Disordered gambling: focusing on more than just ‘problem gamblers’

The psychiatrists’ bible, the DSM-5, recently added ‘gambling disorder’ to its list of ‘behavioural addictions’. But how true is its definition, and should it be changed? AAP/Mick Tsikas

Since the issue of problem gambling was placed under the national spotlight by the Productivity Commission in 1999, we have witnessed ongoing public debate about Australia’s gambling industries. The commission estimated the prevalence of problem gambling to be 2.1% of the adult population, translating at the time to approximately 290,000 people.

However, the debate about problem gambling is plagued by shifting definitions and understandings. Earlier this year, the American Psychiatric Association (APA) released the fifth edition of its keystone Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an update on the DSM-IV that:

…marked the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental disorders.

The DSM is the psychiatrists’ bible, providing the diagnostic criteria for all forms of mental disorders. It is designed to enable psychiatrists to better identify the symptoms of mental illness and diagnose them accurately, with a view towards effective treatments and interventions.

One of the new additions to the DSM-5 is “gambling disorder”, the only entry in a new “behavioural addictions” category. It reflects research findings that gambling shares certain similarities with substance-specific addictions (such as alcohol and stimulant use) in terms of clinical expression, neurobiology, comorbidity and treatment.

This gives “disordered gambling” a somewhat unique position as the sole behavioural addiction, separating it from its previous categorisation (APA DSM-IV) as an impulse control disorder, alongside such conditions as the plucking of body hair, pyromania, explosive anger, kleptomania, sexual compulsion, skin picking, internet addiction and compulsive shopping. The shifting classification of pathological gambling - or disordered gambling as it is now known - belies the inevitably arbitrary nature of these psychiatric categories.

Surely a better definition of gambling disorders is a good thing? In the words of the APA:

Recognition of these commonalities will help people with gambling disorder get the treatment and services they need, and others may better understand the challenges that individuals face in overcoming this disorder.

Well, to a point. As British sociologist Nikolas Rose points out, part of the answer depends on how the labels created by the “psy sciences” to describe aberrant consumers such as pathological gamblers, kleptomaniacs, anorexics, bulimics, and shopaholics actually get used in our society. These are powerful terms, and while they can be used for diagnosis and treatment, they can also be subverted to the interests of powerful players.

To take a step back, there have been negative consequences for individuals and families ever since gambling has existed. However, it has only been relatively recently that we have started to consider the problems with gambling as a form of individual pathology. “Pathological gambling” emerged as a fully-fledged mental disorder in the DSM-III in 1980, although attempts to study the deviant anatomy of those suffering “gambling mania” date back to the 19th century.

The disordered gambler, as seen through the lens of 19th century proto-psychiatry, Théodore Géricault, The Woman with Gambling Mania, c.1820.

While in Australia the term “problem gambling” is preferred to pathological gambling in policy circles, the psychometric tools used in prevalence studies largely are based on the pathological gambling definition. The key point here, one also made by gambling researcher Charles Livingstone, is that this process takes a complex social problem and locates responsibility for it firmly within the mind of the aberrant individual. Moved back into the public arena, the implication is that if we had none of these irksome and maladjusted problem gamblers all would be well.

To this end, nearly every Australian state and territory has collectively spent millions trying to address problem gambling over the past two decades. One of their primary responses has been to conduct numerous and expensive prevalence studies to measure the numbers of problem gamblers in each jurisdiction. However, based our own research experience over the ten years, including the running of a prevalence survey and as advisor to others, we argue that problem gambling prevalence studies are virtually useless for public policy.

If prevalence estimates fall over time it is tempting to assume that somehow policy has made a difference. Conversely, rising estimates may be attributed to increased gambling availability. Simply put, unless we have identified a direct causal mechanism linking a particular policy or harm-minimisation measure to pathological gambling levels, then these associations may be spurious. Prevalence studies simply do not help governments to know if what they do makes any difference.

To make matters worse, the measurement error involved in estimating the number of problem gamblers is so great that identifying any trends in problem gambling rates with any degree of precision is nigh on impossible. For example, we were simplifying matters earlier when we stated that the Productivity Commission’s 1999 survey found that 2.1% of adults were problem gamblers. More accurately, the commission found that, had it repeated its survey 20 times, it would expect that on 19 of these hypothetical occasions it would have pegged the problem gambling rate somewhere between 1.6% and 2.4%.

The uncertainty inherent in this estimate – and the unfortunate fact that subsequent surveys have typically used modified methods that are not directly comparable – makes demonstrating trends or the real world effect of any policy change unfeasible.

So why do we keep doing them? The simple answer is that the state-industry gambling complex actually needs the pathological gambler category, not just in an economic sense, but to rationalise their support of the gambling industries.

By locating the source of “the problem” in a pathologised minority, we transfer responsibility from the producers to the consumers of harmful products (and coincidentally keep a small niche of consultants and academic researchers like ourselves in employment). In this way, blame may be tied to the actions of a few unfortunates as opposed to the broader institutions of society (that is, the government and the market).

Gambling remains pervasive in Australian society despite wide research on its social and psychological harms. AAP/Dean Lewins

As James Packer - Australia’s multibillionaire gambling magnate - recently noted, gambling is “a fun business, as long as you’re not hurting people”. It is this fantasy of a gambling industry without harmful consequences that is offered by the precisely-defined category of the problem gambler.

The haunted figure of the pathological gambler reproduced by prevalence studies is a convenient way for the industry and government to absolve themselves of at least some responsibility. The failure to effectively regulate a dangerous product in the form of the pokies has been dressed up as a failure of the individual. And the DSM-5 provides the objective and scientific psychiatric respectability that can be misused to justify this switch.

This is not to argue that gambling problems do not exist, or that people and their families do not experience shocking harms – of course they do. But blaming an aberrant individual through a discourse of pathology just allows for industry and governments to take on less responsibility than they should. Researchers, including ourselves, who have conducted prevalence surveys are complicit in frantically doing nothing about the problem, except reinforcing its location in the individual gambler.

The real gambling pathology lies with the political-economic system of gambling. There are vulnerable people in any society. A civil society is not one that exploits them mercilessly. We support any move that will help the victims of the gambling industries, including counselling and pre-commitment. But it is more important to stop producing gambling harm in the first place.

This means we need to revisit how many pokies we license, how they are configured, and where we put them. Otherwise, we do little other than lament the collateral damage of an industry that puts profits in front of people.

A longer version of this essay, responses by two proponents of problem gambling prevalence research, and a rejoinder were recently published in Addiction Research and Theory, volume 21, no. 1.