Addictions Gambling

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Addictions: Gambling
Article · June 2016

DOI: 10.1093/acrefore/9780199975839.013.832
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Encyclopedia of Social Work

Lia Nower and Kyle Caler
Subject: Addictions and Substance Use, Mental and Behavioral Health, Populations and
Practice Settings
Online Publication Date: Jun 2016 DOI: 10.1093/acrefore/9780199975839.013.832
Abstract and Keywords
Gambling disorder is a significant public health concern. The recent and continued
proliferation of land-based and interactive gambling opportunities has increased both
accessibility and acceptability of gambling in the United States and abroad, resulting in
greater and more varied participation. However, there is currently no designated federal
funding for prevention, intervention, treatment, or research, and states are left to adopt
varying standards on an ad hoc basis. Social workers receive little or no training in
screening or treating problem gamblers, though research suggests that a significant
proportion of those with mental health and other addictive disorders also gamble
excessively. Raising awareness about the nature and scope of gambling disorder and its
devastating implications for families and children is a first-step toward integrating
gambling into prevention, assessment and treatment education in social work. This, in
turn, will increase the chances of early identification and intervention across settings and
insure that social workers can lend a knowledgeable and credible voice to addressing this
hidden addiction.
Keywords: gambling, gambling disorder, problem gambling, behavioral addictions, gambling prevention, gambling
treatment, social work role
Introduction
The recent proliferation of gambling opportunities across the United States and abroad
has led to increased participation in multiple forms of gambling, both land-based and
online. A majority of those who gamble do so for recreation only. However, about 5
million adults and 3 million youth in the United States meet clinical criteria for gambling
disorder, and double those numbers have serious gambling problems.
Unlike substance abuse, where individuals begin to manifest obvious symptoms over
time, gambling disorder is, essentially, a silent addiction. Disordered gamblers can often
Page 1 of 45
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hide debts, borrow and steal, and move money among accounts so that unsuspecting
family members are caught unaware when the house is in foreclosure, the cars and
money are gone, and they learn of impending bankruptcy and, often, criminal charges.
Despite these devastating consequences—consequences that often adversely impact the
most vulnerable groups and children—gambling is seldom included in routine screenings
in schools, mental health centers, health settings, child welfare agencies, senior centers,
or other areas where social workers practice. Most schools of social work omit the
diagnosis and treatment of gambling disorder from addiction curriculum, opting instead
to adhere to teaching materials that feature only substance use disorders. In addition,
only a handful of gambling researchers are faculty in schools of social work. This article
will familiarize social workers with the nature, course, and scope of this behavioral
addiction, including: (a) terminology and history of the disorder; (b) etiology of gambling
problems and disordered gambling; (c) the prevalence of disorder, particularly among
special populations; (d) comorbidity; (e) individual and societal impacts; (f) screening and
clinical interventions; and (g) policy considerations and the role of social workers.
Terminology and History of the Disorder
Defining maladaptive gambling behavior has long been the subject of debate among
gamblers, clinicians, and researchers. Historically, gambling has been viewed as a vice,
and those with gambling problems labeled “degenerate gamblers” lacking in self-control.
To combat this stigma, individuals with gambling problems have long referred to
themselves as “compulsive” gamblers, suggesting that excessive gambling is beyond their
volitional control. This perspective was shared by psychiatrist Dr. Robert Custer, a
pioneer in the field who first brought awareness to the devastating effects of gambling
disorder in his book When Luck Runs Out: Help for Compulsive Gamblers and Their
Families (Custer & Milt, 1985). The research and larger medical community, however,
rejected the notion that excessive gambling is a compulsion, in large part because a
majority of gamblers find the activity pleasurable and arousing (i.e., ego-syntonic rather
than ego-dystonic) until the money runs out and they are forced to deal with the negative
consequences of losses (Moran, 1970).
Confusion regarding the nomenclature is reflected in the evolution of the diagnostic

criteria. Sigmund Freud was the first to identify uncontrolled gambling as an illness
worthy of treatment (Freud, 1928). However, disordered gambling was not officially
recognized until the World Health Organization identified it as a psychiatric illness in the
1979 edition of the International Classification of Diseases (World Health Organization,
1979), followed by recognition in the third edition of the Diagnostic and Statistical Manual
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of Mental Disorders of the American Psychiatric Association (DSM-III, American

Psychiatric Association (APA), 1980). Both criteria use the term “pathological” rather than
“compulsive” to identify gamblers who meet diagnostic criteria for disorder, attesting to
the volitional nature of the disorder.
Despite use of the term “pathological,” gambling disorder was classified with compulsion-
like impulse control disorders that were difficult to place in the diagnostic rubric and
shared few other commonalities with gambling: kleptomania, trichotillomania, explosive
temper disorder, and pyromania. Based largely on feedback from addiction counselors,
who viewed gambling as a behavioral addiction, the DSM-III-R (APA, 1987) included
criteria that paralleled those for psychoactive substance dependence: preoccupation,
tolerance, and loss of control. But the psychiatric community was still resistant to
reclassifying disordered gambling as an addiction.
All versions of the DSM criteria have retained two hallmark characteristics of gambling
disorder: (a) the unique notion of “chasing” or repeated attempts by the gambler to
continue a winning streak or end a losing streak by gambling more frequently and (b)
“bailouts,” in which the gambler seeks money from family, friends, and others to address
growing debt. Despite inclusion of additional items, the DSM-III-R met with criticism from
the gambling community, who criticized the criteria as vague and repetitive (Rosenthal,
1992), failing to capture the unique nature of a behavior addiction. In particular, the
treatment community viewed gambling disorder as a unique mix of addiction and
impulsive behavior rather than simply a surrogate for substance abuse. In contrast, the
medical community was steadfast in maintaining that addictions should be limited to
those that are substance-based. The resulting DSM-IV criteria (APA, 1994) was a hybrid,
retaining the “pathological gambling” language, an impulse control classification, and
some substance abuse parallel elements while also including common behavioral
consequences, such as chasing, lying, illegal acts, social and educational costs, and bail-
outs.
In the late 1990s, a congressional committee report and national prevalence study
focused on gambling heighted awareness of gambling disorder. Though the classification
and criteria remained unchanged in the DSM-IV-TR (APA, 2000), a number of
neurobiological researchers began documenting physiological similarities between
disordered gamblers and those with substance use disorders (Goudriaan, Oosterlaan, de
Beurs, & Van den Brink, 2004, 2006; Potenza, 2001, 2008). These and other empirical findings
led leading scholars to conclude that the growing evidence regarding the similarities
between gambling and substance use disorders suggest they should be classified
together (Grant, Potenza, Weinstein, & Gorelick, 2010; Potenza, 2006).
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In 2013, pathological gambling was officially renamed “Gambling Disorder” and classified
with substance use disorders as the first behavioral addition in the “Substance-Related
and Addictive Disorders” chapter of the DSM 5 (APA, 2013). Explaining the change, the
American Psychiatric Association reasoned that the scholarly literature had established
that gambling disorder was similar to substance-related disorders in “clinical expression,
brain origin, comorbidity, physiology and treatment” (APA, 2013). The criminal acts
symptom was dropped from the classification, resulting in nine rather than ten criteria
with slightly better classification accuracy than the prior criteria (Petry, Blanco,
Stinchfield, & Volberg, 2013). However, the change in classification left unresolved the
question of how to categorize sub-threshold problem gamblers, also called “low,
moderate, and high-risk” gamblers; cut-scores for these groups differ across research
studies, and the DSM provides no guidance beyond the criteria needed to meet diagnosis
for gambling disorder.
Etiology
The development of gambling disorder is complex and multifactorial, rooted in a wide

