Chapter Two

Another Day on the Treatment Treadmill

Let me back up to 1978, when I first began to work with problem gamblers.

Cleveland, Ohio was never known as a big-time gambling town, although it always had a generous supply of illegal bookies, racetracks, and card rooms. However, it was Brecksville, a suburb south of Cleveland, which became the home of the first hospital-based treatment program for what was called then compulsive gamblers. Robert Custer, M.D. started this program in 1972, six years before the responsibility for it became mine.

Long before meeting my first gamblers, I thought I had already heard the worst stories people could tell about others. But the deceit, the financial loss, the total self-preoccupation, and self-hatred that pathological gambling seemed to create astonished even an experienced psychologist. Honest, well-educated men and women had turned into forgers, spouse abusers, pimps, prostitutes, bank robbers, and worse—all for the love of a game of chance. Why would people pay so dearly for what was supposed to be recreation?

Little did I realize then that people who become problem gamblers often have severe personality problems long before they discover gambling. Everything I had been told suggested that problem gamblers were just ordinary folk who had fallen victim to the Devil's games.

It was tempting to write off these gamblers as fools, criminals, or confidence men. Criminals do not belong in hospitals! To see them as bad was easy. To see them as mentally ill was very difficult at first.

When I had been on the Gambling Treatment Program a few months, and was getting to like and enjoy these patients, gamblers were summarily banished from our hospital by order of the Director. He didn't want us admitting problem gamblers any longer. So, for a month or two in the fall of 1978, my work was confined to alcoholics. However, the calls and letters from desperate gamblers and their families did not stop just because the front office had somehow determined that serious gambling problems should not lead to hospitalization.

Life without the gamblers was suddenly dull and depressing. It was another Blue Monday, and my first task of the day was to work on Friday's unopened mail. The first letter read:

Dear Doctor,

Please have patience with this drawn-out, hand-written letter!

My husband is a compulsive gambler and also a veteran. I truly believe Ed is at a critical stage.

Having only recently become aware of the impact and scope of this disease, I feel an urgency to contact you. I wasted a lot of time through ignorance and still I'm only scratching the surface. I want to help my husband and not hinder his recovery.

Here is a run-down. At this time, I have not seen or heard from him in four weeks. We have lost everything of value, including vehicles, property, etc. He even sold our wedding rings. My two children and I live with my family. Up until his disappearance, Ed was working out of town and visiting us on weekends. He disappeared because of bad gambling debts, and he took three checks from a friend's checkbook and forged his name to (hundreds of dollars) worth. (The) extent of indebtedness [sic] counting gambling and legit debts (is) $15,000, to my knowledge.

Extent of legal trouble includes … bad checks … a couple of civil suites (sic) … and a couple breach of trusts, these being considered honorable business transactions, but he cheated the people and used the business to gamble.

His family (parents and brothers) are alienated … he has no friends left. We have been married for 18 years and I honestly don't know if I want to stay in it. My patience and love have been almost used up. I feel a strong moral responsibility as in, “In sickness and in health,” even more so now that I realize he is suffering from a mental illness. Before I viewed it as laziness, irresponsibility, and weak morals.

I am starting legal separation proceedings. I'm not filing for divorce because I'm not sure. I think I need the legal separation for two reasons -_ legal protection and to get custody of our … children.

But … please understand, I will help in any way I can. Mostly, I just don't know the route. Up until now I've been very forgiving and supportive, but I think I hurt him more than helped him. His big excuse is he's really a nice guy, but he's forced to do the things he does for financial reasons. We have had some troubles and he is chronically sick. He has ulcers and diabetes … so at times it has been hard (for him) to make a living. He is a (occupation deleted). He's very intelligent, articulate, and has a charming personality, which has probably saved his skin up to now! But he has not faced the fact that gambling is our problem, not bad luck, bad health, or anything else.

He desires help but can't see a stopping place. “As soon as blah, blah, blah, I'll get help.” I feel he is now completely out of control and not living in reality at all. If I knew where he was and what to do I would have him committed to a hospital so he couldn't hurt himself … he may be suicidal … or he may commit even worse illegal acts than he already has. He is desperate.

