Practical Issues and the Assessment of Pathological Gamblers in a Private Practice Setting Charles D. Maurer, Phi), ABPP
Seattle, Washington
With increased awareness and knowledge of pathological gambling comes the opportunity to share various perspectives and emerging skills. Descriptions of the assessment and treatment of the pathological gambler, spouse, and family have mushroomed in the past twenty years. However, most treatment summaries have come out of institutional or government funded settings. This article discusses various practical aspects of working with pathological gamblers in an outpatient, fee for service private practice setting. The author also describes refinements made in the assessment process since he first began working with pathological gamblers in 1979.
P R A C T I C A L ISSUES IN SEEING P A T H O L O G I C A L GAMBLERS I N A P R I V A T E P R A C T I C E S E T T I N G
With increasing empirical research and clinical experience we are finding significant differences from our initial perceptions of who are pathological gamblers and how they are to be assessed and treated. For example, more women are being observed with gambling difficulties than in the past. The stereotype of the educated, verbal, employed and married caucasian male as the "prototype compulsive gambler" is being
Send reprint requests to Charles D. Maurer, PhD, ABPP, 1001 Broadway, Suite 315, Seattle, WA 98122.
Journal of Gambling Studies Vol. 10(1), Spring 1994 9 1994 Human Sciences Press, Inc.
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replaced with solid evidence that there are clearly several clusters that require different forms of outreach and treatment (Volberg and Stedman, 1992). Adolescent surveys reveal the sophistication of adolescent gambling and the need for more targeted interventions and awareness programs (Volberg, 1993a, 1993b, and Fisher, 1993). Gamblers also differ by geographic region and by availability of different forms of gambling. In Washington, for example, we note the high incidence of pull tab play among women while next door in Oregon, women seem to prefer interactive video terminal play. The modal problem or compulsive gambler in Washington state is male, non white, under the age of thirty, not well educated and is earning less than $25,000 per year. It is rare in my clinical experience to see the effusive male gambler adorned with jewelry and a high rolling mentality. Different treatment entry points also reveal different issues in the assessment and treatment of pathological gamblers. The first section of this paper will highlight several issues that I perceive in an outpatient private practice setting that influence directly how assessment occurs and how eventual treatment unfolds.
The Directness of the Clinical Relationship One primary issue centers on the direct relationship between the clinician and the gambler. In outpatient practice the therapist must assume many more roles than the institutional provider. The private practice clinician has no "buffer;" in institutional practice, roles are spread across providers and services. In a private practice setting the clinicians serve as intake telephone screener; as the assessor of the maze of issues that gamblers typically present; as the primary treatment provider; as the interface with the spouse and family system; and, as the referral source to Gambler Anonymous, lawyers, credit counseling services, and other therapeutic adjuncts. We must deal openly with multiple issues related to treatment compliance as well as with the administrative aspects of service provision. We must set the boundaries and expectations and also role model honesty and hope. O n the other hand, we also directly experience the joy with the gambler when success occurs. Given that there are few buffers between the patient and the clinician in private practice settings, some assessment and treatment
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tasks are different from that found in institutional settings. The clinician is directly involved in all aspects of assessment and treatment and is face-to-face with the gambler and family. This degree of intimacy and sustained exposure can be disarming to a gambler and may lead to an intensification of the self-deception and social alienation described by Rosenthal (1986) during the assessment process. The openness and intensity of the relationship relates directly to engagement of the gambler, to resistance to assessment and treatment, and to compliance.
Trust and Dishonesty Most clinicians trust that what they hear is truthful and that the people that they see want help. I have had to make significant shifts in how I assess gambler motivation and resistance and have become more suspicious and less believing. For example, when recently working with a couple, the husband was struggling with gambling and his wife was deeply hurt by his repeated deceptions. Both were successfully abstinent from alcohol and drugs and were respected members of Alcoholics Anonymous. The wife, having been lied to and taken advantage of, repeatedly asked her husband if he was continuing to gamble. In a treatment session he told her that continued challenges to his honesty were unhelpful and that they were leading him to have relapse thoughts in order to "get back at her for being mistrustful." Months went by before she discovered that he was, in fact, gambling. She was furious and we both felt the deep sting of having been deceived. However, when I asked the husband about his dishonesty, he said that his wife had been asking the wrong question. H e believed he had been honest in saying that he was not gambling at the moment that his wife asked the question. The question his wife should have asked was whether he had placed a bet since last being asked! His self-deception was so deep that he failed to see the impact that it had on her and the treatment process. H e focused more on his cleverness and avoidance, missing his distortions, narcissism, and omnipotence. It is clear to me that if I do not recognize and forcefully challenge the gambler's dishonesty, then m y legitimacy and skills will be questioned. When assessment and treatment become a dance of avoidance or a tug-of-war, I talk with the gambler about it, and openly question
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the gambler's motivation for treatment and my desire to participate in such a process. Occasionally I will recommend that treatment be suspended.
Service, Fees and Money One unavoidable issue centers on the fact that treatment costs money. Very little has been written about the dynamics of money (Katz, 1993) in general, as well as its dynamics between the gambler and therapist. In the private practice setting, the gambler must deal directly with the clinician about money and is not insulated by billing offices. From the beginning of the assessment process, usually over the first telephone contact, both the clinician and the gambler need to deal with the reality that therapy costs money. While scheduling the first appointment, I explain my fees and how they are collected. Individuals are encouraged to check their health care benefits for coverage and are responsible for fee payment irrespective of third party coverage. Early in my treatment of gamblers I learned that the dynamics of money were central to the treatment relationship. For example, several insurance reimbursement checks that were sent to one gambler ended up in the till at the local racetrack. In other cases, delayed payments resulted in large overdue balances. Following the gambling truism that "you don't play if you don't pay," I now require payment at the time of service. Some resistance to this policy was encountered but diminished when the author pointed to the gambler's resourcefulness at obtaining money to gamble. M y experiences with money and gamblers has made it easier to deal with other patients about service, fees and money. When the gambler has insurance coverage for outpatient mental health services, I bill the insurance company and have the benefits assigned to me. Copayment by the gambler is expected at the time of service. With the advent of managed mental health care, outpatient psychotherapy treatment of pathological gambling is not always deemed to be "medically necessary" (Preferred Health Care, 1993). If the gambler has no insurance coverage, I will occasionally make fee adjustments (seeing them at the co-pay amount they would pay if they had insurance coverage) and set up payment plans. It is clear that allowing large balances to accrue is irresponsible and usually reflects clinician avoidance. All of these arrangements are fully delineated in my written disclosure statement as required by Washington state law.
