1
Introduction

Gambling is deeply rooted in American culture (Findlay, 1986). In precolonial times, the proceeds from lotteries authorized by the ruling English monarchy were used to subsidize explorations to, and settlements within, the New World (Ezell, 1960). As colonial America matured, government and private lotteries, as well as social gambling, were common. The colonial era of gambling ended with the spread of Jacksonian morality, aided by numerous well-publicized scandals. Civil War reconstruction introduced a second era of gambling, as lotteries were employed as a form of voluntary taxation to rebuild the wartorn South (Rose, 1998; Ezell, 1977). Gambling continued to spread until 1890, when a scandal involving the Louisiana lottery resulted in federal legislation that effectively banned state lotteries and prohibited other forms of gambling for nearly 70 years (Rose, 1998; Ezell, 1977).

The United States is now in the midst of a third era of widespread legalized gambling, which began in 1931 when Nevada relegalized casinos (Rose, 1986, 1995). Initially, Americans in this era limited legal gambling opportunities to the Nevada casinos, charitable bingo, and pari-mutuel gambling, such as horse and dog track racing. Popular forms of illegal gambling, such as offtrack betting, back room casino games, and numbers, were as-



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--> 1 Introduction Gambling is deeply rooted in American culture (Findlay, 1986). In precolonial times, the proceeds from lotteries authorized by the ruling English monarchy were used to subsidize explorations to, and settlements within, the New World (Ezell, 1960). As colonial America matured, government and private lotteries, as well as social gambling, were common. The colonial era of gambling ended with the spread of Jacksonian morality, aided by numerous well-publicized scandals. Civil War reconstruction introduced a second era of gambling, as lotteries were employed as a form of voluntary taxation to rebuild the wartorn South (Rose, 1998; Ezell, 1977). Gambling continued to spread until 1890, when a scandal involving the Louisiana lottery resulted in federal legislation that effectively banned state lotteries and prohibited other forms of gambling for nearly 70 years (Rose, 1998; Ezell, 1977). The United States is now in the midst of a third era of widespread legalized gambling, which began in 1931 when Nevada relegalized casinos (Rose, 1986, 1995). Initially, Americans in this era limited legal gambling opportunities to the Nevada casinos, charitable bingo, and pari-mutuel gambling, such as horse and dog track racing. Popular forms of illegal gambling, such as offtrack betting, back room casino games, and numbers, were as-

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--> sociated with organized crime and were treated as vice crimes by law enforcement institutions. Then, beginning in 1964, gambling expanded greatly after New Hampshire initiated the first modern state lottery, signifying a change in traditional social and moral barriers. As of this writing, some form of gambling is legal in all but 3 states, casino or casino-style gambling is available in 21 states, and 37 states have lotteries (National Opinion Research Center, 1999). In 1988, Congress passed the Indian Gaming Regulatory Act, which allows tribes to operate any form of gambling currently legalized in the state in which the tribe resides. Resistance by many state legislatures to casino gambling and state-sanctioned sports betting continues, but in numerous jurisdictions other forms of gambling have become institutionalized, with state budgets increasingly dependent on gambling revenues. The advent of state-sponsored lotteries marked a significant policy shift in which the states moved from tolerance to active sponsorship and aggressive marketing of their own games. Public support of this shift is beyond question, with over 80 percent of adults in the United States participating in various forms of commercial or state-sponsored gambling sometime during their lives. Collectively Americans wagered over $551 billion in 1997 in legal gambling activities (International Gaming and Wagering Business, 1998). Although gambling is popular and has social and economic benefits, there are also costs involved for individuals, families, and communities stemming from pathological and problem gambling. Committee Charge In August 1996, President Clinton signed P.L. 104-169, establishing the National Gambling Impact Study Commission, whose purpose is to conduct a comprehensive study of the social and economic impacts of gambling in the United States. Section 4(a), (2)(C) of the new law called for "an assessment of pathological or problem gambling, including its impact on individuals, families, businesses, social institutions, and the economy." The act further states under Section (b)(1): "In carrying out its duties under section 4, the Commission shall contract with the National Research Council of the National Academy of Sciences for assistance in con-

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--> ducting the studies required by the Commission under section 4(a), and in particular the assessment required under subparagraph (C) of paragraph (2) of such section." In response to a subsequent request from the National Gambling Impact Study Commission, the National Research Council established the Committee on the Social and Economic Impact of Pathological Gambling. The committee's charge was to identify and analyze the full range of research studies that bear upon the nature of pathological and problem gambling, highlighting key issues and data sources that may provide scientific evidence of prevalence and multiple effects. In its review and assessment of the contemporary research on pathological and problem gambling, the committee examined the diverse and frequently debated issues regarding the conceptualization of pathological gambling, its prevalence and effects on individuals and society, its causes and cooccurrences with other psychiatric disorders and substance abuse, what we know about preventing and treating it, and the role of technology in the development of gambling. This review included consideration of over 4,000 gambling-related references, of which approximately 1,600 were determined to be related to pathological or problem gambling. Of these, about 300 were found to be empirical research studies. It was this relatively narrow subset of studies, primarily published in peer-reviewed journals, that the committee concentrated on in determining the strength of the available literature in all key areas. Brief History of Pathological and Problem Gambling For as long as humans have gambled, there has been apprehension about excessive risk-taking and intemperate gambling. Histories of gamblers who lose control recur through the centuries, and from early times their behavior was labeled an addiction (France, 1902, cited by Wildman, 1997). In early Roman law, the original addict was a debtor (Rosenthal, 1992) who, because he could not pay what he owed, was brought into court and enslaved (Glare, 1982; Wissowa, 1984). Hence, judges pronouncing sentence could make the addict the slave of his creditor. These early

