Scot. med, J., 1977, 22: 251
'COMPULSIVE' GAMBLING AS AN ADDICTION: DILEMMAS
At a meeting of the Gamblers Anonymous (GA) a man described how he had told his general practitioner about his difficulties in controlling his gambling; 'I think I'm a compulsive gambler', the man had said. The general practitioner had replied that he himself liked gardening and spent much of his time in his garden ... 'am 1 then a compulsive gardener?' This is not to say ,that the general practitioner was unsympathetic to the genuine problem that his patient had put t,o him, but he was certainly loath to extend his concept of compulsions, and indeed illn~ss, to include gambling. Whether or not gambling should be included within a concept of illness, and more specifically, of addiction, is the focus of this comment. Until the late 1960's there was a paucity of scientific studies of gambling. There were reported case studies of chronic gamblers often treated by psychoanalysis, and there were analyses of famous gamblers such as Dostoevsky. Partly as a reaction to this dearth of information and partly because gambling wasrapidly increasing, there followed a flurry of theoretical papers, papers about various forms of therapy for gamblers and papers describing empirical studies in actual gambling situations (Bolen, 1974). It is now firmly established that for some men and women gambling may be the source of a genuinely serious complex of personal, social and economic problems. In the United Kingdom the first meeting of GA took place in Belfast in 1963. Moody (1972)stated that in anyone week the London telephone number of GA received 25 new appeals for help. At the present time there are almost 50 groups of GA meeting weekly in different cities throughout the U.K. (and Gam-Anon., the sister organisation that runs separate meetings for relatives of the gambler). Men and women attending GA meetings generally refer to themselves as 'compulsive' gamblers. The words 'compulsive', 'pathological' and 'addictive' have been used to describe gambling behaviour when it appears to be causing personal problems either to the
gambler and/or to his or her immediate relatives or friends. Estimates of the incidence of such gamblers have ranged from 75,000 'thorough going' gamblers in betting shops to I million for all forms of gambling. No one level of gambling may be said to represent a problem; some people seek help when losing a few pounds per week and others may only do so when they face divorce, prison or bankruptcy. The central feature of the gambler who seeks help is that he experiences an inability to control his cash expenditure on gambling. He may have tried repeatedly to stop with temporary or no success. The most common form of betting for men is the betting office, and approximately 15 per cent of customers report various stages of loss of control and could be said to be 'compulsive'. These customers spend more than 2 hours per day betting in a betting office, at least 3 times a week. They report regularly losing all their cash-in-hand and all describe a feeling of 'wanting to chase it', i.e., once they are inside the shop they experience a desire to bet again and again, especially after a sequence of losing bets. While in the shop and while listening to the race commentary, customers describe tachycardia, sweating, muscle tension, stomach cramps, etc. There is evidence that when men move from punting, or having infrequent bets, to a 'compulsive' level, spending between 20 and 30 hours per week betting, that stake size escalates. The very small percentage of 'compulsive' gamblers who present to psychiatric care are most often referred by general practitioners or by probation officers. They often attract the label 'psychopath', but this may merely reflect the fact that gamblers often lie incessantly-having done so for years to marital partners in an endeavour to hide the true nature of the problem, the habit dies hard. The variety of therapeutic endeavours (including GA) have rarely bettered the success rate of 2 out of 5 gamblers abstinent or controlled by the end of therapy. In an endeavour to shift the point of delivery away from institutions to any helping agencies in the community who might contact gamblers seeking help, the Consultation on 'Compulsive' Gambling published a hrief practical guide (Dickerson, 1975).
