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Chapter 7

Pathology of problem gambling

7.1        This chapter will detail some of the research that attempts to understand why some people develop gambling problems and what can trigger a gambling problem. It will provide context for the following chapters which cover how various models of treatment address the psychology and pathology behind problem gambling.

No 'one type' of problem gambler

7.2        It was acknowledged in evidence to the committee's first inquiry that there is no 'typical' or 'average' problem gambler. Research cannot accurately predict who will develop a gambling problem. However, there are a number of risk factors or experiences that can contribute to developing a gambling problem. For example, the committee heard from Mr Christopher Hunt, Psychologist, Gambling Treatment Clinic, University of Sydney, that an early positive experience with gambling is common for people who develop a gambling problem.[1] He also emphasised that there is no clear reason why some people go on to develop gambling problems and others do not. Apart from an early positive experience, Mr Hunt mentioned other factors such as being in a desperate financial situation and beliefs about money and winning also contributing to developing a problem. He stressed the need for campaigns to address the core pathology of problem gambling, which is a belief that one can win money in the long term.[2]

7.3        Professor Debra Rickwood, Professor of Psychology, University of Canberra; and Fellow, Australian Psychological Society (APS), noted there are many models of understanding gambling and different reasons why people develop problem gambling. Therefore a one-size-fits all approach to understanding problem gambling is not appropriate.

7.4        For example, the Blaszczynski-Nower integrated model emphasises that there are 'behaviourally conditioned' people who are exposed to gambling early; they tend to have early wins and end up chasing losses. In this model, conditioning and cognitive processes appear to be the most relevant in terms of the cause of problem gambling and how to address it. Professor Rickwood emphasised that most psychologists would take an integrated approach to understanding what determines problem gambling. She noted that:

There are also people who become problem gamblers because they are emotionally vulnerable. They have problems. They have problems with depression, anxiety, poor coping skills and social isolation, and the dissociative state that gambling produces helps with the negative emotional states that such people experience. There are also biologically based, impulsive types of gamblers, who tend to be risk-takers. They have a high need for stimulation and arousal. So these different reasons for problem gambling are things we need to take into account in terms of our approach.[3]

7.5        Professor Alex Blaszczynski, Director, Gambling Treatment Clinic, University of Sydney, also emphasised that gamblers are not a homogenous group. He explained the complexity of dealing with addiction:

You see the complex interaction between environmental factors, personality and family upbringing—a whole range of factors that contribute to create problem pathological gambling or addictive type behaviours. In respect to gambling, I think we are making a mistake of conceptualising gamblers as a homogenous group of individuals.[4]

7.6        Professor Blaszczynski went on to describe three groups of gamblers—first, a group influenced by advertising, particularly sports advertising and the integration of gambling commentary into sporting events which normalises gambling. Young people often become involved in this activity. People in this group do not suffer psychiatric comorbidities but develop a belief they can win at gambling. They lose too much and start to chase their losses. This group is generally fairly responsive to brief interventions. The second group who gamble engage in addictive behaviours as a means of dissociating or escaping their problems.[5] Gambling is part of their coping mechanism. The third group have a biological predisposition to a broad range of impulsive and risky behaviours. They may have some degree of ADHD/attention deficit disorder or be from dysfunctional family backgrounds. They may also be engaged in criminal behaviours, drug use and promiscuous behaviour. Professor Blaszczynski emphasised that the important element across all three groups is that the impact of excessive gambling is similar in terms of depression and alcohol abuse.[6]

Triggers for problem gambling are not fully understood

7.7        The committee heard that evidence for what triggers a gambling addiction is still relatively unknown. Anecdotally, life-stressing events can be a factor but there are a variety of reasons for the development of a gambling problem.

