope, M.G. & Jonas, J.M. (1986). Pathological gambling and major affective disorder: Preliminary findings. Journal of Clinical Psychiatry, 47, 201-203. Marks, I. (1990). Non-chemical (behavioural)addictions. British Journal of Addiction, 85, 13851389.
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Standing Conference On Drug Abuse (1987). SCODA national directory: Where to get help. London: BBC Books. McCormick, R.A., Russo, A.M., Ramirez, L.F. & Taber, J.I. (1984). Affective disorders among pathological gamblers seeking treatment. American Journal of Psychiatry, 141, 215-218. Miller, W.R. (1980). The addictive behaviors. Oxford: Pergamon Press. Orford, J. (1985). Excessive appetites: A psychological view of the addictions. C hichester: Wiley. Ramirez, L.F. McCormick, R.A., Russo, A.M. & Taber, J.I. (1984). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behaviors, 8, 425-428.
University of Plymouth
A growing body of empirical and theoretical research has concentrated on the overlaps a n d commonalities a m o n g chemical and non-chemical (behavioural) addictions. Pathological gambling has perhaps been the most widely researched behavioural addiction and some of this research has concerned the co-existing links between pathological gambling and alcohol/drug addiction in both the gambling substance abuser and the substance abusing gambler (i.e. cross addiction). This study was of an exploratory nature and attempted to gather information and data regarding gambling cross addictions in the U K . To achieve this, 456 letters were sent to all drug and alcohol helping agencies in England requesting such information. This yielded 210 returns (46% response rate). Results indicated that gambling cross addictions occur in both adults and adolescents and were almost exclusively a male condition. However, it must be noted only just over half of the responding agencies had encountered g a m b l i n g cross addiction and reasons for this are speculated. Results also indicated the existence of various cross addicted subgroups including an adolescent subgroup who were addicted to fruit machines and abused solvents. Future research ideas are also discussed.
INTRODUCTION
Since the 1980's, a growing body of empirical and theoretical research has concentrated on the overlaps and commonalities among
Reprint requests should be addressed to Dr. Mark Griffiths, Psychology Department, University of Plymouth, Drake Circus, Plymouth, UK, PL4 8AA. A more detailed version of this paper is available from the author on request.
Journal of Gambling Studies Vol. 10(4), Winter 1994 Q 1994 Human Sciences Press, Inc.
371
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JOURNAL OF GAMBLING STUDIES
chemical and non-chemical (behavioural) addictions (e.g., Miller, 1980; Levinson, Gernstein & Maloff, 1983; Orford, 1985; Marks, 1990). Pathological gambling has perhaps been the most widely researched behavioural addiction (i.e. an addictive activity which does not rely on the ingestion of a psychoactive drug) some of which has been concerned with the co-existence of alcohol/drug addiction with gambling addiction (and termed 'cross addiction'). An early study by Custer and Custer (1978) found that 8% of Gamblers Anonymous members were alcoholic and that a further 2 % were addicted to other drugs. Since this study, evidence for coexisting dependencies with pathological gambling have appeared with regularity. Ramirez, McCormick, Russo and Taber (1984) reported that 47 % of pathological gamblers attending at a Veteran's Administration medical centre met the criteria for alcohol and/or substance abuse at some point in their lives (with 39% meeting the criteria in the year prior t o admission). Ciarrocchi and Richardson (1989) reported that of those attending their gambling treatment centre, 34% were abusing alcohol, 6% drugs and 31% both. Studies by both Linden, Pope and Jonas (1986) using male GA members and Lesieur (1988) using female GA members both reported that 52% of their samples had abused alcohol and/or drugs at some point in their lives. Other studies by Dell, Ruzicka and Palisi (1981), Lesieur (1984) and McCormick, Russo, Ramirez and Taber (1984) have also reported links between pathological gambling and alcohol/drug addictions. In addition, some studies have reported the co-existence of gambling and sex addictions (Adkins, Rugle & Taber, 1985; Lesieur, 1988), and gambling and overeating addictions (Lesieur, 1988). There has been little research examining the co-existence of pathological gambling and alcohol/drug addictions using substance abusing populations. Although Haberman (1969) reported that 17 % of his 70 alcoholics under study admitted having "gambling difficulties" (p. 164) it was not until a study by Lesieur, Blume and Zoppa (1986) that more reliable figures were obtained. Lesieur and his colleagues reported that amongst 458 alcohol and drug addict inpatients, 9% were diagnosed as pathological gamblers with a further 10% showing signs of problematic gambling. A further study of 100 multiple substance abusers by Lesieur and Heineman (1988) reported 14% of the sample to be pathological gamblers with a further 14 % showing signs of pathological gambling. More recently, there has been further research highlighting the existence of cross addictions both in clinical
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surveys (Ciarrocchi, Kirschner, & Fallik, 1991) and clinical case studies (e.g. Blume, 1994). It is clear from the research outlined that more research is needed on the co-existing links between pathological gambling and alcohol/ drug addictions in both the gambling substance abuser and the substance abusing gambler. It is also the case that all the data on gambling cross addictions outlined above have been collected in the US. It is with this in mind that the present exploratory study was carried out.
