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THE GAMBLERS’ HOSPITAL

Lesson 3

AMERICAN PSYCHIATRIC ASSOCIATION
DIAGNOSTIC CRITERIA FOR PATHOLOGICAL GAMBLING

  1. The individual is chronically and progressively unable to resist impulses to gamble.
  2. Gambling compromises, disrupts, or damages family, personal and vocational pursuits, as indicated by at least three of the following.
  1. arrest for forgery, fraud, embezzlement, or income tax evasion due to attempts to obtain money for gambling
  2. default on debts or other financial responsibilities
  3. disrupted family or spouse relationship due to gambling
  4. borrowing of money from illegal sources (loan sharks)
  5. inability to account for loss of money or to produce evidence of winning money, if this is claimed
  6. loss of work due to absenteeism in order to pursue gambling activity
  7. necessity for another person to provide money to relieve a desperate financial situation

C. The gambling is not due to Antisocial Personality Disorder.

It has also been pointed out that many ‘compulsive’ gamblers, in the course of treatment, promise themselves ‘slips ‘ or ‘ falls’ from abstinence, such relapses often being planned long in advance and then carried out very precisely.  A rather strange manifestation, surely, of what it supposed to be a disorder of impulse control?

            Custer did a lot of lobbying on the National Council on Compulsive Gambling, set up in 1972 with the express purpose of convincing public opinion that compulsive gambling was a treatable illness.  This, in turn, helped in persuading several states with lottery or other gambling interests to allocate funds for treating gamblers who had fallen victim, as it were, of the state’s exploitation of their weakness – half of one per cent of the profits was the target figure, a not inconsiderable sum.  Even in a small stake like Iowa, for instance, it yielded between $ 500,000 and $ 700,000 a year.  The campaign had its slip-ups, too.  In Washington a national Bill to establish a Commission to study problems of gambling fell through when, as luck would have it, the Senator who was sponsoring it was convicted of bribery and sent to goal.

            Maryland was the first state to legislate for treatment of compulsive gamblers, in May,1978.  The Bill was quite concise, declaring simply that Maryland with its extensive legalized gambling had an obligation to provide a program of treatment for people who became addicted to gambling.  A centre was set up as a pilot project in Johan Hopkins University, which continued until 1983; now replaced by a program at Taylor Manor Hospital in Endicott, Maryland.

            When Julian Taber took over at Brecksville, he formed a quite different view from the psychoanalytic diagnosis proselytized by Custer: compulsive gambling, so he came to believe, wasn’t deeply psychological – it was a character defect.  A roly- poly, genial man with round spectacles, Taber has a down-to-earth, slightly mocking air about him – not at all an evangelist.  He ran the programme for eight years.  By the time he left Brecksville in 1985, he had become thoroughly disillusioned.  ‘I don’t want to have anything to do with gamblers ever again,’ he told me.

            His work with alcoholics, gamblers, overeaters and sexual deviates led him to formulate for his own use a notion of limited character disorder.  ‘The impulsive disorders or, as I like to call them, the “Disorders of Desire”, seem to represent severe but limited developmental or character flaws, as he told the American Psychiatric Association (1979).  ‘The afflicted individuals demonstrate mature and sophisticated self-discipline in most critical life areas such as work, family obligations, schooling and community.’  For example, gamblers when they are using money in everyday life, as a medium of exchange, often display prudence and frugality to high degree, in order to gamble.  ‘Similarly those who impulsively eat, drink, smoke, steal and so forth are usually well able to run their lives in other areas, although the quality of life in all areas is eventually eroded by their specific out of control behaviour.’

            Hamlet’s comment on the King’s ostentatious relish for drinking, one might say, hit the mark exactly:

            So, often it chances in particular men.
            That for some vicious mole of nature in them,
            As, in their birth – wherein they are not guilty…
            Or by some habit that too much o’er-leavens
            The form of plausive manners; that these men …
            Shall in the general  censure take corruption
            From that particular fault   (I.iv.23)

            Anyway, Taber formed the view that total or general loss of impulse control was much rarer than a severe but specific loss.  Reviewing the life histories of alcoholics, gamblers and over-eaters, he concluded that the root of the trouble lay in ‘parental failure to impose conditioning discipline in selected areas of gratification’.  And if this was so, therapy must provide opportunities to practice and to learn the rewards of responsibility: acceptance, patience, self-discipline and sensitivity.  These are the qualities which the process of group therapy is designed to bring out and foster – as it were, a training ground for tolerance.