array of bio-psycho-social factors that evolve over time. Researchers have proposed a
number of etiological models to explain the development of gambling problems, including
social reward (Ocean & Smith, 1993), behavioral (Weatherly & Dixon, 2007), cognitive-
behavioral (Sharpe, 2002), neurobiological and genetic (Ibáñez, Blanco, & Saiz-Ruiz, 2002;
Ibáñez, Blanco, de Castro, Fernandez-Piqueras, & Sáiz-Ruiz, 2003; Potenza, 2013). The
highly cited and multifactorial Pathways Model by Blaszczynski and Nower (2002) asserts
that a combination of specific factors creates predisposing, etiological subgroups of
individuals who develop gambling problems in response to exposure to ecological stimuli,
behavioral conditioning, and erroneous cognitions in a gambling environment.
The model proposes there are three subtypes of gamblers, distinguished by the presence
or absence of specific premorbid psychopathology and biological vulnerabilities. All three
groups share the commonalities of gambling opportunities that lead to the habituation of
gambling and foster irrational and erroneous cognitions regarding winning and
randomness (Blaszczynski & Nower, 2002). For Pathway 1 or “behaviorally conditioned”
problem gamblers, those factors alone are enough to move them along the spectrum
toward disorder; they lack evidence of mood, personality, or other pathology before the
development of their gambling problems. In contrast, the model asserts that Pathway 2
“emotionally vulnerable” problem gamblers have a history of mood disorders, comorbid
addictions, poor coping and problem-solving skills, problematic family backgrounds, and/
or child abuse or neglect. As a result, these gamblers initiate gambling to escape aversive
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mood states and ultimately develop gambling problems in response to the ecological,
conditioning, and cognitive factors outlined previously. Finally, the Pathways Model
theorizes that Pathway 3 “antisocial-impulsivist” gamblers possess all the vulnerabilities
of the previous pathway; however, in addition, these gamblers manifest high levels of
impulsivity and antisocial personality traits and behaviors and a history of comorbid
addiction and attention deficits. For this group, gambling is one of many pleasure-seeking
behaviors.
A number of studies have attempted to explore or validate the Pathways Model in a