Now, Doctor … I want him to come to your hospital … Ed needs a place to go immediately … as soon as he turns up.

I don't know where he is, but I figure he's moved on down the road to make enough money to get out of his latest scrape. Only, of course, he'll gamble it away, too. He's never gone this long without contacting me and I am worried. What can I do to help him? Thank you for listening. My address is (deleted). God bless you and your work.”

Jane Doe, Anytown, USA

What a simple, sincere plea! I put her letter in my Waiting for Answer tray and tried to think about how to tell her we had gone out of the business of treating gamblers.

My bad habit of writing letters in my head instead of on paper was interrupted by the telephone. Annoying. Ill have to make this brief since it's almost time to go into group therapy with the guys.

It was the Hospital Director's office. “Our Ohio Congressman and some of his staff are on their way over to see you, Dr. Taber,” said a very nervous secretary, “and the Hospital Director will expect a full written report of everything! This is highly unusual. The Congressman doesn't want a representative from the Director’s office to be there. The Director is very upset.”

“I'll get back to you as soon as he leaves,” I promised.

I hadn't worn a suit to work that day, but I found a vest and a borrowed tie.

Expensive pinstripes were soon marching down the hall in my direction. The tallest pinstripe turned out to be our local congressman who was also the Chairman of the Congressional Veterans Affairs Committee. I didn't panic; after all, I'd just completed seven years of dealing with a ward full of dangerous lunatics. A congressman might be a nice change.

It was unusual for a mere ward psychologist to get a personal visit from a congressman, and I knew there would be an angry, embarrassed Hospital Director to deal with after that, to say nothing of a swarm of service chiefs, all feeling very left out.

The congressman's visit was not totally unexpected on my part. I was just beginning to understand the importance of the Gambling Treatment Program when our Hospital Director arbitrarily and without explanation closed the program. After seven years of hard work by others, the world’s only inpatient program for pathological gambling, which was attracting patients from all over the United States, was closed. Shut! Out of business!

It was probably my fault. I had voluntarily submitted figures for the first seven years of program activity to the Director's office in my request for additional manpower. Our waiting time for admission had grown to over four weeks, and we were swamped with calls for information and admissions. However, more often than not in a federal bureaucracy, if one is doing something important, you try not to come to the attention of remote superiors. I had violated that rule.

The only (and second-hand) explanation about the closure given me was that gamblers are not sick people, they are bad people. Anyway, we were told there was no authorization for such a program. The bureaucracy was acting like a bureaucracy once again. It was pretending it hadn't been doing what it had been doing for seven years.

Bob Custer had long since left Brecksville, to work in the VA Central Office in Washington, D.C., although I had the marvelous benefit of many telephone conversations with him as work on his pet program went forward.

But the founder and patron saint of gambling treatment was no longer present on the grounds to defend the many fine efforts begun by him at Brecksville. Even working as a highly placed official in Washington, he was unable to obtain a reversal of the Director's order. At the time, hospital directors had enormous power. When all this happened they were still hiring medical doctors to run hospitals, a nasty habit replaced in recent years by an equally insidious penchant for hiring people with degrees such as Master of Business Administration, or Master of Public Health!

At a certain level of administration, it seems that experience and degrees become irrelevant as the desires to protect turf and power drive out all good sense. Administration can be the most dangerous element in any large organization. It is most pernicious when that organization is not required to show a profit.

The hallway to the ward was now filled with a crowd of bustling, exited people. Our housekeeping technician was trying to empty wastebaskets and tidy up. Patients, nurses, an intern or two, and the Congressman and his staff were all milling in circles, looking for a place to be. This was not starting out to be a good day. Or was it?

I never set out to be a psychologist, but it pays pretty well, and you get to be called Doctor a lot. Certainly, there had been no desire to become some kind of expert on problem gambling. In fact, Mother always told me to avoid strange people, especially those who drank, smoked, and gambled. This would eliminate most politicians and mental patients. Obedient son that I am, most of my adult life has been spent working all day every day with boozers, druggies, gamblers, and flat-out lunatics. (Her words, not mine.)

