Lia Nower, JD, PhD, has researched gambling addiction both in the United States and internationally. She is an Assistant Professor of Social Welfare at the University of Missouri, St. Louis, a state- and nationally certified compulsive gambling counselor, and a clinical supervisor for the National Council on Problem Gambling in Washington, D.C. The combination of her legal and mental health expertise gives her a unique perspective in understanding this issue.

HR: I know that you have conducted research and numerous seminars on this topic. How did you personally become interested in gambling addiction?
LN: I had the good fortune to be mentored by Dr. David Ohlms, an addiction psychiatrist and medical director of Anheuser-Busch and his wife, Terri Ohlms, a clinical social worker who was the first certified compulsive gambling counselor in Missouri. When I joined their practice, they essentially said, “Pick an addiction.” Sex, drugs, alcohol, shopping — so many options, so little time! Gambling was the most complex and challenging to treat (it was also a relatively new field) so I thought I’d try my hand.

HR: Share a few statistics with us. How common is gambling addiction? Is the incidence of this problem really increasing or is it merely that we are just hearing more about it now?

LN: The general prevalence estimate is that 1.7 percent of adults (3 percent to 5 percent of youth) meet diagnostic criteria for pathological gambling and an additional 3 to 5 percent have serious gambling problems. Those figures are often higher in jurisdictions where gambling has been legal longer. Studies have yet to track the yearly incidence of pathological gambling, so it is anybody’s guess how that number is fluctuating, though we believe that availability, accessibility, and acceptability tend to increase overall rates in a given area.

HR: Is there a personality profile — say a cluster of personality traits — that makes one more susceptible to this behavior?

LN: The research in this area is still in its infancy but, in general, individuals with certain traits and bio-psycho-social predispositions are more likely than others to develop problems. Those at highest risk are impulsive, intensity seeking, addicted to other substances, and typically depressed or anxious. They start gambling or pursuing other risk-taking behaviors at an early age and report childhoods marked by abuse or neglect and caregivers with addictions.

HR: Let’s say that Joe or Jane average gambling addict hits the casinos and loses enough money to bankrupt a small financial institution. Moreover, he or she can’t afford to do so. What is the mind-set that keeps him or her coming back for more?

LN: The hope that some day, some how, Lady Luck will smile down again. To understand the insanity of that thinking you have to understand the cycle. Early on, people gamble for recreation and tend to win something. Statistically, the less you gamble, the more likely your wins will outpace your losses. Many problem gamblers report they had an early big win that left them hungering for more. This precipitates “chasing” behavior — gambling more often in hopes of recreating that early win. The more you gamble, the more you lose. So, before long, gamblers have lost a lot of money. Bills aren’t getting paid, the mortgage is behind. They’re borrowing, taking out new credit cards just to meet their financial obligations. And they start lying to friends and family members with fantastic requests for loans. At this point, gambling is no longer a pastime but a necessity. A big win represents the only foreseeable way of ever catching up and breaking even. So they gamble more and lose more — until they’ve lied, stolen, manipulated and juggled so many things that they can’t hide it anymore. The bank is foreclosing on the house, the repo man’s coming for the car. That’s why the risk of suicide is high with this population — by the time they’ve reached the desperation phase, they are faced with financial and social ruin with few options left. If they’re lucky, they suddenly stop maneuvering long enough to ask: “How the heck did I get here?”

HR: What about all those books and courses . . . you know. How to beat the slots . . . the horses . . . whatever?

LN: A bunch of nonsense. Odds are odds and probabilities are probabilities. Even the games with the best odds like blackjack are still weighted in favor of the house. Unless you’re a card counter, a cheat, or a real professional who gambles in tournaments, you’re going to lose your shirt if you gamble all the time. Slots and video poker are hopeless, largely because the odds against you are astronomical. They are governed by random chance, which is, by definition, unpredictable. Without getting too technical, what you see on a slot machine is definitely not what you get. The computer is driven by a random generator that decides the outcome the minute you push the button. The wheels you see spinning — what we call the “virtual reel” — bear little relation to what’s really going on inside the computer. So when you think you’ve only missed the three cherries by a fraction of an inch, it’s actually an optical illusion. Depending on the set up of the “real reel” in the computer, you could have missed by hundreds of numbers or more.