METHOD In March and April 1989 a total of 456 letters were sent to all drug and alcohol helping agencies in England (i.e. National Health Service and private addiction treatment units and clinics, self-help groups, drug and alcohol help lines, counselling services, youth agencies etc.) requesting information regarding cross addictions to gambling (i.e. information on individuals who were addicted to gambling and at least one other activity like drug taking, drinking etc.) The letter made no reference as to whether these behaviours occurred simultaneously or sequentially. All addresses were obtained from the Standing Conference On Drug Abuse National Directory (1987). The letter asked for no specific information leaving potential respondents the chance to write as much or as little as they felt necessary. Since funds were limited only one mailing was carried out with no follow up reminders. A total of 196 replies were received in addition to 14 letters "returned to sender" leaving a total of 246 potential respondents unaccounted for. Below is a breakdown of the replies received: 1. Letters (n = 142) and telephone calls (n = 8) providing information of varying amounts about cross addictions. 2. Letters which would/could not provide information about cross addictions (n = 7) because of "moral" and/or "professional" obligations to their clients. 3. Letters (n = 38) and telephone calls (n = 1) which provided no information regarding cross addictions but gave a follow up contact. These were only followed up if the person/ organization had not been contacted in the original mailing. (As a result of this process two follow up contacts were made in Scotland)
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4. Letters returned to sender (n = 14) because the organization had disbanded leaving no forwarding address.
RESULTS AND PRELIMINARY DISCUSSION Due to its qualitative nature much of the data reported in this results section cannot be reported without some kind of initial interpretation which would normally constitute inclusion in the discussion. A more general discussion will follow this section. O f the 150 replies yielding information, 53% (79 out of 150) reported they had encountered at least one case of gambling cross addiction whereas the remaining 47 % of respondents (71 out of 150) were of the view that gambling cross addiction did not exist or that they had not directly encountered it during their professional careers. This very small latter group constituted 2 % of the usable sample (3 out of 150) and reported they only knew of cases through third parties (e.g. partners of their clients) but had not seen it for themselves. One of the major arguments for the nonexistence of gambling cross addiction was that all an addict's energies go into one addiction. Statements putting forward this argument were abundant. Typical responses included the following (Note: places are county names, therefore individuals cannot be identified): "A drug addiction makes it necessary for (addicts) to spend most of their time and energy obtaining their drug of preference" (Drug Project Director,
Yorkshire). "In my own experience so far, serious addiction to one object or event usually does not leave room for a concurrent cross addiction" (Director of an Addic-
tion Trust, Norfolk). ~'It is unusual to see cross addictions to gambling since severe drug addicts have little money to gamble with" (Consultant Psychiatrist, London).
A few respondents said the reported non-existence might be due to other factors. For instance: "Although we have no records of cross addictions to gambling, this might not mean there are no such clients. It may be that we missed picking up such a vital point, but you have opened our curiosity. Hopefully this might make us more
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vigilant in picking up such things in the future" (Manager of a Substance Misuse Service, Lancashire). "We have not found instances of gambling and drug use. I should say, however, that this is not something we have been looking into so it remains a possibility that such cross addictions operate" (Drug Researcher, Scotland).
A number of respondents made the point that it may be possible for a person to have been addicted to both gambling and to have had an alcohol/drug addiction in their lives, but that it was unlikely that it happened concurrently. For instance: "People who use drugs heavily have little spare for other purposes although I wouldn't exclude the possibility that some people get heavily into gambling between bouts of heavy drug use" (Coordinator of a Drug Help Agency, Shropshire). "We occasionally notice that in the years prior to a client's drug problem he has had a phase of gambling addiction, but once he has moved onto drug abuse his time and money are totally committed to replenishing his drug supply" (Drug Team Leader, Warwickshire). "In a lot of cases, drug addicts are drinkers and gamblers too although they have not got enough money to support all three. In the case of drug addicts, the drug comes first" (Administrative Assistant, Drugs Advice Service, Cumbria).
