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March/April 2009 Issue

High Risk Recreation — Problem Gambling In Older Adults
By David Surface
Social Work Today
Vol. 9 No. 2 P. 18

Busloads of elders commute daily to the casinos. For some, it is harmless fun; for others, it is an invitation for trouble.

For many decades, the stereotypical concept of what a gambler looked like has been dominated by images culled from movies and television: the swaggering tough guy in a tuxedo at the blackjack table, the middle-aged man with a cigar in his mouth at the racetrack. As gambling has become more accessible and acceptable in our culture, our awareness of who gamblers really are has also broadened to include young and old alike.

A 2008 study conducted at Wayne State University examining the motivations among older adults for participating in casino gambling reveals that they gamble for both extrinsic and intrinsic reasons. While extrinsic reasons include winning money and supplementing income, intrinsic reasons include entertainment, being around other people, distraction from everyday problems such as loneliness and boredom, and escaping feelings of grief and loss associated with the death of a loved one or close friend.

People are more likely to develop a gambling problem when they’re coping with major life changes or losses. The sudden social isolation that can come with retirement, the increased awareness of physical limitations that accompany aging, and the grief after the death of loved ones constitutes an overwhelming number of difficult life transitions that make older adults particularly vulnerable to developing gambling problems. In addition, many older adults may hide their gambling problem due to shame and social stigma, while reduced contact with friends, family, and coworkers can make the signs of problem gambling hard to spot, creating the ingredients for a formidable issue that social workers working with elders must address.

Casinos: The New Senior Centers?
Fayetta Martin, MLS, MSW, DL, is an assistant professor at Wayne State University whose current research focuses on women’s gambling behavior and treatment barriers for older women with disabilities. She is also interested in older women with and without disabilities who gamble and how gambling addiction is associated with other mental health and substance use disorders among older Americans.

Martin first became interested in problem gambling among older adults in 2004 during her postdoctoral work, which was funded by the National Institute on Drug Abuse at the George Warren Brown School of Social Work at Washington University in St. Louis. What surprised Martin was not merely how many older adults have an addictive relationship with gambling but the extent to which the gambling industry appeared to enable the problem.

“During my research and visits to the casinos, I noticed that the casino was supplying older adults with scooters and wheelchairs,” Martin recalls. “Many even provided oxygen. In the bathroom, there were boxes for diabetics to dispose needles. Older adults told me stories of how the casinos always remember their birthday, and if they stayed away too long, the casino would send them a card saying that they were missed.”

Of course, casinos are not the only businesses that make a conscious effort to market gambling to elders. Today, older adults can find plentiful opportunities to gamble in senior centers and retirement homes where bingo nights and poker clubs are often part of standard activities.

While gambling’s temptation can have a powerful effect, gambling alone doesn’t draw older adults to the casinos; as with other addictive behaviors, the social experience can exert an equally strong attraction.

Lia Nower, JD, PhD, an associate professor and the director of the Center for Gambling Studies at the School of Social Work at Rutgers University in New Jersey, points out how shame is not the only motivating factor for older adults who hide their gambling problem. “For those in senior centers who have bus trips to the casino, poker clubs, and bingo nights, one reason for them to hide their problem is because this is their social outlet,” Nower explains. “They’re lonely and isolated, and this provides some element of camaraderie.”

Nower describes a phenomenon that may also attract older adults to gambling. “Some elders say that when they’re gambling, they don’t notice their pain,” says Nower. “This is something that’s been said to me by a lot of treatment providers who specialize in older adults, that they are not as preoccupied with their physical discomfort when their minds are disengaged that way.”

“At any given hour at the casino, you find older adults,” says Martin. “Just this past weekend I was at the MGM [Grand Casino] in Detroit counting the number of people who appeared to be over 60 who were on the slot machines at 2 in the morning. I would say five out of 10 were older adults, mostly women. One lady who was in a wheelchair told me that the casino for her was a safe place, and when she was at the casino, nobody noticed the fact that she was in a wheelchair.”

Risks for Older Adults
In some ways, the risks of problem gambling for older adults are the same as those faced by younger gamblers—a sudden, devastating loss of financial security and accompanying legal troubles. But older adults with gambling problems also have unique risks. Reduced cognitive capacity among some elders can make it difficult for them to make sound decisions. Also, older adults living on a fixed income with limited savings can’t necessarily afford the financial drain of a gambling disorder.

Nower describes a related problem that should concern social workers. “The law limits the ‘look back’ period for qualifying financially for a Medicaid bed in a nursing home,” Nower explains, “Though rules vary by state, if you’ve divested yourself of a sizeable portion of your assets within the last five years, you may not be eligible for Medicaid. And the law doesn’t distinguish between gifts to relatives and gambling losses. Imagine an older adult who loses their savings and yet they can’t qualify for a Medicaid bed.”

