IV

Toxic Compulsion 4: Gambling Dependence

My problem with gambling is the losing part. I hate to lose money. Losing to me is so unpleasant that I would rather not even play. If it wasn’t for that, my risk-taking nature might well make me a candidate to become a problem gambler.

Like most addicts, I like the easy fix, the thing that just drops into your lap for no apparent reason, the thing that just changes your life. This is the kind of magical thinking that leads one to think he is going to find a treasure chest or win the lottery. For me, fortunately, gambling was not a viable pathway for addiction because of my distaste for losing money. I could never get over the fact that those big buildings in Las Vegas didn’t get built because there were a lot of people winning.

So it was a bit of a surprise to me when I discovered just how widespread the gambling compulsion has become. A common assumption has been that people with alcohol problems are twice as numerous in the United States as people with gambling problems. When researchers at the University of Buffalo’s Research Institute on Addictions reported survey results in 2011 showing that the number of problem gamblers now exceeds the number of persons with alcohol dependence, skepticism was initially expressed by longtime addiction specialists.

Combining data from two U.S. national surveys in which a total of about 5,000 people were interviewed, age patterns for gambling and alcohol involvement were compared. What emerged was the finding that after 21 years of age, alcohol abuse dropped off and gambling problems multiplied until, from ages 31 through 40, gambling was a bigger problem than alcohol abuse. “I didn’t expect problem gambling to be more common than alcohol dependence for such a wide age range,” commented John Welte, the institute’s chief investigator of the study, which was published in the Journal of Gambling Studies (March 2011).

Despite the skepticism voiced by some in the treatment field regarding the survey results, other indicators support the view that gambling and the social ills generated by it may be a toxic trend we will have to reckon with for decades to come.

States, churches, synagogues, charities, they’ve all gotten into the gambling business and helped to make it socially acceptable and available virtually everywhere in this country. So it’s not just the huge proliferation in the number of casinos in the United States occurring over the last two decades that characterizes the growing potential for compulsive gambling. All forms of risk taking with money are now readily accessible and everywhere to be found, whether it’s lotteries, horse and dog tracks, church bingo games, office betting pools, charity raffles, home poker games, or Internet gaming. (To me, having governments use lottery gambling as a way to support public education seems particularly warped and absurd.) Even chronic betting on stocks and commodities futures in volatile markets can be considered a form of problem gambling with many of the same symptoms of abuse evident.

“Pathological” gamblers—the severely addicted who experience withdrawal symptoms similar to drug dependency—constitute only about 1 percent of adults. But the other category of abusers, “problem” gamblers—people with money woes, strained marriages, and other problems associated with their compulsion to gamble—is a fast-growing segment of the population. There may be 11 million or more problem gamblers in the United States and less than one in 10 of them ever seeks treatment, probably because of the shame, guilt, and stigma associated with being identified as having this disorder.

For simplicity’s sake, here is the scale used by Nancy M. Petry, professor of psychiatry at the University of Connecticut Health Center, to identify the types of gamblers and the severity of associated problems:

Dr. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA, likened the levels of gambling compulsion to the “beginning signs of cancer—full-blown pathological gambling is like full-blown cancer that spreads throughout your body and mind.”

Key Facts About Gambling Addiction

Professor Nancy Petry’s book, Pathological Gambling (2005, American Psychological Association), gives us a deeper insight into how problem gambling touches many more lives—and in many more ways—than just that of the gambler. From Petry’s book:

• By some estimates, each pathological gambler “directly affects the lives of 8 to 10 other people … ranging from spouses to other immediate family members (children, parents, and siblings) to employers and coworkers.”
• Helpline statistics from the United States, the United Kingdom, and New Zealand indicate that “over 40 percent of calls [for help] are from partners of gamblers rather than from gamblers themselves.”
• Based on the results of 14 studies of people with gambling problems, “young people suffer from disordered gambling at about two to three times the rates of adults.”
• Less than 8 percent of pathological gamblers (Level 3) seek treatment (National Research Council, 1999.) Among problem gamblers (Level 2), “virtually none seek or receive assistance.”

Is Compulsive Gambling a Genetic Disease?

Treatment expert Arnie Wexler called compulsive gambling “a progressive disease, much like an addiction to alcohol or drugs. In many cases, the gambling addiction is hidden until the gambler becomes unable to function without gambling. Lying becomes a way of life. They will try to convince others and themselves that their lies are truths and they will believe their own lies. Inability to stop gambling often results in financial devastation, broken homes, employment problems, criminal acts and suicide attempts.”

Is pathological gambling really a brain disease? Prof. Timothy Fong has studied the question by conducting neuroscience and brain-imaging studies as an associate professor of psychiatry at UCLA and codirector of the UCLA Gambling Studies Program. “The brains of pathological gamblers are very different than those who do not have a gambling addiction,” said Fong. “One of our first research papers showed that gambling addiction caused brain damage similar to that caused by methamphetamine abuse. That raised a question: is gambling somehow neurotoxic just like drugs of abuse?”