HR: What part does Internet gambling play in the overall
picture?

LN: Hard to estimate with certainty since Internet gambling is theoretically illegal so revenues aren’t officially tracked. However, most people in the gambling field view Internet gambling as the fastest-growing segment of the industry, generating millions and, according to some, billions of dollars each year.

HR: Let me hit you with a few casino questions. First, you told me a fascinating story about a pathological gambler featured on a casino billboard ad. The story illustrated that the glitzy ads don’t always paint a realistic picture of the horror that lurks beneath the surface. Would you be willing to briefly summarize that story for our readers?

LN: “Bill” was a divorced guy, government worker. Lonely, with some health problems. Started going to the boat with an elderly relative and playing slots. Before long, he had gambled away his pension and savings and started borrowing from loan sharks to cover the bills. One night, he got lucky and won a car. There was lots of fanfare — people coming out from everywhere congratulating him, buying drinks — and the casino asked to take his picture for advertisement. There he was, smiling and waving out of the door of this brand new sports car for all the world to see. What no one knew is he never drove the car off the lot. By the time he won, he was so in debt that the IRS took the cash value of the car for back-taxes and Bill was left to fend off the loan sharks.

HR: I know you have traveled the world to study the phenomenon of gambling addiction. In the United States, casinos conjure up the image of luxury . . . miles of slots that sparkle so intensely that you could comb your hair in the shiny chrome edges of the machines if need be. Is this luxurious, roll-out-the-red-carpet carnival atmosphere par for the course when you visit casinos worldwide?

LN: It depends. Some tribal casinos and/or temporary casinos are big, bare smoky rooms with lots of machines. Casinos owned by big operators, no matter where they’re located, are typically opulent and filled with sights, sounds, and scents that make patrons feel pampered and welcome.

HR: Are there multicultural differences in terms of problem gambling?

LN: There probably are, with higher rates, for example, reported in Asian populations where gambling is entrenched in the culture or among American Indians with high rates of drug and alcohol problems. Unfortunately, the few studies that have looked at these factors have too many methodological problems to generalize. We know that there are definitely socioeconomic differences. A disproportionate number of problem gamblers in some studies were underemployed, with lower-than-average household incomes. There is increasing concern regarding the percentage of older adults and persons with disabilities frequenting some venues. Several years ago, an investigative reporter in Minnesota wrote a story that tracked the large amount of public aid withdrawn at or near casinos. All these factors taken together suggest that lower income families may be disproportionately represented. However, we also know that pathological gambling is a disorder that cuts across all of society: no matter how much you make, you can still gamble it away.

HR: Where do lotteries fit into the puzzle? Is society sanctioning a serious form of addiction?

LN: On one level, lotteries are like any other form of gambling — totally dependent on random chance. There are some important differences, however. Contrary to popular slogans like “Somebody’s got to Lotto, it might as well be you,” the truth is that it’s much more likely to be anybody other than you. Unlike with casino table games with predictable odds, you have a much better chance of getting struck by lightening twice than you do to win even a modest sum in the lottery. There are also those who say the lottery is a regressive tax on the poor; it’s actually a regressive tax on the poorly informed. Lottery tickets, particularly scratch-off variations, provide immediate gratification and arousal that fuel more impulse purchases, similar to putting coin after coin in a slot machine. There are those who become addicted and many who spend much more than they should. But problem gamblers who only play the lottery make up a very small percentage of those with serious financial and psychosocial problems.

HR: I know you champion a three-phase model of gambling disorder. Tell us about that.