variety of settings and populations (Balodis, Thomas, & Moore, 2014; Gupta, Nower,
Derevensky, Blaszczynski, Faregh, & Temcheff, 2013; Ledgerwood & Petry, 2010;
Tirachaimongkol, Jackson, & Tomnay, 2010; Turner, Jain, Spence, & Zangeneh, 2008;
Valleur et al., 2015). A latent class analysis of gamblers using data from the National
Epidemiologic Survey on Alcohol and Related Conditions (NESARC) identified three
subtypes of disordered gamblers that corresponded roughly to the Pathways subtypes,
ranging from a group with low levels of gambling severity and psychopathology to one
with high levels of problem severity and comorbid psychiatric disorders (Nower, Martins,
Lin, & Blanco, 2013).
As theorized by the Pathways Model, a growing number of empirical studies suggest that
some proportion of problem and disordered gamblers have genetic and/or biological
vulnerabilities that predispose them to sensation seeking and risk taking, which can lead
to problem gambling. Early genetic studies found associations between dopamine-related
gene sequences and disordered gambling (Comings et al., 1996, 1997, 2001); these gene
sequences typically predispose individuals to engage in activities like gambling, which
stimulate the release of dopamine, a chemical that mediates pleasure responses in the
brain. As further evidence of this phenomenon, Parkinson’s disease medication, which
supplements depleted dopamine, can induce disordered gambling behavior (Clark &
Dagher, 2014; Ray et al., 2012).
Recently, Slutske and her colleagues undertook several related investigations of the
genetic, familial transmission of disordered gambling behavior using data from more than
3,500 same-sex twins from the Australian Twin Registry. In one study, the researchers
found that one-half to two-thirds of those with gambling disorder, particularly males, also
shared a genetic vulnerability for alcohol use disorder (Slutske, Ellingson, Richmond-
Rakerd, Zhu, & Martin, 2013). Other studies reported that sharing genetic or
environmental factors with family members, especially personality traits of negative
emotionality, were key predictors of gambling frequency and disorder in later adulthood
(Slutske et al., 2014; Slutske, Cho, Piasecki, & Martin, 2013). Notably, difficulty controlling
emotion at age three significantly predicted gambling problems in young adulthood, even
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when controlling for IQ and family socio-economic status (Slutske, Moffitt, Poulton, &
Caspi, 2012). Mood-related impulsivity is also associated with disordered gambling in
genetic studies (Clark et al., 2012). Taken together, these findings suggest there are
strong, genetic familial factors (mood dysregulation, impulsivity, comorbidity) that are
correlated with developing gambling problems. It is likely that these factors interact with
ecological factors, conditioning effects, and cognitions that lead to disordered gambling.
These findings are supported by psychosocial research, reporting that early exposure to
gambling, primarily with family members, is positively associated with disordered
gambling. In one study, adolescent males who believed their fathers gambled too much
were more than 3 times as likely than others to develop serious gambling problems, while
girls who believed their fathers abused substances were at 2.5 times greater risk for
disordered gambling (Nower, Derevensky, & Gupta, 2004). For adolescents, receiving
lottery tickets as gifts during childhood has been associated with problem gambling and
the continued purchase of tickets (Kundu et al., 2013). King and colleagues (2010) noted
that parental substance use problems, combined with negative emotions and impulsivity,
predicted gambling-related cognitive distortions, time spent gambling, and gambling
problems, particularly in males. Most notably, it was the youth’s perception, whether or
not true, that proved to be the most influential factor. Another study confirmed that
parental gambling participation alone, even without demonstrating problems, predicted
early gambling for boys and girls (Vitaro &Wanner, 2011). These findings support research
that has established that perceived parental permissiveness toward gambling and other
risky behaviors was significantly related to gambling, drug, and alcohol problems
(Leeman et al., 2014) This is particularly troubling in light of the fact that gambling is
typically viewed by parents and teachers as harmless activity (Campbell, Derevensky,
Meerkamper, & Cutajar, 2011; Derevensky, St. Pierre, Temcheff, & Gupta, 2014). Indeed,
teachers in one study reported that gambling in school can constitute a good learning
experience (Derevensky et al., 2014), and a growing number of schools and districts
feature casino nights, poker tournaments, and classes in stock investing without
providing any prevention programs for problem gambling.
Traumatic experiences in childhood have also been linked to disordered gambling later in
life. Specifically, several studies have reported that disordered gamblers are significantly
more likely than their peers to report childhood sexual, physical, and emotional abuse
(Black, Shaw, McCormick, & Allen, 2012; Felsher, Derevensky, & Gupta, 2010; Hodgins et
al., 2010; Jacobs et al., 1989; Scherrer et al., 2007). In addition, the severity of childhood
maltreatment has been linked to earlier onset of gambling behavior (Petry & Steinberg,
2005), mainly in female disordered gamblers who are more likely than males to report
childhood victimization (Boughton & Brewster, 2002; Dowling et al., 2014; Petry &
Steinberg, 2005). Not all studies have identified linkages between childhood trauma and
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disordered gambling (Leppink & Grant, 2015), though experiencing trauma has been
linked to higher rates of comorbid disorders (Leppink & Grant, 2015) and negative impacts
on functioning in those with preexisting comorbidity (Kausch, Rugle, & Rowland, 2006).
Finally, a key component in the etiology of problem gambling that is common across
groups is the role of cognitive distortions during play. Gamblers erroneously perceive the
nature of randomness, luck, and skill and believe they can somehow control the
uncontrollable (Ladouceur & Walker, 1996; Clark, 2010). Four types of distortions are
common to most disordered gamblers: the illusion of control, the gambler’s fallacy,
biased evaluation, and the “near win.” The “illusion of control” (Langer, 1975) is the belief
that a gambler can somehow control the gambling outcome through luck, skill, or a
winning system. A preference for picking lottery numbers over those that are computer
generated, using lucky daubers or troll dolls at a bingo game, or engaging in rituals
before throwing dice demonstrate this erroneous cognition. Similarly, the “gambler’s
fallacy” (Tversky & Kahneman, 1971) suggests that, as losses increase, the chances of
winning big increase as well. By example, if “tails” comes up three times in a coin toss, a
gambler might bet on “heads” because it is “due”; in reality, however, the chance of
either heads or tails is exactly 50%, because each toss is independent of the one that
came before. Gilovich (1983) first proposed that gamblers engage in “biased evaluation,”
tending to accept wins at face value but explain away or discount their losses. This
practice, in turn, results in characterizing a loss as a “near win” or in failing to identify
losses disguised as wins, that is, where the win was smaller than the spin wager (Dixon,
Harrigan, Sandhu, Collins, & Fugelsang, 2010). While these erroneous cognitions are
common, to some extent, among all gamblers, it is reasonable to theorize that beliefs
about luck, superstition, and winning also possess a transgenerational component, with
caregivers modeling these misperceptions for their children who, in turn, adopt them as
well. Combined with other etiological risk factors, these cognitions can fuel play and the
development of disorder.
Prevalence
Between 78% and 86% of adults in the U.S. will gamble in their lifetimes, 63% to 82% in
the past year (Kessler et al., 2008; National Opinion Research Center, 1999; Welte, Barnes,
Wieczorek, Tidwell, & Parker, 2002). A majority of these adults will gamble occasionally
and for recreation only. However, a proportion of those who gamble will do so to excess,
resulting in serious adverse social, psychological, physical, familial, and legal
consequences.
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The prevalence of disordered and sub-threshold problem gambling varies widely among
jurisdictions, many of which assess “problem gambling,” which includes disordered and
sub-threshold gamblers, rather than adopting the stricter DSM-based clinical
classification. In a comprehensive worldwide review of prevalence studies, Williams,
Volberg, and Stevens (2012) reported that the standardized past year rate of problem
gambling ranges from 0.5% to 7.6%, with a mean of 2.3%. Lower than average rates have
been reported in Great Britain, South Korea, Iceland, Hungary, Norway, France, and New
Zealand. The United States, Canada, Australia, Sweden, Switzerland, Estonia, Finland,
and Italy report average rates. Above average rates were found in Belgium and Northern
Ireland with the highest prevalence rates observed in Singapore, Macau, Hong Kong, and
South Africa (Williams et al., 2012). Disparities in prevalence rates are due to a number of
factors, including differences in: (a) assessment tools and differing scoring thresholds; (b)
assessment time frames (e.g., lifetime versus past year); (c) survey administration (e.g.,
in-person interviews versus telephone surveys, mail surveys, etc.); (d) survey description
(e.g., gambling survey versus health and recreation survey); and (e) time frame used for
each question (e.g., weekly gambling, any past year gambling, etc.) (Williams et al., 2012).
In the United States, general population surveys have reported rates of past year problem
gambling of around 2% and lifetime rates approaching 3% (Kessler et al., 2008; National
Opinion Research Center (NORC), 1999; Welte et al., 2002). Studies have also noted a
relationship between higher prevalence rates and closer proximity to gambling venues.
For example, individuals living within 50 miles of a casino in one study had double the
rate of disordered gambling (NORC, 1999). Another study found that living within 10 miles
of a casino increased the odds of being a problem gambler by 90% (Welte et al., 2004),
although subsequent regression analyses found that residential proximity was predictive
only for men over 29 years but not for other demographic groups (Welte et al., 2007).
Nevada, where gambling has long been legal and accessible, has slightly higher rates of
problem gambling, particularly in counties closest to casinos (Shaffer, LaBrie, &
LaPlante, 2004); those rates, however, are still modest, considering the amount of
gambling available relative to other jurisdictions.
Williams et al. (2012) reported that rates of problem gambling have stabilized in recent
years, despite a steady increase in availability. Those authors suggest this phenomenon
could be due to a number of factors, including: (a) increased awareness of the potential
harms, (b) decreased overall population participation in gambling after the novelty wore
off, (c) problem gamblers leaving the population pool due to severe adverse
consequences of their gambling (e.g., bankruptcy, suicide), (d) increased industry and/or
government efforts at harm reduction and informed choice, and (e) increasing age of the
population (Williams et al., 2012).
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Special Populations
Despite this relative stability, there are sub-groups who experience significantly higher
rates of problem gambling than other groups. Notably, these groups are also of particular
interest to social workers, because they may be at risk for exploitation or abuse in society
and/or be particularly susceptible to marketing ploys or gambling machines that typically
result in greater losses.
Gender
Men report two to three times the rate of gambling pathology when compared to women
(Petry, Stinson, & Grant, 2005). Men who develop gambling problems typically begin
gambling at a younger age than women, who characteristically begin gambling later in
life (Black et al., 2015; Ibanez, Blanco, Moreryra, & Saiz-Ruiz, 2003; Gonzalez-Ortega,
Echeburua, Corral, Polo-Lopez, & Alberich, 2013; Nower & Blaszczynski, 2006; Tang, Wu, &
Tang, 2007). Despite the later onset, however, women typically prefer gaming machines
like video poker and slots (Nower & Blaszczynski, 2006), which have been called the “crack
cocaine” of gambling because they rapidly generate losses and lead to serious gambling
problems (Dowling, Smith, & Thomas, 2005). Irrespective of gender, frequent gambling
and engaging in multiple forms of play lead to increases in problem severity (Ellenbogen,
Derevensky, & Gupta, 2007).
Specific demographic profiles vary by jurisdiction and sampling strategy. For example, in
a study of 2,670 gamblers who self-excluded from casinos in Missouri, the women were
more likely to be older at the time of application, African American, and either retired,
unemployed, or otherwise outside the traditional workforce (Nower & Blaszczynski, 2006).
Women in that study were also more likely to report a prior bankruptcy (Nower &
Blaszczynski, 2006), though Grant and Kim (2002) found equal rates of bankruptcy by
gender, with women writing more bad checks and men more likely to lose significant
savings. An Australian study found that female problem gamblers were more likely than
males to be older and prefer machine gambling,;however, they were also more likely to
be married, living with family and dependent children, and to report less than half the
debt owed by males (Crisp et al., 2004). Several studies have reported that women prefer
gaming machines and bingo while men opt for cards and sports betting (Grant & Kim,
2002;Odlaug, Marsh, Kim, & Grant, 2011; Potenza et al., 2001). In contrast, a recent large-
scale Australian prevalence study found that younger age, low education, unemployment,
non-English speaking, and playing gaming machines, table games, and lotteries were
significant predictors of both male and female problem gamblers (Hing, Russell,
Page 9 of 45

