Problem Gambling and Treatment in Nevada*
Introduction
For many years, it was moral experts, rather than medical and academic ones, who told us who gambled “too much.” Speaking from pulpits rather than podiums, church leaders informed us that gambling was uniquely subversive of the American way of life, for its something-for-nothing promise threatened to undermine the popular ethic of honest toil and gradual accumulation of goods. Samuel Hopkins, in an 1835 sermon on “The Evils of Gambling,” captured this sensibility: “Let the gambler know that he is watched, and marked; and that . . . he is loathed. Let the man who dares to furnish a resort for the gambler know that he is counted a traitor to his duty, a murderer of all that is fair, and precious, and beloved among us” (Hopkins, 1835:17-18).
In those days, problem gamblers were seen as especially weak manifestations of an evil enterprise. Even those who sought to help problem gamblers (those who “dared furnish a resort,” in Hopkins’ words) were often seen as immoral. More recently, we have arrived upon a kinder, gentler understanding of those whose gambling has become a problem, and we now treat as “sick” those whom we once labeled as “evil.
In Nevada , the history of those who gamble too much is a predictably complex one, and one that speaks to our unique relationship with the “product” that problem gamblers indulge. Early on, Nevada ’s gambling establishments were reputed to have a soft spot for gamblers who were “down on their luck.” Stories abound of casino employees handing bus tickets home to those who gambled too much during their stay in the Silver State . More recently, casinos have developed formalized “responsible gaming” policies for their employees and patrons. In the policy world, we have recently seen reason for optimism, as the state legislature has at long last recognized problem gambling as a legitimate public health concern, outlining a broad agenda for action and state dollars to support it. As a result, we are now on the brink of what promises to be a new era in Nevada ’s history of dealing with those who gamble too much in the gambling capital of the world.
National and International Context
Jurisdictions around the world have often turned to Nevada for expertise when it comes to gaming. After all, the state has been at this the longest, and through trial and error has arrived upon world-class approaches to everything from regulation to architecture to marketing. There is one exception to this pattern, and it is in the area of social health. While jurisdictions around the world turn to us for advice on operational matters, as a state we have to look elsewhere for model problem gambling programs at the state government level.
In Oregon, for instance, the state’s program for problem gambling services has an annual budget of $4.65 million. By contrast, Nevada has yet to spend a single dollar in this area, though this will change soon due to the most recent Legislature’s mandate. On top of this, Oregon’s lottery devotes $1.2 million per year to advertising and awareness campaigns designed to help the public better comprehend this oft-misunderstood affliction. This budget pays for an impressive array of services, including inpatient and outpatient treatment programs that cover the most severe pathological cases all the way to the “at-risk” populations who have not developed a full-blown addiction.
Louisiana has a similarly impressive problem gambling approach. This state, which rarely sits atop national rankings of social service provisions, is a leader in the provision of problem gambling services. Like Oregon, Louisiana has developed a comprehensive statewide program, and one that ensures that all state residents receive access to inpatient or outpatient treatment regardless of their financial circumstances. The latter point is an important one. Problem gamblers are unique in the medical annals, for they deplete the very resources that they often need to get better. Louisiana’s response to Hurricane Katrina did not get high marks, but the state excelled in at least one respect: local agencies did not miss a single help line call from problem gamblers, nor did they cancel a single treatment session. Like Oregon’s problem gamblers, Louisiana residents addicted to gambling have a “safety net” built by a coalition of state, private, and service provider organizations.
Internationally, the picture is much the same, as many gaming jurisdictions have chosen to devote substantial resources to problem gambling treatment and awareness. In both Australia and Canada the advancement of gaming has been marked by substantial public backlash, but the funding for research, education, and treatment of problem gamblers helped ease up concerns. In just about every region where gaming is instituted, the question of how the jurisdiction will be dealing with problem gambling is among the first asked of potential operators and regulators.