I grew up thinking everyone was crazy, so when my undergraduate psychology teachers began to validate my simple observation, I decided to join psychology in the pursuit of that profession. The basic assumption of universal insanity has served me well. It seldom disappoints. It doesn't hurt so much when you know they're all crazy.

But how the hell do you entertain a United States Congressman in a mental hospital in the middle of a busy morning? You don't; they're having too much fun already!

Like most people, I never thought much about the Veterans Administration once I had used up my GI educational benefits and bought my first home with a VA-backed loan. Certainly I had no concept of the extent of this monster bureaucracy. Nor did I realize that the strong fingers of veterans’ organizations reached throats at the very highest levels of government, through the most tightly held purse strings in the federal budget.

When I was a kid, the traumatized veterans of World War I were in their 30s and forties. Thousands of angry veterans, many of them physically disabled, were out of work during the Great Depression of the 1930s. They were learning how to vote and how to get organized into political pressure groups. Hundreds of veterans took to the streets of Washington, D.C., in the early 1930s, demanding something, anything: jobs, food, education, medical help, a bonus, even a memorial or two for their fallen comrades. These protesting veterans were chased and beaten by our very own federal troops, lead by officers who would later become famous generals in World War II. But the vets prevailed. The Veterans Administration, later the Cabinet level Department of Veterans Affairs, was founded in the 1930s.

What did the veterans get for their pains? After World War II the government gave them money for education, and then left them alone with the universities to work out the details. The government didn't try to go into the education business by starting government universities. Smart move, money well spent. At least they didn't repeat the mistake made when the VA began setting up hospitals, outpatient clinics, and vocational counseling centers to compete with the private sector in medical care. By the 1980s there were about 172 Veterans Hospitals spending billions of dollars every year, mostly on medical and mental problems which had nothing to do with past military service. The veterans' groups thus joined the National Rifle Association and the American Medical Association to become world-class political power brokers.

In these VA hospitals, waiting lines were long, service was indifferent, and standards were generally the lowest in the medical industry. A vet seeking help with a problem that was truly service related was rare indeed. What the veterans got was low-grade, socialized medicine for the underprivileged few, a minority consisting of any veterans who could not afford or would not buy health insurance.

Into this barrel of political pork called the VA, there did fall at times a fertile seed. One such robust germ was Robert Custer, M.D., one-time Chief of the Medical Staff at the Brecksville VA Hospital in Brecksville, Ohio. Dr. Custer and Durand F. Jacobs, Ph.D., Chief of the Psychology Service, enjoyed a brief time of creativity and innovation at Brecksville in the early 1970s. These two were just getting started when they brought me to Brecksville in 1971, to organize a behavior modification unit. I had the psychological expertise, but Drs. Custer and Jacobs made it happen administratively. We began novel programs that were quite radical in a politically conservative agency. Without these two men’s vision and aggressive, courageous support, none of this could ever have come about in a VA hospital.

As I began in 1971 to organize a program for some of the most difficult psychiatric cases in the hospital, the administration also created an outstanding inpatient alcohol treatment program, which literally began saving the lives of hundreds of veterans who had been rejected everywhere else they had gone for help.

Dr. Martin Bielefeld then established what was to be a highly successful vocational rehabilitation unit that ended up working with hundreds of gamblers who had finished four weeks of initial treatment for problem gambling.

A drug-dependency treatment program came into being, new outpatient programs were established, and research papers began to flow into the professional journals. For the first time, problem gamblers were taken seriously and admitted for treatment to a small, specialized section set up within our Alcohol Treatment Program.

Helping vets with gambling problems seemed correct, since gambling has been a major recreation of soldiers for as long as there have been wars for them to fight. Our own armed forces offered slot machine and other forms of gambling in service clubs all over the world. Historically, drinking, gambling, and wenching are what most soldiers do between battles and stints of training.