Prof. Fong’s definition of gambling is broad, including all forms of risk taking. “I’m talking about stocks and investments, the risk-taking behaviors. One reason our economy got into such a mess is that we’ve become almost a nation of people taking risks well beyond what we could actually afford, and taking those risks repeatedly. That’s a form of gambling.

“We know gambling is a genetic disease. There are biological factors passed on from father to son and mother to son that create vulnerabilities. It’s a disease that starts early in life. We know that the brains of people with gambling addiction are functioning differently and are built differently from those who don’t have gambling addiction.”

Dr. Howard Shaffer, associate professor of psychiatry at Harvard Medical School, and director, Division on Addictions, the Cambridge Health Alliance, agrees with Fong: “There’s quite a bit of work all around the world showing that various activities like gambling energize the pleasure centers of the brain similarly to the way that psychoactive drugs energize the pleasure centers of the brain. It doesn’t matter whether it’s a process addiction like gambling or a drug addiction. All will affect the brain and change the way we feel and our subjective state.”

To underscore the contention of these experts about the genetic factor, research on twins published in the Journal of Abnormal Psychology (March 28, 2011) showed that gambling problems “run in families” and half of the vulnerability to gambling addiction “comes from shared genetic rather than shared environmental influences.”

What also fascinates Prof. Fong, and supports a theme of this book, is why “one person falls into gambling addiction, and another person falls into drugs, and another into sexual compulsions. And why, in recovery, they switch addictions.”

Gambling Problems Come Linked to Other Disorders

If you’ve ever been in a casino, you know how common it is for people to be gambling with an alcoholic drink in one hand and a cigarette dangling from a corner of their mouth. It’s no secret that the free or low-priced liquor being dispensed so copiously by casino employees is designed to “loosen” gamblers up so they will spend more money than they might normally.

For several decades research evidence has mounted that alcohol and gambling are the proverbial two peas in a pod. A 1998 National Opinion Research Center study found that pathological or problem gamblers had about seven times the rate of alcohol dependence as non-gamblers or nonproblem casual gamblers.

Marijuana abuse or dependence is now threatening alcohol abuse and dependence’s position as the number one co-occurring disorder with gambling. A 2002 study, cited by the book Pathological Gambling, found that in some parts of the United States “patients with marijuana use disorders were more likely to suffer from gambling problems than patients with any other substance-use disorder.”

Alcohol- and marijuana-use problems represent just one of a whole list of compulsions associated with problem gambling. Based on a survey of 43,093 people conducted by University of Connecticut Health Center researchers, estimates of the prevalence of co-occurring substance use, mood, and personality disorders among pathological gamblers were developed. Women respondents with likely gambling disorders had co-occurring disorders that were, on average, more severe than those of participating men with likely gambling disorders.

• 73.2 percent of pathological gamblers had an alcohol-use disorder
• 60.8 percent had a personality disorder
• 60.4 percent had nicotine dependence
• 49.6 percent had a mood disorder
• 41.3 percent had an anxiety disorder
• 38.1 percent had a drug-use problem

(Source: “Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions.” Petry NM, Stinson FS, and Grant BF. J Clin Psychiatry. 2005 May;66(5):564–74.)

For many people problem gambling is also linked to eating disorders, sexual compulsive disorders, and chronic or binge shopping problems.

Professor Nancy Petry of the University of Connecticut Health Center determined in a 2000 study that “severity of gambling problems in substance abusers was significantly and independently predictive of engaging in risky sexual activities that spread infectious diseases.” In her seminal book, Pathological Gambling, Petry cited studies indicating that among one group of female Gamblers Anonymous members, 20 percent were “compulsive overeaters.” Research shows that pathological gamblers also have “increased rates of compulsive buying and [compulsive] sexual behaviors.”

Depression and thoughts of suicide shadow pathological gamblers like birds of prey. A Canadian survey of 1,471 college students found that nearly 27 percent of the pathological gamblers among them didn’t just fantasize about killing themselves, but had actually attempted suicide.

Harvard’s Prof. Howard Shaffer urged anyone seeking help for a gambling problem to also address the underlying disorders that trigger out-of-control gambling. “Gambling often serves—for many, not all—as a self-medication or a treatment, if you will, for these underlying disorders which people are not always aware of. Mood disorders, anxiety, some personality disorders, post-traumatic stress disorders, all are very common among gamblers. There are all kinds of self-help interventions available to get screened for those disorders. My experience is that when we start to pay attention to these associated disorders, people feel much better and are much more in control of their addictive behavior.”