7.8        Professor Blaszczynski stated that among a range of triggers for losing control, some people can start to believe that gambling is a way of earning income:

They experience some clusters of good luck in the early stages of gambling, increase their gambling behaviour, start to accumulate debts and subsequently try to chase those debts...So there are a variety of reasons why people lose control.[7]

7.9        He added that research has found impulsivity is one of the key factors that contributes to the risk of developing problem gambling. He explained:

Males tend to be at risk for gambling behaviour simply because they tend to be more risk takers. Women tend to gravitate towards the games that are less prone to problems—apart from the gaming machines—bingo, lotteries and so forth. But slot machines, I think, had a peculiarity from the onset when Charles Fey developed the first one in the 1890s. He tapped into an excellent marketing tool of people simply pressing buttons for a reward—equivalent to pigeons taking a reward—which modifies people's behaviours.[8]

7.10      Ms Abigail Kazal, Senior Clinical Psychologist and Program Manager, Gambling Treatment Program, St Vincent's Hospital, also confirmed that from her clinical experience of 10 years:

...there is no single factor or group of factors about which you can say, 'Yes, this is causal', or, 'This will lead or predispose a person to gambling'. It is such a mix, such a variety—it can affect anyone.[9]

7.11      Regarding triggers for problem gambling, Ms Kazal also added:

Sometimes we say it is like being at the wrong place at the wrong time. These things may have happened to the person, but they happen to a lot of people who do not then develop gambling problems.[10]

Significant life events

7.12      Moderate gamblers can become problem gamblers by increasing the frequency or intensity of gambling or by a change in their situation. The reasons and predictors for escalating or reducing gambling are not well understood.[11] Professor Blaszczynski noted that certain life events can also trigger problem gambling behaviours in some individuals:

In my own experience dealing with some particular cases, I have had actual data regarding gambling behaviour—two years of their internet sports betting accounts. I had the good fortune to interview this particular person. Within six months of an emotional life-stressing event that occurred, one could see a rapid escalation of gambling behaviour. Surprisingly, in some individuals the birth of a child triggers excessive gambling behaviour. Again, that is anecdotal. But I guess what I am alluding to is the notion that there are certain life events that do occur that subsequently trigger gambling behaviours. There are anecdotal cases of housewives who suddenly find their husbands are having an affair. They become depressed and turn to gambling as an anger mechanism. We had a case of a person who had Parkinson's disease who became quite depressed and believed her partner would abandon her. She consequently turned to gambling behaviour in an attempt to secure herself financially, but she achieved the opposite result.[12]

7.13      Dr Katy O'Neill, Clinical Psychologist, Gambling Treatment Program, St Vincent's Hospital, also confirmed that there is no single cause, but that the transition from casual to problem gambling can be due to a life event such as redundancy, divorce and bereavement.[13] Natural disasters can also lead to rates of problem gambling increasing, as she explained:

To someone unfamiliar with gambling that may seem really odd, but in a way you can sort of see the logic in it. As for people who are under financial duress, if there is no hope of getting the money that they need they might as well risk an amount on the chance that they might get a win.[14]

7.14      Dr Mark Zirnsak, Member, Australian Churches Gambling Taskforce, also emphasised that there are various life events that can make people more vulnerable to developing a gambling problem:

That is why we think there is a role for the community, through its governments, to provide protection for those vulnerable people against an industry that might otherwise prey on and profit from those vulnerabilities.[15]

7.15      The committee heard that some people gamble to escape their problems. Ms Rhian Jones, Member, Gambling Impact Society NSW, told the committee the story of what triggered her problematic gambling:

Ms Jones:  [I started playing socially] In 1998. And within weeks I was heavily addicted. By 1999, I was losing hundreds of thousands of dollars.

Senator XENOPHON:  On poker machines?

Ms Jones:  Yes.

Senator XENOPHON:  What triggered it? Was it an early win? What was it? Can you remember?

Ms Jones:  I really do not know. I was socially playing and the next minute I was addicted. It was a place for me to go, to get away from pressures in the home.[16]

7.16      Demographic risk factors for problem gambling include: age, (the earlier one starts gambling, the greater the likelihood of developing problems); higher rates of disordered gambling among members of ethnic minorities; lower socioeconomic status; marital status, with risky and problem gamblers more likely to be divorced or separated; and being male.[17]

7.17      Dr Katy O'Neill emphasised that the easy access and availability of gaming machines is also a factor as to why people play them.[18] Anglicare Tasmania also pointed out the factors that cause people to lose control at the gaming venue:

Anglicare's research into gambling problems for people on low incomes in Tasmania has found there are a number of factors that cause people to lose control in a gaming venue, including the design of the poker machine, patrons' misunderstanding of how poker machines work, their desperation to get money and the consumption of alcohol.[19]

Some forms of gambling are riskier than others

7.18      The Productivity Commission's 2010 report into gambling stated clearly that poker machine gambling is the riskiest form of gambling activity.[20]