Tolchard, & Nower, 2015). These findings suggest that jurisdictional differences may play
a role in the gambling preferences of men and women.
There are also gender differences in physical and mental health comorbidity. Female
problem gamblers report more mental and physical health problems than their same-age
peers. A variety of studies have found that poorer overall general and mental health (Afifi,
Cox, Martens, Sareen, & Enns, 2010), depressed mood (Blanco, Petry, Stinson, & Grant,
2006), suicidal thoughts and somatic complaints (Tang, Wu, & Tang, 2007), anxiety, and
eating disorders (Dannon et al., 2006) are particularly characteristic of female problem
gamblers and that those associations may begin in childhood and adolescence (Nower,
Gupta et al., 2004). Women gamblers are much more likely than controls to be victims of
intimate partner violence (Echeburua, Gonzalez-Ortega, Decorral, & Polo-Lopez, 2013) and
physical abuse (Ibanez et al., 2003), to report a family history of alcoholism (Ledgerwood,
Wiedemann, Moore, & Arfken, 2012) and to suffer from poor self-esteem (Echeburua,
Gonzalez-Ortega, de Corral, & Polo-Lopez, 2011).
Compared to women, men who gamble problematically are much more likely to smoke
excessively, be classified as heavy drinkers (Martins, Tavares, da Silva Lobo, Galetti, &
Gentil, 2004), receive lifetime diagnoses of alcohol and drug use disorders (Blanco et al.,
2006; Dannon et al., 2006; Desai, Maciejewski, Pantalon, & Potenza, 2006; Desai & Potenza,
2008), report incarceration (Potenza, Maciejewski, & Mazure, 2006), and engage in more
sexual risk taking behavior (Martins et al., 2004). However, gambling problems are
associated with increased odds of most past year mood and personality disorders,
regardless of gender (Martins et al., 2004).
Race/Ethnicity
Higher rates of disordered gambling occur among racial and ethnic minorities,
particularly Native Americans (Volberg & Abbott, 1997; Zitzow, 1996A, B), Asians (Marshall,
Elliott, & Schell, 2009; Petry, Armentano, Kuoch, Norinth, & Smith, 2003; Toyama et al.,
2014), Latinos (Barry, Stefanovics, Desai, & Potenza, 2011A; Welte, Barnes, Wieczorek,
Tidwell, & Parker, 2001) and blacks (Barnes, Welte, Hoffman, & Tidwell, 2009; Barry,
Stefanovics, Desai, & Potenza, 2011B; Cunningham-Williams, Cottler, Compton, &
Spitznagel, 1998; Petry, Stinson, & Grant, 2005; Welte et al., 2001; Welte, Barnes, Wieczorek,
Tidwell, & Parker, 2002; Welte, Barnes, Tidwell, & Hoffman, 2008). Analysis of the National
Epidemiologic Survey on Alcohol and Related Conditions data found that Native
Americans and Asians had the highest rates of disordered gambling, 2.3%; followed by
blacks, 2.2%; whites, 1.2%; and Latinos, 1.0% (Alegria et al., 2009). That general
Page 10 of 45

population survey found that groups also differed significantly on socioeconomic

indicators, comorbid psychopathology, and health conditions. Few studies have
specifically investigated gambling disorder in particular minority groups in a large
sample; rather, a majority of the studies have small, non-representative samples.
Nevertheless, rates of disorder in most investigations are higher than those found in the
white population.
Among Native Americans, both men and women have high prevalence rates for problem
and disordered gambling, primarily because of low socio-economic status, unemployment,
increased alcohol use, depression, historical trauma, and lack of social alternatives
(Zitzow, 1996B). In studies comparing Native and non-Native Americans, Native American
adults began gambling later in life than other adults but quickly developed problems
(Zitzow, 1996B), whereas Native American adolescents report an earlier age of onset and
higher levels of involvement than their peers (Zitzow, 1996A). However, much more
research is needed to understand the nature and course of disorder in this group.
It is widely known that certain Asian groups, particularly Chinese, gamble at much higher
rates than other gamblers. The insular nature of many Asian communities, combined with
potential for stigma and language barriers, has limited research in this ethnic group.
Petry et al. (2003) surveyed Southeast Asian refugees in community service organizations
in the United States and found extraordinarily high rates of disordered gambling; about
59% of those surveyed met criteria for gambling disorder. In addition, more than half of
all respondents had gambled within two weeks of the interview and 42% wagered more
than $500 in the previous two months. A study of Cambodian refugees in the United
States noted similar, though less severe, rates of disordered gambling, with 13.9% of
participants meeting criteria for lifetime disordered gambling; traumatic exposure
emerged as one significant predictor of higher rates of disorder (Marshall, Elliott, &
Schell, 2009). In Japan, Toyama and colleagues (2014) reported very high rates of gambling
disorder among men (9.0%), compared to women, who had average rates of pathology
(1.6%). The findings, which controlled for socioeconomic and other demographic factors,
noted that a majority of gamblers played Pachinko machines, highlighting the culturally
specific facets of gambling preference and the severity of losses on machines,
irrespective of type or location.
There are few studies of gambling among Latinos, and a majority of those are small-scale
investigations of specific sub-groups. One general population survey that examined
gambling problem severity and psychiatric disorders found that Latinos with sub-
threshold gambling problems were more likely to have comorbid mood, anxiety,
substance use, and personality disorders than white participants. In another study of
Latino American veterans, Westermeyer and colleagues (2005) reported the lifetime
prevalence rate for disordered gambling was 4.3%, significantly higher than rates in the
Page 11 of 45

general population; gambling disorder was also accompanied by high rates of major
depressive (14.1%), alcohol (22.9%), and posttraumatic stress (12.2%) disorders.
A small study of undocumented Mexican immigrants in New York City found that more
than half of those surveyed reported lifetime gambling and a majority of gamblers played
scratch and win tickets or the lottery (Momper, Nandi, Ompad, Delva, & Galea, 2009).
Those who sent money home to their families or had lived in the United States more than
12 years and those who reported one to five days of poor mental health in the past 30
days were most likely to gamble. As Latinos become a larger proportion of the population
with increasing access to gambling opportunities, these findings suggest it will be
imperative to ensure the availability of adequate screening and specialized gambling
treatment in Spanish. Currently, few if any states have Spanish-speaking certified
gambling counselors, and the few who are practicing are often geographically
inconvenient for many Latino gamblers.
Similar needs exist with regard to black gamblers, including African Americans. Large-
scale prevalence studies have long identified higher rates of disordered gambling among
blacks, though blacks traditionally have lower rates of overall gambling participation
(Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998; Welte et al., 2001). Compared
to whites in the epidemiologic NESARC study, for example, blacks had twice the rate
(2.2%) of disordered gambling and lower scores on general health measures; they were
also more likely to be women in the lowest income brackets (Alegria et al., 2009). Black
youth are significantly more likely than whites to engage in heavy gambling (Barnes,
Welte, Hoffman, & Tidwell, 2009). Being young, male, and non-Hispanic black was
associated with high rates of gambling disorder in the U.S. National Comorbidity Survey
Replication (NCS-R) data (Kessler et al., 2008). These findings generally mirror
sociodemographic characteristics and comorbidity patterns found in earlier studies (Petry
et al., 2005; Welte et al., 2001). Controlling for gender, age, and socioeconomic status, one
study reported that blacks had 1.6 times the odds of being frequent gamblers, 3.7 times
the odds of being disordered or problem gamblers, and 5.8 the odds of being disordered
gamblers when compared to whites (Welte et al., 2001).
Smaller-scale studies support these findings as well. Comparing black and white callers
to a gambling hotline, Barry et al. (2008) found that black problem gamblers were more
likely to be female with less education who reported a longer history of problem
gambling. A comparison of casino self-excluders found that women who self-excluded as
problem gamblers were more likely to be black, older, separated, divorced, or widowed,
report low personal income, and not be employed full-time (Nower & Blaszczynski, 2006).
Most alarming, in a study of 275 predominantly black homeless individuals, nearly half
reported gambling problems and 12% met clinical criteria for disordered gambling
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(Nower, Eyrich-Garg, Pollio, & North, 2015). Despite these findings, few social workers
who work on hotlines or in homeless shelters, community agencies, or hospitals have
familiarity with these statistics nor are they trained to conduct routine screening for
symptoms, pathology, or adverse consequences of problem gambling. Ironically, diversity
courses in master’s programs in social work that include content on addictive disorders
also uniformly fail to address gambling problems as well.
Youth
In the United States and Canada, between 70% and 85% of adolescents report having
gambled and 4% to 6% experience serious gambling problems—double the rate for adults
(Blinn-Pike, Worthy, & Jonkman, 2010; Chalmers & Willoughby, 2006; Volberg, Gupta,
Griffiths, Ólason, & Delfabbro, 2010). Gambling typically begins at home, and early
gambling experiences appear to predict later onset of gambling problems (Kundu et al.,
2013; Nower, Derevensky, & Gupta, 2004).
As discussed in the section on etiology, gambling is typically viewed as a benign activity