Time to Get Honest with Yourself

These questionnaires won’t be the first or last word on whether you have a gambling problem, but your answers will, if you are honest with yourself, illuminate the extent to which your gambling behaviors may be more than just a controllable habit.

Do you need help? Questions for self-evaluation

• Do you gamble when you are feeling lonely, depressed, angry, or under stress?
• Do you gamble as a way of coping with loss or grief?
• Do you have trouble setting and staying within limits on time and money spent gambling?
• Do you spend money on gambling that you need for essential expenses (rent/mortgage, utilities, etc.)?
• Do people close to you criticize or complain about your gambling?
• Do you gamble to the exclusion of other recreational or social activities?
• Do you borrow money to gamble or to cover expenses due to gambling losses?
• Do you gamble at times when you should be taking care of responsibilities such as work, family, or school?
• Do you return to gambling to try to win back money you have lost?
• Do you find yourself thinking more and more about gambling or getting money for gambling?

(Sources: State of Connecticut, Department of Mental Health and Addiction Services. National Council on Problem Gambling, www.ncpgam-bling.org.)

Answer yes or no to these statements about your gambling behavior

1. You have often gambled longer than you had planned.
2. You have often gambled until your last dollar was gone.
3. Thoughts of gambling have caused you to lose sleep.
4. You have used your income or savings to gamble while letting bills go unpaid.
5. You have made repeated, unsuccessful attempts to stop gambling.
6. You have broken the law or considered breaking the law to finance your gambling.
7. You have borrowed money to finance your gambling.
8. You have felt depressed or suicidal because of your gambling losses.
9. You have been remorseful after gambling.
10. You have gambled to get money to meet your financial obligations.

If you (or someone you know) answer yes to any of these statements, you may have a gambling problem and should seek professional help and group support. (Source: The National Problem Gambling HelpLine Network [800-522-4700]).

Separating “pathological” from “problem” or “social” gamblers

Treatment specialists rely on the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders to make determinations about the severity of gambling problems experienced by clients. To receive a diagnosis of pathological gambling, you must be experiencing five or more of the following conditions in your life:

1. You are preoccupied with gambling, meaning you are preoccupied with reliving past gambling experiences, planning the next venture, or thinking of ways to obtain money with which to gamble.
2. You feel the need to gamble with increasing amounts of money to achieve a desired level of excitement.
3. You experience repeated unsuccessful efforts to control, cut back, or stop gambling.
4. You feel restless or irritable when you attempt to cut down or stop gambling.
5. You gamble as a way of escaping problems in your life, or to relieve feelings of helplessness, guilt, anxiety, or depression.
6. After losing money gambling, you often return another day to regain your losses.
7. You lie to family members, therapists, or others to conceal the extent of your involvement with gambling.
8. You have committed illegal acts such as forgery, fraud, theft, or embezzlement to finance your gambling.
9. You have jeopardized or lost a significant relationship, a job, or an educational or career opportunity because of your gambling.
10. You rely on others to provide money to relieve a desperate financial situation caused by your gambling.

Three questions from the brief biosocial gambling screen

For a really short but meaningful assessment of your gambling habits, answer these three questions:

1. During the past year, have you become restless, irritable, or anxious when you have tried to stop or cut back on the time and money spent gambling?
2. During the past year, have you tried to keep your family or friends from knowing how much money and time you spend gambling?
3. During the past year, did you have financial trouble as a result of gambling and did you seek help with living expenses from family, friends, or welfare programs?

Answering yes to any of the three questions indicates you should seek an evaluation from a mental health professional to determine how serious your gambling problem may have become.

Four Clues to Identify Internet Gambling Addiction

One of the fastest growing ways to access games of chance is through the Internet, and it’s also about the quickest path to addiction and financial ruin.

While sitting at your computer, you can play electronic slot machines or bet on sporting events as they are being played. The betting has become so sophisticated, accessible, and speedy that you can actually place wagers on whether the next batter in a live major league baseball game will strike out.

Using a credit or debit card, you can almost instantaneously pull out money from your accounts to feed your gambling online. It’s easy and it’s dangerous. You can go broke without ever leaving your home or standing up to stretch your legs.

Prof. Howard Shaffer of Harvard Medical School and addictions specialist Julia Braverman of Cambridge Health Alliance published a 2010 study in the European Journal of Public Health in which they identified behavioral markers for high-risk Internet gambling problems using information about 48,114 people who had opened Internet betting service accounts. Nine out of every 10 were men, with an average age of 28, and they were residents of 21 countries, Germany being the most frequent country of origin.

“It is essential to identify gamblers at higher risk of developing gambling-related problems as early as possible,” wrote the study’s two authors, explaining why they conducted this analysis of Internet gambling.

They found that within the first month of a person engaging in live-action Internet gambling, four behaviors can help to identify who will be at risk for developing serious gambling problems.