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Marital psychotherapy is rarely covered by insurance, and couples pay on a session by session basis, irrespective of presenting problem. Gamblers in outpatient group psychotherapy pay the group fee one month ahead of time and the fee is treated like tuition. If a group is missed, the fee is still paid. These policies have lessened spurious focus on monetary issues and allowed the work of psychotherapy to proceed with fewer distractions. They have also brought into focus many dynamic issues around money that are often avoided in therapy. Motivation and Resistance While there is no forced treatment of pathological gamblers, clinicians who have seen many gamblers realize that the majority are not "self' referred. Assessment of the motivation of the gambler to look at and change their behavior is a critical element in the effectiveness of eventual treatment. In any treatment setting, the gambler is free to terminate treatment at any time, although I suspect that there are many social influences and pressures to remain in treatment in an inpatient or institutional setting. In my experience, more than a handful of gamblers have lied to family members, employers, and others about still being in treatment when in fact they were not. The statutes regarding confidentiality are clear and I can not inform a family m e m b e r about treatment compliance except under extreme conditions, usually secondary to suicidal threat. The gambler's resistance to treatment, to accepting how problematic their gambling is, to attending Gamblers Anonymous meetings (there are currently just five within the greater Puget Sound area and ten across the entire state of Washington), and to facing the multitude of physical, emotional, and family system issues is reflective of their denial and self deception. Awareness of this is particularly necessary for clinicians without experience in addictions treatment, dual disorders, and personality disorders. In my experience, however, too direct confrontation of this denial and resistance during the assessment phase can lead to early termination. W h e n first treating gamblers, one mistake that I made was to announce that abstinence must begin at the onset of assessment. M y long distance supervisor, Dr. Robert Custer (personal communication, 1980), cautioned that strategy might be setting up an unconscious bet between me and the gambler. He suggested a balance between accep-
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tance of the gambler's need to disconnect more slowly and the clinician's need to confront the gambler about the realities of his or her life. M y current approach is to accept where the gambler is and to build rapport while gently challenging the gambler's defense against acknowledging the consequences of the gambling. To establish rapport I disclose how I became involved in the assessment and treatment of gamblers and how legitimate and complex an issue it is. I make it clear that I have neither met nor treated a pathological gambler who was able to control the level of his or her primary form of gambling. I also share vignettes of gamblers who have attempted responsible, social gambling of non-preferred forms of gambling and failed, returning either to their preferred form of gambling or escalating play in a new area of gambling. ! share my strong opinion that abstinence is what works. If gambling continues then I escalate confrontation of the gambler's denial. The still gambling client probably presents more frequently in private practice offices and in outpatient clinics where access to gambling is ongoing and there are fewer controls than in inpatient facilities. This may relate to their being in an earlier phase of gambling involvement and they may be less desperate, have fewer negative consequences, and engage in more denial than in later stages. I encourage the gambler to be curious and to make various self assessments about her or his gambling behavior. I teach them how to become more observant and descriptive of their behavior, how to track their urges to gamble, and become more aware of the sequence of thoughts, feelings, and behavior that make up their gambling experiences. Together we build a topology of actions and consequences and explore the link between the gambler's choices, responsibilities, and negative outcomes. I draw a fine line between using current gambling as "a living laboratory" to fu/ther their personal understanding and allowing/sanctioning gambling as a way of life. If the gambler continues to gamble my confrontation escalates. For example, a gambler who worked in a gambling establishment was referred to me after floating several checks written to his employer. It was obvious that significant amounts of money were being borrowed from family members and co-workers and spent at an adjacent bingo hall on pull tabs. The gambler was placed on suspension and began weekly outpatient treatment. H e continued, however, to play bingo once a month, and made an annual family trip to Nevada. Initially we
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utilized his gambling experiences to understand what he obtained from gambling and the link between his urges to gamble and the need to escape various stressors. However, he resisted attending Gamblers Anonymous and continued monthly bingo play, despite losing his Class Three license to work. I increased my confrontation, described my concerns about continued bingo play (even at a non-problematic level) and his non-attendance at self help meetings. Only when he understood in very concrete ways that he would lose his job because of his gambling and his noncompliance with employer and therapist suggestions, did he "toe the line." If gambling continues, I most frequently suggest that referral for inpatient treatment is most appropriate and that our treatment relationship may be enabling the gambler to gamble under the guise of obtaining help. If treatment is suspended I will offer the gambler a future opportunity to work together, and indicate that m y treatment door is always open. I continue, however, to struggle with the parallel ethical dilemmas of patient abandonment and the necessity to provide honest and appropriate treatment.
R E F I N E M E N T S IN T H E A S S E S S M E N T OF T H E PATHOLOGICAL GAMBLER
Like other clinicians in the field, my approach to the assessment and treatment of the pathological gambler, spouse, and family has benefited from converging advancements in diagnostic criteria (APA, 1980, APA, 1987, and Lesieur and Rosenthal, 1993), screening instruments (Lesieur and BIume, I987), and research, particularly that related to M M P I data (Graham and Lowenfeld, 1986) and parallel dual disorder issues (Ramirez, McCormick, Russo, and Taber, 1985 and Lesieur, Blume, and Zoppa, 1986). M y assessment has become more efficient with these advancements, as well as with m y increasing clinical experience. Faster and more appropriate triage occurs during the initial telephone contact, and referrals are often made to Gamblers Anonymous meetings, attorneys, or Consumer Credit Counseling Service, prior to personal contact with the gambler or family member. Assessment is for pre-treatment triage, treatment planning, for employee assistance and managed mental health screening, and for deferred prosecution or pre-sentencing forensic purposes. Any gain-
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bier, irrespective of the reasons for assessment, is given at least the South Oaks Gambling Screen (SOGS), the Twenty Questions of Gamblers Anonymous, and their maladaptive gambling is compared to the D S M - I I I - R / D S M - I V diagnostic criteria.
Screening Assessment The formal assessment process begins with the telephone contact setting up the intake appointment. I strongly suggest that, if married or in a personally significant relationship, the gambler ask his/her parent, spouse, or partner to the intake appointment. This suggestion is made to not only have some validity check on the gambler's self report but to also provide support and triage for the significant other. It is important to establish an affect bridge with the gambler not only to establish and build rapport but also to help convince the gambler that he/she does in fact have a serious problem. In my experience, the g a m b l e r often does not believe that his/her experience is disordered and deserving of professional attention and treatment. O f the 187 gamblers that I have met with for an intake interview, only six have indicated that they were seeking professional help purely of their own volition. Most were coerced into treatment by a spouse, parent, family member or attorney. After appropriate disclosure has occurred, the gambler is interviewed for ten to fifteen minutes about what he or she expects from the initial consultation. I listen for self-oriented statements as opposed to external reasons for seeking help. A brief gambling history is taken with particular emphasis on the severity of the gambling. I determine what phase of gambling they are in, the legal, occupational, and interpersonal consequences, and what previous attempts they have made to deal with their gambling. Motivation for attendance at Gamblers Anonymous meetings is assessed and they are strongly encouraged to attend at least two meetings during the next week. I emphasize that attendance at Gamblers Anonymous meetings is an important aspect of treatment, that the meetings are free, and that that is where the real experts in compulsive gambling gather to share and help one another. I also discuss the importance of active involvement in Gamblers A n o n y m o u s as an important aspect of successful gambling cessation. The more personally revealing, honest, self-descriptive, and motivated the gambler is, the more likely she or he will comply with