by parents and teachers, who either tacitly condone or actively participate in gambling
with minors (Campbell, Derevensky, Meerkamper, & Cutajar, 2011; Derevensky, St-Pierre,
Temcheff, & Gupta, 2014).
This is particularly troubling since a significant body of research indicates that youth who
begin gambling at a young age are more likely to experience later gambling problems
(Rahman et al., 2012), have sex before age 18 (Martins et al., 2014), use and abuse
substances (Nower et al., 2004), and engage in delinquent behaviors (Vitaro, Brendgen,
Ladouceur, & Tremblay, 2001).
Youth who begin gambling with family or who have parents with addictions are most
likely to develop gambling problems (Nower et al, 2004; Pagani, Derevensky, & Japel, 2009),
particularly those who also experience impulsivity and emotional lability (Slutske, Moffitt,
Poulton, & Caspi, 2012), anxiety and/or depression (Ste-Marie, Gupta, & Derevensky, 2006;
Nower et al., 2004), and poor parental monitoring and disciplinary tactics (Vachon, Vitaro,
Wanner, & Tremblay, 2004).
In the United States, card play and casino gambling have been frequently associated with
disordered gambling symptoms in adolescents and young adults (Welte, Barnes, Tidwell,
& Hoffman, 2009). The most troubling risk for youth, however, appears to be the
increasing availability of Internet gambling. Despite attempts to monitor and limit online
gambling to those over 18 in the three states where it is legal (New Jersey, Delaware, and
Nevada), youth can still gamble on off-shore sites and, sometimes, gamble using their
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parents’ accounts with their permission. A growing number of free sites and social media
outlets like Facebook offer gambling games that may serve as a gateway to high stakes
gambling sites. A recent study of adolescents between 12 and 17 years found that 31.5%
of participants engaged in simulated gambling activities on free gambling sites, social
media, smartphone applications, and video-games (King, Delfabbro, Kaptsis, & Zwaans,
2014). The study found that adolescents with a history of gambling in simulated activities
are at highest risk of endorsing symptoms of disordered gambling. Studies have also
identified a significant association between online gambling, Internet addiction,
psychopathology, and lower school achievement (Floros et al., 2013). These studies
suggest that youth raised in an era with wide access to video and online games are at risk
to move from free to pay sites over time. Studies of Internet gamblers have reported
higher rates of gambling problems, greater gambling frequency, and gambling on a
greater variety of games than non-Internet gamblers (Gainsbury, Russell, Hing, Wood, &
Blaszczynski, 2013; Wood & Williams, 2007). This is likely amplified by the current legal
status of daily fantasy sports betting as a non-gambling activity.
Older Adults
Historically, older adults reported lower rates of gambling participation (Kallick, Suits,
Dielman, & Hybels, 1976; Mok & Hraba, 1991). However, rates began increasing with the
widespread legalization of casino gambling in the 1990s (NORC, 1999; Welte et al., 2001). In
1975, only 35% of adults 65 and over reported lifetime gambling (Kallick, Suits, Dielman,
& Hybels, 1976) as compared with 69% of those 61 and older in a 2001 survey (Welte et
al., 2001).
Older adult gamblers typically begin gambling later in life but may develop problems
more quickly than some of their younger peers (Nower & Blaszczynski, 2008; Petry, 2002).
Studies have identified higher rates of older adult problem gambling among women
(Nower & Blaszczynski, 2008; Petry, 2002); patrons of casino bus-trips (Bazargan, Bazargan,
& Akanda, 2000), residents of senior centers and/or those attending bingo halls (Erickson,
Molina, Ladd, Pietrzak, & Petry, 2005); ethnic minorities and veterans (Bazargan et al.,
2000; Levens, Dyer, Zubritsky, Knott, & Oslin, 2005), and individuals with disabilities
(Southwell, Boreham, & Laffan, 2008).
The typical older adult gambler reports a lower income and fewer gambling-related
problems, arrests, illegal behavior, and debt than younger gamblers (Potenza, Steinberg,
Rounsaville, & O’Malley, 2006). Those who frequent casinos are also more likely to be
widowed, less educated with lower incomes, lack transportation, and report poorer
mental health status and less social support than non-casino patrons (Zaranek &
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Chapleski, 2005). Among recreational gamblers, older adults are more likely than younger
gamblers to gamble daily or multiple times per week and to report big wins (Desai et al.,
2004). One study of self-excluded casino problem gamblers found that older adults began
gambling in mid-life, experienced gambling problems around age 60, reported
preferences for non-strategic forms of gambling like slot machines, and self-excluded
due, in part, to fear of suicide (Nower & Blaszczynski, 2008). For comprehensive reviews of
the literature on older adult gambling, see Subramaniam et al. (2015), Ariyabuddhiphongs
(2012), and Tse, Hong, Wang, & Cunningham-Williams (2012).
Disability
The National Research Council of the National Academies first highlighted the
relationship between chronic illness and disability more than a decade ago, reporting that
about 6% of problem gamblers received disability services (National Research Council,
1999). Prevalence and other studies have also found higher levels of gambling pathology
among the underemployed, those with chronic health problems, and those with lower
incomes (Nower & Blaszczynski, 2006, 2008). Despite these mentions, there has been little
research in these areas. One of the only studies reported that 26% of individuals
receiving disability services met criteria for disordered or problem gambling (Morasco &
Petry, 2006). In addition, those receiving disability services self-reported more gambling-
related problems and lower levels of mental and physical health than those who did not
receive disability services.
Individuals with lower levels of cognitive functioning may also be at higher risk of
developing gambling problems (Lubinski, 2009; Rai et al., 2014; Shamosh et al., 2008).
Wachter (2008) reported that adults with intellectual disability have nearly double the rate
of gambling disorder compared to the general population. In a large population survey in
England, researchers found that individuals with estimated verbal IQ scores below 85
were five times more likely than those with verbal IQ scores over 100 to be problem
gamblers even when controlling for various sociodemographic factors (Rai et al., 2014).
This association between cognitive functioning and problem gambling has also been
reported with adolescents. Studies have found higher rates of gambling disorder in
adolescents with learning disorders (Parker et al., 2013), even after controlling for
negative affectivity and ADHD symptoms. A key determinant in this relationship may be
the role of cognitive distortions. In the general population, erroneous cognitions
regarding luck, the possibility of winning, and the nature of randomness have been found
to fuel excessive gambling. However, researchers have found that youth with special
educational needs hold more erroneous beliefs about gambling and, therefore, have a
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higher risk of developing problematic gambling patterns than their peers (Taylor, Parker,
Keefer, Kloosterman, & Summerfeldt, 2015).
Comorbidity
It is well established that a majority of disordered gamblers have comorbid mental health
and substance use disorders. In a national study in the United States, more than 73% of
disordered gamblers met criteria for an alcohol use disorder, 38% for a drug use
disorder, 60% for nicotine dependence, 50% for a mood disorder, 41% for an anxiety
disorder, and 61% for a personality disorder, even after controlling for gender, race,
marital status, age, geographic location, and socioeconomic status (Petry, Stinson, &
Grant, 2005). A number of other studies have likewise reported significantly higher levels
of mood, bipolar, generalized anxiety, posttraumatic stress, and substance use disorders
in disordered gamblers as compared to the general population (Chou & Afifi, 2011; Kessler
et al., 2008; Ledgerwood & Petry, 2006. For a review, see Dowling et al., 2015) Those figures
are higher in the homeless population, which reported very high rates of problem (46%)
and disordered (12%) gambling as well as personality, bipolar, and post-traumatic stress
disorder (PTSD) and drug, alcohol, and nicotine abuse and dependence (Nower, Eyrich-
Garg, Pollio, & North, 2015).
A growing number of studies investigate the relationship of disordered gambling to PTSD