7.19      Mr Tom Cummings told the committee about his personal experience with poker machines and described why he found them so addictive:

In my personal experience, once I had developed my problems—once I was in the throes of gambling on the pokies and not stopping—it was a case where I would lose myself in the game. Once I started playing, everything else would go away. I could stop worrying about the money that I owed, the hours I was losing from work or the fights that I was having with my partner. When I was playing, that was all there was. It was just the screen, the reels and waiting for the wins. If the win came up, it was great. I would take that and just keep playing. If I lost, I would just hit it again. It becomes your world when you are playing a poker machine because it is so constant, so quick and so repetitive. I hesitate to use phrases like 'the zone' or 'a trance', because they have been overused a lot, but I found that I would fall into the game. I would lose myself in it and I could play for hours without realising it. I reached a point where I would have to set an alarm on my watch to go off after two hours to remind me that I had to get back to work because I had already used twice my lunch break. That was almost a voluntary term for me, but I would often just turn the alarm off and keep playing for another hour or so, then sneak back to work.

Even without the immersive measures that other companies are trying to develop, it is extremely easy to lose yourself in it because it is so constant. You can bet over and over again. I found with the horses, as a parallel, that it is something you have to take part in. You have to make a decision. You go off and choose which horses. If you are really interested, you have a look at the form and work out which horses are running well or not running well. I do not follow the horses. I have been a few times, and it has been a novelty. But I have gone with a budget. I think: 'I'll take $50. I'm prepared to lose this.' I have lost it and had fun, and I have had no inclination to keep going. It was with the pokies from the very first time. Once I lost my money, I thought, 'No, I'll have to go and win this back,' because there was always the idea that I could. You do not have to do anything; you just push a button. So it is easy. That is the way it feels.[21]

7.20      From his own experience, Mr Cummings stressed to the committee that poker machine players differ from those attracted to other forms of gambling:

I fully believe that poker-machine addiction and problem gambling are two very different things. A problem gambler is someone who is addicted to gambling in general—this is my opinion—whereas a poker-machine addict is addicted to a particular form of gambling, being poker machines. That is why I call myself a former, maybe even current, poker-machine addict. I do not have a problem and have never had a problem with gambling; it was only ever poker machines. I think the majority of calls to health services are to do with poker machines. As far as I know, there is not a lot of transference between poker-machine playing and other forms of gambling. Certainly in my experience they are worlds apart.[22]

7.21      Although services are starting to see and treat people with gambling problems from using the internet, the majority of clients still have a problem with poker machines. Ms Abigail Kazal, Senior Clinical Psychologist and Program Manager, St Vincent's Hospital, explained:

...we have not necessarily seen such a significant increase in internet gambling considering the much more significant availability of it so we are still seeing that the majority of our clients are actually having problems with poker machine play, rather than with the internet, so there has not been a mass increase in internet gambling.[23]

7.22      Dr Sally Gainsbury also reminded the committee of the differences between types of gambling:

Sports gamblers are different from gaming machine players, and now internet gambling is introducing a whole new variable that we are currently looking at to understand how it impacts. It seems that existing problem gamblers gravitate to that form, and this unique mode also creates problems for gamblers who would not otherwise have had problems. The games develop and change. A gaming machine today is not the same as a gaming machine 20 years ago. That is why, as an ongoing research project, we really need to look at the differences in the games. With sport betting, you now have in-play betting, where it is possible to make bets every 30 seconds or every other minute instead of one bet once a week. It is important that different activities appeal to different types of people and cause their own unique problems as well.[24]

What is pathological gambling?

7.23      Clinicians gave evidence to the committee about the concept of gambling addiction and the pathology underlying it. The Royal Australian and New Zealand College of Psychiatrists (RANZCP) told the committee that gambling is recognised as 'part of the suite of disorders that come under the rubric of addictions'.[25] Its submission defined problem gambling as follows:

...a pattern of behaviour that compromises, disrupts or causes damage to health, family, personal or vocational activities; the extreme end of this behaviour can be described as ‘pathological gambling’.[26]

7.24      Professor Alex Blaszczynski described addiction as repeated engagement in a particular behaviour which provides a person with some degree of benefit:

Those benefits may not be clearly observable or understandable from an external point of view. Certainly they are provided with some benefit.[27]