LN: The Pathways Model proposes that gamblers are not all alike. They come to problem gambling from different pathways and, as a result, require different treatments to stop gambling. Pathway 1 gamblers play initially for socialization, to be part of a group. They are relatively healthy folks who fall prey to the addictive nature of variable ratio reinforcement: there’s going to be a payoff, and the longer the play the bigger the payoff, but you just don’t know when. Older adults who start gambling because they’re lonely after their spouse dies are characteristic of this pathway. They are the easiest to treat and, typically, the only group who may be suitable for controlled gambling in the future. Most gamblers fall in Pathway 2. They have some history of family instability, low self-esteem or significant life losses, depression or anxiety and/or comorbid addictions. They gamble initially for escape or arousal then, like the Pathway 1 gamblers, succumb to operant conditioning. Pathway 3 gamblers are the hardest to treat. They have serious personality pathology, mood disorders, terrible childhoods, histories of antisocial behavior, and comorbid addictions. There is strong evidence of a biological component — ADHD, risk taking, impulsivity. For this group, the prognosis is very poor.

HR: What is the first thing a counselor should do when confronted with a client who is addicted to gambling?

LN: Be realistic with themselves and the client. The success rate is very low with these clients, in part because a lot of them aren’t ready to get well. There will always be a lot more falls than slips, a lot more slips than walks with sure footing. Sometimes the most we can do is raise the bottom. Therefore, counselors can’t get their egos invested in the client’s level of success or they won’t be effective. The counselor also needs to understand that, for most problem gamblers, gambling offers more than fun and excitement — it provides meaning and hope. And you can’t take that away from a person without replacing it. It’s like telling an alcoholic: “Stop drinking.” The alcohol is more than drink; it’s often the glue that holds the personality together. So when you say “Stop,” the alcoholic hears a threat to his existence and fears that, without alcohol, he’ll simply fragment all over the place. The same is true of gambling. Gambling treatment is a partnership and I tell my clients: “If you want to get better, I’m here to help you stop gambling and find some meaning for your life. If you want to play me and use me to lie to your family or yourself, don’t waste my time.”

HR: Do you always advocate abstinence after the addicted individual begins treatment?

LN: I don’t typically advocate anything outright. Because as soon as you tell someone not to do something, that’s exactly what they’ll do. It’s human nature. Few gamblers come in saying, “I never want to gamble again.” They all think deep down that someway, somehow, they can learn to control it. So what I do is set up a little behavioral experiment. Together we decide, based on their budget, a “reasonable” amount they could spend on entertainment, in this case, gambling. And we decide how many times a week they can afford to gamble with that amount of money. Then we agree that they will gamble that much and no more. The following week, we check the progress. If the person is a problem gambler, they will never stick to the plan. So, the next week, we change the plan, upping the ante and making it a bit more “reasonable.” But, alas, once again, the person goes over the limit. Through this process the gambler comes to the conclusion that controlled gambling doesn’t work for her. And if she thinks that revelation is her idea, she’s one step closer to abstinence.

HR: What are your feelings about fellowships such as Gamblers Anonymous (GA) or perhaps Alcoholics Anonymous (AA)? Are these modalities appropriate for everybody and do they constitute a treatment per se or merely a supplement to psychotherapy?
LN: I’m a big advocate of GA and AA. I think that no one can talk to an addict like someone who’s been there. Few counselors can effectively confront someone in denial like someone who’s been in denial. I don’t see support groups as a treatment in the traditional sense, though I do believe some people are able to quit gambling without attending formal counseling. The best prescription is counseling plus GA. That way, the counselor helps the gambler address the reasons behind the excessive behavior and the illogical cognitions that sustain it, and peers in GA provide support, guidance, and accountability.

HR: What is the dumbest mistake counselors make with this type of addict?