From 1972 until she left Ohio in 1978, Dr. Alida Glen coordinated the Gambling Treatment Program, and she became a nationally recognized authority on the treatment of gambling problems. Dr. Glen's departure in the spring of 1978 was a great loss to Brecksville, but it opened a door for me. After seven years of running a psychiatric ward, I wangled a transfer to the Alcohol Treatment Program, where I was given this little gambling program to manage … essentially, a program within a program.

The transition from my work with institutionalized schizophrenics to problem gamblers was just the kind of jolting experience one needs every few years to restore the challenges of psychology. What I did not appreciate was the sudden immersion into the politics of VA medical treatment!

It was the members of Cleveland Gamblers Anonymous who first approached Dr. Custer in 1971, asking why, if alcoholics could get hospital treatment, compulsive gamblers could not also be admitted and cared for. Bob Custer was that rare psychiatrist who could really listen to people. He could set aside his own prejudices, preconceptions, theories, and other professional baggage, to open his mind and hear. He was Chief of the Medical Staff, and he could do as he wished. And after careful consideration, what he wished was to admit gamblers to treatment. Never mind that no one had ever done this before; Bob didn't need precedents or orders from the top. In 1972 our Gambling Treatment Program opened at Brecksville, as a sub-specialty of alcohol treatment.

At that time I thought, How curious, and continued my work with chronic psychotics one floor below.

From the beginning, Cleveland Gamblers Anonymous formed a public support base for the program. They drove their own cars thousands of miles through all kinds of weather to take patients to local GA meetings. And when they found themselves with a depressed and possibly suicidal new guy just off the street, they now had our professional treatment program for backup.

Nevertheless, from 1972 until I assumed responsibility for the program in 1978, the Gambling Treatment Program had no official charter, nor any other internal recognition as anything more than a kind of curiosity shop. It was something management in Washington allowed to happen without official sanction.

I would not live with a shadow program. We had potential not only for significant research on problem gambling, but we could serve as a resource and model for other programs in other institutions. Maybe we pushed management's buttons too hard too soon, but it relieved me to see the situation approaching some resolution. I had relentless support locally from Gamblers Anonymous, and nationally from the National Council of Problem Gambling, a group that, at the time, had as its President a wonderful, storybook character named Monsignor Joseph A. Dunne, former chaplain for the New York City Police Department.

So, not long after I took on the program in 1978, the Hospital Director closed it. Word of the closure circulated in Cleveland, New York, and Washington, D.C. Little did the Director know how important the work of Drs. Custer and Glen had become to a nearly invisible but extremely energetic constituency. In relatively short order, unknown to me, a vocal and angry group of Cleveland Gamblers Anonymous members paid a visit to our Hospital Director.

Unheard of in the VA! None of us were used to angry customers complaining about indifferent service. Apparently this vocal delegation was dismissed as simply irrelevant. At the time, the administration was dealing with another huge problem; young veterans of combat in Vietnam were beginning to come to VA hospitals, demanding that their needs be addressed. The imperial VA medical establishment was under siege by these young hoodlums, who were angry, bitter, and hostile. They drank and used drugs. They disdained the older, more obedient World War II vets to whom we were accustomed. They were often dirty, they smelled, and they looked liked hippies. Some lived in caves, in the woods and fields, or on the streets. They hated big government, and they didn't want to be locked up in hospitals. Veterans of a humiliating national defeat were demanding something, anything; jobs, food, education, medical help, a bonus, even a memorial or two for their lost buddies.

It would be some 20 years before the VA finally recognized the significance of post-traumatic stress disorder (PTSD), and began designing programs to help, but that's a different story, now well told by others.

Mindful of the history that had brought us to this point, in my borrowed tie and mismatched vest, I greeted the Congressman and his assistants. Nurse Hilda Newman and a secretary found enough clean cups for coffee. The alcoholics were sent off to meet by themselves in the day room. What a contrast the groups made in the hall as we sorted it out; pinstripes versus a little crowd of shaggy and generally bearded patients in blue jeans.