            Gamblers are easy to work with (less passive than alcoholics), being direct, talkative and challenging.  Each new group member would prepare an account of his own experience to present to the others.  In daily sessions discussion focused on the feelings and problems which result from individuals’ behaviour as compulsive gamblers: social stigma, personal failure, alienation and distrust, inability to express love, ‘magic’ thinking, and so on.  The therapist must try to avoid being assertive.  The worst an inexperienced therapist can do, in my opinion,’ Taber added, ‘is to treat the addicted person as some kind of neurotic and set out to probe the past for psychic distortions.’

            ‘No one knows,’ he declared, ‘which features of our program contribute materially to long-term abstinence … One suspects that the drastic step of surrender to hospitalization is itself the first major curative step in the required life-style change and that it really may not make too much difference exactly what we do by way of a program so long as we encourage the practice of a mature and controlled existence.’  

      In the absence of factual data, it was likely that treatment would continue to be based on ‘theory’, so it was important, Taber suggested.  To look carefully at the credentials of the theorists themselves.  Thus he is somewhat skeptical of claims by Custer and others that about 50 per cent of gamblers going through a treatment program achieved an appreciable period of abstinence.  ‘I can accept political and economic need (he meant the need  to convince the people back at HQ) for simple outcome statistics such as recovery rate, but I see neither a professional  nor scientific purpose for this information.  Slips occur and may serve a therapeutic role in the long-term turn-around of a life style.’

            After patients left Brecksville things like length of abstinence, dollar value if gambling losses and the duration and frequency of slips could be measured, but only imperfectly.  As a behaviorist, following Skinner rather than Freud, Taber dislikes such statistical analysis in making what are essentially value judgment.  ‘We must measure something, but how do we measure the quality of life?  … Gamblers, their habits, and their personalities,’ he concluded in this report, ‘display a variance that will confound every effort at gambles when they tell us what they think helped them the most … What successful abstainers tell us probably deserves greater credence than our theories, personality tests, and professional opinions … There is so much to ask him other than, “Have you gambled lately?” If this is all we can ask we shall deserve the answers we get.’

            This skepticism about the value of the professionals’ contribution seems to have deepened  in Taber.  By the time he left Brecksville he had become disenchanted, to put it mildly, with gamblers. ‘They’re awful, they’re fakers, they went there, to Brecksville, to get out of their legal obligations and their debts, to gain a breathing space.’  What, all of them?  ‘Well …yeah … that was the obvious temptation, to escape.  I don’t want to have anything to do with gamblers ever again.’  In response, I suggested that he was like one of Graham Greene’s lapsed believers, a burnt-out case: he still believed in the program, but he had been too closely involved with compulsive gamblers for too long.

            Certainly he remains committed to treating patients suffering from ‘disorders of desire’, gambling excepted, as can be seen from his new job, which is even more demanding: running a special clinic for drug addicts, this time in Reno (where many of the cases are inevitably gambling – related ).  But Taber has pushed his theory still further, that the patients as a group know better than the professionals how to deal with their problems           

  ‘I let the group decide what to do, how to handle each case.’   What if the patient doesn’t accept, doesn’t agree?  ‘He can leave.  I ask each man who comes in, “Do you want to be cured?” If he wants to be cured, he joins the group.  He accepts what the group says.  Most of these guys, what they need is to find some simple job, like working at a filling station.  Then they can start to learn how to become a decent  human being again.’  Yes indeed, but what happens if a patient who is told by  group to get a new job and start a new life has other commitments, has been living far away from Reno, say in Oklahoma, leaving a family behind?  Taber gives a shrug.  ‘Does the man want to be cured or not?  If he does, he stays.  If not he can quit.’
            Taber’s model, one might sum up, is valid for him; Custer’s approach for others.  In gambling, as in treatment of their addictive disorders, no single approach has the imprimatur of a proven ‘cure’.  Theories have their uses, certainly, but they also have their limitations.  And just as there are different models of alcoholism, so there is a variety of medical as well as social models to explain compulsive gambling.

            Reviewing the field, Iain Brown (whose experiment to test gambler’s heartbeats is reported at the end of Chapter 5) notes that if a social learning theory of gambling was patterned on theories of drinking and drug abuse, it would probably suggest that gambling begins with limitation learning, perhaps copying a hero figure in adolescence, but more commonly that gamblers pick up the habit from their social group.  Once it takes hold, major losses occur, ‘chasing’ begins; the gambler then devises new ways of raising money, leading in turn to a life crisis.