1. Gambling frequency. If an escalating pattern of days spent gambling emerges, that is a warning sign.
2. Gambling intensity. A higher than average number of bets placed per day is another benchmark for trouble.
3. Gambling variability. Normal gamblers exhibit a uniform, stable, and consistent pattern of gambling wagers, whereas high-risk gamblers deviate from this norm by constantly experimenting.
4. Gambling trajectory. If gamblers continually increase the amount of money wagered during the first month, they may be at risk for problems because most studies have shown that nonaddicted gamblers tend to decrease the amount of money they wager after the first eight-day period of gambling.

How Does Gambling Resemble Other Addictions?

There are some clear and significant differences between the compulsion to gamble and its attendant problems compared to alcohol and drug abuse, or the other Seven Toxic Compulsions. Compulsive gambling creates a unique set of treatment and recovery challenges.

From Howard J. Shaffer, associate professor of psychology, Harvard Medical School, and director, Division on Addictions, the Cambridge Health Alliance: I don’t thinking gambling is very different from substance-use disorders. You may have a more rapid loss of money with gambling than with drug use. But I don’t see a difference genetically, biochemically, or neurobiologically. Each expression of addiction brings unique problems. Gambling brings all kinds of money and debt problems with it, usually family problems as well, and then the emotional problems. Now among pathological gamblers, the treatment seekers, they’re fairly quick to say that they like the action. It’s not the winning or the losing; it’s the action. Gamblers like the rush of the action. But no one really needs to drink alcohol, use psychoactive drugs, or gamble. It’s not a requirement of life. So if you’re struggling with any of those, if you’re insisting on continuing your relationship with any of those addictions, it’s important to ask yourself the same questions: What does it do for me? What do I need from this? Are there other substitutes that would be less problematic for me in my life? Why do I want to keep struggling with this? What does this struggle do for me? Do I just want to be sort of uncomfortable all the time?

From Arnie Wexler, compulsive gambling expert and counselor: This addiction is a little different than alcohol and drugs. There’s no track marks, no dilated pupils, no smell. It’s invisible. If I came here and told you I was an alcoholic and hadn’t had a drink in 43 years, but then I had a drink, you’d know it right away. You smell it, you see it. But if I just came from the casino, or called my bookmaker, or bought a hundred lottery tickets 10 minutes ago, you wouldn’t know. Problem gamblers have shame and guilt. Unlike alcoholics who might go around saying, “I’m an alcoholic,” it’s very rare to get gamblers to admit they have a problem. They’re embarrassed. They’re afraid. Your drug dealer is not sending a limo for you. A casino is sending a limo. They’re giving you free rooms and meals. They’re giving you a feeling, a fantasy. That doesn’t happen in other addictions.

From Sheila Wexler, compulsive gambling expert and counselor: Gamblers go further, longer, and they don’t pass out. So they usually don’t get intervened upon as soon as someone with a drug or an alcohol problem. And the more you can bet, the more excitement you have. But when you can’t make that bet, any level of bet will do. With alcoholism, there’s a point where reverse tolerance takes place, where the little amount kills you or certainly makes you pass out. With gambling, you could go out there forever and ever. There’s no change. There may be more excitement if you could bet more money. They put everything in jeopardy. It doesn’t matter. Your wife doesn’t matter. The kids don’t matter. The job doesn’t matter.

From Dr. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA: A lot of gamblers say, “My problem isn’t that I gamble too much. My problem is that I don’t have enough money or time to gamble with.” And those same people will say, “If I just keep on playing, eventually I’m going to win.” You don’t get that from drug addicts or alcoholics. They don’t say, “If I just got the perfect hit of cocaine, my life would be perfect.” There are some similarities between gambling and other types of addiction recovery. When we focus on our treatment for gambling, it’s very much like what we do for drugs and alcohol. It’s about learning to tolerate negative feelings. It’s about learning to let go of past traumas. It’s about dealing with yourself in the moment from liking who you are. It’s about tolerating shades of gray and not living in black or white. It’s about living in the moment and not living in a fantasy world.

Nine gambling myths

From Arnie and Sheila Wexler, who present workshops and seminars on compulsive gambling addiction and run a national hotline for problem gamblers: 888-LAST BET:

1. The big win is just around the corner with the next bet I make.
2. I can get even again, and then I will stop gambling.
3. I am not like drug addicts or alcoholics.
4. I can stop anytime I want. I just don’t want to stop.
5. I am too young to be a gambling addict.
6. If I had more money I know I could win.
7. I am smarter than the rest of the gamblers.
8. The losses are not my fault right now because I’m having bad luck.
9. I know I can beat this game.