Three respondents highlighted the fact that they knew their clients liked to gamble but it was at non-addictive levels. Fourteen percent of respondents who reported no existence of gambling cross addiction (10 out of 71) additionally mentioned that they had encountered other cross addictions. Some typical admissions include: "Some of our individuals certainly abuse multiple substances--alcohol and heroin for example" (Drug Researcher, Scotland). "We certainly come across poly abuse e.g., the amphetamine user who when supplies are short turns to alcohol--but not to gambling" (Drug Help Line Project Worker, Bedfordshire).
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"If you had chosen the connection between nicotine and either alcohol or opiate addiction (rather than gambling), it would have been a different matter. Two small samples I did at former places of work both had 90 % cross addiction" (Clinical Psychologist, Berkshire). As reported above, 53% of the respondents (79 out of 150) reported at least one case of gambling cross addiction although 65 % of these (51 out of 79) gave no specific incidence figures--only rough impressionistic estimates. Using these estimates it would appear that reports of more than nominal gambling cross addiction (i.e. those reports which would seem to indicate at least 10% of people encountered are cross addicts) account for 26.5% of cases (21 out of 79; see Table 1), however, this may not be the "true picture." There were a number of reasons why respondents did not give exact details, the primary reason being that such information was not kept or collated. Other respondents gave no reason or rationale for their rough estimates while still other respondents gave reasons of a more idiosyncratic nature (e.g. trying to decide what behaviours constitute bona fide addictions and cross addictions). 35% of respondents (28 out of 79) gave specific statistics of the incidence of gambling cross addiction. This low figure was probably due to the low incidence rates involved i.e. there were so few cases that these were either remembered well or specifically recorded because of their 'novelty.' O f the 28 specific replies, 57 % reported having encountered only one gambling cross addict in their careers (16 out of 28) with 36% reporting under ten cases (10 out of 28). However, a few of the incidences in this latter group were current annual figures rather than total cases ever recorded. Table 2 shows the main types of gambling cross addiction. Although 'drugs' could technically include alcohol, solvents, amphetamines etc., it is assumed that respondents reporting 'drug' addictions meant opiate addictions (e.g. heroin) although this of course may be a false assumption and may also include various stimulants (e.g. cocaine) and hallucinogens (e.g. LSD). Allowing for this assumption, results show that 'alcohol/gambling' cross addictions were the most frequently reported by the respondents (42%), followed by ~drugs/ gambling (20 % ), 'solvents/fruit machines' (10.5 % ), 'alcohol and drugs/ gambling' (7 %) and 'amphetamines/gambling' (3.5 %). This type of profile appeared to correspond with the more detailed replies from the
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Table 1 Gambling Cross Additions and Type in Treatment Establishments by Region Where Incidence is Presumed to be at Least I0% Treatment Establishment
Geographical Location
Incidence of Gambling Cross Additions
Main Types of Cross Additions
01
I.R.
Buckinghamshire
"quite a few"
alcohol/gambling
02
H
Devon
8-10 per year
alcohol/gambling
03
I.R.
Devon
04
S.H.
Hampshire
05
I.R.
Hertfordshire
06
I.R.
Hertfordshire
07
I.R.
Lancashire
08 09
I.R. I.R.
London London
"increasing numbers" "quite a few" ~'a high number" "quite a few" "quite common" "very common" approx. 10%
solvents/fruit machines drugs/fruit machines
t0
I.R.
London
nine (currently)
drugs/gambling
11
I.R.
London
seven (10%)
drugs/gambling
12
S.H.
London
"quite common"
heroin/gambling
13
I.R.
Northumbria
H I.R.
Nottinghamshire Shropshire
16
I.R.
Surrey
17
I, R.
Surrey
18
I.R.
Surrey
19
I.R.