            The disease and social learning models each have their draw-backs, Brown adds.  One danger of the medical model is its concentration on extreme  cases, leading to treatment suitable only for the seriously sick.  A weakness of the social learning model is that it underestimates the importance of internal responses (such as arousal).  On the other hand the disease analogy is easily understandable, whereas behaviorist explanations offer no familiar analogy in everyday life, which makes it harder for the gambler and his family to adapt to change.
            The conclusion offered is that exclusive reliance on any one model leads to impoverishment of both research and methods of help.  Even if a social learning poker theory of gambling were to become dominant, ‘the medical, moral and other perspectives on gambling Addictions).

            So far as Brecksville is concerned, a key point is to keep in touch with people who have been through treatment contact by phone; some return on a monthly basis; nearly all keep going to GA.  Experience has shown that the further away a man lived, the more likely he was to slip back into gambling.  If a man did not make contact the case was assumed to have been a failure.  Holding down a job vocational training was included at Brecksville – offered the best chance of a return to normal life.  Custer believes they were 50 per cent successful in the Cleveland area; the GA rate of success across the country  is usually put at around 5 to 20 per cent.

            Given the variety of ‘substance abuse’ as the problem is known, it would be gratifying to have a general theory of addictions, comparing similarities and differences between alcoholics, heavy smokers, drug takers, over-eaters and pathological gamblers (who are not involved with a ‘substance’ as such).  Fortunately, such a theory is to hand, conceived by one of the founding psychologists at Brecksville, Durand Jacobs, now chief of the Psychology Service at a veterans’ hospital in Loma Linda, California.  Whereas the usual practice is to study each type of addiction as a separate entity, Jacobs and his colleagues set about cross-checking the behaviour and background of different types of addicts.  What they found is that all addicts share the same objective – a common aim – what Jocobs and his colleagues term ‘ a dissociated state’, meaning a state of altered identity.

            From the very start, they say, the addict’s pattern of use provides relief from distressingly high or subnormal levels of physiological tension.  ‘In addition the manner and circumstances under which the chosen substances is used, or how the chosen activity is pursued, concurrently serves to release the would-be addict from longstanding psychological maladjustments and permits fantasies of being wanted, successful, recognized and admired.’  This doubly gratifying physiological and psychological end-state powerfully reinforces the behaviour that produced it.

            Of course many casual users experience the same sort of physiological release or high.  Only the addict, according to this theory, finds the additional psychological reward of entering a dissociative  end-state, where it is possible to live out his fantasies.  ‘It is this double-barrelled end-state that constitutes the common denominator which binds different kinds of addicts into a community of fellow travelers.’
            The addictive pattern of behaviour is maintained by a series of positive (i.e. reward) and negative (i.e. escape from pain) reinforcements:

            What is the nature of this end point gratifying experience?  Does the drug addict experience it all that differently than the alcoholic, or the compulsive gambler, or the overeater, or the addicted runner or skydiver, or the addicted commodity trader, or the helplessly infatuated lover?  We believe that, while there may be wide differences in the means (i.e. the substances or activities chosen for pursuing an addictive form of behaviour ), certain aspects of the end state may be much the same for all addicts.  That is: the attainment of a dissociated state.  (Jacobs, Marston, Singer, 1984)
            As Jacobs explained his theory to me, an element of chance - in the form of the first opportunity to indulge – has also to be present, for a user to turn into an abuser and thence into an addict.  Adolescents, naturally, are particularly vulnerable to such chance encounters.

            ‘It’s like fire.  You need a substance, which is the physical arousal level.  You need kindling, which is the psychological flashpoint.  And for a fire to burn you must have oxygen, which is analogous to a conducive situation.  If these three elements do not co-exist, you don’t get a flame.’  In other words, a person who might be, by his physical and psychological make-up, a potential compulsive gambler, runs no risk of addiction if the opportunity to gamble isn’t there.  If he lives, shall we say, in the middle of Alaska rather than a couple of bocks off Las Vegas Boulevard South.

            Fire is an attractive analogy.  If one or other of these three elements is lowered, the flame of an addictive form of behaviour can be extinguished, at least temporarily.  Treatment, therefore, must take account of psychological and physical stresses and the environment too.  The practical aim of all this theoretical work, which Jacobs and others are continuing, is to develop an early warning system – a way of screening high-risk adolescents before they get caught in an addictive pattern of behaviour.
            ‘Everybody has got his own theory,’ Custer summed it up, ‘It’s up to them to prove it.’

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