USA Today (Society for the Advancement of Education): Refuting the myths of compulsive gambling

ROBERT TERRY, the Philadelphia Inquirer's chief police reporter, borrowed money from that city's police commissioner and other department officials. Despite the fact that such borrowing creates a blatant conflict of interest, Terry was suspended with pay, with no decision made on a final disciplinary action. His managing editor, James Naughton, accepted Terry's explanation that it was a "disease" of gambling that put him in such dire straits. Naughton stated that he would await the outcome of a therapy program intended to cure Terry's "disease" before rendering final judgment.

In 1992, former "ABC Monday Night Football" producer Chet Forte was given a suspended sentence for bank fraud and income tax irregularities after Gamblers Anonymous testified at his sentencing hearing.

Former Baltimore Colt quarterback Art Schlichter went from object of scorn to one of pity in 1983 when it was claimed that his wagering, which had cost him hundreds of thousands of dollars, was the result of the "disease of compulsive gambling" (sometimes called "pathological gambling"). The late psychiatrist Robert Custer, often referred to as the father of compulsive gambling, stated, "Art has suffered the full effects of his disease."

In mid 1989, it was revealed that baseball hero Pete Rose dropped more than $500,000 through heavy gambling. It also was reported that he had to sell treasured memorabilia because of his debts. After weeks of bad press following a denial that he had a problem with gambling, Rose made a public statement that he had what his recently acquired psychiatrist called "a clinically significant gambling disorder" that rendered him powerless over his gambling. He then went on a media tour, during which he was greeted by a lengthy standing ovation from Phil Donahue's television audience and congratulations for his "admission" from Barbara Walters. Rose had gone from miscreant to courageous victim.

Since then, press attention to compulsive gambling--with uncritical acceptance of its being an illness and uncontrollable--has abounded. It has been heralded as the "Addiction of the 1990s." In the Journal of Gambling Studies (JGS), the major academic journal on gambling and social issues, editor Henry Lesieur wrote quite accurately in 1992 that "Not a day goes by . . . without something appearing in the professional literature or mass media about compulsive gambling."

The groundwork for the successful promotion of the disease model for heavy gambling was laid firmly more than a decade ago. After years of what JGS called his "unflagging advocacy," Custer persuaded The American Psychiatric Association in its 1980 update of the Diagnostic and Statistical, Manual (DSM-III) to elevate gambling to one of its categories of impulse disorders or, more specifically, a "Disorder of Impulse Control not Elsewhere Classified." This act was heralded in articles and media appearances by prominent gambling researchers as establishing that heavy, self-destructive gambling was a disease, the medical identity that was seen as necessary for sympathy for heavy bettors, and status and financial support (third-party payments, grants, etc.) for the researchers themselves, of whom few were--or are--medical doctors. If such gambling were a disease (the manual uses the term disorder, but its "nomenclature" specialist, Robert Spitzer, claims that it may be considered the same as disease), it was axiomatic that it was beyond the individual's control.

The problem is that there is no evidence that compulsive gambling is a disease (a point psychiatrist Thomas Szasz has made for decades) or uncontrollable. Revealingly, there are indications that, at least as far as the disease claim is concerned, many gambling researchers don't believe it either. Moreover, the consequences of accepting compulsive gambling as addictive or uncontrollable may be to hinder efforts of heavy gamblers to resist their urges.

Psychiatry's diagnostic manual lists no medical criteria in its "diagnostic criteria" for pathological gambling, only those referring to frequency of wagering and its social, financial, and legal consequences. Put simply, heavy gambling is not an illness in the sense that most people think of one. There is no credible evidence whatsoever of any neurochemical or neurophysiological status causally linked to heavy gambling, only changes such as increased adrenaline or palpitations caused by the excitement of the action. No study has found any neurobiological status specific to compulsive gamblers as contrasted with other excitable people. Yet, the finding of neurobiological correlates--especially if they were specific to heavy, gambling--would constitute a Holy Grail for researchers, providing a basis for maintaining that it is a disease and uncontrollable.

Thus, it was discouraging to gambling researchers in the late 1980s (and confirmed in recent follow-ups) when a year-long study at the National Institute of Alcohol Abuse and Alcoholism showed no differences in serotonin levels between compulsive gamblers and normal men. A positive finding could have been used to argue that such gamblers lacked impulse control.

In 1989, however, gambling researchers argued that they finally had their "proof." A study published in 7he Archives of General Psychiatry found that 17 heavy gamblers had neurochemical elevations correlated with their "extroversion." The article was--and continues to be--heralded by gambling researchers and the popular press as evidence that gamblers' biology is destiny. The New York Times headline read: "Gambling: Biology May Hold Key," and a piece in the February, 1992, Harvard Mental Health Letter argued that the 1989 study demonstrates that "The gambling addiction may even have a physiological basis."