LN: Treating problem gambling with a substance abuse model. There are some similarities between the two disorders —the level of dependency, the reported tolerance and withdrawal symptoms, the desperate maintenance behavior. But gambling disorder is much more complex. Unlike substance abuse, gambling becomes “addictive” as a result of a multifactorial constellation of factors: predisposing psychosocial and neurological vulnerabilities combined with a highly addictive variable ratio reinforcement schedule. There is a high level of reported suicidality and, sometimes, homicidality, so there is little margin for error. With gambling, there is no physiological dependence on a substance, though the psychological dependence and differential effects of the behavior on the individual can generate those changes on PET scans. A smart counselor refers pathological gamblers to a specialist — someone with the skills and training to address the neurobiological predispositions, behavioral reinforcement, underlying psychosocial issues, gambling-related illogical cognitions, and meaning-centered deficits that lie at the heart of the disorder.

HR: I know you treat a lot of folks in your private practice. Are insurance companies and managed care companies sympathetic to your treatment needs or do you need to fight for an appropriate number of sessions?

LN: Things are getting better. Some states like Missouri, where I practice, contract with providers to offer state-funded treatment to gamblers. Insurance companies vary depending on the company. It used to be that an Axis I mood disorder was required for treatment approval. Happily, this is changing.

HR: Are most counselors who deal with gambling addicts properly trained? Specifically, what type of training do you recommend?

LN: No. As I said previously, I take a hard line with regard to treatment qualifications. Just as I believe counselors without special qualifications shouldn’t treat anorexia or bulimia, I also believe the only counselors who should be treating pathological gamblers are those who are state- and, preferably, nationally certified. Most states offer a certification, which consists generally of 60 hours of gambling-specific training for licensed clinicians. The National Council on Problem Gambling in Washington D.C. offers a national certification which requires state certification, two years or 24 hours of supervision by a certified clinical supervisor, passage of a national exam, plus 2,000 direct practice hours with gamblers. A counselor with that level of training is the only one I’d trust with my family member.

HR: In some areas of the nation politicians are pushing casinos to secure gambling taxes as a remedy for our ailing schools, which have been assaulted by budget cuts and related ills. Should we replace Charlie Wilson’s 1955 adage of “What’s Good for General Motors is good for the rest of America” with “What’s good for Harrahs is good for the country’s educational system”?

LN: I try to stay out of politics and deal with the realities that exist. The facts are that most states — and most prosperous countries around the world — are invested in and dependent on the gaming industry for revenue. Whether that’s good or bad is an issue for politicians and radio commentators. Whether schools ever see a dime of the theoretically earmarked tax dollars that are actually spent on general fund budget deficits is an issue for accountants. What concerns me is that any state, province, or country that’s going to legalize gambling has a social obligation to provide enough money for counseling and research to offset the level of devastation to the 1.7 percent of the population and their families who will invariably be affected in a permanent way.

HR: Any feelings about hotlines and helplines sponsored by casino funding? The whole thing sounds . . . well . . . a little paradoxical.

LN: Like putting the vampire in charge of the blood bank? That may be true in some cases. In most instances the hotlines are run by independent, ethical organizations irrespective of funding. Personally, I think any state with legalized gambling should budget for treatment, research, and hotline costs before legalizing gambling. But, often, in the United States, we do a lot of reactive damage control rather than proactive prevention. So, given the current nature of things, I’d rather have the casinos funding a hotline than no hotline at all. Why deny anyone the opportunity to do good?

HR: Thank you for taking time out of your busy schedule to share your knowledge and expertise.

Dr. Howard Rosenthal is the Program Coordinator of Human Services at St. Louis Community College at Florissant Valley and the author of the Encyclopedia of Counseling and the first-ever Human Services Dictionary.

F ootnote
For more information, see Nower, L. & Blaszczynski, A. (2004). The Pathways Model as harm minimization for youth gamblers in educational settings. Child & Adolescent Social Work Journal, 21(1), 25-45, and Blaszczynski, A. & Nower, L. (2002). A Pathways Model of problem and pathological gambling. Addiction, 97(5), 487-500.

This article is published in Counselor,The Magazine for Addiction Professionals, August 2004, v.5, n.4, pp. 14-20.