(Ledgerwood & Milosevic, 2015; Ledgerwood & Petry, 2006; McCormick, Taber, &
Kruedelbach, 1989; Specker, Carlson, Edmonson, Johnson, & Marcotte, 1996; Taber,
McCormick, & Ramirez, 1987). For example, Ledgerwood and Petry (2006) found that 34%
of treatment-seeking gamblers reported a high frequency of PTSD symptoms, which were
further correlated with gambling and psychiatric symptom severity, impulsivity, and
dissociation. This association is particularly notable among veterans. Westermeyer and
colleagues (2005) reported that 10% of Native American veterans met lifetime criteria for
gambling disorder and had a high prevalence of comorbid substance, mood, and
antisocial personality disorder. Higher rates of gambling disorder have been identified in
veterans with history of gambling in the family (Daghestani, Elenz, & Crayton, 1996) and
those with poor coping skills (Castallani et al., 1996).
Societal and Individual Costs
Increasingly limited options often compel disordered gamblers to resort to criminal

behavior. In fact, the behavior is so common that it was removed as a criterion in the
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DSM-5 (APA, 2013). In addition, mounting debts can also lead to bankruptcy and its
attendant societal costs.
Crime
There is a significant relationship between crime and disordered gambling (Blaszczynski

& McConaghy, 1994; Folino & Abait, 2009; Meyer & Fabian, 2005; Potenza, Steinberg,
McLaughlin, Rounsaville, & O’Malley, 2000; Turner, Preston, Saunders, McAvoy, & Jain,
2009). For a comprehensive summary of this topic, see Nower and Blaszczynski, 2013). In a
national survey of gambling in the United States, more than 30% of disordered gamblers
and 36% of sub-clinical problem gamblers reported arrests, compared to around 12% of
low-risk and 5% of non-gamblers (National Opinion Research Center [NORC], 1999). The
study also reported that 31% of disordered and problem gamblers go to jail, compared to
just over 4% of low-risk and non-gamblers, costing the criminal justice system around
$2,000 per gambler. Those rates are consistent with findings in other studies (see e.g.,
[Australia] Blaszczynski & McConaghy, 1994; [Argentina] Folino & Abait, 2009; [Germany]
Meyer & Fabian; 2005; [Canada] Turner et al., 2007) as well as in treatment (Ledgerwood,
Weinstock, Morasco, & Petry, 2007), Gamblers Anonymous (Abait & Folino, 2008), and
hotline caller populations (Potenza et al., 2000).
High rates of gambling pathology have, likewise, been identified among prisoners,
probationers, and parolees (Templer, Kaiser, & Siscoe, 1993; Turner et al., 2007, 2009). One
study reported that 34% of non-imprisoned participants who were on remand, probation,
or parole at the time of the study met criteria for disordered gambling, and 38% did so
for problem gambling (Lahn, 2005). About 25% of those surveyed endorsed gambling as a
key contributor to their offense, and nearly 50% of respondents reported obtaining
money illegally to gamble. Another study reported that about 20% of newly sentenced
inmates claimed their crime was gambling-related, 21% met criteria for gambling
disorder at the time of assessment, and 16% did so in the six months before going to
prison (Abbott, McKenna, & Giles, 2005).
Despite these findings, there is still limited understanding regarding the relationship of
disordered gambling and crime. A majority of existing studies consist of self-report with a
small, self-selected group of volunteer participants who may be subject to recall and
social desirability biases. It is also generally unknown which offenses were motivated by
the desire to generate funds for gambling or cover up the consequences of gambling and
which were related to other causes, including a penchant for antisocial and impulsive
behavior. Few arrest, pre-sentence, probation, or other court reports and documents
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detail the reason the crime was committed; rather, reports typically state the nature of
the offense and the evidence for believing the defendant committed it. For that reason,
there is no way to independently verify whether crimes are, in fact, gambling-related in
the vast majority of cases.
Debt and Bankruptcy
The main reason gamblers initiate gambling is to win money. As habitual, excessive
gambling proceeds toward disorder, gamblers typically accumulate significant amounts
of debt, file for bankruptcy, and suffer personal and familial consequences like divorce
and suicide (Downs & Woolrych, 2010; Edwards, 2003; Ladouceur, Boisvert, Pepin,
Loranger, & Sylvain, 1994; NORC, 1999; Nower & Blaszczynski, 2008).
Research has yet to clearly establish whether legalized gambling opportunities have led
to overall increases in rates of personal bankruptcy, primarily because most governments
fail to require debtors to detail precipitators of debt. Several studies have found
statistical correlations between the introduction of casino gambling and overall increases
in per-capita bankruptcy filings (Nichols, Stitt, & Giacopassi, 2000). For example, Nichols
and colleagues (2000) reported that filings rose significantly in five of eight counties
studied; however, the analysis failed to control for unemployment rate, percentage of
males in population, and other variables that may significantly impact rates. Another
study reported that bankruptcy filing in a gambler’s home state increased 10% following
visits to casinos in other states (Garrett & Nichols, 2008) in all but one state studied.
Modeling the association of bankruptcy filing rates around casinos, Barron, Staten, and
Wilshusen (2002) found that removing casinos would result in a 5% decrease in bankruptcy
filing locally and a 1% decrease in the national bankruptcy rate. However, other studies
have identified unemployment rates (de la Vina & Bernstein, 2002) and socio-demographic
factors (Thalheimer & Ali, 2004) as the most significant determinants of personal
bankruptcies, not access to gambling.
Such conflicting research findings mirror the lack of consensus in court decisions
regarding guidelines for treating gambling-related credit card debt. In general, courts
consider a number of factors, including the length of time (pattern) between the charges
and the filing of the bankruptcy, the number and amount of charges, and the financial
condition and employment of the gambler at the time of the charges (see In re Dougherty,
1988; In re Troutman, 1994). Whether or not gamblers meet the discharge threshold,
there are social cost implications. Destitute gamblers and their families utilize public
assistance and services at a cost to the community; discharged credit card debt is also
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passed on to other customers and businesses in the form of fees and interest, further
increasing the societal cost associated with this disorder.
Health, Mental Health, and Familial Consequences
Studies have found that a lifetime diagnosis of disordered gambling is associated with
medical disorders and increased medical utilization (Morasco & Petry, 2006). Specifically,
one national study in the United States reported that disordered gamblers were more
likely than low-risk gamblers to have been diagnosed with tachycardia, angina, cirrhosis,
and other liver diseases; they were also more likely to have been treated in an emergency
room in the past year (Morasco & Petry, 2006). These health problems often coexist with
psychiatric conditions reported in “COMORBIDITY.”
A number of studies have also investigated the impact of problem gambling on families:
anger, emotional distress, depression (Hodgins, Toneatto, & Makarchuk, 2007; Lorenz &
Shuttleworth, 1983; Lorenz & Yaffee, 1986; see Kourgiantakis, Saint-Jacques, & Tremblay,
2013for a review). Female partners of problem gamblers report higher rates of suicidal
ideation and attempts, somatic complaints, substance abuse, and impulsive spending in
response to the stress caused by gambling losses (Lesieur & Rothschild, 1989; Lorenz &
Shuttleworth, 1983; Lorenz & Yaffee, 1986). In addition to an increased likelihood of
developing addictions, children of problem gamblers report disrupted relationships,
financial difficulties, diminished need fulfillment and higher levels of stress, anxiety, and
depression than youth with no parental gambling problems (Hsu, Lam, & Wong, 2014).
They are more likely than their peers to experience parental physical violence and abuse,
to feel sad, shameful, helpless, and isolated (Jacobs et al., 1989; Lesieur & Rothschild, 1989).
News reports have documented children found abandoned on casino premises while their
parents gambled. Notably, the U.S. National Gambling Impact Study Commission (1999)
underscored that cases of child abandonment at one large casino were so common that
authorities posted signs in parking lots warning parents not to leave their children
unattended.
Excessive gambling is also related to family violence and child maltreatment. Afifi and
colleagues (2010) found that gambling disorder was associated with increased odds of the
perpetration of dating violence, severe marital violence, and severe child abuse
victimization. An in-depth study of family violence and gambling in Australia, New
Zealand, and Hong Kong reported that more than half of help-seeking family members of
problem gamblers had experienced some form of family violence in the past year (Suomi
et al., 2013). The research concluded that family violence was more likely to evolve from
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deep-seated anger and mistrust and that victimization was typically an outcome of the
gambler’s anger and frustration.
In extreme cases, gambling disorder can lead to suicide and familicide (Anderson, Sisack,
& Varnik, 2011). Studies have reported that problem gamblers are more than three times
as likely as the general population to attempt suicide (Newman & Thompson, 2007). Of
treatment-seeking disordered gamblers, more than 81% in one study expressed suicidal
ideation and 30% reported one or more attempts in the past year (Battersby, Tolchard,
Scurrah, & Thomas, 2006). In a large study in Hong Kong, 20% of treatment-seeking
gamblers reported suicidal ideation and 0.6% indicated they were thinking of killing their
families (Wong, Kwok, Tang, Blaszczynski, & Tse, 2014). Another study of completed
suicides found that nearly 20% showed evidence of gambling prior to death and 47%
involved individuals with gambling-related debts (Wong, Chan, Conwell, Conner, & Yip,
2010). Rates are similar in youth and young adults. Stuhldreher and colleagues (2007) noted
that college students who gambled were twice as likely as other students to consider or
to attempt suicide; problem and disordered gambling also proved the most significant
predictor of suicidality in teenagers, irrespective of level of depression (Nower, Gupta,
Blaszczynski, & Derevensky, 2004).
Diagnosis and Treatment
Since the early 21st century, researchers have developed a number of screening tools for
disordered gambling. Most of these tools are hampered by a lack of conceptual clarity
over how to identify and classify sub-threshold problem gamblers and by the every-
shifting criteria in new iterations of the DSM.
Screening
The South Oaks Gambling Screen (Lesieur & Blume, 1987), a 20-item screen based on the
DSM-III-R, was developed for use in clinical settings but subsequently used for population
surveys as well. While reliability of the tool is satisfactory, the SOGS yields high rates of
false positives in some populations (Stinchfield, 2013). A majority of prevalence surveys no
longer use the tool, which has also been replaced in a majority of clinical settings by
measures based on the current version of the DSM or with more robust psychometric
properties.
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The Canadian Problem Gambling Index (Ferris & Wynne, 2001) was developed in response
to the need for a psychometrically sound measure for use in general population surveys.
The CPGI is a 31-item instrument, which includes the nine-item Problem Gambling
Severity Index (PGSI). The PGSI was based on the most predictive items of the SOGS as
well as DSM core items so as to be useful to non-clinical samples and generalizable
across populations, including countries that do not use the DSM system of classification.
The PGSI has demonstrated high internal consistency and validity (Stinchfield, 2013) and is
currently the “gold standard” instrument used in both clinical settings and prevalence
studies worldwide. The instrument scores respondents in categories: non-problem, low-
risk, moderate-risk, and problem gambling. Currie, Hodgins, and Casey (2013) have
proposed an alternate scoring that better discriminates the low- and moderate-risk
categories.
Stinchfield (2013) has summarized the uses, strengths, and limitations of a majority of
available brief and extended problem severity screening tools in his comprehensive
review. In addition to tools that measure gambling problem severity, a number of authors
have published instruments that assess aspects of gambling, including motives (Stewart
& Zack, 2008), craving (Young & Wohl, 2009), and cognitions (Raylu & Oei, 2004). An
etiological screening instrument, based on the Pathways Model (Blaszczynski & Nower,
2002), is currently under review. That tool will allow clinicians to assign clients to
pathways and tailor treatment to include relevant etiological risk factors.
Treatment
Behavioral interventions, particularly those with a cognitive component, are the standard
treatments for gambling disorder. A meta-analysis of behavioral therapies reported a
large effect size of 2.01 at the end of treatment and an effect size of 1.59 at 17-month
average follow-up (Pallesen, Mitsem, Kvale, Johnsen, & Molde, 2005). Despite
neurobiological features of the disorder outlined previously, a similar meta-analysis of
pharmacological treatment failed to strongly support the use of any specific medication to
treat gambling disorder (Bartley & Bloch, 2013), though individual cases may warrant
tailored drug therapy.
A key feature in cognitive-behavioral therapy is addressing cognitive distortions that fuel