Historical Overview and Current Programs
The first professional problem gambling resource for Nevadans was established in 1986 in Las Vegas. Gamblers Anonymous, it should be noted, had been around for some time since it was first established in California in the 1950’s. That year, Dr. Robert Custer, the widely acknowledged “founding father” of problem gambling treatment, came to Las Vegas to start a treatment program based upon the practices he had established in a VA hospital in Brecksville, Ohio. Dr. Custer affiliated with the local CharterHospital organization, a for-profit mental health center, and selected Dr. Rob Hunter to open the state’s first treatment facility for those with gambling problems.
The Charter program brought positive publicity to the state, as the national media noted local efforts to help those who gambled too much in the gambling capital of the world. The program was helped by a successful and memorable ad campaign that asked of residents: “If you don’t get help at Charter Hospital, please, get help somewhere.” This campaign revealed the importance of not only having successful treatment programs available, but in also encouraging awareness of these programs: after all, it did not do Nevadans any good to have strong programs that nobody knew about.
In the 1980’s and 1990’s, the U.S. mental health field changed dramatically, and cuts in mental health care were common. As a result, large inpatient programs, including the Charter problem gambling center, had to adapt to the adverse financial environment by mutating into smaller outpatient programs. More generally, the field of mental health underwent drastic macro-economic changes, leading Charter Hospital, along with many others, to go out of business in the late 1990’s.
In Nevada, the leaders of what was formerly the Charter program re-configured as a non-profit, which now operates as The Problem Gambling Center (www.gamblingproblems.com).
- The program, still under the direction of Dr. Hunter, recently doubled its clinical offerings, and announced that it will soon open a Reno office.
- Over the years, the program has treated more than 3,000 individuals, and currently serves a few hundred problem gamblers annually.
- Impressively, the Center served as the model for recently-opened problem gambling centers that offer treatment services in Seoul, Korea, and Sydney, Australia.
The Problem Gambling Center insists upon working hand in hand with Gamblers Anonymous (GA), http://www.gamblersanonymous.org/, the 12-step organization devoted to helping problem gamblers admit and address their problems. In Nevada, GA offers over one hundred weekly meetings, in which the only “admission criterion” is the desire to overcome a gambling problem. In what is perhaps an indirect measure of the scope of the problem in the state, other communities and states have far fewer regular GA meetings. The organization’s 12-step approach offers assistance from those who probably know this problem most intimately – other problem gamblers. A partner organization, Gam-Anon, http://www.gam-anon.org/gamanon/index.htm, also offers meetings for the relatives and friends of those with a gambling problem.
Beyond PGC and GA, a handful of other organizations have offered treatment services to specialized populations. Dr. Rena Nora, for instance, moved to the state from New Jersey and continued her pioneering work with VA hospitals. Dr. Nora has also served as a key advisor to a number of state policy entities. More recently, the Salvation Army began offering problem gambling services to their clients who sought help for drug and alcohol problems.
Treatment organizations are not the only state organizations have helped Nevada’s problem gamblers. The Nevada Council on Problem Gambling, http://www.nevadacouncil.org/, is a non-profit organization focused on education and awareness of problem gambling. Notably, this organization (as well as the Problem Gambling Center) was started with significant financial support from gaming businesses; it is doubtful that these organizations could have gotten off of the ground without it.
The Council, led by Carol O’Hare, offers a toll-free hotline (1-800-522-4700) that connects callers with treatment providers. It also offers community outreach programs that target specialized sub-populations, including school district programs, after-school programs, and programs targeting military enlistees. Finally, the Council provides training for employees of gaming businesses as well as mental health providers. Overall, its awareness and education thrust complements nicely the treatment offerings in the state.
At the university level, both UNLV and the University of Nevada offer programs designed to recognize and research problem gambling. Down South, UNLV’s International Gaming Institute (IGI) mandates the inclusion of problem gambling education in every 101-level hotel management course. The IGI has also offered specialized problem gambling education programs to students, regulators, and gaming industry employees, and it continues to conduct internationally-recognized research.
