THE NEED FOR A NATIONAL POLICY ON

PROBLEM AND PATHOLOGICAL GAMBLING IN AMERICA

Background

In 1976 when the Commission on the Review of the National Policy Toward Gambling issued its final report, only thirteen states had lotteries, only one state had approved off-track wagering, and there were no casinos outside of Nevada. The Commission estimated that the total volume of money legally wagered on gambling in 1974 was $17.3 billion.

By 1992, the amount had reached $329.9 billion (Christiansen 1993)--a 1900% increase in just eighteen years. Today a person can make a legal wager of some sort in every state except Utah and Hawaii. Over thirty states and the District of Columbia operate lotteries, so that the majority of states not only actively promote gambling, but have become dependent on it for essential revenues. There is an increasing urgency by state lotteries to go beyond scratch-off tickets and weekly drawings to faster and more exciting games. Lottery keno offers a new game every five minutes. By 1993, eight states already had lottery keno in operation; twenty others had bills to introduce it. Right behind lottery keno are video lottery terminals (VLTs) and video poker machines. These are already allowed in four states and others are very interested in legalizing them.

Casino gambling, once confined to Nevada and Atlantic City, has spread rapidly across the country, partly in response to the need for additional revenues for local and state governments, but also as a result of the Indian Gaming Regulatory Act of 1988. This landmark legislation allowed Native American tribes to operate any form of gaming legally allowed in their state.

Since many states allow charities to have “Las Vegas nights,” this opened the door to high-stakes casino gambling on Indian land. Tribes rushed in to take advantage. By 1993, there

were 153 high-stakes bingo halls and/or casinos operating in 27 states while gross wagering on Indian reservations had reached $15 billion (Christiansen 1993; Connor 1993). The most successful of the Native American casinos is Foxwoods in eastern Connecticut which, with $200 million in annual gross receipts, is the largest table games revenue-generating casino in the world. The addition of video machines could bring the total to $500 million and make it arguably the world's largest casino.

Numerous tribes are now working with companies in the gaming industry to create Las Vegas-style casinos in several states. Since few of the profits from these Native American casinos go to the states in the form of taxes, it is only logical that some states have considered legalizing casino gambling in order to get in on the action.

Thus, casino-type gambling is rapidly spreading in some form across the country. By 1993, riverboat gambling had been legalized in six states--Illinois, Indiana, Iowa, Louisiana, Mississippi and Missouri--with other states seriously considering it. Riverboat gambling or dockside gambling may be the wave of the future, as gaming interests find the concept easier to sell to reluctant legislators than land-based casinos. In Mississippi, for example, riverboats have already been liberally redefined so that they neither need to look like a boat nor move from shore.

Casino gambling has also been legalized in historical communities in Colorado and South Dakota and in urban areas such as New Orleans. Experts project that there will be some form of casino-style gambling in half of the states by 1995 (Rose 1992).

On the horizon are technological innovations which will make gambling even more accessible, while speeding up games to make them more involving for the participant and the exchange of money more efficient. Soon there will be “cashless" gambling in which wagering is done by insertion of a credit or debit card, home access in which cable television will bring satellite wagering into the home, and interactive television in which one can stop the action of a sporting event and wager on each aspect of the game. A cable television company has proposed televising gaming events twenty-four hours a day so that at-home participants can wager on gaming events around the world. Airlines have plans to offer interactive gambling during international flights.

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To date, the innovation with the greatest impact has been the video gaming machine, commonly known as video poker. Like other technological advances in this field, video poker was introduced without any attempt to assess potential harm on the lives of participants. Widelypublicized remarks by one clinician calling video gaming the "crack cocaine" of gambling (Bulkeley 1992) and observations by hotline counselors who report an increasing frequency of calls from video poker players underscore the need for systematic impact studies of this form of gambling.

At what point will the American public have enough gambling? Comparisons with other countries suggest that saturation is a long way off. In the United States, expenditures per capita on legal gambling in 1991 was $200 compared to $400 in Australia (Williams 1992). Some American states have already equaled or exceeded Australia, most notably Minnesota with $500 per capita and Nevada with $1,000.

Defining Problem and Pathological (Compulsive) Gambling

Most Americans are social gamblers. They gamble for entertainment and typically do not risk more than they can afford to lose. If they should “chase” their losses to get even, they do so briefly, there is none of the long-term chasing or progression of the pathological (compulsive) gambler.