Top 10 reasons why compulsive gamblers quit

A 2002 study in the journal Addiction Research and Theory surveyed problem gamblers who had successfully terminated their gambling dependence. Here are their reasons, along with the percentage of survey respondents who cited that reason for quitting:

1. Financial concerns—96 percent
2. Emotional factors—92 percent
3. Concern about family/children—69 percent
4. Hitting “rock bottom”—61 percent
5. Pros and cons evaluated—54 percent
6. Humiliating event happened—50 percent
7. Physical health concerns—48 percent
8. Work problems—43 percent
9. Confrontation with loved one—43 percent
10. Major lifestyle change—43 percent

After four decades of working with problem gamblers, Arnie Wexler evolved his own unique take on what motivates people to quit: “What gets a gambling addict into treatment? Pain. They lose everything. And intervention. The wife has to say something like ‘I’m putting the house in my name, or I’m leaving.’ The gambler must understand he has an addiction. He must be willing to attend Gamblers Anonymous and seek professional help. By the time a gambler is ready to get help, he has no more money, for the most part. And his family is sick and tired of bailing him out.”

Sometimes pathological gamblers quit only when they are seized by despair after a lifetime of denying the problem. They even attempt suicide. Dr. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA, relates one such case from among his patient files: “We saw a gentleman in our psychiatric hospital, he was 80 years old, had been gambling for 60 years. He’s gambled incredible amounts of money away as a pathological gambler for 60 years. Never wanted to seek help, never wanted his family to seek help for him. They were basically living in pain and suffering for 60 years as a family. And that finally ended when he jumped off a building and broke both of his legs and his pelvis. It’s just an awful tragedy. The family had supported him in his addiction for years. It’s an example where harm and suffering can go on for decades and no one will notice. And we’re really trying to bring that out of the shadows and really tell folks, you know, these signs and symptoms are not just somebody’s personality. They are, in fact, signs of a disease.”

Some Pathological Gamblers “Recover” Without Quitting

It’s an inconvenient truth, but there is study evidence that some gamblers with a pathological habit can undergo cognitive behavioral treatments and, with more healthy thinking patterns in place, can control their gambling behaviors until they no longer have a “problem” as defined by diagnostic manual criteria.

Australian researchers divided up a group of female pathological gamblers into two groups—one that underwent cognitive behavior treatment to control their gambling until it was no longer a problem, and another that experienced the same treatment regimen but with the goal of complete abstinence from gambling. The study authors concluded that “pathological gamblers selecting controlled gambling displayed comparable levels of improvement to those displayed by gamblers selecting abstinence … 89 percent of the gamblers selecting abstinence compared with 82 percent selecting controlled gambling no longer satisfied the diagnostic criteria for pathological gambling by the completion of the six-month follow-up period.” (Source: “A preliminary investigation of abstinence and controlled gambling as self-selected goals of treatment for female pathological gambling.” Dowling N, Smith D, and Thomas T. J. Gambl Stud. 2009 Jun;25 (2):201–14.)

A second study a year later, also from Australia and published in the journal Addiction, came to a similar conclusion after surveying 4,764 adults to identify gamblers who met the criteria for pathological gaming. Just 104 of those surveyed, about 2 percent, screened positive for a lifetime history of pathological gambling, and of those, 44 had severely cut back gambling until it was no longer a problem affecting their lives. This “controlled gambling” was mostly achieved without resort to any formal intervention therapy. (Source: “Pathological gambling recovery in the absence of abstinence.” Slutske WS, Piasecki TM, Blaszczynski A, and Martin NG. Addiction. 2010 Dec;105(12):2169–75.)

“The findings are in line with what has been seen in the treatment of alcohol abuse,” the Reuters news agency commented on the study. “That is, some people in recovery cut back on drinking rather than abstaining completely. This approach is sometimes referred to as ‘harm reduction.’ And the results suggest that problem gamblers, too, can recover even if they do not quit altogether.”

Dr. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA, added this perspective: “There probably is a significant percentage of gamblers who can do it on a controlled basis. The problem is we don’t know who they are and what they’re capable of when they show up in our office. A lot of times gamblers will come in and if I say to them, ‘You can never ever place a bet the rest of your natural life,’ that’s someone who’s never going to come back to our office. Whereas if I say, ‘Listen, my goal is to eliminate pain and suffering from your life and if that means getting rid of your gambling, fine, if that means controlling your gambling, great. If that means limiting your gambling, that’s fine, too. Then they are more likely to come back. I don’t care whether they stop gambling or not, as long as they get rid of the damage in their life.”

Some Pathological Gamblers “Recover” Without Treatment

A study appearing in a 2006 issue of The American Journal of Psychiatry evaluated two surveys involving more than 45,000 pathological gamblers in the United States. Only about 12 percent had ever sought individual or group treatment or attended meetings of Gamblers Anonymous.