Surrey
20 21
I.R. H
Sussex Yorkshire
"quite common" "many" '`quite common" "many" (out of 300 + ) 'fairly common" "a sizeable number" ~very common" "a fair number"
alcohol/gambling
14 15
48/225 (21.3 %)
solvents/fruit machines alcohol/gambling alcohol/gambling * */gambling alcohol/gambling
alcohol/gambling amphets/fruit machines drugs/gambling not specified alcohol/gambling alcohol/gambling solvents/fruit machines alcohol/fruit machines
H = Hospital, I.R. = Independent Rehabillitation and S.H. = Self Help **alcohol, drugs, tranquilizers & overeating
respondents. Although gambling type was not specifically asked for in the letter requesting information, it should be noted that those agencies reporting gambling type noted that the problem concerned fruit machines. From a number of the replies it seems there were two groups of gambling cross addicts differentiated by age and type of gambling, with
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OF GAMBLING
STUDIES
Table 2 M a i n Types of Gambling Cross Addictions as Reported by Respondents (n = 79) Type of Cross Addiction
n
Alcohol/gambling* Drugs/gambling* * Solvents/fruit machine gambling Alcohol & drugs/gambling Amphetamines/gambling* * * Tranquillizers/gambling Overeating/gambling C annabis/gambling Computer games/gambling Caffeine/gambling Exercise/gambling
36 17 09 06 03 02 02 01 01 01 01
Not Specific
13
Total
86****
*Includes 3 fruit machines **Includes 4 fruit machine gambling ***Includes 1 fruit machine gambling ****Some respondents gave more than one answer
an increasing awareness that young gamblers can be just as problematic as their older counterparts: '7 see gambling chiefly in two client groups, fruit machine problems with young drug users (under 18) and betting in alcohol users" (Director of a Drugs Advice Service, Sussex). 'Cross addicts who gamble tend to be male from social classes 4 and 5, often with criminal records who tend to have severe drinking problems to the point of physical dependence~ (Consultant Psychiatrist, Nottinghamshire). "One particular sub-group came to mind which consisted of fairly young adolescents who seem to get caught up in a cycle of gambling on fruit machines and solvent abuse" (Clinical Psychologist, Addiction Centre, Kent).
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"Of the 225 appointments booked, 21.3 % werefor gambling . . . Most of the clients were fairly young (15-25 age group) and fruit machines was the main form in which the gambling presented. (Clinical Psychologist, Addiction
Unit, Yorkshire). "The only addicts I personally encounter are younger clients who frequent amusement arcades awaiting friends and dealers" (Drug Counsellor, Hum-
berside). Reasons for the links between gambling and other addictive activities were only touched upon by a few respondents, however, those who did give reasons had interesting hypotheses: '7 suspect there is a cultural element . . . The pub and the bookies tend to be fairly close together. In a sense this is acknowledged legally, as gambling was outlawed from public houses in 1948 and prior to that, had serious restrictions placed upon it" (Consultant Psychiatrist, Addiction Clinic, Devon). "I feel that situational forces also come into play in so much that pubs are also centresfor gambling and amusement arcades are centres, at least in (this town), for youth culture drug dealing" (Director of a Drugs Advice Service,
Sussex). "My suspicion is that this is largely due to the social and cultural milieu that the person was circulating in, where gambling was predominant . . . These were men in their mid-30's to mid-50's. In most cases, the drinking pre-dated the gambling episodes, and in all the cases I can think of, the gambling and drinking were in the individual's family history" (Co-ordinator of a Drug
Outreach Project, London). "Most of my referrals (for solvent abuse and fruit machine addiction) are quite young i.e. 12 to 15years o l d . . . ~ The interest displayed by theseyoungsters is usually flirtation initiated by curiosity and peer pressure" (Solvent Abuse
Counsellor, Lancashire). "One area of concern is ethnic groups. The oriental~eastern cultures have a very clear link with gambling and narcotics and one only has to look at the facts concerning Soho in London in the sixties" (Co-ordinator of a Drug Project,
Buckinghamshire).
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Typical reasons put forward by respondents as to the psychological motivations behind their client's addictive behaviour problems: "In character many (cross addicts) are searching for instant fun or an immediate resolution of stress, and it is often the impulsive quality that presents a barrier to treatment" (Consultant Psychiatrist, Yorkshire). "Following counselling, the root cause (of his opiate and fruit machine addiction) turned out to be his inability to communicate or mix socially, hence the need to play the machines to avoid feeling foolish and to dissipate feelings of loneliness" (Drug Project Worker, Yorkshire). "(Those fruit machine addicts who abuse solvents) are clearly seen to have inadequate personalities, are low achievers with little or no self-esteem, usually from difficult home circumstances" (Solvent Abuse Counsellor, Lancashire ) . "My client's problems while causing him enormous difficulties are secondary to his long term social and emotional deprivation" (Co-ordinator of a Drug and Alcohol Advice Centre, Oxfordshire).