Clinicians tend to use the terms pathological and compulsive gambling interchangeably. This goes back to 1980 when the American Psychiatric Association first recognized compulsive gambling as a bonafide mental disorder and included it in its Diagnostic and Statistical Manual (DSM-III). However, they changed its name. Compulsive gambling was thought a misnomer (Moran 1970), since in the language of psychiatry, compulsive behavior is involuntary and "ego-dystonic" (externally derived or foreign to the self). Examples of a compulsion would include repetitive hand washing or the irresistible urge to shout an obscenity. Pathological gambling is more like an addiction. It is typically experienced in its early states as pleasurable.

The essential features of the disorder (American Psychiatric Association, in press) are a

continuous or periodic loss of control over gambling; a progression, in frequency and in amount wagered, in the preoccupation with gambling and in obtaining monies with which to gamble; and a continuation of the behavior despite adverse consequences. This is essentially the definition of an addiction.

Other similarities with alcohol and substance dependence have been noted (Levinson et al 1983; Miller 1980; Moran 1970). While money is important, most pathological gamblers say they are seeking “action”, an aroused, euphoric state comparable to the “high” derived from cocaine or other drugs. Many will go for days without sleep and for extended periods without eating or relieving themselves. Clinicians have noted the presence of cravings, the development of tolerance (increasingly larger bets or the taking of greater risks to produce a desired level of excitement, [Lesieur 1977]), and the experience of withdrawal symptoms (Meyer 1989; Rosenthal & Lesieur 1992; Wray & Dickerson 1981). Some gamblers report a “rush", characterized by sweaty palms and rapid heart beat experienced during the period of anticipation of gambling. Other gamblers may exhibit different symptoms. For example, because many women gamblers gamble as an escape mechanism and are more passive in their gambling behavior, their physical reactions may differ from that of the action-seeking male gambler.

For both male and female gamblers there are distortions in thinking--notably denial, various superstitions and fixed beliefs, and an illusion of power and control (Rosenthal 1986). This latter sense of certainty or conviction about the future is born out of desperation. Trance-like or dissociative states have also been reported.

In order to be diagnosed as a pathological gambler, an individual must meet at least five out of ten diagnostic criteria established by the American Psychiatric Association. These criteria are based on solid research and have been shown to be highly reliable and valid. The ten criteria include: loss of control; tolerance; withdrawal; increasing preoccupation; gambling to escape problems and dysphoric feelings; chasing one's losses in an effort to get even; lying about one's gambling; jeopardizing family, education, job or career; serious financial difficulties requiring a bailout; and illegal activities to finance gambling or pay gambling debts (American Psychiatric As

sociation, in press).

It is not poor luck or the loss of money that makes one a pathological gambler. Some individuals have sought help in the early stages of their gambling careers, when they were still winning. They were astute enough to become concerned about their intense physical reactions or the preoccupation with gambling which created problems at home or work. Others experience gambling problems without developing all the signs of pathological gambling, most notably the lack of progression or preoccupation with long term chasing. The term "problem gambling” (Rosenthal 1989; Lesieur & Rosenthal 1991) has recently been introduced to describe this group, which may represent an early stage of pathological gambling. The term is also used as a more inclusive category which encompasses pathological or compulsive gambling as one end of a continuum of problematic gambling involvement.

Epidemiology

The only national prevalence study to date was conducted by the University of Michigan's Institute for Social Research under the auspices of the Commission on the Review of the National Policy Toward Gambling. The results were published by the Commission (1976) and as a separate report by the Survey Research Center (Kallick et al 1979). The authors concluded that, in the year of their inquiry (1974), there was a prevalence rate of 0.77% or 1.1 million probable pathological gamblers in the United States.

While most researchers contend this rate is low, only Nadler (1985) has published an extended critique of the study. He ends his analysis with what he considers to be three undeniable conclusions: (1) the methodology of the Michigan study renders its prevalence estimate equivocal (2) many social and clinical changes have occurred since the national study was completed and (3) a “national study is badly needed.....to generate a valid and reliable estimate of pathological gambling which can serve as the basis for decision making in all affected realms of society.” Eight years later, there is still no national study of the prevalence of pathological gambling.

Although there has been no recent national study, prevalence studies have recently been