In the UNLV counseling department, http://www.unlv.edu/Colleges/Urban/Counseling/, Larry Ashley has started a ground-breaking program designed to train counseling students to treat problem gamblers and their families. In the university’s Student Health program, Steven Oster (current president of the Nevada Council on Problem Gambling) has devoted his office’s resources to students on campus who have developed a gambling problem.
Up north at the University of Nevada, Dr. William Eadington’s Center for the Study of Gambling and Commercial Gaming, http://www.unr.edu/gaming/index.asp, has pioneered research and conference programs on both youth and problem gambling. As the dean of gambling research in the U.S., Dr. Eadington’s publications on macro-level impacts of gaming in society serve as an important resource to all Nevadans.
Research on Problem Gambling in Nevada
There is one study on problem gambling in Nevada that merits especially close attention, as it produced the first defensible statewide estimates of problem gambling. In 2002, the state of Nevada funded two problem gambling prevalence surveys. The Nevada Department of Human Resources, along with Gemini Research, http://www.geminiresearch.com/, released two reports: “Gambling and Problem Gambling in Nevada,” and “Gambling and Problem Gambling among Adolescents in Nevada.” These studies yielded a series of findings central to our discussion.
Adult Problem Gambling: Volberg Report, 2002
According to the authors of Volberg Report,
- “the combined current (adult) prevalence rate of problem and probable pathological gambling in Nevada in 2000 is 6.4%,” a rate that the authors contend is “higher than in every other jurisdiction where similar surveys have been carried out.”
This rate is arrived upon by using the SOGS (the South Oaks Gambling Screen), http://www.gov.ns.ca/health/gambling/IsThereAProblem/SouthOaks/, an instrument that until recently served as the foundation for virtually every major prevalence study conducted in the U.S. and quite a few studies abroad. It should be noted that the SOGS has come under criticism, for it tends to yield higher numbers that can be compared with other jurisdictions’ figures. Comparability is achieved, but perhaps at the cost of accuracy. Some researchers have contended that the other instrument used in the study may actually yield lower than normal rates.
The authors also take these prevalence rates of the study and project them onto the populace, declaring that
- “between 40,100 and 63,900 Nevada residences can be classified as current probable pathological gamblers. In addition, between 32,700 and 53,500 Nevada residents can be classified as current problem gamblers.”
Unfortunately, due to administrative errors, the Nevada adult study does not inspire a great deal of confidence in its findings. Because the number of high-frequency gamblers was much higher than anticipated by the research team (and indeed, higher than is commonly found in other jurisdictions), the interview process was scaled back considerably. Thus, rather than administering the problem gambling questionnaire to all of those who indicated that they had been gambling monthly or more often, it was decided to administer it to those who had been gambling weekly or more often. This means that a relatively large number of gamblers were not given the problem gambling questions. Furthermore, the completion rates for the survey were low – even by the standards of telephone survey research, a methodology whose response rates have declined in recent years.
The firm that produced the study, Gemini Research, has been admirably up-front about these shortcomings. In a responsible manner, it outlines the limitations the project encountered. It seems that a change in management at the survey center that Gemini hired to conduct the local survey contributed significantly to these problems. Given these limitations, it may well be that the definitive study on adult problem gambling rates in Nevada has not yet been done.
Adolescent Problem Gambling: Volberg, 2002
When it was released, the adolescent problem gambling study report widely viewed as “good news” for our gambling state. We should note that this report does not suffer from the same shortcomings as the adult problem gambling project discussed above. While the adult report focused on higher prevalence rates, the adolescent report focused on relatively low (but not insignificant) prevalence rates for Nevada’s youth. After surveying 1,004 Nevada residents aged 13-17, the report found that:
- “Compared with adolescents in Georgia, New York, Texas, and Washington State, where similar surveys have been carried out, adolescents in Nevada are less likely to gamble weekly or more often.”