“About one-third of the individuals with pathological gambling disorder in these two nationally representative U.S. samples were characterized by natural recovery,” observed the study author. Recovery could be defined as either total abstinence, or some level of controlled gambling that reduces the level of harm previously associated with compulsive gaming. (Source: “Natural recovery and treatment-seeking in pathological gambling: results of two U.S. national surveys.” Slutske WS. Am J Psychiatry. 2006 Feb;163(2):297–301.)

Natural recovery can result either from pressure exerted by friends and family members to change gambling behaviors or from an exercise of willpower and impulse control techniques learned and practiced by the gambler on his or her own.

“It is possible for people to recover from addiction on their own without treatment,” observed Harvard’s Prof. Howard Shaffer. “The way to restore control isn’t simply to say, ‘I won’t do it anymore.’ Because when you do that, you give the addiction more power. What you need to do is to find out what your addiction means, why you have it, and then substitute new activities that are in conflict with your addiction.”

Dependence Often Begins Early in Life

Gambling behavior conditioning usually starts in childhood. Whether the first exposure was raffles and prizes at a kid’s restaurant, or watching the Wheel of Fortune game show on television, kids get a steady diet of cultural messaging that many of the rewards in life come from taking risks that challenge luck and chance.

By the time these kids become teenagers, gambling behaviors take root alongside drug and alcohol abuse to form what psychologists call “conduct disorders.” A 2011 study published in the American Journal of Addiction, for example, surveyed 2,274 youth 14 to 21 years of age and found a pattern in which “problem gambling occurs within a problem-behavior syndrome with other substance-use behaviors.”

Being male, black or Hispanic, were found to be significant predictors of who would become a problem gambler at this age. “Clinical interventions for one specific problem behavior in youth,” concluded the researchers at the University at Buffalo Research Institute on Addictions, “should consider assessing the other problem behaviors as well.” (Source: “The co-occurrence of gambling with substance use and conduct disorder among youth in the United States.” Barnes GM, Welte JW, Hoffman JH, and Tidwell MC. Am J Addict. 2011 Mar–Apr;20(2):166–73.)

Women and Adolescents Are the Fastest Growing Groups of Addicts

It’s definitely a stereotype, though still a common one, that men are the most likely candidates to become problem gamblers. Whatever the source of the myth, adult men today are no longer the primary pool from which new gamblers are drawn. Women and adolescents can now claim that dubious distinction.

From Sheila Wexler, compulsive gambling expert and counselor: More than 50 percent of the people we see for treatment are women. A large percentage of them play slot machines. They got addicted later in life. They don’t have this pumped-up ego thing that male gamblers have. They’re kind of meek and maybe uncomfortable with themselves and something happens in their life—a divorce, the children leave home, they’re lonely—and they become escape gamblers. With slot machines you don’t have to be educated in gambling, unlike with blackjack and other card games. You just stick your money in the machine and you have this oblivion for whatever length of time you can sit at that machine. I had a lady that came to me for help, a 73-year-old woman, who lost a quarter of a million dollars in slot machines. I have female clients who have embezzled money to support their gambling habit. One African-American lady, 42 years old, a very religious lady who went to church every Sunday, got hooked on slot machines and embezzled a million and a half dollars from the county she worked for. She lost it all in slot machines. She got a 17-year jail sentence.

From Arnie Wexler, compulsive gambling expert and counselor: We run this gambling hotline and in the last three years, one third of all the calls coming in are coming in are from poker players between the ages of 12 and 30, young kids, or parents of these kids. I see these kids all the time who don’t want to go to college. They’re going to be professional poker players.

From Prof. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA: We know gambling as a disease starts very early in life. We’re talking kindergarten years, if not earlier, when people are exposed to rewards and games and money. Think about how Chuck E. Cheese restaurants have raffles and prizes. It is part of our culture but it taps into the biological underpinnings of those who are genetically vulnerable. We know this generation of kids is growing up in a culture that promotes and celebrates gambling. You think of a poker player as a sports figure, a role model. This culture is very much of an impulse-driven, immediate reward-driven culture. We see a lot of very smart, young kids who decide to become professional poker players instead of going to graduate school and getting PhDs and real jobs. So what we’re seeing is that gambling throughout America is probably having a much more subtle impact on our culture than we ever thought.

If you’re in a relationship with a problem gambler

There are general do and don’t lists for those of you who have a pathological or problem gambler in your life. Whether the person is a relative or a friend, these pieces of advice are offered to help you cope with the impact of their often unpredictable and disturbing behaviors.

Do the following:

• Continue to recognize your partner or friend’s good qualities.
• Always remain calm when speaking to your partner or friend about their gambling and its consequences.
• Explain the gambling problem to your children if you are the spouse of a problem gambler.
• Seek the support of others dealing with similar problems. This could take the form of attending Gam-Anon, a self-help group for the families of problem gamblers. Let your partner know that you are seeking help for your own sake because of the way gambling affects you and the family.
• Make a commitment to allot time for the treatment of problem gambling.
• Take control of family finances and continually review bank and credit card statements to monitor the gambler’s behavior and protect the family.