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treatment suggestions. In my experience, those gamblers with a history of prior addictions or mental health treatment and 12-step program involvement are significantly more motivated than those gamblers with no prior addictions, self help or mental health contact. More extensive education is given to those without prior treatment or recovery experience on addictions, dependencies, and parallel mental disorders. I also guide them to a Gamblers Anonymous member who has a solid recovery. The South Oaks Gambling Screen, (Lesieur and Blume, 1987), the D S M - I V proposed criteria (Lesieur and Rosenthal, 1993) and the Gamblers Anonymous Twenty Questions (Gamblers Anonymous, 1983) are then verbally administered. M y experience suggests that distortion, minimization, and evasion can occur if these instruments are not given in this manner. If the spouse is present, their validation is extremely helpful. The Custer Vee curve is given to the gambler to determine where he/she would locate him/herself with respect to progression of pathological gambling. Diagnostic impressions are then shared. The gambler's reaction to this information is assessed, particularly when treatment options are discussed. If the gambler is unusually resistant, then I become even more curious about what the gambler wants from the initial consultation and with respect to gambling. It has been helpful in initial sessions to be non-confrontive and to create an atmosphere of acceptance so that the gambler leaves the intake session without unnecessary guilt or shame and with a sense of curiosity and openness to treatment alternatives. It has been my experience that about one-third of gamblers screened do not return for more than a few visits, another third return for rather brief contact (about five to ten sessions), and a third engage in longer term psychotherapy. Those who are coerced into assessment or treatment generally maintain brief contact. Their motivation is minimal and they are highly resistant to admitting that they have problems and need outside help. For example, during a recent intake with a couple, it was obvious that the gambling wife did not see her gambling as serious. Her husband was in great distress and decided that he could take no more of her denial, deception, and gambling. As a test of her resistance and his resolve, I described the gambling treatment program at Charter Hospital in Las Vegas, but she was not interested in a referral. I then
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suggested, following her lead that, "it is a problem I can lick on my own," that she agree to attend a Gamblers Anonymous meeting a week, that she telephone the Washington State Council on Problem Gambling helpline and ask for an information packet, that she telephone me should she have any urges to gamble, and that we schedule an appointment four weeks from the intake date. The coupie did arrive for their second appointment, but only after his reminder. She had gambled three times, had to be "reminded/ nagged" to attend the Gamblers Anonymous meetings, had not phoned the Washington State Council on Problem Gambling, and had not called me prior to her gambling episodes. H e r resistance was sufficient for her husband to consult an attorney to begin the process of dissolution. She thought that he was overreacting and was "wasting years of good marriage." It was clear, however, that he had spent significant and painful time assessing his own issues and reached a personal resolution. I suggested to the wife that it takes time to face reality squarely and that when she felt that she could not "do it alone" that she continue in Gamblers Anonymous and return for treatment. The second group of clients convey their interest in solving their gambling difficulties by being open and curious, by reading about and legitimizing their gambling problems, and by "checking out" Gamblers Anonymous meetings. They tend to focus primarily on their gambling and do not extend their interest in exploring nongambling personal or emotional issues. Their assessment leads us towards a treatment approach of gambling cessation that centers on teaching the gambler a variety of cognitive/behavioral interventions and impulse control procedures. The third group either emerges out of the second group after they have abstained for a while or those who are convinced at intake that their gambling is complex, that there is more than meets either the "eyes or the ears," and who know that commitment to treatment and Gamblers Anonymous is central to their change. They are more open to inpatient referral, and many have already dealt with substance use issues or other mental or emotional disorders. They also seem more depressed, distressed in their own lives, marriages, and occupations, have had more direct negative consequences, and seem to "feel their pain." Their extended assessment leads us towards a more extensive, psychodynamic psychotherapy. O n e change that I am currently making is to inform the gammer while setting up the initial appointment that a commitment is expected
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for at least three to five assessment visits so that the most appropriate treatment planning can occur. M y obvious preference would be to have an extended assessment that would lead to either referral for inpatient treatment or for a commitment to ongoing psychotherapy. Extended Assessment
For those who do return after the intake, a longer clinical interview of up to three hours is spent reviewing the gambler's life history. I was directly influenced in this by Glen (1985) and T a b e r (1985) and have found Rosenthal's assessment outline (1991) to be quite helpful. Significant case history information helps to formulate treatment approaches. If there are parallel substance use disorders then they must be treated first. In my opinion, the gambler needs to be "fully present" to deal with all that is required to stop gambling; chemical use sabotages those efforts. I will act as a liaison to the treating chemical dependence program, will serve as a resource for informing them about parallel gambling related issues, and will see the gambler on a less intensive level. If parallel emotional issues are present requiring possible medication, I refer the gambler to a knowledgeable psychiatrist for medication evaluation and treatment. If the gambler is in extreme financial distress and is unemployed, then I will make referrals to legal and social service agencies. The state Division of Vocational Rehabilitation has been open to receiving referrals of under- or unemployed gamblers. If the extended assessment indicates marital or family system distress then I will see the spouse for a brief assessment and make appropriate referrals. If the gambler has not had a dental or physical examination in two years the author strongly suggests that occur given the high incidence of parallel physical problems in this group. The gambler is usually given the M M P I - 2 (Hathaway and McKinley, 1989) and other appropriate tests like the Beck Depression Inventory (Beck, 1978), the Holmes-Rahe Schedule of Recent Experience Scale (Rahe and Holmes, 1966), and the Alcohol Use Inventory (Horn, Wanberg, and Foster, 1987). I use the M M P I - 2 to help guide treatment interventions. Clinical profiles tend to parallel those summarized in the literature (Graham and Lowenfeld, 1986), with elevations on scales 2 and 4 being most prominent, followed by code types 2-4-7, 4-9, and 2-4-9. The validity scale configurations parallel the gambler's
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presentation during the intake process. The most resistant gamblers tend to have elevations on the L and K scales with low F scales, and those more open and revealing have higher F scales. The recent addition of the Addiction Admission and Addiction Potential Scales will be useful in assessing openness and resistance. Life stressors are important to assess in the gambler and the Schedule of Recent Experience Scale is often utilized to graphically describe the negative behavioral and health consequences of the gambling and how they are intertwined with other areas of life. It is my hope that we develop an instrument like the Alcohol Use Inventory (AUI) which is extremely useful in exploring the benefits, styles, consequences and awareness of the alcohol. For those gamblers who drink, use of the A U I is always helpful. Forensic Assessment
Forensic assessment is more thorough, extensive, and expensive. M y approach parallels Lorenz's (1988) summary. I have evaluated pathological gamblers whose attorneys have attempted (with no success) to use an insanity or diminished capacity defense. More frequently attorneys request pre-sentence evaluations and assessment for deferred prosecution. In contrast to the gambler seen in an intake, the gambler seen for forensic assessment is highly motivated, aware, and seeking a treatment oriented outcome. Those gamblers referred for forensic assessment who are either too manipulative or who mention their gambling only in passing tend to have substantial character trait issues and psychopathy. One gambler was referred for a presentence evaluation and brought the Gamblers A n o n y m o u s Big Book, When Luck Runs Out (Custer and Milt, 1985), and other literature but never referred to a history of gambling that was pathological. Assessment led to the conclusion that as an accountant he was a financial predator, strategically placing himself in voluntary positions with vulnerable organizations. H e was given a m a x i m u m sentence. The general forensic assessment includes a review of all case material, several hours of interviews, and, at a minimum, the following psychological test battery: Wechsler Adult Intelligence Scale Revised (Wechsler, 1981), Wide Range Achievement Test - Revised (Jastak and Wilkinson, 1984), Shipley Institute of Living Scale (Zach-
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ary, 1986), Minnesota Multiphasic Personality Inventory - 2 (Hathaway and McKinley, 1989), Millon Clinical Multiaxial Inventory (Millon, 1982), selected subtests of the Wechsler M e m o r y Scale Revised (Wechsler, 1987), the Trail Making Test, the SOGS, the Gamblers Anonymous Twenty Questions, and the D S M - I V proposed criteria. This battery not only looks at cognitive and intellectual functioning, but also for soft neuropsychological factors and personality variables.