- “Furthermore, the prevalence of problem gambling among adolescents in Nevada is lower than among adolescents in three of the other four states where similar surveys have been conducted.”
There are a number of plausible hypotheses that might explain these phenomena. Most intriguing is the observation that in a state where gambling has normalized, going gambling is simply not that rebellious an act for those seeking to rebel. In much the same way that European youth may not have the hang-ups about drinking that their North American counterparts do, early exposure may “inoculate” Nevada’s youth to gambling.
Southern Nevada Community Assessment:
Southern Nevada United Way and Nevada Community Foundation, 2002
In 2003, the Southern Nevada United Way and the Nevada Community Foundation joined forces to support the region’s first-ever Community Assessment, which utilized both previous research and new large-scale surveys to determine the scope of a wide variety of social problems. The 2003 Community Assessment, www.uwaysn.org, asked a large sample of Southern Nevadans about the problems that plagued their communities and their households. When asked about their concerns,
- Southern Nevadans rated “gambling problems” 10 th out of a list of 45 community concerns, with 55% stating that this was a “major” issue.
- Perhaps more strikingly, 31% of Southern Nevadans indicated that someone in their household had experienced a challenge with a gambling problem during the past year, and 6.4% said that this was a “major” challenge.
In light of these and other data on addictions, the researchers concluded that
- “These are significant findings for a community in which outside-of-the-norm behaviors are visibly and explicitly encouraged among those who come here to play (think of Las Vegas’ current ad campaign, “what happens here, stays here”). As a group, Southern Nevadans are extremely concerned about the specific mental health issues faced by those battling behaviors of excess.”
These findings are interesting in that they do not rely upon “expert” assessment, but rather reflect residents’ own perceptions of problems that plague their homes and communities. It should also be noted that these data cannot speak to non-Southern Nevadans, as its inquiries were limited to the greater Las Vegas valley. Still, we may conclude that problem gambling is a community issue that concerns many residents (for a more comprehensive presentation of the community and household concerns summarized in this report, consult the tables in the “Supplementary Materials” section at the end of this paper).
Casino Employees and Problem Gambling
In exploring the impacts of problem gambling on Nevada, one other important study merits attention. Shaffer, Vander Bilt, and Hall’s 1999 study found that casino employees are at a higher risk for the development of gambling disorders than the general population. To be sure, we cannot infer causality in this chicken-and-egg dilemma – working in a casino may cause the problems; but then, those who already developed problem gambling habits may be drawn to work in casinos. Either way, this sub-population of Nevadans deserves special attention, as its members represent the foundation of our state’s key industry.
Prospects for the Future and Policy Recommendations
The 2005 NevadaState Legislature witnessed a major victory for the state’s problem gamblers. After similar bills died during the two previous legislative sessions, Senate Bill 357, http://www.leg.state.nv.us/73rd/Reports/history.cfm?billname=SB357, was signed by Governor Kenny Guinn on August 9, 2005. The 2005 version was authored by State Senator Dennis Nolan, after pioneering efforts by Mark James in previous legislative sessions. For the very first time in our sate, this bill sets aside dollars for assisting problem gamblers, allocating $1 per gaming machine in 2006 and $2 per gaming machine in 2007. The money, which is to be collected through the Nevada Gaming Control Board, http://gaming.nv.gov/, totals just more than $2.5 million for the biennium. Over the next two years, a specially-appointed advisory panel will help determine which service providers will receive support from this fund.