7.25      Dr Enrico Cementon, Royal Australian and New Zealand College of Psychiatrists Fellow, told the committee that problem gambling should be seen as a mental health issue:

This may be different to other health organisations and even other parts of the medical profession which may not identify problem gambling as a health issue, but it is something that is important for the College of Psychiatrists. Our expertise lies in a couple of areas. One which is particularly important in terms of prevention of problem gambling is that we know a lot about how certain health problems develop, particularly behavioural disturbances. We see gambling as an example of a behavioural problem. Problem gambling often starts during adolescent years. Although the gambling may not be a problem early on, it is something that then continues for a while and given the right circumstances—be it access to gambling or other stresses which may influence the person into increasing their gambling—harms, and problems develop as a result of that. Developmental problems are an area of expertise that we have.[28]

Reducing the perceived benefits of gambling through treatment

7.26      Treatment of gambling addiction, according to Dr Cementon, should aim to reduce the perceived benefits people receive from gambling:

There is a lot of satisfaction and a lot of self-esteem bolstering...There are all these positive effects which occur as a result of engaging in the behaviour.

One of the first things you address in the treatment of addiction is trying to reduce the positive effect associated with the behaviour and to increase the negative effect, because it is that balance which is one of the core drivers of the person's decision-making and the behaviours they engage in. When the negative effect associated with gambling outweighs the positive effect, the person seeks to do something about it—to change their behaviour in some way. They either seek treatment or do something else. I agree that there is an anomaly: there is so much positive reinforcement which goes along with gambling in our culture that that therapeutic strategy of trying to redress the balance by increasing the negative effect and decreasing the positive effect is very difficult.[29]

Pathological gambling in the DSM-IV and DSM-V

7.27      The Diagnostic and Statistical Manual of Mental Disorders[30] (DSM-IV) categorised pathological gambling as a clinical disorder in 1980. In the fifth version of the DSM to be introduced in 2013, it is likely that pathological gambling will be classified as an addiction because of its similarities to substance use disorders and the associated characteristics of tolerance, withdrawal and difficulty controlling urges.[31]

7.28      The current diagnostic criteria in DSM-IV for pathological gambling are as follows:

• is preoccupied with gambling;
• needs to gamble with increasing amounts of money in order to achieve the desired excitement;
• has repeated unsuccessful efforts to control, cut back or stop gambling;
• is restless or irritable when attempting cut down or stop gambling;
• gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, depression);
• after losing money gambling, often returns another day to get even ('chasing' one's losses);
• lies to family members, therapist or others to conceal the extent of involvement with gambling;
• has committed illegal acts such as forgery, fraud, theft or embezzlement to finance gambling;
• has jeopardised or lost a significant relationship, job, or educational or career opportunity because of gambling;
• relies on others to provide money to relieve a desperate financial situation caused by gambling.[32]

7.29      Currently, to be diagnosed with pathological gambling, a person needs to have five or more out of the 10 possible symptoms. The DSM is in the process of being updated with revisions in diagnostic codes typically driven by evolving research that transforms the understanding of a disorder. Under proposed revisions by the DSM-V working group, the diagnosis may be reclassified from an impulse control disorder to a behavioural addiction within a new classification of 'Addiction and Related Disorders'. This category would replace the current 'Substance-Related Disorders' classification. The working group has also proposed to rename 'Pathological Gambling' to 'Disordered Gambling'.[33] The rationale for these changes are explained as follows:

...the growing body of scientific literature, especially research on the brain’s reward center, has revealed many commonalities between pathological gambling and substance-use disorders, including cravings and highs in response to the gambling, alcohol or drug; the hereditary nature of all of these disorders; and evidence that the same forms of treatment (e.g., 12-step programs, cognitive behavioral therapy) seem to be effective for both gambling and substance-use disorders.