Assessment Vignette The author received a telephone call from a thirty-three year old man of Eastern European origin who was a naturalized United States citizen. H e was married, had three children, and was a successful new car salesman. He asked a senior member of Gamblers Anonymous for the name of a clinician to consult about his gambling. He had several "brushes" with Gamblers Anonymous, particularly after his wife discovered his heavy losses. A brief interview revealed that he "really did not know" what he needed nor whether he really had a gambling problem. He had gambled sporadically since college but over the past two years had played poker at an alarmingly heavy level, typically in licensed cardrooms or on sporadic trips to Las Vegas and more recently at a newly opened tribal casino. He said that he had probably lost at least $40,000 over the last two years and was currently about $10,000 in gambling related debt. H e gambled two days before the intake appointment, reported that his marriage was in great distress, and that his wife was about to initiate a legal separation. H e was in good physical health, admitted to no alcohol or drug use, but said that he ignored exercise and that his diet was deteriorating. H e denied feeling significantly depressed or suicidal. He appeared, to the author, however, significantly depressed and to be minimizing the severity of most areas touched on during the brief interview. Screening assessment left little doubt about this man's gambling related problems. Administration of the S O G S revealed a score of 15; he endorsed nine of the ten proposed D S M - I V criteria (Lesieur and Rosenthal, 1993) and all nine of the D S M - I I I - R criteria, answered affirmatively to eighteen of the twenty Gamblers Anonymous ques-
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tions, and placed himself around "increasing losses" and "blaming others" on the Custer Vee chart. He minimized the severity of his pathological gambling and was assessed to be highly resistant. After receiving diagnostic feedback, the patient indicated that he and his wife recently sold their house and decided to move to Utah because there was no legal gambling there. H e said that "if that does not help, then we will move to Hawaii." He had a vague awareness of "geographic cures" but acknowledged that "gambling can occur anywhere." W h e n asked what he expected from this first visit, he asserted that he was curious about what the author "had to offer" and hoped for some tips on how to stop gambling. Guided by the patient's clear resistance and plans to be moving in two weeks, the author suggested that he come in for severn appointments in order to learn how to recognize and perhaps understand more about his urges to gamble. A secondary purpose would be to explore treatment resources in Utah. The patient explained that he could not make another appointment until he knew his work schedule. He left the session, paying for it with a check partially filled in and signed by his wife. He did not schedule a second appointment and subsequently did move to Hawaii. H e sent a note in response to a billing issue and indicated that "everything is fine, so far."
CONCLUSION After having assessed and or treated over 187 pathological gamblers, I continue to be impressed with the complexity of the disorder. This complexity demands clinician flexibility, resilience, patience, and skill. The importance of characterological issues, parallel dual disorder/addictions, physical consequences, and substantial marital, occupational, and social consequences, demonstrate the need for a multimodal assessment and treatment model. It seems imperative that clinicians working with this population have a blend of addiction and mental health experience, particularly in a private practice setting. The importance of legitimizing pathological gambling as a serious health concern and not just as frivolous behavior needs to be emphasized early in the assessment process. In my opinion, motivation of the gambler to see his/her behavior as serious and in need of work is a key in helping them. Teaching them how to become more curious, partic-
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ularly about themselves, and how to be guided by their resistance is central to this work. The shift from an externally dependent frame of reference to one that is more internal and self reflective seems a crucial step in the engagement of the patient. Depending upon one's geographic proximity to other clinicians who assess and treat gamblers, working with this group can be lonely. The difficulty in cross validating assessment strategies and treatment approaches is quite real. In my experience, the assessment and treatment of pathological gamblers and their families is extremely challenging and demands access to peer consultation, supervision, and current research and clinical information. The importance of access to journal articles, to consultation groups, to continuing education, and to national conferences is essential for independent practitioners. The challenges in working with pathological gamblers are evident, but so are the joys. The cases mentioned in this article do not illustrate the number of gamblers who have taken on the challenge of teasing out their own existence, stepping back, and then making substantial shifts in their identity and behavior. The satisfaction of knowing gamblers who have not gambled in over twelve years is substantial. REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual, third edition. Washington, D.C.: Author. American Psychiatric Association (1987). Diagnostic and statistical manual, third edition, revised. Washington, D.C.: Author. Beck, A.T. (1978). Depression inventoTy. PhiIadelphia: Center for Cognitive Therapy. Custer, R.L. (1980). Personal communication. Custer, R.L. with Milt, H. (1985). When luck runs out. New York: Facts on File Publications. Fisher, S. (I992). Measuring pathological gambling in children: the case of fruit machines in the U.K. Journal of Gambling Studies, 8, 263-286. Gamblers Anonymous (1983). Sharing recoverythrough Gamblers Anonymous. Los Angeles: Gamblers Anonymous Publishing. Glen, A.M. (1985). Diagnosing the compulsive gambler. Journal of Gambling Behavior, 1, 17-22. Graham, J.R. & Lowenfeld, B.H. (1986). Personality dimensions of the pathological gambler. Journal of Gambling Behavior, 2, 58-66. Hathaway, S.R. & McKinley, J.C. (1989). MMPI-2: Manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Horn, J.L., Wanberg, K.W., & Foster, F.M. (1987). Guide to the Alcohol Use Inventory. Minneapolis, MN: National Computer Systems, Inc. Jastak, S. & Wilkinson, G.S. (1984). The Wide Range Achievement Test-Revised: Administration manual. Wilmington, DE: Jastak Associates. Katz, D. (1993) Men, women & money: the last taboo. Worth, June, 1993. Lesieur, H.R. & Blume, S. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal ofPsychiaoy, 144, 11841 I88.
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Lesieur, H.R., Blume, S., & Zoppa, R.M. (1986). Alcoholism, drug abuse, and gambling. Alcoholism: Clinical and Experimental Research, 10, 33-38. Lesieur, H.R. & Rosenthal, R.J. (1991). Pathological gambling: a review of the literature (Prepared for the American Psychiatrie Association Task Force on DSM-IV Committee on disorders of impulse control not elsewhere classified). Journal of Gambling Studies, 7, 5-39. Lesieur, H.R. & Rosenthal, R.J. (1993). Draft of the textfor the DSM-IV pathological gambling section. Unpublished document. Lorenz, V.C. (1988). On being the expert witness for the compulsive gambler facing legal charges. Journal of Gambling Behavior, 4, 320-328. Maurer, C.D. (1985). An outpatient approach to the treatment of pathological gamblers. In W.R. Eadington (ed.) The gambling studies: Proceedings of the sixth national conference on gambling and risk taking (205-217). Reno, Nevada: Bureau of Business and Economic Research, University of Nevada. Miller, W. (1986). Individual outpatient treatment of pathological gambling. Journal of Gambling Behavior, 2, 95-107. Millon, T. (1982). MiUon Clinical Multiaxial Inventory manual, second edition. Minneapolis, MN: National Computer Systems, Inc. Preferred Health Care (1992) The PHC manual: Clinical protocols and procedures (Second edition). Wilton, CN. Rahe, R.H. & Holmes, T.H. (1966) Life crisis and major health change. Psychosomatic Medicine, 28, 774. Raimirez, L.F., McCormick, R.A., Russo, A.M. & Taber, J.I. (1984). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behaviors, 8, 425-428. Rosenthal, R.J. (1986). The pathological gambler's system of self deception. Journal of Gambling Behavior, 2, 108-120. Rosenthal, R.J. (1991). "The initial evaluation and assessment," presented at the First Training Program for Trainers, sponsored by the National Council on Problem Gambling, in conjunction with the Fifth National Conference on Gambling Behavior, Duluth, MN, July 12, 1991. Taber, J.I. (1985). Pathological gambling: The initial screening interview. Journal of Gambling Behavior, 1, 23-34. Tepperman, J.H. (1985). The effectiveness of short-term group therapy upon the pathological gambler and wife. Journal of Gambling Behavior, 1, 119-130. Volberg, R.A. (1993a). Gambling andproblem gambling in Washington state. Report to the Washington State Lottery. Albany, NY: Gemini Research. Volberg, R.A. (1993b). Gambling and problem gambling among adolescents in Washington state. Report to the Washington State Lottery. Albany, NY: Gemini Research. Volberg, R.A. & Steadman, H.J. (1992). Accurately depicting pathological gamblers: policy and treatment implications. Journal of Gambling Studies, 8, 401-412. Wechsler, D. (1981). Manual for the Wechsler Adult Intelligence Scale-Revised. New York: The Psychological Corporation. Wechsler, D. (1987). Wechsler Memory Scale - Revised Manual. New York: The Psychological Corporation. Zachary, R.A. (1986). Shipley Institute of Living Scale, revised edition. Los Angeles: Western Psychological Services.