DISCUSSION
Since this study was of an exploratory nature in which no specific information was asked for, it is perhaps unsurprising that the range of information given was varied and at times somewhat anecdotal. However, m a n y of these anecdotes and assertions were duplicated and confirmed by other responding agencies providing reasonable evidence for the widespread prevalence - albeit minor-- of gambling cross addictions. It should also be pointed out that the data from this study were collected some years ago and that it is possible that the situation has changed, but this is probably unlikely. Accepting the study's limitations, results indicate that gambling cross addictions amongst people with drug problems exist and thus confirm the findings of Lesieur, Blume and Zoppa (1986). However, it must be added that only just over half the responding agencies had encountered it. Prevalence levels of gambling cross addiction were hard to estimate although approximately a quarter of the responding agencies gave levels (assumed by
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the author) of at least 10% which is similar to the figures of 9% and 14% reported by Lesieur et al (1986) and Lesieur and Heineman (1988) respectively. It was clear from the results that most of the agencies that did not acknowledge the existence of gambling cross addiction argued it was because a drug addict's finances and time could not simultaneously be stretched over more than one addiction. Since cross-addiction has no universally accepted definition bar some vague notion of dual/multiple addiction within an individual, it may be that cross addiction to some of the agencies reporting its non-existence meant simultaneous drug and gambling addiction co-existence whereas for others who responded it may have meant an individual going from one addiction (say heroin) to another (say gambling) but not actually occurring concurrently. Alternatively (as a few agencies reported), it may just be because gambling cross addiction was not specifically looked for. These observations highlight the need for strict and widely available operational definitions of what cross addiction constitutes and perhaps more importantly what it does not constitute. It also highlights the need for more records to be kept by the helping agencies. However, it should be noted that other cross addictions (i.e. dual/multiple drug users but non gamblers) were additionally reported by 14% of the respondents not reporting gambling cross addiction. It is perhaps worth noting that some behaviours reported as being "addictive" by some agencies may not be perceived by others (including other agencies and the general public) as bona fide addictions because they do not involve the ingestion of a drug (e.g. overeating addictions), are legally prescribed (e.g. benzodiazepines) or are commonplace and socially acceptable (e.g. nicotine). These observations lead to the conclusion that not only should the term "cross addiction" be adequately defined but that the term "addiction" itself should have practical operational definitions for research purposes. This is perhaps the fault of the author for not being explicit as to the information required. Although there is no precise breakdown of cross addiction by sex, it is clear from the information received that for nearly all of those agencies referring to specific instances and/or case studies, the gamblers were almost always male. The only female cross addiction mentioned in replies from the agencies were non gambling ones involving nicotine and benzodiazepines. Cross addictions involving
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gambling and alcohol were the most widely reported (see Table 2); although given the comparable social histories of these two activities (outlined in the previous section by some of the respondents), it is perhaps unsurprising that they should co-exist among some people. The data suggested that alcoholics who also had a gambling addiction gambled on horse racing, whereas other gambling cross addicts tended to gamble on fruit machines. The latter was particularly noted amongst adolescents and young adults. Such a suggestion that particular types of gamblers (e.g. horse race gamblers, fruit machine gamblers etc). tend to abuse particular substances requires more substantial empirical support. However, it is interesting that a number of agencies reporting instances of gambling cross addiction should independently report the co-existence of fruit machine playing and solvent abuse amongst adolescents (9 out of 79). This is a little documented phenomenon and would make an interesting area of potential study. It is known that fruit machine playing is a common activity in adolescence that can in some cases reach addictive levels (Griffiths, 1989; 1991), but there is little evidence in the literature to date to suggest addicted fruit machine addicts abuse either alcohol, solvents and/or other drugs. This study clearly indicates that adolescents as well as adults can become cross addicts. A n u m b e r of reasons for the link between fruit machines