For Problem Gamblers in the United States, the Resources are Scarce

“I don’t understand.” “You are kidding, right?” “That’s not fair.” “That cannot
be right!”

Such expressions of disbelief are common for many operators of problem gambling helplines, as troubled gamblers and their families search for help.

Though every county in the United States offers assistance for health, mental health, and addiction concerns, only 19 states offer help for those with gambling problems regardless of ability to pay or through state-subsidized care with sliding fee scales. For those seeking help with gambling problems, the lack of subsidized care can mean disaster. Typically problem gamblers and their families are in financial crisis and are desperate when they hit bottom and seek help. The lack of available resources leaves callers to problem-gambling helplines in most states with only self-help groups.

What can we do?
Gamblers Anonymous (GA) and Gam-Anon are the oldest and most extensive networks of support for problem gamblers and their families, but do not compare to the size and availability of Alcoholics Anonymous (AA) and Al-Anon. AA has about 55,000 meetings in the United States alone, compared with about 12,000 GA meetings and Gam-Anon fewer yet. Counselors trying to make a referral to self-help will face challenges, so it is both helpful and important to remember:

1. Meetings come and go frequently. In many communities, few or no GA or Gam-Anon fellowship meetings take place nearby. Only large metropolitan areas will have seven or more meetings a week available for those clients you would like to see attend 90 meetings in 90 days. Most problem gamblers are fortunate to have one meeting a week within an hour drive. Check out local meeting schedules (see http://www.gam-anon.org/ or http://www.gamblersanonymous.org/) to be sure the meeting close to your client is still meeting regularly.

2. Nationally, GA attendees are still predominantly white, middle-aged males, though the numbers of women are catching up, especially in those states where electronic gaming devices, video lottery terminals, or slots are readily available.

3. Many GA meetings differ from AA meetings in that they often run for 2 or more hours. With fewer meetings available, time is taken to hear from all who care to share or may be struggling.

4. The more non-secular language of the 12 steps for GA includes in the fourth step a “fearless moral and financial inventory,” a critical item for gamblers.

5. Most GA meetings are offered only in English, although some states offer Spanish-language meetings now.

If you are a counselor, particularly in a behavioral health care setting, here’s how you can help:

6. Learn the warning signs of problem gambling, and learn how to screen and at least refer a client who is in need. Basic information can be found on The National Council on Problem Gambling Web site at http://www.ncpgambling.org/. Click on state affiliates to be linked to whatever resources your state may have (only 36 states have some kind of problem gambling council or resource, though all states have at least some GA meetings). If in doubt, call the National Helpline (800-522-4700) to be directed to the closest resources available.

7. Find out how to help or refer a problem gambler or family member to find care. Help change the words of desperation, confusion, and disbelief about the scarcity of competent care into words of thanks and appreciation for your knowledge and concern. Start with GA (http://www.gamblersanonymous.org/) and the Association of Problem Gambling Service Administrators (http://www.apgsa.org/).

8. Screen for a gambling disorder among clients. Prevalence rates tell us the disorder is more than 10 times more common among at-risk populations, which include addicts, the mentally ill, and those working in gambling venues — EAPs beware!

If you are concerned about relapse rates among your clients, check for an unrecognized gambling problem. Unfortunately, many of the people struggling to get even, “chasing” their losses, desperate for just one more win, don’t realize they have crossed a line and indeed have a gambling problem. This “invisible addiction” can fool anyone not trained to both see the warning signs and know how to help.

Joanna Franklin, MS, NCGCII ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) is Director and Trainer for Trimeridian, Inc. Resources for Problem Gambling, in Baltimore, MD. She has designed and implemented clinical training programs since 1980 and is currently Co-chair of the National Gambling Counselor Certification Board, vice president of the Institute for Problem Gambling, president of the Maryland Council on Problem Gambling and on the Board of Directors of the National Council on Problem Gambling.

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