Seattle, Washington
With increased awareness and knowledge of pathological gambling comes the opportunity to share various perspectives and emerging skills. Descriptions of the assessment and treatment of the pathological gambler, spouse, and family have mushroomed in the past twenty years. However, most treatment summaries have come out of institutional or government funded settings. This article discusses various practical aspects of working with pathological gamblers in an outpatient, fee for service private practice setting. The author also describes refinements made in the assessment process since he first began working with pathological gamblers in 1979.
P R A C T I C A L ISSUES IN SEEING P A T H O L O G I C A L GAMBLERS I N A P R I V A T E P R A C T I C E S E T T I N G
With increasing empirical research and clinical experience we are finding significant differences from our initial perceptions of who are pathological gamblers and how they are to be assessed and treated. For example, more women are being observed with gambling difficulties than in the past. The stereotype of the educated, verbal, employed and married caucasian male as the "prototype compulsive gambler" is being
Send reprint requests to Charles D. Maurer, PhD, ABPP, 1001 Broadway, Suite 315, Seattle, WA 98122.
Journal of Gambling Studies Vol. 10(1), Spring 1994 9 1994 Human Sciences Press, Inc.
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replaced with solid evidence that there are clearly several clusters that require different forms of outreach and treatment (Volberg and Stedman, 1992). Adolescent surveys reveal the sophistication of adolescent gambling and the need for more targeted interventions and awareness programs (Volberg, 1993a, 1993b, and Fisher, 1993). Gamblers also differ by geographic region and by availability of different forms of gambling. In Washington, for example, we note the high incidence of pull tab play among women while next door in Oregon, women seem to prefer interactive video terminal play. The modal problem or compulsive gambler in Washington state is male, non white, under the age of thirty, not well educated and is earning less than $25,000 per year. It is rare in my clinical experience to see the effusive male gambler adorned with jewelry and a high rolling mentality. Different treatment entry points also reveal different issues in the assessment and treatment of pathological gamblers. The first section of this paper will highlight several issues that I perceive in an outpatient private practice setting that influence directly how assessment occurs and how eventual treatment unfolds.
The Directness of the Clinical Relationship One primary issue centers on the direct relationship between the clinician and the gambler. In outpatient practice the therapist must assume many more roles than the institutional provider. The private practice clinician has no "buffer;" in institutional practice, roles are spread across providers and services. In a private practice setting the clinicians serve as intake telephone screener; as the assessor of the maze of issues that gamblers typically present; as the primary treatment provider; as the interface with the spouse and family system; and, as the referral source to Gambler Anonymous, lawyers, credit counseling services, and other therapeutic adjuncts. We must deal openly with multiple issues related to treatment compliance as well as with the administrative aspects of service provision. We must set the boundaries and expectations and also role model honesty and hope. O n the other hand, we also directly experience the joy with the gambler when success occurs. Given that there are few buffers between the patient and the clinician in private practice settings, some assessment and treatment
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tasks are different from that found in institutional settings. The clinician is directly involved in all aspects of assessment and treatment and is face-to-face with the gambler and family. This degree of intimacy and sustained exposure can be disarming to a gambler and may lead to an intensification of the self-deception and social alienation described by Rosenthal (1986) during the assessment process. The openness and intensity of the relationship relates directly to engagement of the gambler, to resistance to assessment and treatment, and to compliance.
Trust and Dishonesty Most clinicians trust that what they hear is truthful and that the people that they see want help. I have had to make significant shifts in how I assess gambler motivation and resistance and have become more suspicious and less believing. For example, when recently working with a couple, the husband was struggling with gambling and his wife was deeply hurt by his repeated deceptions. Both were successfully abstinent from alcohol and drugs and were respected members of Alcoholics Anonymous. The wife, having been lied to and taken advantage of, repeatedly asked her husband if he was continuing to gamble. In a treatment session he told her that continued challenges to his honesty were unhelpful and that they were leading him to have relapse thoughts in order to "get back at her for being mistrustful." Months went by before she discovered that he was, in fact, gambling. She was furious and we both felt the deep sting of having been deceived. However, when I asked the husband about his dishonesty, he said that his wife had been asking the wrong question. H e believed he had been honest in saying that he was not gambling at the moment that his wife asked the question. The question his wife should have asked was whether he had placed a bet since last being asked! His self-deception was so deep that he failed to see the impact that it had on her and the treatment process. H e focused more on his cleverness and avoidance, missing his distortions, narcissism, and omnipotence. It is clear to me that if I do not recognize and forcefully challenge the gambler's dishonesty, then m y legitimacy and skills will be questioned. When assessment and treatment become a dance of avoidance or a tug-of-war, I talk with the gambler about it, and openly question
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the gambler's motivation for treatment and my desire to participate in such a process. Occasionally I will recommend that treatment be suspended.
Service, Fees and Money One unavoidable issue centers on the fact that treatment costs money. Very little has been written about the dynamics of money (Katz, 1993) in general, as well as its dynamics between the gambler and therapist. In the private practice setting, the gambler must deal directly with the clinician about money and is not insulated by billing offices. From the beginning of the assessment process, usually over the first telephone contact, both the clinician and the gambler need to deal with the reality that therapy costs money. While scheduling the first appointment, I explain my fees and how they are collected. Individuals are encouraged to check their health care benefits for coverage and are responsible for fee payment irrespective of third party coverage. Early in my treatment of gamblers I learned that the dynamics of money were central to the treatment relationship. For example, several insurance reimbursement checks that were sent to one gambler ended up in the till at the local racetrack. In other cases, delayed payments resulted in large overdue balances. Following the gambling truism that "you don't play if you don't pay," I now require payment at the time of service. Some resistance to this policy was encountered but diminished when the author pointed to the gambler's resourcefulness at obtaining money to gamble. M y experiences with money and gamblers has made it easier to deal with other patients about service, fees and money. When the gambler has insurance coverage for outpatient mental health services, I bill the insurance company and have the benefits assigned to me. Copayment by the gambler is expected at the time of service. With the advent of managed mental health care, outpatient psychotherapy treatment of pathological gambling is not always deemed to be "medically necessary" (Preferred Health Care, 1993). If the gambler has no insurance coverage, I will occasionally make fee adjustments (seeing them at the co-pay amount they would pay if they had insurance coverage) and set up payment plans. It is clear that allowing large balances to accrue is irresponsible and usually reflects clinician avoidance. All of these arrangements are fully delineated in my written disclosure statement as required by Washington state law.