Downloaded from scm.sagepub.com at Bobst Library, New York University on March 1, 2016
Comments
It is in its presentation to psychiatric care that gambling seems much like the addictions. Often relatives or friends have initiated the referral. The gambler is often personally, if not socially, isolated. He may have tried controlling his betting behaviour previously without success. His actual gambling behaviour will exhibit loss of control and the size of his stake will be 10 or more times that of the average gambler. Furthermore, although not yet well documented, gamblers who stop betting report depressed mood, irritability, motor agitation, tremors, inability to concentrate and a wide variety of physical complaints. Most common of these are nausea and headaches. Even after abstinence from betting for a year or more some GA members report brief outbursts of gambling without any apparent psychological precipient. Usually the physical symptoms briefly reappear. If 'compulsive' gambling were eventually to be classified among the addictions then this might be thought helpful in the provision of care. With investment of funds it might be made rather easier for the 'compulsive' gambler to present for help. It might become an accepted reason for referral for specialist health/psychiatric care. On the other hand, it is quite possible that the development of help for gamblers along such traditional health care lines might be less effective in the long term than modifying the gambling environment itself. Certainly in alcoholism the present shift in emphasis is towards modifying
the situation in which the addictive behaviour develops, and this would seem to be the most useful approach to 'compulsive' gambling. Despite the absence of a psychoactive agent, 'compulsive' gambling might be classified as an addiction solely on the basis of loss of control, escalation of stake size and cold turkey' features following cessation of gambling. The inclusion of 'compulsive' gambling in the class of addictions might validly emphasise the role played by the repetitive stimulus characteristics of an environment in the genesis of addictions. On the other hand, maybe the discussion is now back with the gardening general practitioner. Perhaps, to extend the concept of addiction to include 'compulsive' gambling is not credible and would lead to a loss of the heuristic function of the concept itself. MARK DICKERSON,
Principal Psychologist, Royal Edinburgh Hospital, Edinburgh, 10. REFERENCES
Bolen, D. W. (1974). Gambling: Historical Highlights, Trends and their Implications for Contemporary Society. Paper presented to First Annual Conference on Gambling, Las Vegas Dickerson, M. G. (1975). Gambling: Associated Problems; A guide for helping agencies. Consultation on 'Compulsive' Gambling. Report No.1 Moody G. E. (1972). The Facts about the 'Money Factories'. London: The Churches' Council on Gambling
252
Downloaded from scm.sagepub.com at Bobst Library, New York University on March 1, 2016
'COMPULSIVE' GAMBLING AS AN ADDICTION: DILEMMAS
At a meeting of the Gamblers Anonymous (GA) a man described how he had told his general practitioner about his difficulties in controlling his gambling; 'I think I'm a compulsive gambler', the man had said. The general practitioner had replied that he himself liked gardening and spent much of his time in his garden ... 'am 1 then a compulsive gardener?' This is not to say ,that the general practitioner was unsympathetic to the genuine problem that his patient had put t,o him, but he was certainly loath to extend his concept of compulsions, and indeed illn~ss, to include gambling. Whether or not gambling should be included within a concept of illness, and more specifically, of addiction, is the focus of this comment. Until the late 1960's there was a paucity of scientific studies of gambling. There were reported case studies of chronic gamblers often treated by psychoanalysis, and there were analyses of famous gamblers such as Dostoevsky. Partly as a reaction to this dearth of information and partly because gambling wasrapidly increasing, there followed a flurry of theoretical papers, papers about various forms of therapy for gamblers and papers describing empirical studies in actual gambling situations (Bolen, 1974). It is now firmly established that for some men and women gambling may be the source of a genuinely serious complex of personal, social and economic problems. In the United Kingdom the first meeting of GA took place in Belfast in 1963. Moody (1972)stated that in anyone week the London telephone number of GA received 25 new appeals for help. At the present time there are almost 50 groups of GA meeting weekly in different cities throughout the U.K. (and Gam-Anon., the sister organisation that runs separate meetings for relatives of the gambler). Men and women attending GA meetings generally refer to themselves as 'compulsive' gamblers. The words 'compulsive', 'pathological' and 'addictive' have been used to describe gambling behaviour when it appears to be causing personal problems either to the