For example, the DSM-V Work Group cited studies showing a high rate of co-occurring substance use disorders with pathological gambling. One of the most definitive is the analysis of the gambling data in the National Comorbidity Survey Replication (NSC-R), a nationally representative sample of 9,282 English-speaking adults. The authors found that almost all participants who had pathological gambling during the course of their lifetime also had another lifetime psychiatric disorder (96.3 percent), and 64.3 percent suffered from three or more disorders. Substance-use disorders were significantly elevated among participants with pathological gambling (Kessler, Hwang, LaBrie, Petukhova, et al., 2008).[34]

7.30      Other changes proposed include eliminating the 'illegal acts' criterion as it does not appear to be a decisive symptom for most people with gambling problems:

Individuals who commit illegal acts as a result of their gambling already reach the threshold of five or more symptoms and, therefore, this symptom does not improve the precision of the diagnostic code for identifying most individuals with pathological gambling.[35]

7.31      Although the DSM-V working group has not proposed to alter the description of pathological gambling as a 'persistent and recurrent disorder' this has been challenged by several studies which found that:

...while healthy gambling and non-gambling behavior appears to be relatively stable over time, individuals with gambling problems experience considerable movement in and out of more severe and less severe levels of gambling disorders (LaPlante, Nelson, LaBrie, & Shaffer, 2008). Moreover, the authors observed that rates of recovery from pathological gambling, the most severe level of the disorder, appeared higher than anticipated. Consequently, the authors found no evidence to support the assumptions (1) that individuals cannot recover from disordered gambling, (2) that individuals who have more severe gambling problems are less likely to improve than individuals who have less severe gambling problems, and (3) that individuals who have some gambling problems are more likely to get progressively worse than individuals who do not have gambling problems.[36]

7.32      Professor Debra Rickwood, Professor of Psychology, University of Canberra; and Fellow, Australian Psychological Society, noted the proposal to classify problem gambling as an addiction due to its similarities with substance use disorders. She emphasised that:

...most psychologists would take a broader approach. We see problem gambling in a biopsychosocial context so that problem gambling should be defined on a continuum of varying severity so that it is not viewing it just within a pathologised context, [which] is not a holistic view; there are biological, psychological and social aspects to problem gambling, and we need to take a holistic perspective.[37]

7.33      Professor Malcolm Battersby, Head of Department, Human Behaviour and Health Research Unit, Flinders University also spoke on this issue:

There is now irrefutable evidence that problem gambling is a mental illness or mental disorder. It is in the DSM-4, and there are now proposals to have it moved into the addiction section in DSM-5. But that is a secondary issue in the sense that it has all the characteristics of every other mental disorder: distress, dysfunction and disability. You have a recognisable set of symptoms that people can be trained to assess and diagnose. There are a range of disabilities and severities, which means that a whole range of skills need to be put into place to really address this.[38]

7.34      Professor Battersby's submission argued that severity of gambling addiction and not risk of gambling addiction should be measured when dealing with pathological gambling:

Because problem gambling has been defined as a mental disorder in the American Psychiatric Association Diagnostic Manual DSM IV-R as pathological gambling, it is treated by gambling therapy clinicians with mental health training in Australia, similarly to anxiety disorders or depression, i.e. there are clinical diagnostic criteria and validated screening tools for anxiety disorders and depression with cut off scores either giving specificity and sensitivity for correctly allocating the diagnosis, or cut offs for severity levels, mild, moderate or severe e.g. the Beck Depression scale. Gambling should be treated similarly with scales which measure severity not risk. Risk implies a much more theoretical and less real situation than severity and underestimates the implications of the problem in terms of its seriousness and consequences for the individual, their family and the community.[39]

Committee view

7.35      The committee recognises that not everyone who gambles develops a gambling problem. This is the case for poker machines, even though the risks associated with poker machines are higher than for other forms of gambling and they still account for the vast majority of problem gamblers.[40] Unfortunately there does not seem to be one simple answer as to why some people develop gambling problems and others do not.[41] The triggers for problem gambling are not well understood and no single risk factor or group of risk factors can be pinpointed. Triggers may range from significant life events such as childbirth, bereavement or divorce, experience of natural disasters, to early experiences of 'winning' at gambling. The committee heard that people who develop gambling problems are not a homogenous group. The fact that discussions about the nature of pathological gambling as an addiction are still being conducted in clinical and academic settings indicates to the committee that there is still much to learn about problem gambling and how to treat it.  

7.36      As discussed in earlier chapters, there is no 'one size fits all' approach to prevention messages; different messages need to be tailored appropriately to reach different audiences. Similarly, the committee recognises that there can be no 'one size fits all' approach to treatment of problem gambling. In the following three chapters, the committee will examine how pathological or problem gambling is treated, including the range of treatment services available and how these services may be improved. The report will then conclude with a chapter looking at gambling research and data collection, including the evidence base for treatments and methods of evaluation.

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