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Marital psychotherapy is rarely covered by insurance, and couples pay on a session by session basis, irrespective of presenting problem. Gamblers in outpatient group psychotherapy pay the group fee one month ahead of time and the fee is treated like tuition. If a group is missed, the fee is still paid. These policies have lessened spurious focus on monetary issues and allowed the work of psychotherapy to proceed with fewer distractions. They have also brought into focus many dynamic issues around money that are often avoided in therapy. Motivation and Resistance While there is no forced treatment of pathological gamblers, clinicians who have seen many gamblers realize that the majority are not "self' referred. Assessment of the motivation of the gambler to look at and change their behavior is a critical element in the effectiveness of eventual treatment. In any treatment setting, the gambler is free to terminate treatment at any time, although I suspect that there are many social influences and pressures to remain in treatment in an inpatient or institutional setting. In my experience, more than a handful of gamblers have lied to family members, employers, and others about still being in treatment when in fact they were not. The statutes regarding confidentiality are clear and I can not inform a family m e m b e r about treatment compliance except under extreme conditions, usually secondary to suicidal threat. The gambler's resistance to treatment, to accepting how problematic their gambling is, to attending Gamblers Anonymous meetings (there are currently just five within the greater Puget Sound area and ten across the entire state of Washington), and to facing the multitude of physical, emotional, and family system issues is reflective of their denial and self deception. Awareness of this is particularly necessary for clinicians without experience in addictions treatment, dual disorders, and personality disorders. In my experience, however, too direct confrontation of this denial and resistance during the assessment phase can lead to early termination. W h e n first treating gamblers, one mistake that I made was to announce that abstinence must begin at the onset of assessment. M y long distance supervisor, Dr. Robert Custer (personal communication, 1980), cautioned that strategy might be setting up an unconscious bet between me and the gambler. He suggested a balance between accep-
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tance of the gambler's need to disconnect more slowly and the clinician's need to confront the gambler about the realities of his or her life. M y current approach is to accept where the gambler is and to build rapport while gently challenging the gambler's defense against acknowledging the consequences of the gambling. To establish rapport I disclose how I became involved in the assessment and treatment of gamblers and how legitimate and complex an issue it is. I make it clear that I have neither met nor treated a pathological gambler who was able to control the level of his or her primary form of gambling. I also share vignettes of gamblers who have attempted responsible, social gambling of non-preferred forms of gambling and failed, returning either to their preferred form of gambling or escalating play in a new area of gambling. ! share my strong opinion that abstinence is what works. If gambling continues then I escalate confrontation of the gambler's denial. The still gambling client probably presents more frequently in private practice offices and in outpatient clinics where access to gambling is ongoing and there are fewer controls than in inpatient facilities. This may relate to their being in an earlier phase of gambling involvement and they may be less desperate, have fewer negative consequences, and engage in more denial than in later stages. I encourage the gambler to be curious and to make various self assessments about her or his gambling behavior. I teach them how to become more observant and descriptive of their behavior, how to track their urges to gamble, and become more aware of the sequence of thoughts, feelings, and behavior that make up their gambling experiences. Together we build a topology of actions and consequences and explore the link between the gambler's choices, responsibilities, and negative outcomes. I draw a fine line between using current gambling as "a living laboratory" to fu/ther their personal understanding and allowing/sanctioning gambling as a way of life. If the gambler continues to gamble my confrontation escalates. For example, a gambler who worked in a gambling establishment was referred to me after floating several checks written to his employer. It was obvious that significant amounts of money were being borrowed from family members and co-workers and spent at an adjacent bingo hall on pull tabs. The gambler was placed on suspension and began weekly outpatient treatment. H e continued, however, to play bingo once a month, and made an annual family trip to Nevada. Initially we
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utilized his gambling experiences to understand what he obtained from gambling and the link between his urges to gamble and the need to escape various stressors. However, he resisted attending Gamblers Anonymous and continued monthly bingo play, despite losing his Class Three license to work. I increased my confrontation, described my concerns about continued bingo play (even at a non-problematic level) and his non-attendance at self help meetings. Only when he understood in very concrete ways that he would lose his job because of his gambling and his noncompliance with employer and therapist suggestions, did he "toe the line." If gambling continues, I most frequently suggest that referral for inpatient treatment is most appropriate and that our treatment relationship may be enabling the gambler to gamble under the guise of obtaining help. If treatment is suspended I will offer the gambler a future opportunity to work together, and indicate that m y treatment door is always open. I continue, however, to struggle with the parallel ethical dilemmas of patient abandonment and the necessity to provide honest and appropriate treatment.
R E F I N E M E N T S IN T H E A S S E S S M E N T OF T H E PATHOLOGICAL GAMBLER
Like other clinicians in the field, my approach to the assessment and treatment of the pathological gambler, spouse, and family has benefited from converging advancements in diagnostic criteria (APA, 1980, APA, 1987, and Lesieur and Rosenthal, 1993), screening instruments (Lesieur and BIume, I987), and research, particularly that related to M M P I data (Graham and Lowenfeld, 1986) and parallel dual disorder issues (Ramirez, McCormick, Russo, and Taber, 1985 and Lesieur, Blume, and Zoppa, 1986). M y assessment has become more efficient with these advancements, as well as with m y increasing clinical experience. Faster and more appropriate triage occurs during the initial telephone contact, and referrals are often made to Gamblers Anonymous meetings, attorneys, or Consumer Credit Counseling Service, prior to personal contact with the gambler or family member. Assessment is for pre-treatment triage, treatment planning, for employee assistance and managed mental health screening, and for deferred prosecution or pre-sentencing forensic purposes. Any gain-
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bier, irrespective of the reasons for assessment, is given at least the South Oaks Gambling Screen (SOGS), the Twenty Questions of Gamblers Anonymous, and their maladaptive gambling is compared to the D S M - I I I - R / D S M - I V diagnostic criteria.