gambler and/or to his or her immediate relatives or friends. Estimates of the incidence of such gamblers have ranged from 75,000 'thorough going' gamblers in betting shops to I million for all forms of gambling. No one level of gambling may be said to represent a problem; some people seek help when losing a few pounds per week and others may only do so when they face divorce, prison or bankruptcy. The central feature of the gambler who seeks help is that he experiences an inability to control his cash expenditure on gambling. He may have tried repeatedly to stop with temporary or no success. The most common form of betting for men is the betting office, and approximately 15 per cent of customers report various stages of loss of control and could be said to be 'compulsive'. These customers spend more than 2 hours per day betting in a betting office, at least 3 times a week. They report regularly losing all their cash-in-hand and all describe a feeling of 'wanting to chase it', i.e., once they are inside the shop they experience a desire to bet again and again, especially after a sequence of losing bets. While in the shop and while listening to the race commentary, customers describe tachycardia, sweating, muscle tension, stomach cramps, etc. There is evidence that when men move from punting, or having infrequent bets, to a 'compulsive' level, spending between 20 and 30 hours per week betting, that stake size escalates. The very small percentage of 'compulsive' gamblers who present to psychiatric care are most often referred by general practitioners or by probation officers. They often attract the label 'psychopath', but this may merely reflect the fact that gamblers often lie incessantly-having done so for years to marital partners in an endeavour to hide the true nature of the problem, the habit dies hard. The variety of therapeutic endeavours (including GA) have rarely bettered the success rate of 2 out of 5 gamblers abstinent or controlled by the end of therapy. In an endeavour to shift the point of delivery away from institutions to any helping agencies in the community who might contact gamblers seeking help, the Consultation on 'Compulsive' Gambling published a hrief practical guide (Dickerson, 1975).
Downloaded from scm.sagepub.com at Bobst Library, New York University on March 1, 2016
Comments
It is in its presentation to psychiatric care that gambling seems much like the addictions. Often relatives or friends have initiated the referral. The gambler is often personally, if not socially, isolated. He may have tried controlling his betting behaviour previously without success. His actual gambling behaviour will exhibit loss of control and the size of his stake will be 10 or more times that of the average gambler. Furthermore, although not yet well documented, gamblers who stop betting report depressed mood, irritability, motor agitation, tremors, inability to concentrate and a wide variety of physical complaints. Most common of these are nausea and headaches. Even after abstinence from betting for a year or more some GA members report brief outbursts of gambling without any apparent psychological precipient. Usually the physical symptoms briefly reappear. If 'compulsive' gambling were eventually to be classified among the addictions then this might be thought helpful in the provision of care. With investment of funds it might be made rather easier for the 'compulsive' gambler to present for help. It might become an accepted reason for referral for specialist health/psychiatric care. On the other hand, it is quite possible that the development of help for gamblers along such traditional health care lines might be less effective in the long term than modifying the gambling environment itself. Certainly in alcoholism the present shift in emphasis is towards modifying
the situation in which the addictive behaviour develops, and this would seem to be the most useful approach to 'compulsive' gambling. Despite the absence of a psychoactive agent, 'compulsive' gambling might be classified as an addiction solely on the basis of loss of control, escalation of stake size and cold turkey' features following cessation of gambling. The inclusion of 'compulsive' gambling in the class of addictions might validly emphasise the role played by the repetitive stimulus characteristics of an environment in the genesis of addictions. On the other hand, maybe the discussion is now back with the gardening general practitioner. Perhaps, to extend the concept of addiction to include 'compulsive' gambling is not credible and would lead to a loss of the heuristic function of the concept itself. MARK DICKERSON,
Principal Psychologist, Royal Edinburgh Hospital, Edinburgh, 10. REFERENCES
Bolen, D. W. (1974). Gambling: Historical Highlights, Trends and their Implications for Contemporary Society. Paper presented to First Annual Conference on Gambling, Las Vegas Dickerson, M. G. (1975). Gambling: Associated Problems; A guide for helping agencies. Consultation on 'Compulsive' Gambling. Report No.1 Moody G. E. (1972). The Facts about the 'Money Factories'. London: The Churches' Council on Gambling
252
Downloaded from scm.sagepub.com at Bobst Library, New York University on March 1, 2016