Finally we were settled in a small circle of chairs. “Dr. Taber,” began the Congressman, “in Washington we hear very good things about the work with compulsive gamblers that goes on here in Brecksville. I was talking with the (VA) Director the other day to find out why your program had suddenly been closed. Seems he's as mystified as I am. Don’t you believe we should be treating troubled gamblers in a hospital?”

It occurred to me that mystification about most things is a hiring criterion for Washington Beltway appointees. Bite your tongue, Taber.

“Sir, it’s the most meaningful work I’ve ever done. I have calls every day from depressed and desperate men asking for help, and if we don't do something, there will simply be no help for the worst cases. Increased crime and suicide are inevitable when there is no help. Our programs for treating alcoholism, drug abuse, and gambling are the only units in the hospital from which men return to productivity and go back on the tax rolls when they complete treatment.”

“OK, Taber,” said the Congressman, “If I make sure you get the people you need, can you show me that it works? Will you keep records and do the research that needs to be done?”

“Yes, sir! Research is one of the things we psychologists do well. You'll get results!”

“Good. Do two things, Taber. Write up two budgets, one for the optimal resources you could use here and one for the least amount you could live with. Your Hospital Director will be working with you, and I’ll be checking on your progress from Washington. You people have been doing something right; you have surprisingly strong support out there in the community.”

Clearly, my friends in Gamblers Anonymous had not been discouraged at the local level. They had gone on up the chain of command to Washington, D.C., and the results were now evident.

That was the general nature of my rather brief meeting. I wrote up my budgets and personnel rosters. Big Budget No. 1 scared everybody, as it was supposed to do, and so Little Budget No. 2 looked like a bargain. The Hospital Director, predictably, demanded detailed reports of both past work and future plans. I immediately resumed admitting gamblers to the hospital but already the internal battles had begun. The Hospital Director, for reasons unrelated to all this, was replaced by an amiable but hardheaded businessman. Although uncomfortable at first playing political hardball, I learned quickly.

I wanted a particular social worker with me on the program, but the Chief of Social Work refused to assign a person full-time, and certainly would not agree for me to have any authority over that person. He capitulated only when I turned to Nursing Service, offering the position to a clinical nurse specialist. That got me the social worker, but left me with the task of making amends with Nursing, without whose support nothing in the hospital could be successful.

Next, I wanted to hire a particular man from outside as a technician for the program, a man whose personal experience and hard-won wisdom would make work with Gamblers Anonymous much more productive and rewarding. However, technicians already hired for other programs wanted a shot at the job. But in the end I won most of my battles over control and turf. The program expanded its personnel into a real working team; psychologist, social worker, psychiatric technician, nurse, part-time physician, and program secretary. We were official. We could offer training experience to graduate interns. We could do research. We could hang out a real shingle for the whole world to see. It was an extremely exciting time for all of us on the front line.

And now I could respond to that sad letter sitting in my Answer tray.

We could send out information about the hospital’s gambling program, about Gamblers Anonymous and Gam-Anon, and some hopeful words of encouragement. “Have him call us.” What else could I say? I could not send out a paddy wagon or ambulance. A hospital has no legal right to confine a person against his will unless there is a clear and immediate danger of harm to self or others. Without an emergency, people cannot be deprived of their civil rights and due process in the courts, even when their actions appeared foolish, self-destructive, and potentially fatal to me.

Tempting as it often seems, taking full and direct control over the life of another person almost always proves ineffective, because it practically eliminates the possibility that new learning can take place. No one can be forced to learn, to change, or to grow psychologically. The resentment created by attempts to force change upon defiant, belligerent gamblers all but guarantees defeat. The law itself is loath to assume control of wayward citizens, and does so only when it must, to protect people, not to change them. The pathological gambler is an even tougher nut to crack.

I settled down to lunch in my office. A call to the Director could wait. First let's make a few notes and develop some strategy.

Ah! Someone knocking on my door. It might have been better to walk over to the cafeteria, but there were sure to be people there I wasn't quite ready to confront.