Screening Assessment The formal assessment process begins with the telephone contact setting up the intake appointment. I strongly suggest that, if married or in a personally significant relationship, the gambler ask his/her parent, spouse, or partner to the intake appointment. This suggestion is made to not only have some validity check on the gambler's self report but to also provide support and triage for the significant other. It is important to establish an affect bridge with the gambler not only to establish and build rapport but also to help convince the gambler that he/she does in fact have a serious problem. In my experience, the g a m b l e r often does not believe that his/her experience is disordered and deserving of professional attention and treatment. O f the 187 gamblers that I have met with for an intake interview, only six have indicated that they were seeking professional help purely of their own volition. Most were coerced into treatment by a spouse, parent, family member or attorney. After appropriate disclosure has occurred, the gambler is interviewed for ten to fifteen minutes about what he or she expects from the initial consultation. I listen for self-oriented statements as opposed to external reasons for seeking help. A brief gambling history is taken with particular emphasis on the severity of the gambling. I determine what phase of gambling they are in, the legal, occupational, and interpersonal consequences, and what previous attempts they have made to deal with their gambling. Motivation for attendance at Gamblers Anonymous meetings is assessed and they are strongly encouraged to attend at least two meetings during the next week. I emphasize that attendance at Gamblers Anonymous meetings is an important aspect of treatment, that the meetings are free, and that that is where the real experts in compulsive gambling gather to share and help one another. I also discuss the importance of active involvement in Gamblers A n o n y m o u s as an important aspect of successful gambling cessation. The more personally revealing, honest, self-descriptive, and motivated the gambler is, the more likely she or he will comply with
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treatment suggestions. In my experience, those gamblers with a history of prior addictions or mental health treatment and 12-step program involvement are significantly more motivated than those gamblers with no prior addictions, self help or mental health contact. More extensive education is given to those without prior treatment or recovery experience on addictions, dependencies, and parallel mental disorders. I also guide them to a Gamblers Anonymous member who has a solid recovery. The South Oaks Gambling Screen, (Lesieur and Blume, 1987), the D S M - I V proposed criteria (Lesieur and Rosenthal, 1993) and the Gamblers Anonymous Twenty Questions (Gamblers Anonymous, 1983) are then verbally administered. M y experience suggests that distortion, minimization, and evasion can occur if these instruments are not given in this manner. If the spouse is present, their validation is extremely helpful. The Custer Vee curve is given to the gambler to determine where he/she would locate him/herself with respect to progression of pathological gambling. Diagnostic impressions are then shared. The gambler's reaction to this information is assessed, particularly when treatment options are discussed. If the gambler is unusually resistant, then I become even more curious about what the gambler wants from the initial consultation and with respect to gambling. It has been helpful in initial sessions to be non-confrontive and to create an atmosphere of acceptance so that the gambler leaves the intake session without unnecessary guilt or shame and with a sense of curiosity and openness to treatment alternatives. It has been my experience that about one-third of gamblers screened do not return for more than a few visits, another third return for rather brief contact (about five to ten sessions), and a third engage in longer term psychotherapy. Those who are coerced into assessment or treatment generally maintain brief contact. Their motivation is minimal and they are highly resistant to admitting that they have problems and need outside help. For example, during a recent intake with a couple, it was obvious that the gambling wife did not see her gambling as serious. Her husband was in great distress and decided that he could take no more of her denial, deception, and gambling. As a test of her resistance and his resolve, I described the gambling treatment program at Charter Hospital in Las Vegas, but she was not interested in a referral. I then
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suggested, following her lead that, "it is a problem I can lick on my own," that she agree to attend a Gamblers Anonymous meeting a week, that she telephone the Washington State Council on Problem Gambling helpline and ask for an information packet, that she telephone me should she have any urges to gamble, and that we schedule an appointment four weeks from the intake date. The coupie did arrive for their second appointment, but only after his reminder. She had gambled three times, had to be "reminded/ nagged" to attend the Gamblers Anonymous meetings, had not phoned the Washington State Council on Problem Gambling, and had not called me prior to her gambling episodes. H e r resistance was sufficient for her husband to consult an attorney to begin the process of dissolution. She thought that he was overreacting and was "wasting years of good marriage." It was clear, however, that he had spent significant and painful time assessing his own issues and reached a personal resolution. I suggested to the wife that it takes time to face reality squarely and that when she felt that she could not "do it alone" that she continue in Gamblers Anonymous and return for treatment. The second group of clients convey their interest in solving their gambling difficulties by being open and curious, by reading about and legitimizing their gambling problems, and by "checking out" Gamblers Anonymous meetings. They tend to focus primarily on their gambling and do not extend their interest in exploring nongambling personal or emotional issues. Their assessment leads us towards a treatment approach of gambling cessation that centers on teaching the gambler a variety of cognitive/behavioral interventions and impulse control procedures. The third group either emerges out of the second group after they have abstained for a while or those who are convinced at intake that their gambling is complex, that there is more than meets either the "eyes or the ears," and who know that commitment to treatment and Gamblers Anonymous is central to their change. They are more open to inpatient referral, and many have already dealt with substance use issues or other mental or emotional disorders. They also seem more depressed, distressed in their own lives, marriages, and occupations, have had more direct negative consequences, and seem to "feel their pain." Their extended assessment leads us towards a more extensive, psychodynamic psychotherapy. O n e change that I am currently making is to inform the gammer while setting up the initial appointment that a commitment is expected
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for at least three to five assessment visits so that the most appropriate treatment planning can occur. M y obvious preference would be to have an extended assessment that would lead to either referral for inpatient treatment or for a commitment to ongoing psychotherapy. Extended Assessment
For those who do return after the intake, a longer clinical interview of up to three hours is spent reviewing the gambler's life history. I was directly influenced in this by Glen (1985) and T a b e r (1985) and have found Rosenthal's assessment outline (1991) to be quite helpful. Significant case history information helps to formulate treatment approaches. If there are parallel substance use disorders then they must be treated first. In my opinion, the gambler needs to be "fully present" to deal with all that is required to stop gambling; chemical use sabotages those efforts. I will act as a liaison to the treating chemical dependence program, will serve as a resource for informing them about parallel gambling related issues, and will see the gambler on a less intensive level. If parallel emotional issues are present requiring possible medication, I refer the gambler to a knowledgeable psychiatrist for medication evaluation and treatment. If the gambler is in extreme financial distress and is unemployed, then I will make referrals to legal and social service agencies. The state Division of Vocational Rehabilitation has been open to receiving referrals of under- or unemployed gamblers. If the extended assessment indicates marital or family system distress then I will see the spouse for a brief assessment and make appropriate referrals. If the gambler has not had a dental or physical examination in two years the author strongly suggests that occur given the high incidence of parallel physical problems in this group. The gambler is usually given the M M P I - 2 (Hathaway and McKinley, 1989) and other appropriate tests like the Beck Depression Inventory (Beck, 1978), the Holmes-Rahe Schedule of Recent Experience Scale (Rahe and Holmes, 1966), and the Alcohol Use Inventory (Horn, Wanberg, and Foster, 1987). I use the M M P I - 2 to help guide treatment interventions. Clinical profiles tend to parallel those summarized in the literature (Graham and Lowenfeld, 1986), with elevations on scales 2 and 4 being most prominent, followed by code types 2-4-7, 4-9, and 2-4-9. The validity scale configurations parallel the gambler's
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presentation during the intake process. The most resistant gamblers tend to have elevations on the L and K scales with low F scales, and those more open and revealing have higher F scales. The recent addition of the Addiction Admission and Addiction Potential Scales will be useful in assessing openness and resistance. Life stressors are important to assess in the gambler and the Schedule of Recent Experience Scale is often utilized to graphically describe the negative behavioral and health consequences of the gambling and how they are intertwined with other areas of life. It is my hope that we develop an instrument like the Alcohol Use Inventory (AUI) which is extremely useful in exploring the benefits, styles, consequences and awareness of the alcohol. For those gamblers who drink, use of the A U I is always helpful. Forensic Assessment
Forensic assessment is more thorough, extensive, and expensive. M y approach parallels Lorenz's (1988) summary. I have evaluated pathological gamblers whose attorneys have attempted (with no success) to use an insanity or diminished capacity defense. More frequently attorneys request pre-sentence evaluations and assessment for deferred prosecution. In contrast to the gambler seen in an intake, the gambler seen for forensic assessment is highly motivated, aware, and seeking a treatment oriented outcome. Those gamblers referred for forensic assessment who are either too manipulative or who mention their gambling only in passing tend to have substantial character trait issues and psychopathy. One gambler was referred for a presentence evaluation and brought the Gamblers A n o n y m o u s Big Book, When Luck Runs Out (Custer and Milt, 1985), and other literature but never referred to a history of gambling that was pathological. Assessment led to the conclusion that as an accountant he was a financial predator, strategically placing himself in voluntary positions with vulnerable organizations. H e was given a m a x i m u m sentence. The general forensic assessment includes a review of all case material, several hours of interviews, and, at a minimum, the following psychological test battery: Wechsler Adult Intelligence Scale Revised (Wechsler, 1981), Wide Range Achievement Test - Revised (Jastak and Wilkinson, 1984), Shipley Institute of Living Scale (Zach-
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ary, 1986), Minnesota Multiphasic Personality Inventory - 2 (Hathaway and McKinley, 1989), Millon Clinical Multiaxial Inventory (Millon, 1982), selected subtests of the Wechsler M e m o r y Scale Revised (Wechsler, 1987), the Trail Making Test, the SOGS, the Gamblers Anonymous Twenty Questions, and the D S M - I V proposed criteria. This battery not only looks at cognitive and intellectual functioning, but also for soft neuropsychological factors and personality variables.
