The Scientific Review of Mental Health Practice

Objective Investigations of Controversial and Unorthodox Claims in Clinical Psychology, Psychiatry, and Social Work

BOOK REVIEW

A Review of a Review

Review of Pathological Gambling: A Critical Review


The contributors to this National Research Council project were drawn from a very impressive list of organizations: the Committee on the Social and Economic Impact of Pathological Gambling, the Committee on Law and Justice, the Commission on Behavioral and Social Sciences and Education, and the National Research Council. No fewer than 89 professional people had some input on one or another committee, commission, panel, or workshop in the production of this comprehensive review. No previous effort, to this reviewer's knowledge, has drawn into focus such a broad array of findings and theory on the subject of pathological gambling. Two metaphorical descriptors might apply: watershed and springboard. Practitioners and researchers alike would do well to check out the contents of this book. Its entire text is available at www.nap.edu.

One of the values of Pathological Gambling can be found in its attempt to come to grips with the vexing problem of defining of terms. A statement on page 38 is instructive: "The committee was charged to review excessive gambling as 'pathological' according to the American Psychiatric Association." The committee also used the unusual term "medicalization" to characterize its definitional approach. Though the authors seemed pressed to assume this particular perspective in their efforts, it did not really simplify the task of defining "pathological gambling." If one cannot be certain how to delineate what is being counted, any conclusions about the prevalence or incidence of the supposed medical disorder are bound to be clouded.

Indeed, the concepts of prevalence and incidence are accorded a special emphasis. The authors make a point about adding the dimension of time, where on page 64 they defined prevalence as "average total number of cases during a given time period." Incidence is declared to be the "number of new cases arising in a given time period." The appendix cites three successive statements about prevalence as they appear in the various editions of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM). None, however, contains the time dimension. In 1980 the entry under this heading was "[n]o information." The 1987 edition said that "[r]ecent estimates place prevalence at 2%-3% of the adult population." Somehow, the adolescent population is totally overlooked. The 1994 DSM states that "[t]he limited data available suggest that the prevalence of pathological gambling may be as high as 1%-3% of the adult population." Again, younger ages are omitted, and the frequency per unit time has been overlooked.

Estimates of prevalence have ranged widely and wildly, from a few million to 14 million classified as pathological and problem gamblers combined, in the adult population over 18 years of age. Caution is also raised that gambling behavior in the population of adolescents is already widespread and continues to grow. The chapter entitled "Pathological and Problem Gambling in the United States" details the valiant efforts of researchers to find answers to the question of "how many." The authors' conclusion regarding research on prevalence is less than encouraging: ". . . it is important to emphasize how inadequate that research base is for drawing confident conclusions about the prevalence of pathological and problem gambling in the U.S. population or in important subpopulations" (p. 100).

The chapter entitled "Origins of Pathological and Problem Gambling" follows an obvious course, considering the tilt toward "medicalization" present in the book. There is a heavy emphasis on neurobiological and genetic factors in causation. Other potential causal variables are explored: age, gender, minority, and urban/rural connections. Even a chicken-and-the-egg scenario is considered. In gambling-related suicide, does the depression associated with suicide precede the gambling behavior, or is it a consequence of the gambling? Ultimately, the authors of Pathological Gambling come up with a smorgasbord of ideas for further research. Much work is needed to illuminate the etiology of gambling behavior that has turned either pathological or problematical.

The section entitled "Social and Economic Effects" deals with a natural set of events that follow any major change in the organization of society. In 1931 only one state, Nevada, had legalized commercial gambling. Today, all but three states have some form of legal gambling establishments. Appendix C cites Hawaii, Utah, and Tennessee as the holdouts. Hawaii does, however, allow something euphemistically called "social gambling" (p. 290). The societal question becomes: Just what has been happening around us over these past 70 years? Put in stark terms, one assessment of the situation says it this way: excessive gambling "ranks among the most expensive illnesses afflicting society" (Politzer, Morrow, & Leavey, 1985, p. 131).

Although this may be an overblown assessment, the presence of "Social and Economic Effects" in Pathological Gambling suggests an urgent call to make serious cost/benefit analyses in social as well as individual human terms. To take only the cost/benefit calculations published by, say, the American Gaming Association would clearly be biased to the extreme. To listen only to the anecdotal horror stories of lives upended by pathological gambling would be equally unfair. The concluding call is for more and better research: ". . . benefit-cost analysis of pathological and problem gambling remains undeveloped" (p. 185).

The chapter entitled "Treatment of Pathological Gamblers" presents an equally pessimistic picture. In the context of the problems associated with "how many," this is the current assessment: "What is known about treatment of pathological gambling lags behind what is known about it prevalence and etiology" (p. 220). Considering the already-noted inadequacies in these areas, this is almost a perfect segue to the chapter entitled "Organization and Technology of Gambling." Here is where the bias of the reviewer comes into play (pun intended).

The focus, then, takes a complete shift. No longer are we asked to study the familial, genetic, biological, or psychiatric dimensions traditionally associated with the causation of problem gambling. This last main chapter in the book should give us pause to consider that, just maybe, the environmental factors surrounding the act of gambling might be causative. To nudge this shift, we might also consider using the word "gambling" as an adjective rather than a noun. What pathological gambling really refers to is gambling behavior. Our attention is thus directed to a human being engaging in some simple act such as pressing a button or pulling a lever, as in the case of slot machines. With this perspective we can examine a remarkable number of human actions over relatively short periods of time with a minimum of energy expenditure.