In a recently published study, Nower and her colleagues found that older adults were most likely to ban themselves from casinos because of their fear of suicide.

“When you’re younger, maybe you’re $100,000 in debt, but you’ve got your spouse, you’ve got your children, your job; you still have some reason to get up in the morning,” Nower says. “If you’re an older adult who lives on a fixed income and now you don’t have enough money to pay for your Medicaid bed, why would you want to get up tomorrow?”

Problem Behaviors, Problematic Definitions
The ability of mental health professionals to diagnose and treat any behavioral problem has always been affected (and often limited) by the current definition of the problem. This is particularly true of addictive behaviors, and gambling is no exception.

Like other addictive behaviors, such as alcohol and drug addiction, gambling has historically been thought of as a character flaw signifying a lack of moral strength or willpower; in other words, it’s something that only “bad” or “weak” people do.

Today, problem gambling is still identified by terminology that came in use in 1980: “pathological gambling.” According to the DSM-IV-TR, there are 10 criteria for pathological gambling, including a preoccupation with gambling, the need to gamble with increasing amounts of money to achieve the desired excitement, lying to others to conceal the extent of the involvement with gambling, and committing illegal acts such as forgery, theft, or embezzlement to finance gambling. Five out of the 10 criteria are required for a pathological gambling diagnosis.

Martin believes that this current definition of pathological gambling has serious drawbacks. “The quantitative framework of DSM-IV diagnosis requires that people be separated into two groups—either pathological gamblers or nonpathological gamblers,” says Martin. While this type of diagnosis is clearly defined and allows clinicians to communicate with one another and make treatment outcome comparisons across cases, Martin believes it also excludes a lot of information.

“If there are variations within the groups,” Martin says, “it may lead to overinclusion or inaccurate diagnosis of people who do not have serious gambling problems.” More alarmingly, the five-out-of-10 criteria definition of pathological gambling may also leave people with destructive gambling problems undiagnosed. “It does not include people who fail to meet the five criteria,” explains Martin. “This group would not be diagnosed as pathological gamblers but may be serious problem gamblers, creating exactly the same social problems in their surrounding environment.”

Many professionals in the field have been lobbying for changes in the DSM-IV definition of problem gambling, and Nower is one of them. “Pathological gambling is categorized with impulse control disorders like kleptomania, chronic fire setting, hair pulling—things that don’t really seem a lot like gambling,” she says. “Gambling is a behavioral addiction. We need a reconceptualization of addictive disorders, looking at them as substance and nonsubstance based or behavioral disorders.”

According to James Loree, LMSW, ACSW, CAAC, of the Center for Addiction and Relationship Recovery in Okemos, MI, there are many negative consequences of the current definition. “The fact that pathological gambling is located in the DSM-IV as an impulse control disorder seems to undermine the severity of the addiction, the need for valid recognition and accurate reimbursement by insurance companies, and deliberate and proactive diagnosis by clinicians,” he says.

Identifying the Problem
According to Martin, gambling should be identified as a problem when it disrupts, damages, or limits a person’s life. Signs of problem gambling that Martin points out for inclusion are spending more money on gambling than intended; feeling bad, sad, or guilty about gambling; not having enough money for food, rent, or bills; being unable to account for blocks of time; experiencing social withdrawal; and experiencing anxiety or depression.

While these signs of problem gambling apply to all age groups, they may be more difficult to identify in older adults. Older adults may try to hide or deny a gambling problem, they may feel hopeless or ashamed about the situation, or they may be unaware that help is available. In addition, because older adults tend to have less contact with friends and family, gambling-related problems may go unnoticed.

“With a substance abuse disorder, you can tell when someone’s intoxicated,” Nower points out. “But with gambling, you can’t see it in their eyes or smell it on their breath. It’s very easy for someone to get hundreds of thousands of dollars in debt and maintain a façade that there are no problems.”

Perhaps the greatest obstacle to identifying problem gambling among older adults is their unwillingness to seek treatment. “There is a stigma in older adults that’s attached to any type of addictive behavior,” says Martin, “specifically, those behaviors that are seen as a moral vice or a failure of willpower.”

Martin advises that social workers use an indirect, nonconfrontational approach when attempting to determine when an older client has a gambling problem.

“If you think that an older adult may have a problem with gambling,” Martin advises, “start by asking a few questions like, ‘What do you do for fun?’ ‘Do you ever play bingo or the lottery?’ ‘Do you ever go to the casino?’ Then, if the person says that he or she does gamble regularly and seems willing to talk about it, ask them what they like about going to the casino or playing the slots, bingo, or the lottery. Then ask them if there’s anything they don’t like about it. The way older adults answer these last questions may suggest that they spend more than they feel they should, or that they wish they could stop but need to win first. One can then mention that you have heard that gambling can cause problems for many people and that some social workers specialize in helping people with gambling-related problems.”