“Yes, Ruth, come on in. Exciting morning, eh? What's up?”

“Line two. You have an urgent call.”

“Right. When does my trial start?”

“It's long distance. She’s upset and confused.”

“Me too. We'll get along well.”

The call was from the mother of a gambler. Once she was sure she was speaking to a professional who understood gambling problems, her story poured out.

“My son Dave is 38, and he's gambled for years. When he was little his father used to take him to the racetrack. I told his Dad at the time it was wrong, but for him it never was a problem. He said it was just something for the two of them to do together on the weekend.

“Well, my son's gambling has been getting worse for years, especially since my husband died 10 years ago. I can't help Dave anymore. All our savings are gone. I mortgaged my home; Dad's insurance had it paid off once. I had to do it because my son said they’d hurt him, and burn my house anyway if he didn't pay.”

I had to interrupt at this point to get some facts, but I tried to be gentle. The panic in her voice told me this was not a casual inquiry or complaint. In a crisis call you get certain facts early in the conversation; names, addresses, phone numbers, and so forth.

She was 76 and was calling from her home in a small New England town hundreds of miles away. The son was an only child, a college graduate with good earnings. No, he would not be willing to talk to us, and he had no idea that she was making this call. She knew he would reject any suggestion that he come to a hospital for treatment. He would be furious at the idea. He had never admitted that his gambling was the real problem, it was always something else like unfair odds, bad luck, or not having enough money to get a good return on the bets he did win.

“How did you learn about our program for compulsive gamblers?” I asked.

“The newspaper. They said that gamblers could be cured. I just hope you can help me get Dave straightened out.” She was pleading, not demanding.

While I was trying to think of what to say to that, she rushed on. “He always promises to quit, it's always going to be the last time. Sometimes I think he really would like to quit. I sold my car … I don't drive anymore, anyway. Then I even had to sell my jewelry and some paintings and my silver … he … he hits me sometimes … “

Now she was in tears and had to stop for breath. I made some quiet, sympathetic sounds to let her know I was still there, and that I was not making any judgments.

Clearly, she was finally telling someone else all the things that had been her own terrible secrets for years. Her relief seemed like a physical link between us, and I wanted time to pass so this feeling of relief could sink in for her. So much of her own terror had been her inability to share her feelings and thoughts or to get new information and insight from others. For so long she had been a prisoner to her son’s addiction, and, like a prisoner, her first venture out into the light must have been both scary and exciting.

Soon she calmed down and went on. “We had to sell Dad's stocks when Dave got involved with a local bookie and went overboard betting on football. Can you believe this bookie worked in the mayor's office and threatened to ruin our reputation all over town? Dave just goes on and on saying he'll win it back and make everything right, but it just gets worse. He's my son and I love him and I couldn't let him get hurt or go to jail … could I? It's probably my fault; he blames me all the time, anyway. I do my best and it makes him worse. If only Dad were still here … “

Now she was crying again.

Dad? Dad was the guy who gave Dave a powerful role model on which to base a life of gambling. Good old Dad is one complication we don't have to deal with now.

I'd heard it before, and my heart went out to her in her pain, but the thinking that guided this woman's life, the values by which she lived, seemed as crazy to me as the ranting of any schizophrenic.

Sure, non-judgmental therapists make judgments all the time. I make plenty, but we are very, very careful to keep them out of sight, and treat them as private hypotheses that may later re-surface as gentle questions, when the timing seems right.

Almost all my colleagues in the mental health professions would have taken her at face value; a woman deeply troubled by circumstances not of her own making that held her captive. I would have loved to have sat down with her one-to-one, to have the chance to help sort out her assumptions and beliefs, to help her see some real options, and perhaps to challenge her to muster up the courage to change.

She wanted me to help Dave in some magical and powerful way. But Dave himself had no desire for help. She thought a mother had a lifetime obligation to give her son anything and everything anytime it was needed, even if it were killing him! She was ready to blame everybody but Dave for Dave's problems; and she wanted everybody to make the changes she would never dream of requiring him to make for himself.

