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IN 1972 THE AMERICAN Psychiatric Association formally classified compulsive gambling as a disease.  This was an unusual step to take.  We all know when we catch measles that it is disease, or regard a common cold as an annoying minor illness.  But compulsive gambling?  This was something new.

            The decision by the APA was the result of pioneering work in the field by Dr. Robert Custer, and his wife Lilian.  Custer, now in his 60s (no relation to the hero of Little Big Horn), has devoted a lifetime to treating gamblers; in particular, he was the moving spirit behind the so-called hospital for compulsive gambler’, set up in Brecksville, Ohio.  This out - of – the – way unit is located within the big, clean-swept neuropsychiatric hospital south of Cleveland, part of the Veterans Administration network of medical care for ex-servicemen; there are 30 million veterans in the United States and the VA, far the biggest medical institution in he country, disposes of an annual budget medical institution in the country, disposes of an annual budget running into hundreds of millions.
            When Custer went to Brecksville as consultant psychiatrist back in 1969 he found, as might be expected, that drinking problems were quite common among veterans.  He set up a 50-bed unit for alcoholics.  Then one morning he received a curious call: three men who were already members of Alcoholics Anonymous had come back to the hospital to tell him they couldn’t stop gambling: they had been diagnosed as suicidal, and Custer decided they would benefit from a short stay in the hospital.  He did not know anything about poker gambling, so he started going to Gamblers Anonymous meetings, and his wife Lilian to Gam-Anon, the family members group which supports GA.  His growing interest in the subject led him to get eight beds set aside for treating gambling cases.  The old guard at the hospital was mistrustful, but the staff recruited from the alcoholics programme was enthusiastic, and from its inception in April, 1972 the unit took off.  About a third of the patients were active GA members, the others had been admitted for various psychological disorders.
            It was the only such program in the world and Custer got calls from   far and wide about it.  What really put Brecksville on the map was the media, which latched on to what looked like a hot news story.  After all, everyone has gambled at some time in their life, but to go to hospital for it! Half the referrals to the unit came via press reports.
            Perhaps the media imagined hardened gamblers, trying to kick the habit, lying back on fresh laundered sheets being fed sweet California grapes by soft-eyed nurses.  The reality was somewhat harsher.  ‘We insisted on total abstinence, as we do with alcoholics, ’ Custer recalls.  Patients were allowed to play poker competitive games – checkers, pool and cards – but without betting; they were discouraged form watching sports on television, and told to take exercise themselves.

  This did little to relieve the agitation and tension they felt, in their desperate urge to gamble – but there they were.  ‘The hospital, ’ as one report by the medical team frankly conceded, is not a pleasant place to be.’
            The first weeks were pure trial and error, custer recalled in his book When Luck Runs out (written with Harry Milt, 1985).  ‘We just worked and waited to see what would happen.  We only had a vague idea about what we were dealing with and how it ought to be handled.’  The program was designed by Custer and his associate Dr. Alida Glen on the pattern of their treatment of alcoholics.  ‘But when we got together in our staff conferences- the counselors, psychologists, psychiatrists, social workers and nurses – we found ourselves zeroing in on something. As these patients began to tell us in detail about what they had done in the course of their compulsive gambling, we realized that they all had in common several negative traits of personality and behaviour.’

            To appreciate what Custer and his team meant by ‘negative traits’ and what they were up against – the abysmal depth of the human problem – you need to have some idea of the degradation and despair which many of the men had sunk to.  Some of the gamblers case histories recounted in When Luck Runs out  could provide material for cinema-verite almost too painful to contemplate – though such experiences in this milieu of habitual losers are quite common.  I quote a couple of brief scenes to convey the awfulness of it all.
            First, black comedy.  Here’s Rachel, a serviceman’s loyal wife, who for many months had been unable to grasp the extent of her husband’s secret gambling, facing the final moment of disillusion:
            It was our wedding anniversary and he said he would take me to some elegant place for the weekend…When we got there, and I saw the hotel, I was thrilled.  It was just as beautiful as the pictures in the brochure… It was one of those heavenly southern nights, with a soft, warm breeze coming off the ocean, the scent of night-blooming flowers floating to us from below … In the magic of the night and the wine all my concerns about his gambling melted away, all my anger was gone… We sat on the balcony for a while, and then, with the unspoken understanding of lovers, I got undressed and changed into my flimsiest negligee.  While I was still in the bathroom, he shouted to me that he had just remembered and had to go down to the desk and straighten out something about our reservations.  He suggested I get into bed and wait for him …
            The next thing I knew I was being awakened out of a deep sleep by the loud barking of some dogs… The lights in the room were still on…
            By seven o’clock I had my bags packed and called a taxi to take me to the airport.  He walked in jut as the bellhop was coming to get my bag … disheveled, grimy, unshaven … I didn’t even bother to listen to the rest of it.
            This might be taken as black comedy but for the fact that Rachel later miscarried.  Here’s another story which is simply black tragedy:
            Ralph had cashed a lot of little cheques around town and got away with it, but one night the police came out and took him off to jail; with no funds in the house, he told his wife to get some money from his mother to bail him out.
            We were out there standing in front of the police station, and I asked her where the rest of the money was.  She asked me, ‘What rest of the money?’ ‘The money to bet with … ’ I screamed at her … I figured I could still make the late afternoon races …
            As his wife had only got him bail money, with nothing over, the infuriated Ralph left her standing there and drove over to his mother’s.