Moving forward, the state should strongly consider the following recommendations for its future efforts to help Nevadans with gambling problems:
Continued State Support for Problem Gambling Services
The 2005 Nevada State Legislature’s decision to support problem gambling services was commendable. However, service providers fear that in 2007, they will have to fight again for support from the state, and if the state’s economy takes a turn for the worse, they fear that problem gambling bills will be voted down. As a state, Nevada is maturing into a world-class tourist destination, offering a range of recreational opportunities as diverse as Lake Tahoe’s slopes and Lake Bellagio’s fountains. We must demonstrate to a world that has only recently (and grudgingly) come to respect this state’s offerings that we are also committed to “taking care of our own” communities and residents.
A Public Health Approach
Recently, a number of prominent scholars in the field have suggested that a problem as complex as gambling addiction requires a comprehensive solution. A public health approach ensures, among other things, that the entire range of gambling behaviors is taken into consideration – from no risk to at-risk to problem and pathological gambling (see Figure 1 for an illustration of this approach). In this model, prevention or “harm reduction” programs might target at-risk populations who have not yet developed problems, while education programs would target a range of vulnerable populations and treatment or gamblers with a full-blown addiction. The state should encourage collaborative efforts from a public health perspective – relying, wherever possible, upon the latest in scientific research.
Public Awareness Campaigns
Relatively speaking, we as Nevadans rarely hear about problem gambling. Again, this may be attributed to our concerns about stigmatizing our key industry, but given the awareness of problem gambling in other jurisdictions, this is hardly an excuse. Nevadans need to know that this is a potentially severe disorder – but one that is treatable when help is made available and affordable. These messages need to be heard not only in gaming environments (as they currently are), but also in broader health and educational settings.
Insurance for Treatment of Problem Gamblin
The state and its service organizations should work with insurance companies to help improve coverage for treatment for those with gambling problems. As mentioned previously, by the time they reach treatment providers, the problem gambler’s financial situation is often dire. It is hard to imagine a change more far-reaching in its scope than one that would allow problem gamblers to access treatment independent of their financial status.
Special Populations: Gaming Employees
Nevadans should take special care to target special populations in their efforts to help problem gamblers – most notably, the state’s population of gaming employees. In many public policy debates over the pros and cons of gaming in society, gaming employees are a forgotten group. In the aftermath of Hurricane Katrina, for instance, some anti-gaming activists openly celebrated the area casinos’ destruction, with little thought devoted to the lives of the thousands of employees who worked there (as well as their families). In Nevada, we simply cannot ignore the population whose labor sustains this state’s major industry. Since these workers are a bona fide “at-risk” group, our intervention and education efforts should target them in a concerted fashion. Our current education programs are designed primarily to help customers in gambling venues, but they should also be directed toward those who work to keep those customers happy.
Research-based Solution
This analysis would be incomplete without a strong pitch for more research. In the young field of problem gambling, this is especially important, and especially in a state whose revenues are so dependent upon gambling. As numerous scholars have pointed out, gambling’s recent boom times should be considered with caution, for the industry has enjoyed dramatic peaks and valleys in the past. In Nevada, we have banned gambling twice – and legalized it three times. Gambling’s most knowledgeable historians note that what has brought the entire industry to a halt in the past has been an inability to deal with public backlash over everything from problem gambling to moral codes to a thrown World Series in baseball. To protect the well-being of all of Nevada’s citizens, then, we need to commit to an aggressive research agenda that monitors the issue that has produced gambling’s loudest social protests – problem gambling and its impacts on individuals, families, businesses, and communities. More specifically, we should monitor in an ongoing fashion problem gambling prevalence rates, problem gambling awareness levels, treatment efficacy, and all of the other public health efforts that we develop to combat this disorder. To do otherwise would be ignorant of our own history.
Conclusion
Many are of a mind that Nevada’s problem gamblers face an impossible burden, and hence should move away from a state where gambling opportunities seem to be ubiquitous. This “solution” fails on at least two levels: there are no longer gambling-free environs to move to (especially with the advent of internet gambling), and as we have seen in this report, Nevada actually has a strong network of social service organizations helping problem gamblers and their families.