Even this study, the gambling researchers' best evidence that chronic gambling is compulsive and a disease, proved little beyond what one would expect--namely, that gamblers are excitable personalities who evidence heightened neurological measures of excitement. It demonstrates neither that such biological differences are causal nor that they are specific to compulsive gamblers or even gamblers at all. As the study's senior researcher, psychiatrist Alec Roy concedes, the gamblers "were not compared to other groups, so we cannot answer the question with regard to specificity." He adds that no follow-up studies have been done or currently are being done to his knowledge.

Responsible gambling researchers do not maintain that there is any proof of biological causation in compulsive gambling. Sirgay Sanger, president of the National Council on Problem Gambling, admits in The Journal of the Americal Medical Association what one rarely, if ever, reads in gambling researchers' quotes in the popular press: Pathological gambling "has the smell of a biochemical addiction in it," but, he admits, "there is no research proof."

The most prominent medical doctor promoting the gambling-as-disease concept is psychiatrist Sheila Blume, the medical director for the alcoholism, chemical-dependency, and compulsive gambling programs at South Oaks Hospital, Amityville, N.Y. She often talks about heavy gambling as an illness, but there is reason to believe she doubts the claim herself and uses medical language only for strategic purposes.

In an article in JGS, Blume makes a remarkably frank recommendation that, regardless of objections to the medical model, heavy gambling should be considered an illness for practical benefits for gamblers and their doctors: "It is concluded that the many individual and social advantages of the medical model make it the preferred conceptualization of our present state of knowledge." Lesieur also has cited the strategic importance of public acceptance of pathological gambling as an illness, arguing that, without it, the gamblers themselves are less likely to accept the disease model, an acceptance he views as crucial to successful treatment.

Valerie Lorenz is executive director of the National Center for Pathological Gambling and one of the most vocal promoters of the illness model for gambling in her constant beseechings for governmental and other source funding. She sees the acceptance of gambling-as-illness as critical to legal exculpation and counsels that "the expert witness for the compulsive gambler facing legal charges" must "educate" judges and others as to the "illness" of the "compulsive gambler" in legal trouble, in order to avoid the unfair punishing of those who are "seriously disturbed" and "out of control."

Significantly, Norman Rose, a professor of law and vice-president of the California Council on Compulsive Gambling, who, according to JGS, is the "nation's leading authority on gambling and the law," disputes the medical model for compulsive gambling. In an interview, he expressed skepticism regarding the notion that heavy gambling can be a disease: "I have a lot of trouble with that idea, especially within the law, where it is used as an excuse." In terms of insanity-like defenses, wherein people are found not guilty of crimes by virtue of suffering from pathological gambling, Rose says, "It just doesn't work anymore," even though the plea still is attempted. What does work to some degree--and probably is increasing in usage--is its employment in criminal cases to provide alternative sentencing programs comparable to alcohol treatment programs, as well as in divorces, tax problems, and bankruptcy.

Regardless of questions of validity, the public appears conditioned to call any deviant behavior disease if the situation entails sufficient poignancy. In an article in Good Housekeeping titled "When Gambling Becomes a Disease," the magazine asserts that "It is only when gambling overtakes a person's life that it moves from recreation to an illness." However, does gambling really overtake people's lives?

Is compulsive gambling treatable?

In the wake of the claim of the astronomical prevalence (almost six percent of all adults in Maryland--more than one in every 20) of problem or pathological gambling, legislation was passed in Maryland to require all state lottery tickets to carry the following warning: "Compulsive gambling is a treatable illness." Those six words concede all three of the major disputable claims of the gambling researchers: that heavy, self-destructive gambling is an illness, is uncontrollable, and is treatable, which implies that treatment programs have been shown to be significantly helpful to those who seek aid to resist the urges. (The study was fueled by a National Institute of Mental Health study using a broad definition of pathological gambling, nearly guaranteeing a large claim.)

Researchers who argue that compulsive gambling is beyond control believe the proof to be self-evident by virtue of the devastating consequences of such activity and confirmed by the participants' claims that they can not stop. How, they wonder, could people willfully gamble themselves into such financial, legal, and family problems, consequences that define for the most part gamblers' "chronic and progressive failure to resist impulses to gamble" as required for psychiatry's current diagnostic manual (DSM-III-R)? This is, of course, a circular definition, as no one can verify a person's ability to control his or her behavior. Let us look at that assertion with reason as a guide.