By some estimates, a gambler can activate an electronic gambling device 400 to 500 times per hour. This can reach a maximum of 1,000 button presses or lever pulls per hour (Grochowski, 1999, p. 8; Scarne, 1974, pp. 450-451). The authors of Pathological Gambling seem to sense the research value of this enormous body of data involving the frequency of gambling behavior per unit time. They encourage time series studies in natural settings. They also suggest the use of longitudinal studies. However, they take a somewhat negative view of their own suggestion: ". . . it is possible that little is to be gained from a dedicated longitudinal prospective study of pathological gambling, since only a tiny percentage of the sample is likely to develop a gambling problem" (p. 259). The pejorative "tiny" suggests, erroneously, that such a research approach is largely a waste of time, money, and energy.

The authors overlook the classic small sample, time series, longitudinal research strategy reported in great detail by Thomas North Whitehead (1938). The essential feature was to record, over 5 years, the moment-by-moment output of 5 research subjects in the Western Electric Hawthorne Plant in Chicago. From 1927 to 1931 Whitehead gathered frequency-per-unit-time (accurate to .2 of a second) data from 5 people (Whitehead, vol. 1, p. 27). This was done 8 hours per day, 5 days a week, for 50 weeks each year. Over that period of time some 3 million bits of behavior were recorded. Finding a way to implement this research paradigm in a present-day gambling situation becomes the challenge.

Current technology may, indeed, hold some of the keys to how compulsive or pathological gambling behavior develops. For well over 50 years the concept of intermittent reward or a variable ratio schedule (VRS) of reinforcement has been described in animal and human research (Knapp, 1976). Elsewhere, Knapp described gambling succinctly in these terms: ". . . no other contemporary public policy issue provides such an isometric fit with the principles of behavior analysis as gambling: an easily counted repetitious behavior which is maintained by its consequences" (1997, p. 130). When the consequence to each bit of gambling behavior is an uncertainty based on a variable ratio schedule of possible payoff, the behavior persists. However, the authors of Pathological Gambling tend to play down this significance. Witness: ". . . since few gamblers become compulsive, intermittent and variable reward alone cannot explain problem or pathological gambling" (p. 240). Here, the authors seem very sure of the estimates of prevalence to allow the pejorative judgement of "few." The prevalence estimate mentioned earlier of 14 million problem and pathological gamblers seems a mandate for exploring the VRS as a prime suspect in analyzing such behaviors.

Frequency, time, and frequency per unit time are mentioned very early in Pathological Gambling as crucial, basic elements for measuring gambling behavior. "New technology holds the potential . . . to increase how often, how much, and how long people gamble" (p. 5). Sophisticated electronic card devices can be used to track the behavior of gamblers and as a marketing tool to entice and hold the players. They can also provide hard data for the researcher to assess the influence of the VRS of the payoff on subsequent behavior of the gambler. As a matter of course, it might become possible for a patron of the casino to receive a printout of time, money spent, and types of wagers and gambles per unit time after each visit. Anyone who has passed a credit card through a device and been given a printout of grocery purchases can attest to the availability of this technology. With the collection of these kinds of data, the linkage, if any, between pathological gambling behavior and the VRS of reinforcing payoff could be studied in detail.

In short, Pathological Gambling is very rich in ideas and inspiration for needed research and well worth a read from this perspective. But it is very poor in suggesting approaches for practitioners hoping to help people wanting to reduce the frequency per unit time of their gambling behavior. The impending legalization of online gambling in the home might enhance the data-gathering component of research. Though it might be easy to monitor gambling behavior on the Internet, the ease of wagering at home has potential to increase the prevalence and incidence of the pathologies, compulsions, and addictions associated with such behavior. We shall see. Pathological Gambling is, indeed, a springboard for glimpse at what the future holds in this field.

References

Grochowski, J. (1999). The slot machine answer book. Chicago: Bonus Books, Inc.

Knapp, T. (1976). A functional analysis of gambling behavior. In W. Eadington (Ed.), Gambling and society (pp. 276-294). Springfield, IL: Charles C. Thomas.

Knapp, T. (1997). Behaviorism and pubic policy: B. F. Skinner's views on gambling. Behavior and Social Issues, 7, 129-139.

National Gambling Impact Study Commission: Final report. (1999). Washington, DC: U.S. Government Printing Office.

National Research Council. (1999). Pathological gambling: A critical review. Washington, DC: National Academy Press.

Politzer, R., Morrow, J., & Leavey, R. (1985) Report on the cost benefit/effectiveness of treatment at the Johns Hopkins Center for Pathological Gambling. Journal of Gambling Behavior, 1, 131-142.

Scarne, J. (1974). Scarne's new complete guide to gambling. New York: Simon & Schuster.

Whitehead, T. N. (1938). The industrial worker, vols. 1 & 2. Cambridge, MA: Harvard University Press.


Calvin K. Claus, Ph.D.
Professor Emeritus, National-Louis University
E-mail: clauscn@attbi.com

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The Scientific Review of Mental Health Practice, vol. 1, no. 2 (Fall/Winter 2002).
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