While we no longer “treat” problem gamblers by subjecting them to social ostracism and scathing moral judgments, it is important to remember that the problem gambling field is still a young one. Hence, while Nevada’s citizens and leaders should recognize that we have come a long way, we also need to understand that we have a long way to go.
In the acclaimed documentary In the Fog of War, former U.S. Secretary of State Robert McNamara explores the vicissitudes of a professional life he led in the most visible offices in the land. In the midst of a number of articulate laments, McNamara’s face glows when speaking of one decision in particular. When serving as president of Ford Motors in the post-WWII era (a period in which the company enjoyed a dramatic resurgence), McNamara and his colleagues at the company became painfully aware that some users of their product – cars – were devastated by the their interactions with Ford’s product. This was the time when we were just beginning to understand the toll of automobile crashes, which were caused in part by problems with the product and in part by problems with the drivers. It was at this moment that McNamara and Ford decided to commit to the then-novel concept of seat belts, determining that these belts would take care of those harmed by the product they so proudly engineered. Movingly, at the end of his career, McNamara takes special pride in a decision to help those hurt by “his” product – a decision that has since saved many thousands of lives.
The gaming industry and those at its helm may now face a similar moment of truth. Of course, this is an imperfect metaphor, as there are plenty of differences between automobiles and slot machines (as well as in the ways that these products are used). However, it seems that this too is a moment when we are beginning to understand the nature of the pains and the problems that some “customers” endure, and we are also beginning to understand how we might mitigate them. Let us hope that generations from now, we as Nevadans can also take special pride in the decisions that we made about those harmed by “our product” during this period, and in the positive results that followed.
Data Sources and Suggested Readings
Hopkins, Samuel. 1835. The Evils of Gambling: A Sermon. Montpelier, VT: E. P. Dalton and Son.
The Louisiana Association on Problem Gambling: http://www.laprobgam.org.
Oregon Department of Human Services: http://www.oregon.gov/DHS/addiction/gambling.shtml.
Volberg, Rachel A. 2002. Gambling and Problem Gambling in Nevada. Northhampton, MA. Available for download at www.geminiresearch.com.
Volberg, Rachel A. 2002. Gambling and Problem Gambling among Adolescents in Nevada. Northhampton, MA. Available for download at www.geminiresearch.com.
Shaffer, Howard J., Hall, Matthew N., and Vander Bilt, Joni. 1997. Estimating the Prevalence of Disordered Gambling Behavior in the United States and Canada: A Meta-analysis. Boston: President and Fellows of Harvard College.
National Gambling Impact Study Commission. Available for download at http://govinfo.library.unt.edu/ngisc/.
Community Resources
UNLV Student Health provides problem gambling assistance to undergraduate students. Tel. 702-895-3627.
UNLV Counseling provides the nation’s only problem-gambling specific counseling program. Tel. 702-895-3935.
The UNLV International Gaming Institute develops research and provides educational programs on problem gambling. Tel. 702-895-2935.
The University of Nevada Institute for the Study of Gambling and Commercial Gaming develops conferences, conference proceedings, and publications on problem gambling research. Tel. 775-784-1442.
The Nevada Council on Problem Gambling provides educational outreach programs, workforce development programs, and a toll-free 24 hour help line. Tel. 702-369-9740. Toll-free helpline: 1-800-522-4700.
The Problem Gambling Center provides outpatient treatment programs as well as one-on-one counseling. Tel. 702-363-3633.
The Veteran’s Administration Medical Center provides problem gambling services for veterans. Tel. 702-259-4646.
The Salvation Army provides problem gambling treatment services for those with alcohol or drug problems. Tel. 702-399-2769.
This report was prepared by Dr. Bo J. Bernhard, Director of Gambling Research, UNLV International Gaming Institute, and Assistant Professor, Departments of Sociology and Hotel Management. Tel. 702-895-2935. Email: bo.bernhard@unlv.edu. Dr. Bernhard is a fifth-generation Nevadan.