play, habituation, and, ultimately, the cycle toward disorder. Treatment primarily
attempts to restructure cognitions through education on the concepts of randomness and
the independence of events, the odds of winning, and the futility of common cognitive
fallacies (Gaboury & Ladouceur, 1990; Ladouceur, Sylvain, Letarte, Giroux, & Jacques,
1998). Studies that also incorporate problem solving and relapse-prevention are the most
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successful at decreasing gambling severity and urges and increasing the perception of
control over time (Bujold, Ladouceur, Sylvain, & Boisvert, 1994; Ladouceur et al., 1998;
Sylvain, Ladouceur, & Boisvert, 1997). See Blaszczynski and Nower (2013) and Fortune and
Goodie (2012) for reviews of cognitive-based treatment studies and techniques. To date,
even successful manualized treatments are largely homogenous “one-size-fits-all”
programs that disregard the possibility that etiological sub-groups, ethnic minorities, and
others may require individualized treatment to be successful and prevent relapse.
A number of new and promising variations on traditional therapy are generating research
interest: mindfulness-enhanced cognitive therapy (Toneatto, Pillai, & Courtice, 2014),
meditation awareness training (Shonin, VanGordon, & Griffiths, 2014), imaginal
desensitization (Blaszczynski & Nower, 2013), motivational enhancement (Hodgins, Currie,
& el-Guebaly, 2001; Ledgerwood et al., 2013), and brief, motivational treatments (Hodgins,
Currie, el-Guebaly, & Peden, 2004; Hodgins, Currie, Currie, & Fick, 2009). A majority of
these techniques focus on enhancing motivation, a key strategy in engaging gamblers in
treatment and limiting drop-out rates.
Researchers have yet to clearly understand why gamblers fail to attend treatment at
rates comparable to those with substance use disorders; however, studies have
consistently found that gamblers are reticent to present for treatment. Aside from 1-800
numbers and occasional billboards, there is little promotion of problem gambling
services. As a result, studies have found there is low awareness of the availability of
services (Gainsbury, Hing, & Suhonen, 2014). Gamblers have also reported being
concerned about cost, effectiveness of treatment, and stigma (Rockloff & Schofield, 2004).
Insurance programs do not always cover gambling disorder absent a co-occurring mood
disorder, and not all states in the United States provide subsidized treatment. Excessive
gambling has long been seen as a vice rather than a disease, leading some gamblers to
hide their problems even when circumstances are dire. Other gamblers, sometimes the
most severe, deny they have a gambling problem and see no reason to attend treatment
(Suurvali, Hodgins, Toneatto, & Cunningham, 2012).
Motivating clients to attend treatment does not necessarily result in treatment