Don’t do the following:

• Get angry, preach, or lecture.
• Make threats or issue ultimatums unless you intend to carry them out.
• Exclude the problem gambler from family life and activities.
• Bail out the gambler.
• Cover-up or deny the existence of the problem to yourself, your family, or other people in your life.
• Expect immediate recovery, or that all problems will be resolved once the gambling stops.

(Source: Connecticut Department of Mental Health and Addiction Services, www.ct.gov/dmhas.)

Tips on How to Keep Your Gambling Recreational

Gambling always needs to be viewed as a periodic form of entertainment, not as a way for you to make money or relieve stress and boredom. When you lose money, as you inevitably will, the loss should be viewed as the cost of entertainment for the day no different than tickets to a movie or play.

The California Office of Problem Gambling, part of that state’s Department of Alcohol and Drug Programs, provides these guidelines to moderate your play and help prevent gambling from undermining your life. I have taken the liberty of expanding their tip advice and adding a few more of my own:

• Never borrow money to gamble.
• Never gamble with money needed for everyday expenses or for your mortgage, rent, or monthly expenses.
• Set a dollar limit for the day and stick to it, which means leave your debit and credit cards at home or in the car.
• Set a time limit for gambling and stick to it. Whether you’re winning or losing, leave the casino or stop your play when you reach that time limit.
• Take frequent breaks from your gambling. This means breaks of days and weeks between gambling episodes, and frequent breaks while you are gambling. Most casinos have restaurants or even live music and other forms of entertainment to distract you. Take advantage of these distractions as a reminder that compulsive gambling is a trap that should be avoided.
• Never chase your losses. Trying to win back what you have lost is usually a recipe for losing even more money and, as a result, feeling bad about yourself.
• Never let your gambling become a substitute for your family and friends, and never let it interfere with your relationship obligations.
• Never use gambling as a way to cope with any emotional or physical pain that you might be feeling. That means never gamble when you feel stressed, depressed, or troubled.
• If you feel compelled to gamble and don’t trust yourself to keep promises about the amount spent or the time spent, bring a trustworthy friend or nongambling friend along and ask him to remind you that you have promises to keep.
• If you don’t trust yourself to keep any of these promises you make to yourself, you have just triggered one of the warning signs for problem gambling. That means it’s time to seek help.

Behavior Substitution Can Be an Effective Treatment

To complete treatment and maintain recovery from pathological or problem gambling, one must address the underlying issues or disorders—whether it’s boredom, depression, or loneliness—that trigger and prolong the gambling fixation. One strategy involves substituting healthier alternative behaviors and activities when the urge to gamble surfaces.

Examples of substitution include:

(Source: Adapted from Helpguide.org.)

Two Experts on Their Treatment Approaches

Every treatment specialist has a slightly different approach to pathological gambling depending on the gambler and the severity of the problem. Here are two of the leading U.S. experts on their treatment priorities.

From Prof. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA: What’s undeniable is that when people come into our office now, compared to 10 or 15 years ago, their problems are much more severe. That’s because of the ability for people to get more money through running a credit card. And then online gambling, just being able to tap into your bank account so easily, it creates problems at a much quicker rate than it ever did before.

We use biological approaches, psychological approaches, and then social approaches to treatment. Our psychological treatments are really geared at helping people develop ways to control their behavior. And that might be something as simple as having people identify high-risk situations when they’re likely to gamble, such as when they have money in their hands or when they have an argument with their wife. We give them tools on how to say no to the urges.

We use a lot of psychological therapy to get people more motivated to look at how to build a life with lots of things other than just gambling. With many of our gamblers, you’d ask, “What else do you enjoy in life?” And they’d say, “Nothing, it’s just gambling.” And so psychological treatments look at why they don’t do other things, like exercise, spending time with their family, working on their jobs, or going back to school.

And then we have social treatments really geared at making it harder for them to gamble. So things like limited access to cash and credit, or surrounding themselves with people who are committed to recovery from gambling, like Gamblers Anonymous. As an example, I had a guy I had tried everything with, but it wasn’t until we took away his car that he was able to finally get four or five months of freedom from gambling.

I know the person who’s going to get better is the one who has the ability to be honest with themselves and the people around them. It’s critical to also treat the family of problem gamblers because that is often times where most of the damage has occurred.

(For more information on these treatment approaches, go to trans-formgambling.ca.gov., or to uclagamblingprogram.org.)