and solvent abuse and drugs could be speculated. It could be that the arcade subculture in some way "promotes" deviant activities and is thus utilized by drug dealers. With regards to solvents, it could just be that they are relatively easy to obtain in comparison with other drugs (i.e. they are legally available to b u y ) - - a t least at the time of the study. Alternatively, it could be characteristics of the individuals themselves. The sparse anecdotal accounts from the responding agencies reporting fruit machine addiction/solvent abuse appeared to suggest that at a psychological level, addictions were related to social deprivation and isolation, a lack of self esteem, a lack of communication skills and difficult home circumstances. All of these hypotheses require further support. A further line of research could be based on the observation by one respondent that in his experience cross addicted males abused alcohol prior to their gambling problems whereas in women the gambling pre-dated the drinking. Reasons for why this should be the case are unclear but nevertheless should be investigated. M o r e research is
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also n e e d e d into gambling cross addictions a m o n g s t ethnic minorities. It could well be that different cultural forces are at work in relation to their addictive b e h a v i o u r than n o n minorities. T o the author's knowledge this is the first study to examine g a m b l i n g cross addiction in the U K and as such the data (although a d m i t t e d l y sparse and somewhat anecdotal) are of existential value. M u c h of the data reported here are inconclusive and m u c h research needs to be done to confirm or disconfirm the suggestions raised. H o w e v e r , cross addiction clearly exists and studies such as this d e m o n s t r a t e there is a need to educate addiction workers to ask about gambling. REFERENCES Adkins, B.J., Rugle, L.J. & Taber, J.I. (1985, November). A note on sexual addiction among compulsive gamblers. Paper presented at the First National Conference on Gambling Behavior of the National Council on Compulsive Gambling, New York. Blume, S.B. (1994). Pathological gambling and switching addictions: Report of a case. Journal of Gambling Studies, 10, 87-96. Ciarrocchi, j . & Richardson, R. (1989). Profile of compulsive gamblers in treatment: Update and comparisons. Journal of Gambling Behavior, 5, 53-65. C iarrocchi, J., Kirschner, N.M. & Fallik, F. (1991). Personality dimensions of male pathological gamblers, alcoholics and dually addicted gamblers. Journal of Gambling Studies, 7, 133-141. Custer, R.L. & Custer, L.F. (1978, December). Characteristics of the recovering compulsive gambler: A survey of 150 members of Gamblers Anonymous. Paper presented at the Fourth Annum Conference on Gambling, Reno, Nevada. Dell, L.J., Ruzicka, M.F. & Palisi, A.T. (1981). Personality and other factors associated with gambling addictions. International Journal of the Addictions, 16, 149-156. Griffiths, M.D. (1989). Gambling in children and adolescents. Journal of Gambling Behavior, 5, 6683. Griffiths, M.D. (1991). Amusement machine playing in childhood and adolescence: A comparative analysis of video games and fruit machines. Journal of Adolescence, 14, 53-73. Haberman, P.W. (1969). Drinking and other self indulgences: Compliments or counter attractions? The International Journal of the Addictions, 4, 157-167. Lesieur, H.R. (1984). The chase: The career of the compulsive gambler. Cambridge, MA: Schenkman Books. Lesieur, H.R. (1988). The female pathological gambler. In W.R. Eadington (Ed.), Gambling &udies." Proceedings of the 7th International Conference on Gambling and Risk Taking. Reno, Nevada: University of Nevada press. Lesieur, H.R., Blume, S.B., & Zoppa, R.M. (1986). Alcoholism, drug abuse and gambling. Alcoholism: Clinical and ExDen'mental Research, 10, 33-38. Lesieur, H.R. & Heineman, M. (1988). Pathological gambling among youthful multiple substance abusers in a therapeutic community. British Journal of Addiction, 83, 765-771. Levinson, P.K., Gernstein, D.R. & Maloff, D.R. (Eds.)(1983). Commonalties in substance abase and habitual behavior. Lexington, Mass.: Lexington Books. Linden, R.D., Pope, M.G. & Jonas, J.M. (1986). Pathological gambling and major affective disorder: Preliminary findings. Journal of Clinical Psychiatry, 47, 201-203. Marks, I. (1990). Non-chemical (behavioural)addictions. British Journal of Addiction, 85, 13851389.
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Standing Conference On Drug Abuse (1987). SCODA national directory: Where to get help. London: BBC Books. McCormick, R.A., Russo, A.M., Ramirez, L.F. & Taber, J.I. (1984). Affective disorders among pathological gamblers seeking treatment. American Journal of Psychiatry, 141, 215-218. Miller, W.R. (1980). The addictive behaviors. Oxford: Pergamon Press. Orford, J. (1985). Excessive appetites: A psychological view of the addictions. C hichester: Wiley. Ramirez, L.F. McCormick, R.A., Russo, A.M. & Taber, J.I. (1984). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behaviors, 8, 425-428.