Assessment Vignette The author received a telephone call from a thirty-three year old man of Eastern European origin who was a naturalized United States citizen. H e was married, had three children, and was a successful new car salesman. He asked a senior member of Gamblers Anonymous for the name of a clinician to consult about his gambling. He had several "brushes" with Gamblers Anonymous, particularly after his wife discovered his heavy losses. A brief interview revealed that he "really did not know" what he needed nor whether he really had a gambling problem. He had gambled sporadically since college but over the past two years had played poker at an alarmingly heavy level, typically in licensed cardrooms or on sporadic trips to Las Vegas and more recently at a newly opened tribal casino. He said that he had probably lost at least $40,000 over the last two years and was currently about $10,000 in gambling related debt. H e gambled two days before the intake appointment, reported that his marriage was in great distress, and that his wife was about to initiate a legal separation. H e was in good physical health, admitted to no alcohol or drug use, but said that he ignored exercise and that his diet was deteriorating. H e denied feeling significantly depressed or suicidal. He appeared, to the author, however, significantly depressed and to be minimizing the severity of most areas touched on during the brief interview. Screening assessment left little doubt about this man's gambling related problems. Administration of the S O G S revealed a score of 15; he endorsed nine of the ten proposed D S M - I V criteria (Lesieur and Rosenthal, 1993) and all nine of the D S M - I I I - R criteria, answered affirmatively to eighteen of the twenty Gamblers Anonymous ques-
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tions, and placed himself around "increasing losses" and "blaming others" on the Custer Vee chart. He minimized the severity of his pathological gambling and was assessed to be highly resistant. After receiving diagnostic feedback, the patient indicated that he and his wife recently sold their house and decided to move to Utah because there was no legal gambling there. H e said that "if that does not help, then we will move to Hawaii." He had a vague awareness of "geographic cures" but acknowledged that "gambling can occur anywhere." W h e n asked what he expected from this first visit, he asserted that he was curious about what the author "had to offer" and hoped for some tips on how to stop gambling. Guided by the patient's clear resistance and plans to be moving in two weeks, the author suggested that he come in for severn appointments in order to learn how to recognize and perhaps understand more about his urges to gamble. A secondary purpose would be to explore treatment resources in Utah. The patient explained that he could not make another appointment until he knew his work schedule. He left the session, paying for it with a check partially filled in and signed by his wife. He did not schedule a second appointment and subsequently did move to Hawaii. H e sent a note in response to a billing issue and indicated that "everything is fine, so far."
CONCLUSION After having assessed and or treated over 187 pathological gamblers, I continue to be impressed with the complexity of the disorder. This complexity demands clinician flexibility, resilience, patience, and skill. The importance of characterological issues, parallel dual disorder/addictions, physical consequences, and substantial marital, occupational, and social consequences, demonstrate the need for a multimodal assessment and treatment model. It seems imperative that clinicians working with this population have a blend of addiction and mental health experience, particularly in a private practice setting. The importance of legitimizing pathological gambling as a serious health concern and not just as frivolous behavior needs to be emphasized early in the assessment process. In my opinion, motivation of the gambler to see his/her behavior as serious and in need of work is a key in helping them. Teaching them how to become more curious, partic-
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ularly about themselves, and how to be guided by their resistance is central to this work. The shift from an externally dependent frame of reference to one that is more internal and self reflective seems a crucial step in the engagement of the patient. Depending upon one's geographic proximity to other clinicians who assess and treat gamblers, working with this group can be lonely. The difficulty in cross validating assessment strategies and treatment approaches is quite real. In my experience, the assessment and treatment of pathological gamblers and their families is extremely challenging and demands access to peer consultation, supervision, and current research and clinical information. The importance of access to journal articles, to consultation groups, to continuing education, and to national conferences is essential for independent practitioners. The challenges in working with pathological gamblers are evident, but so are the joys. The cases mentioned in this article do not illustrate the number of gamblers who have taken on the challenge of teasing out their own existence, stepping back, and then making substantial shifts in their identity and behavior. The satisfaction of knowing gamblers who have not gambled in over twelve years is substantial. REFERENCES American Psychiatric Association (1980). Diagnostic and statistical manual, third edition. Washington, D.C.: Author. American Psychiatric Association (1987). Diagnostic and statistical manual, third edition, revised. Washington, D.C.: Author. Beck, A.T. (1978). Depression inventoTy. PhiIadelphia: Center for Cognitive Therapy. Custer, R.L. (1980). Personal communication. Custer, R.L. with Milt, H. (1985). When luck runs out. New York: Facts on File Publications. Fisher, S. (I992). Measuring pathological gambling in children: the case of fruit machines in the U.K. Journal of Gambling Studies, 8, 263-286. Gamblers Anonymous (1983). Sharing recoverythrough Gamblers Anonymous. Los Angeles: Gamblers Anonymous Publishing. Glen, A.M. (1985). Diagnosing the compulsive gambler. Journal of Gambling Behavior, 1, 17-22. Graham, J.R. & Lowenfeld, B.H. (1986). Personality dimensions of the pathological gambler. Journal of Gambling Behavior, 2, 58-66. Hathaway, S.R. & McKinley, J.C. (1989). MMPI-2: Manual for administration and scoring. Minneapolis, MN: University of Minnesota Press. Horn, J.L., Wanberg, K.W., & Foster, F.M. (1987). Guide to the Alcohol Use Inventory. Minneapolis, MN: National Computer Systems, Inc. Jastak, S. & Wilkinson, G.S. (1984). The Wide Range Achievement Test-Revised: Administration manual. Wilmington, DE: Jastak Associates. Katz, D. (1993) Men, women & money: the last taboo. Worth, June, 1993. Lesieur, H.R. & Blume, S. (1987). The South Oaks Gambling Screen (SOGS): A new instrument for the identification of pathological gamblers. American Journal ofPsychiaoy, 144, 11841 I88.
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OF GAMBLING STUDIES
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