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--> "addicts" were not limited to gamblers, although in early Roman times gambling was rampant (France, 1902, cited by Wildman, 1997). Descriptions of many features of what is now clinically described as pathological gambling have appeared in historical accounts of many world cultures, as well as in American literature since the early colonial period. Some famous Roman emperors were avid gamblers, and there is some evidence that Claudius and Nero would meet a modern definition of a pathological gambler (Wildman, 1997). Fear of a loss of control by his soldiers due to gambling caused King Richard the Lion-Hearted to restrict dice playing during the crusades (Fleming, 1978). In the 17th century, gambling was regarded as a vice that ranged from the making of small wagers to the staking of all the gambler's earthly property, and in some instances the person's title (Wildman, 1997; Rose, 1988). Dostoyevsky in The Gambler (1866), a fictionalized account of his own experiences, writes of the cognitive distortions, loss of control and self-esteem, and hopelessness currently associated with clinical definitions of severe gambling problems. Many historians and other writers have noted patterns of behaviors that resemble current descriptions of clinical symptoms of gambling problems (e.g., Cotton, 1674; Stith, 1752; Dostoyevsky, 1866; France, 1902, Wildman, 1997; Rosenthal, 1998). Landon Carter (cited by Findlay, 1986) spoke for the southern gentry when he compared a man with a passion for gambling to a slave. In 1791 an article in The Western County Magazine refers to gambling as an addiction, and describes the preoccupation and distraction, citing many cases of individuals who lost everything and committed suicide (see Steinmetz, 1869). Admonitions against gambling were also prominent during the 1820s and 1830s, as part of the temperance movement. In 1834, Charles Caldwell, a physician and prominent medical educator, labeled gambling an addictive vice that would render men mad (Caldwell, 1834). Another physician, J.T. Taylor, also described gambling as an addiction and, like Cotton almost 200 years before him, describes most of the criteria and associated features of gambling problems that comprise the current clinical description of pathological gambling as determined by the American Psychiatric Association (1994). He describes the shame, guilt, and se-

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--> crecy of the gambler; preoccupation with gambling; neglect of wife and home; neglect of employment; extravagant spending; turning to theft and other illegal activities to support gambling and other expenses; and, finally, suicide (see Taylor, 1838). During the 1840s and 1850s, clergymen and reformers such as Henry Ward Beecher and William Alcott described the gambler's descent through addiction and madness into crime (see Fabian, 1990:55-56). In the first half of the 20th century, psychoanalysts became interested in gambling (Rosenthal, 1987). Starting in 1914 with Von Hattingberg, they contributed case reports and speculative essays in which patients were often identified as gambling addicts. Freud was particularly interested in why people would deliberately seek out and repeat self-destructive behaviors. He believed that it was not for money that the gambler gambled, but for the gambling itself, what psychoanalysts would refer to today as "the action." Freud thought gambling was an addiction; he placed it in a triad with alcoholism and drug dependence (Freud, 1928). During the 1930s, legalized gambling became widely available in the United States. With 21 states opening racetracks with pari-mutuel betting and the relegalization of casino gambling in Nevada, gambling problems began to gain attention. The first meeting of Gamblers Anonymous took place in Los Angeles in December 1957. The self-help fellowship was founded on the belief that character changes within gamblers themselves were necessary to ameliorate problematic gambling and its effects, and that changes could be made by adopting spiritual principles used by those recovering from addictions (Gamblers Anonymous, 1997). As the fellowship expanded, its now famous 20 questions became the de facto standard used to gauge whether or not gambling behaviors were compulsive (see Appendix A). The questions became the basis for modern classification systems that determine the chronicity and seriousness of gambling problems in part by the consequences of gambling behavior. Subsequently, explanations of the cause of gambling problems began to focus on the gambler's personal attributes rather than solely on social and economic consequences. People with gambling problems were conceptually transformed into problem gamblers. And if the