      My mother was 80 years old.  She was all bent over from having worked at a sewing machine in the factory most of her life.  I had already gotten $ 35,000 from her.  That was what she had left from her savings and what she got out of my father’s insurance when he died.  I had cleaned out all that … She started to cry and pleaded with me, ‘Ralphie, what do you want from me?  I gave you everything.  Now you want to take the food out of my mouth… ’
            I didn’t even hear what she was saying.  I had to have the money.  So I got on my knews and began to cry and I promised her by all the saints that this was the last time, that I would just go straight and my wife and kids would get all my salary.  And she believed me.  She went down to the bank with me and cashed her Social Security check and gave me $200.  An hour later I was at the track.
            But just to emphasize that the problem is not confined to small-time gamblers, here’s Louis , a big player, who had run though his multi-million dollar clothing business  in less than a year, on his return home one night after dropping another $ 150,000 in Las Vegas:

            When I came upstairs, there was Lisa on the bedroom floor, half-conscious, the kids were in there crying.  The housekeeper had gone home, and the kids didn’t know what to do.  Do you know what I was thinking?  I was wishing Lisa would die so I could collect the $ 500,000 insurance.
            You get the picture?  As Custer recalled, these people were not just gamblers, they were dishonest.  They had lied, cheated and deceived in order to get money to gamble.  ‘They had lied, cheated and deceived in order to get money to gamble.  ‘They were abysmally insensitive to other people’s needs and feelings, borrowing without any intention to repay, stripping their nearest and dearest of their money and possessions. We did not know, at that point, whether these traits were thee before the gambling problem began or whether they developed as a result of the addiction.  We subsequently leaned that it was the later, that these had been honest, responsible, considerable people before they had become addicted.’

            The immediate challenge was to the tolerance and stamina of doctors and nurses.  For the patients, inevitably, turned their talents for manipulation on the staff – not to get money, but to ease the strictness of their regime in hospital.  They were, by turns, evasive abusive, obstinate in having their own way, refusing to see themselves as sick, yet insisting on a quick cure, intolerant of anyone not like themselves, negative to all advice.  ‘At this stage, the compulsive gambler is very hard to take, to like or even to sympathize with.’
            The staff met in one strategy session after another, trying to identify the basic mode of treatment.  Out of the this came a clear decision: to deal with the behavioral problems which underlay the gambling.  ‘We decided that the most effective way to take on this rather formidable task… would be concentrate on group therapy.  Group therapy permitted open confrontation … by the patients themselves.’  (A technique which had the further advantage, presumably, of placing the long-suffering analyst or doctor at one remove from the somewhat hard-to-take personalities of the patients.)  In group therapy, people relate to each other the way they have been relating to other people in real life, but in real life people can run away and evade the consequences of their behaviour; in group therapy, they cannot. It ’s all up-front.  The others, the victims, will hit right back, even though they themselves may be guilty of the same offence.
            ‘Each person is compelled to sit there and face the group’s reaction, which may be a very tough one, the kind he never had to contend with before.  This forces the individual to see himself the way others see him, to come face to face with his faults and maladaptive behaviour, and to correct them.  Why correct them?  Because few people – least of all compulsive gamblers – can stand disapproval and rejection by the group.
            Thus Custer – but can one suppose that people who had acted out the kind of monstrous experiences described above, in one variation or another, could be ‘cured’ by a few sessions of group therapy?  Well … Custer believes so.  Changes can take place very quickly in group therapy, he says.  ‘Lifelong ways of feeling, thinking and behaving can be changed in just a few sessions, and this is what we counted on in a our daily group-therapy encounters.’

            In support of this view one may say that everyone who chose to go to Brecksville wanted to be cured.  These were people who had hit rock bottom.  They had been driven to the hospital in desperation, there was no other escape route (bar suicide) out of it.  That motivation was the was the pre-condition for any change.  But it only works, of course, while the gambler sticks at it.  in other words, the four brief weeks of group therapy and individual counseling had to be seen as a prelude to a whole lifetime of self-enforced abstinence through attending Gamblers Anonymous.
            Custer devised an acrostic on the word GAMBLING: G- Gambling: A- Alienation; I-indebtedness; N-needs, mainly money with which to support the family; G- goallessness, so as to break down the problems for each patient as an individual.  Restitution was one of the most important elements.  The process of repaying debts, monetary and moral, was seen as binding the gambler to a realistic and tough programme of action that would instill in him new self-respect.  Such restitution, which might not be more than $25 or $ 50 a week and take years to complete, was regarded as a fundamentals part of a man’s rehabilitation.  All this stemmed directly from GA’s  12 steps to recovery (e.g. make a list of all persons who have been harmed and make direct amends wherever possible) which the Brecksville programme took as it s model.  The practical arrangements indeed were turned over to GA.
            Next, custer tried to bring the wives in.  long-suffering women, they had had it up to here.  So when he arranged for the spouse of each gambler to attend a therapy session with her husband, it turned out to be a complete disaster.  ‘The wives were so full of rage and hostility, they could not do anything but vent their violent emotions on the gambler husband.  This was something they had been aching to do, and here was their chance.  This was the last thing Custer wanted, so another approach was tried, assigning a therapist to talk to the wife on her own, during her husband’s four weeks of treatment.  These sessions went on weekly for three months, enabling the wife to work out her hostility and to view the husband, so Custer hoped, as a sick person who had taken a positive step to get rid of his addiction.

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