Talking to people who suffer from gambling problems is what got me over my skepticism about gambling being a true addiction. Their descriptions of their internal struggles trying to contain gambling behaviors are identical to the descriptions of my patients struggling with substance use disorders. What is strikingly different is their ability to reach altered mental states—leading to destructive compulsive behaviors—without using psychoactive substances.
Winning, one of the valued goals of recreational gamblers, is not, in fact, the goal for many addicted gamblers. Instead, they value the mental state that they are able to achieve during the gambling process, particularly when using slot machines. The goal, therefore, is not to win, but rather to spend as much time as possible using the machine, which has become the means by which they reach the mental “zone” that they seek. They can become so riveted to their seats that they sometimes become incontinent rather than leave to use the restroom. Some, aware that this will occur, go so far as to put on diapers before they leave home.
In her captivating book, Addiction by Design (Princeton University Press, September 2012), the social anthropologist Natasha Schull captures this experience. Even more disturbingly, she describes how the manufacturers of slot machines understand this vulnerability and exploit it. Under the rationale of “giving customers what they want,” they design machines, as well as the entire casino environment, to keep the addict connected with the machine in a way that will maximize the amount of money that will be spent. They understand, for example, that “near wins” can create incentives to keep playing and program these to occur at a greater than random rate. The machines can also monitor the pace at which the person is losing, and interventions are made so that too fast of a pace and premature departure can be avoided.
Although substance use is not necessary, it can facilitate the process. Knowing this, owners of new Baltimore casino convinced the city—despite the protests of nearby bar owners—to allow them to serve alcohol to their patrons 24 hours a day. Furthermore, slot machines placed on outdoor balconies—where users can smoke cigarettes —are the highest-grossing machines at the casino.
The good news is that the broadening acceptance of gambling as a true addiction has led to its inclusion in the Addiction Section of the new DSM-5 and the willingness of most of the major insurance companies to pay for treatment. At Kolmac, we are not only addressing the gambling problems of our substance-using patients, but we are also beginning to work with people who have a gambling addiction, but no substance use problems.