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--> gambling problems were chronic, the problem gambler was considered a "compulsive gambler," an early term for pathological gambler. Organization of the Report The purpose of this report is to describe the current scientific knowledge about the definition, extent, nature, effects, and treatment of pathological gambling, as well as emerging technologies that may affect them in the future. Chapter 2 considers the concept of gambling and describes contemporary patterns of excessive or pathological gambling. It considers gambling from two distinct perspectives: (1) how clinicians and researchers understand gamblers and the ranges of their behaviors and (2) how such behaviors, particularly pathological gambling, can be understood in terms of the harmful consequences associated with these actions. In the course of this discussion, a nomenclature unfolds and is offered for future use. The chapter also lays a foundation for our review of the scholarly literature pertaining to the extent and nature of pathological gambling, its social and economic effects, and its treatment. Finally, this chapter suggests ways of improving understanding of pathological and problem gambling. Inherent throughout is a critical scientific consideration of pathological gambling as both a psychological and a social construct, and an analysis of its definition as a psychiatric disorder. Chapter 3 describes the prevalence of pathological gambling in the United States, making note of complications and limitations in the existing research. Chapter 4 assesses our understanding of the origins of pathological gambling. Chapter 5 discusses the social and economic benefits of gambling and assesses the literature about the effects of pathological gambling on individuals, families, communities, and society. In it we discuss the few available studies of socioeconomic effects as examples of how knowledge in this area can be advanced. Chapter 6 reviews characteristics of treatment seekers, treatment approaches and effectiveness, and health care and prevention issues. Chapter 7 considers how advances in the organization and technology of

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--> gambling have affected pathological gambling and may increasingly do so in the future. References American Psychiatric Association 1994 DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Association. Caldwell, C. 1834 An Address on the Vice of Gambling Delivered to the Medical Pupils of Transylvania University. November 4. Lexington, KY: J. Clark and Co. Cotton, C. 1674 Games and Gamesters of the Restoration. The Compleat Gamester. Reprinted in 1971 by Kennikat Press, Port Washington, NY. Dostoyevsky, F. 1866 The gambler. In The Gambler and Other Stories, C. Garnett, ed. New York: Macmillan. Ezell, J.S. 1960 Fortune's Merry Wheel. Cambridge, MA: Harvard University Press. Fabian, A. 1990 Card Sharps, Dream Books, and Bucket Shops: Gambling in 19th-Century America. Ithaca, NY: Cornell University Press. Findlay, J.M. 1986 People of Chance: Gambling in American Society from Jamestown to Las Vegas. New York: Oxford University Press. Fleming, A.M. 1978 Something for Nothing: A History of Gambling. New York: Delacorte. France, C. 1902 The gambling impulse. American Journal of Psychology 13:364-407. Freud, S. 1928 Dostoevsky and parricide. Pp. 175-196 in Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol XXI, J. Strachey, trans. ed. London: Hogarth, 1961. Gamblers Anonymous 1997 Gamblers Anonymous: Sharing Recovery Through Gamblers Anonymous. Los Angeles: Gamblers Anonymous. Glare, P.G.W. 1982 Oxford Latin Dictionary. Oxford, England: Clarendon Press. International Gaming and Wagering Business 1998 The United States gross annual wager. International Gaming and Wagering Business (supplement) 19(8):3. National Opinion Research Center 1999 Gambling Impact and Behavior Study: Final Report to the National Gambling Impact Study Commission. March 18. Chicago: University of Chicago Press.

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--> Rose, I.N. 1986 Gambling and the Law (1st ed.). Hollywood, CA: Gambling Times. 1988 Gambling and the law. Journal of Gambling Behavior 4:240-260. 1995 Gambling and the law: Endless fields of dreams. Journal of Gambling Studies 11:15-33. 1998 Technology and the Future of Gambling. Unpublished manuscript. Whittier Law School, Costa Mesa, CA. Rosenthal, R.J. 1987 The psychodynamics of pathological gambling: A review of the literature. In The Handbook of Pathological Gambling, T. Galski, ed. Springfield, IL: Thomas. 1992 Pathological gambling. Psychiatric Annals 22:72-78. 1998 The Medicalization of Gambling: Its History as Addiction, Compulsion, and Disease. Unpublished manuscript. Department of Psychiatry, University of California, Los Angeles. Steinmetz, A. 1869 The Gaming Table: Its Votaries and Victims, in All Times and Countries, Especially in England and France. Montclair, NJ: Patterson Smith, 1969. Stith, W. 1752 The Sinfulness and Pernicious Nature of Gaming: A Sermon Preached Before the General Assembly of Virginia. March 1, 1752. Williamsburg, VA: William Hunter. Taylor, J.S. 1838 The Victims of Gambling: Being Extracts from the Diary of an American Physician. New York: Boston, Weeks, Jordon and Co. Von Hattingberg, H. 1914 Analerotik, angstlust und eigesinn. Internationale Zeitschrift fur Psychoanalyse 2:244-258. Wildman, R.W. II 1997 Gambling: An Attempt at an Integration. Edmonton, Alberta, Canada: Wynne Resources. Wissowa, G. 1984 Paulys Real-Encyclopadie der Classischen Altertumswissenschaft. Stuttgart, Germany: Metzler.