completion. Studies employing different methodologies have estimated that 30% to 50%
of treatment seekers drop out after assessment or a few initial sessions (Robson,
Edwards, Smith, & Colman, 2002; Ladouceur, Gosselin, Laberge, & Blaszczynski, 2001;
Sylvain et al., 1997). Those who drop out are characterized by high levels of impulsivity
(Leblond, Ladouceur, & Blaszczynski, 2003) and sensation-seeking traits (Smith et al., 2010),
mood disorders, high levels of guilt and shame, gambling for escape, and a lack of
readiness for change (Dunn, Delfabbro, & Harvey, 2012). Notably, being male and having a
low income job, longer course of gambling problems, higher frequency of play, and higher
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levels of anxiety and depression were correlated in one study with early drop-outs
(Tolchard & Battersby, 2013). That study noted that females, once engaged in therapy,
were likely to continue despite endorsing some of the same risk factors as the male drop-
outs. Perhaps this is due to the fact that women gamblers are more likely than men to
report having received non-gambling-related mental health treatment prior to seeking
help for gambling (Potenza et al., 2001) and to express a greater readiness for change
(Ledgerwood, Wiedemann, Moore, & Arfken, 2012). Incorporating problem-solving and
support-seeking strategies into therapy appears to correlate with more positive attitudes
to treatment for both men and women (Matheson, Wohl, & Anisman, 2009). However, at 6-
months post treatment, one study found that men had improved significantly more on
gambling severity and rates of abstinence than women, who found specific components of
the gambling intervention targeting identification of high-risk situations, gambling
beliefs, and attitudes to be unhelpful (Toneatto & Wang, 2009). These findings suggest that
treatment is highly individualized and dependent, in large part, on the underlying motives
for gambling which, in turn, are likely related to etiological risk factors. The lack of public
awareness about gambling disorder and its effects, combined with limited treatment
availability and intervention strategies, makes it difficult to provide effective treatment,
motivate attendance, and sustain participation over time.
Policy Implications and the Role of Social Workers
This overview of a very complex and understudied disorder clearly demonstrates that
social workers are critical to improving the understanding of gambling disorder and
ensuring that screening, intervention, and treatment are afforded to everyone,
particularly those at risk. On a macro level, there is currently no federal funding for
gambling treatment or research. Insurance companies and employee-assistance programs
are mixed as to whether they will fund gambling treatment independent of another
recognized mental health disorder. Accordingly, gambling treatment is usually funded on
a state-by-state basis, out of taxes on casinos and other gambling operators. Some states
have no formalized treatment infrastructure while others fund hotlines, treatment
networks, and residential facilities. Tax revenue generated in a state typically resides in
the general revenue fund rather than receiving a specific earmark for gambling
treatment only. As a result, in times of economic shortfall, monies are cut back,
eliminated, or reapportioned to substance abuse treatment. This continually impacts the
most vulnerable members of our society—those who are typically championed by social
workers: older adults, ethnic minorities, individuals with disabilities, youth, veterans, and
those with low socioeconomic status and levels of education.
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However, to date, social work has been silent on these issues. There is currently little
expressed interest or awareness in the social work community about problem and
disordered gambling. Gambling is conspicuously absent from the National Association of
Social Workers advocacy, publications, and special practice sections, which still use the
outdated terminology “Alcohol, Tobacco, and Other Drugs” as the only addiction
offerings.
This lack of awareness in the profession is reflected in bachelor’s and master’s level
curricula in schools of social work nationwide. A majority of schools offer no addiction
training at the bachelor’s level. At the master’s level, addiction offerings are generally
limited to one or two courses in substance use disorders, despite the grudging
recognition by the psychiatric community that behavioral addictions have real and
debilitating consequences that parallel those of substance use disorders. As educators,
then, we are graduating practicing social workers and agency administrators who have
no familiarity with gambling disorder in an era of continued expansion of gambling
opportunities. Because of the complex nature of the disorder, the National Council on
Problem Gambling recommends counselors receive at least 30 hours of specialized
training in screening and treatment, leading to national certification. Yet few schools
make this training available in the curriculum or continuing education programs offered
to post-graduate practitioners. As a result, there are few social workers who are trained
to identify gambling problems in the settings in which they work and are most likely to
encounter a high prevalence of problem gamblers: child welfare agencies, mental health
settings, emergency rooms, schools, family violence shelters, human service
organizations, community agencies, homeless shelters, and the criminal justice system.
Given that social workers are the primary, initial points of contact in these settings, it is
imperative that they be educated in the symptoms, consequences, screening, and
treatment of the disorder. Schools of social work should adopt an addiction curriculum
that includes the prevalence, etiology, and treatment of gambling disorder and awareness
of other behavioral addictions, particularly “Internet gaming disorder,” which is a
condition for further study in the DSM-5. In addition, it is important for diversity and
oppression courses to include information on gambling and its disproportionate impact on
ethnic minorities; gambling screenings should accompany other routine assessments in
treatment courses. Most important, social work programs should foster relationships with
state gambling councils to train students and post-grads in treating problem gamblers.
In community and legislative arenas on both the state and federal levels, social workers
could lead efforts to establish funding and infrastructure support for prevention, school
education programs, and diagnosis and treatment of problem gambling. Specifically, in
the coming years it will be increasingly important to ensure that gambling is included in
standardized screens used in health and mental health settings, particularly those that
Page 24 of 45

deal with vulnerable groups and children who are typically left to fend for themselves in
unpredictable, impoverished, and emotionally volatile environments. As more gambling
opportunities become available through interactive media such as mobile phones,
televisions, and the Internet, social workers have a critical role to play in educating and
protecting those we have served throughout history.
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Lia Nower
Professor and Director, Center for Gambling Studies, Rutgers University School of
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Kyle Caler
Center for Gambling Studies
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Encyclopedia of Social Work

Abstract and Keywords

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Terminology and History of the Disorder

Confusion regarding the nomenclature is reflected in the evolution of the diagnostic

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of Mental Disorders of the American Psychiatric Association (DSM-III, American

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The development of gambling disorder is complex and multifactorial, rooted in a wide

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A number of studies have attempted to explore or validate the Pathways Model in a

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population survey found that groups also differed significantly on socioeconomic

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As discussed in the section on etiology, gambling is typically viewed as a benign activity

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A growing number of studies investigate the relationship of disordered gambling to PTSD

Societal and Individual Costs

Increasingly limited options often compel disordered gamblers to resort to criminal

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There is a significant relationship between crime and disordered gambling (Blaszczynski

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Debt and Bankruptcy

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Health, Mental Health, and Familial Consequences

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Diagnosis and Treatment

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A key feature in cognitive-behavioral therapy is addressing cognitive distortions that fuel

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Motivating clients to attend treatment does not necessarily result in treatment

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Policy Implications and the Role of Social Workers

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American Psychiatric Association. (1980). Diagnostic and statistical manual of mental

American Psychiatric Association. (1987). Diagnostic and statistical manual of mental

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

Ariyabuddhiphongs, V. (2012). Older adults and gambling: A review. International Journal

Bartley, C. A., & Bloch, M. H. (2013). Meta-analysis: Pharmacological treatment of

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Blaszczynski, A. P., & McConaghy, N. (1994). Criminal offenses in Gamblers Anonymous

Blaszczynski, A., & Nower, L. (2013). Cognitive-behavioral therapy: Translating research

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Chalmers, H., & Willoughby, T. (2006). Do predictors of gambling involvement differ

Clark, L. (2010). Decision-making during gambling: An integration of cognitive and

Cunningham-Williams, R. M., Cottler, L. B., Compton III, W. M., & Spitznagel, E. L.

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