From Prof. Howard Shaffer, associate professor of psychology, Harvard Medical School, and director, Division on Addictions, the Cambridge Health Alliance: Loved ones need to have a candid conversation with the gambler because the limiting factor for gamblers, unfortunately, is personal wealth—gambling ends when there’s no more money. They need to have this candid conversation early on because you don’t want it to get to that point where all the doors are closed for the gambling family member because there’s no money left.

The idea is to protect this person early on the same way we would protect the person with substance-use or alcohol-related problems. We’d cut off their access to money. Other people might have to take over by power of attorney; banks need to be notified; credit cards need to be cancelled; and all of the financial limitations need to be imposed. Hopefully, that would happen after a candid conversation. But it might have to be imposed with the coordination of the whole family.

Consequences and monitoring are keys, but I think for the vast majority of people who’ve struggled with this issue, the loss of their family, the fear of losing their family, or the fear of loss of a job will go a very long way to helping them regain control.

When people come to me, I don’t expect them to want to change. I expect them to wish that they would want to change. My job is to motivate them. I think ambivalence is the heart of addiction. Exercising that ambivalence, helping people see what they get from addiction, as well as how it hurts them, is essential to recovery. The “just say no” attitude, the “just don’t do it” attitude is not going to work.

What About Medication as a Treatment?

Abnormalities in serotonin, norephinephrine, dopamine, and opioid systems have been noted in gamblers, making these systems targets for pharmacotherapy (drug therapy), according to Prof. Nancy Petry.

Three types of medications have been used to treat pathological gamblers: serotonin reuptake inhibitors, mood stabilizers, and opioid antagonists. Although some positive effects have been noted, “the results are far from conclusive,” said Petry. Patients who have alcohol dependence accompanying their pathological gambling sometimes respond favorably to treatment by the drug naltrexone, which has been approved for diminishing the urges for alcohol.

Dr. Timothy Fong, codirector of the UCLA Gambling Studies Program and associate professor of psychiatry at the Semel Institute at UCLA, is more optimistic about the effectiveness of medications to treat gambling control issues. “The biological treatments we use are essentially medications to help take away urges and cravings,” said Fong. “None of them is FDA approved. We also have a variety of other things like lithium or other antidepressants. There’s another one called N-acetyl, or NAC, which is one that we have used to take away the urges. We now have a toolbox of about six or seven meds that we know can effectively dent the urges and cravings for gambling.”

Effective Treatment Combinations

Cognitive behavioral therapy, a talking process designed to resolve dysfunctional emotions, has a proven record of benefits in treating problem gamblers. Studies showing its effectiveness are numerous.

For example, a study by Canadian researchers applied cognitive correction techniques in a group setting to target pathological gamblers’ erroneous assumptions and perceptions about randomness and chance, then used the therapeutic process to address issues of relapse prevention. Post-treatment results showed that 88 percent of those treated with cognitive therapy no longer met diagnostic criteria for pathological gambling, compared to only 20 percent in a control group that didn’t use cognitive therapy. When those using the cognitive approach were evaluated in 6-, 12-, and 24-month follow-up visits, they had maintained their improvement in self-control. (Source: “Group therapy for pathological gamblers: A cognitive approach.” Ladouceur R, Sylvain C, Boutin C, Lachance S, Doucet C, and Leblond J. Behav Res Ther. 2003 May;41(5):587–96.)

As further insurance for treatment success and relapse prevention, cognitive therapy, either in a group or one-on-one therapeutic setting, can be combined with attendance at Gamblers Anonymous meetings. The evidence from studies strongly suggests that “a combined intervention may enhance therapy engagement and reduce relapse rates.” (Source: “Gamblers anonymous and cognitive-behavioral therapies for pathological gamblers.” Petry NM. J Gambl Stud. 2005 Spring;21(1):27–33.)

Some Treatment Options

For more information about the self-help-oriented treatments mentioned most frequently by the experts interviewed for this book, along with valuable tips about how to utilize these methods and tools, consult the following:

• Brief and motivational interviewing, Seven Self-Care Tools, p. 238
• Cognitive Behavioral Therapy, Seven Self-Care Tools, p. 235
• 12-Step Programs, Seven Self-Care Tools, p. 240

Your 30-Day Challenge for Gambling

Do you have a bad habit or a dependency? Here is another chance to find out.

You have answered the questionnaires for this toxic compulsion. You have read through what the experts have to say. You have thought about the extent to which you exhibit the behaviors associated with either a nondependent use disorder or a dependency.

Do you still have any doubt about whether you have just a bad habit, or whether your behavior meets the criteria for a dependency?

Create a 30-day challenge for yourself. Every time you gamble for 30 days, do three things before you play:

• Set a money-loss amount limit.
• Set a money-winnings amount limit.
• Set a time limit, such as “I will not gamble for more than one hour.”

When any one of these three limits is achieved, you leave and stop playing for that day. If you can’t stop, if you can’t leave, you probably have a gambling problem and should seek professional assistance.