Social workers should also be aware of the possibility of problem gambling in whatever professional setting they find themselves in, including those involving older adults.

“If you’re a social worker and you work in a facility that treats drug and alcohol addiction, you should always screen for gambling problems,” Nower advises. “If you work in an [emergency department] where people come in with drug-related problems, you should screen for problem gambling. If you’re a social worker who works at a senior center and your senior center sponsors casino trips or poker night, you should also be actively sponsoring programs to educate older adults in the dangers of gambling and dispel some of the myths. We need to provide prevention at every opportunity, particularly since a majority of older adults won’t seek out help on their own.”

Treatments: Not One Size Fits All
Existing treatments for problem gamblers largely follow a uniform cognitive behavioral therapy model that, according to many in the field, does not take into account particular differences between varying groups of people—and older adults are no exception.

According to Nower, any effective therapy for older adults must adjust for the fact that older problem gamblers are often motivated by grief and loss issues. “I think that any treatment for older adults has to involve pain, grief, loss, a sense of meaning, hopelessness,” says Nower. “These are issues that older adults deal with.”

Feelings of abandonment, most often by one’s own children, often provokes problem gambling in older adults who’ve been placed in assisted living facilities. Nower recalls one example: “I had an older adult tell me one time, ‘You know, I never heard from my son until I started squandering his inheritance, and then, all of a sudden, he was very interested in me—and that made me all the more determined to spend every single dime.’”

Social Work Education: A Wider Focus
While social workers are commonly trained to identify substance abuse, depression, anxiety, and other concerns, problem gambling is not an issue often addressed in social work education.

Nower agrees: “Social workers are not being trained to identify this problem at all. There are only two universities in the country that offer education in problem gambling. Both Rutgers and the University of Pittsburgh have programs to train counselors in problem gambling.” Of those two, only Rutgers has problem gambling as an official part of its curriculum.

Fortunately, there seems to be some movement toward addressing this. “I was at the Hartford Partnership Program for Aging Education last February in New York,” says Martin, “and the dean of [the University of] Albany School of Social [Welfare], Katharine Briar-Lawson, [MSW, PhD], stated in her presentation to a room full of social workers that problem gambling among older adults needs to become a priority among social workers and schools of social work.”

Loree pulls no punches when describing the inequity of the situation: “Unfortunately, gambling makes billions of dollars in revenue for the casinos and others, while millions of Americans face bankruptcy, relationship conflict or divorce, depression, fines, incarceration, or lost time by becoming addicted to gambling. The consequences affect every level of our existence, yet students today know virtually nothing about it. I’d like to see problem gambling as a current events topic to be addressed by addiction and behavioral health curriculum worldwide.”

The Importance of Empathy
Given that the older adult population is poised to undergo unprecedented growth, social workers can expect to encounter problem gambling among their older clients with increasing frequency. How then should social workers best prepare themselves to deal with this issue?

“Social workers working with older adults with gambling problems must show empathy,” says Martin. “They cannot be morally opposed to gambling. They must be active listeners. They must be nonthreatening and nonjudgmental. But most essential, social workers must realize that older adult clients need to be met where they are, not where the social worker wants them to be. Social workers can help add quality of life to the years older adults have left, and that is well worth the effort.”

— David Surface is a freelance writer and editor based in Brooklyn, NY. He is a frequent contributor to Social Work Today.


Screening For Gambling Disorders
James Loree, LMSW, ACSW, CAAC, of the Center for Addiction and Relationship Recovery, provides the following list of diagnostic tools for social workers and other behavioral health professionals who are interested in screening clients for gambling disorders:

• The National Opinion Research Center DSM Screen for Gambling Problems is widely used by clinicians to demonstrate a client showing problem gambling as evidenced by a score of 3 or 4 and pathological gambling with a score of 5 or more.

• The South Oaks Gambling Screen is a legally valid instrument that asks more specific questions than the National Opinion Research Center DSM Screen, yet it is still relatively brief.

• The DSM-IV-TR lists 10 criteria to diagnose pathological gambling (five of which must be met for the diagnosis) and is coded as 312.31 under the Impulse Control section; currently, no DSM-IV diagnosis for problem gambling exists.

• Finally, the Lie-Bet tool is a two-question screen that any health professional can incorporate into an assessment or conversation with a client to reveal if a more comprehensive gambling assessment is warranted.

PDF versions of the above screening tools are available on the National Problem Gambling Awareness Web site at www.npgaw.org/tools/screeningtools.asp.