When we wrote an article several years ago that "control" is not accessible or measurable except through the potentially self-serving claims of gamblers, Blume responded by accusing us of saying that gamblers could not be believed. Leaving aside that researchers invariably insist that lying is one of the cardinal signs of the compulsive gambler, the point is that a claim of inability to control one's gambling--even if made sincerely--can not logically confirm such inability. At most, the statement might reveal his or her honest belief.

Chet Forte, who gambled himself into millions of dollars of losses, has asked rhetorically how anyone could think he willfully would have "gone through the money" or "destroyed my family"? The answer is twofold. First, his stated concern for his family notwithstanding, many heavy gamblers--including, perhaps, Forte, according to a letter written to us by his first cousin, Anne Perrin, and her husband--simply don't care so much about their families.

Gambling researchers themselves are aware that the image of the heavy gambler whose actions destroy what otherwise would be a great family man (most heavy gamblers are men) is simply a myth. Most compulsive gamblers are not committed family men, with or without their gambling. Perrin stated that Forte defrauded her family, despite his being "someone my mother helped put through college and whose parents were constantly helped financially by my parents!" She adds that Forte has no real remorse and quotes him as saying that he learned that, "when you are stealing, steal big." Along a similar line, gambling researchers who attribute great social costs to gambling, such as those to businesses due to lost productivity, do not consider the possibility that a compulsive gambler who wasn't gambling would not be very productive or might have high absenteeism regardless.

Second, gambling is exciting for many reasons, including the risks and opportunities it provides for "big wins," as well as extensive losses. Heavy gamblers often engage in "chasing," which involves a type of exponentially increasing betting that can win back losses quickly, even substantial ones. Gamblers don't expect to lose.

The assumption that they can not control their urges figures largely in gambling treatment programs, as it does with those for other behavioral "addictions." In fact, the first in the well-known Twelve Steps of Recovery common to such programs is that the addict must admit that he or she has a problem (or illness) and is powerless to resist it. Despite the exaggerated claims of the promoters of groups like Gamblers Anonymous (GA) and Alcoholics Anonymous, there is little or no evidence of their widespread success. With respect to compulsive gamblers, anecdotes exist in abundance, but there are few studies available on the outcomes of such group-oriented treatment.

What studies there are reveal very limited success in achieving gambling abstinence. The astronomical dropout rate of 70% and more in GA and other groups makes it appear that whatever success there is--and sometimes high rates are claimed--is due largely to the high level of commitment of those who stay in the program, rather than the program itself. Neither is abstinence verifiable.

It is time for at least some skepticism regarding the unquestioned need for addicts to admit powerlessness over their own behavior. It is worth considering whether such admissions constitute a self-fulfilling prophesy--that is to say, the belief that a habit is uncontrollable actually may discourage people from trying to stop behaving in a self-destructive manner since it is beyond their control.

Assertions that heavy, destructive gambling is a disease, uncontrollable, and treatable simply do not withstand close scrutiny. Questionable research, reasoning, and evidence are used to criticize the existence of state lotteries, exculpate irresponsible behavior of heavy gamblers, and, in the case of treatment, perhaps undermine efforts to help people resist the urge to gamble. That the unique excitement and risk-taking motivates some people to neglect many important aspects of their lives is intriguing, but not overly surprising. It is the medicalizing of heavy gambling that makes it seem so utterly mysterious.

The debate about compulsive gambling, like that about other self-destructive or socially unacceptable behaviors ranging from compulsive drinking to compulsive shopping (a supposed new disorder whose advocates urge its inclusion in the next revision of psychiatry's diagnostic manual), ultimately comes down to a single question: Should individuals who engage in these behaviors be excused on the grounds that they suffer from a disorder that produces urges they are unable to resist? Without further evidence, we believe the answer to be no.

Whether talking about newspaper employees who have a conflict of interest due to borrowing to pay off gambling debts, people who defraud banks and associates, or athletes who bet on games in violation of league rules, there should be no general moral or legal recognition of compulsive gambling disorder as a valid reason for such behavior. The practical effect of recognizing disorders is to make these excuses significant because they are alleged disorders while rejecting other exculpatory claims.

The implication of this position, however, is not that no differences exist among individual cases of misconduct or self-destructive conduct. Quite the contrary. For instance, the employee who embezzles money to pay for a child's medical care may be entitled to more consideration than the one who pleads compulsive gambling. While both should be made to repay the stolen money, perhaps the former, not the latter, is entitled to a second chance. This much is clear: it is time to stop all special consideration for those whose excuses are sympathy-provoking only because they bear the unscientific "disorder" imprimatur of psychiatry.