Her thinking, values, attitudes, actions, and expectations had ruined her life, and contributed to Dave's addiction by adding the fuel for him to continue gambling. Now some magician was to come on stage, wave a magical wand, and make it all good again. Her physical situation was sad and dangerous, but her mental condition was worse.

I tried to give this unhappy woman some of our usual advice on how she could help herself, if not her gambler son, but it seemed futile. Any attempt at this point to sort out her own needs from those of her son would lead her to overwhelming guilt; and then she would reject the idea that she could just walk away from the problem. Unthinkable as that choice might have been to her, it was, after all, her legal right to walk away and refuse any further contact with Dave. It also would have been the most helpful thing she could do for him. But what could a psychologist say in a few minutes over the phone that would alter the habits and values of a lifetime? What could anyone say that might solve a complex problem that had been 30 or 40 years in the making?

But this call was memorable not because of its tragic message—I was used to that—but because it did not end in the usual way.

Usually I try to end with a few words of encouragement, a local referral, an invitation to call back any time, and a promise that we would mail information about our treatment program. The newspaper article she saw also mentioned an organization called Gam-Anon, a support group for those people who have a compulsive gambler in their lives. While I was giving her the numbers of the Gamblers Anonymous and Gam-Anon groups in her area, and encouraging her to call them, I heard a loud banging sound over the phone.

I also sensed that she was not writing down anything I was telling her. The banging grew even louder and more insistent. I asked her about it.

“It's my son,” she said. “He's at the door. I knew he was coming so I called you quick. The article said you helped compulsive gamblers and their families with their problems. You see, I have a few antiques left and he says I have to sell them. He's got a truck out there. He's in big trouble again. I can't help him anymore, I just can't.”

Bang! Bang! Bang!

She rushed on, “My friends asked me where my other furniture went and I told them I sent things out to be recovered. I lie for him. I try to help. Please don't blame me. He gets so angry that he's just not the same person anymore. I'm so afraid of him. He'll break the door. I can't control him … “

She refused my offer to call her local police department to send help, thanked me for listening, and hung up ignoring my final plea to contact the police herself. She was overwhelmed with what had become a hopeless situation. Perhaps, for her, time had run out.

This story has no happy ending. Happy endings are infrequent in the lives of pathological gamblers and their families, unless help and information are available early. I never learned what happened.

To know what to do is often very, very difficult. Should I have called the local police long distance? I had no permission to violate her confidence. I could not prove that her life and safety were being directly threatened, and she had every right to give her son whatever she wished. Intervention at a distance from a stranger can make things a lot worse. On the other hand, the son had been violent to her in the past, and simple human compassion often demands that we err on the side of intervention. But for this lady, Town Hall was already involved, and the mayor would be reading the local police reports daily. Whatever I did could have serious consequences in a no-win situation such as hers, but I still wonder if I did the right thing.

People have the right to live their lives in ways they think best, even if we do not agree with their choices. My primary concern, and what taxpayers were paying me for, was the program and the patients already under our care. I'd given the woman all the information and advice possible under the circumstances. In deciding what to do, it's always these gray areas that get you. It's always hard when you're alone and have to define your responsibilities in a specific situation, in just a few seconds. But this is part of professional responsibility.

How would all of this have sounded a year or two down the road in a court of law, if something I did or said resulted in litigation?

Inaction can be fatal, but sometimes no action is the best action. We are always looking for the wisdom to know the difference. It isn't easy being powerless, until you learn to relax and appreciate it.

Eventually the Gambling Treatment Program was getting about 200 crisis calls each year, and we would have had many more if our hospital switchboard were not overloaded with routine traffic.

The work with pathological gamblers at Brecksville, Ohio now lies in other good hands, but one can never be the same person again, nor see the world in quite the same way, because of such work. So ultimately traumatic and overwhelming is the obsession to gamble, that anyone associated with the problem, be they gambler, therapist, or family member, has to be affected by it.

As time passed other programs for problem gambling started around the country, and, because of Dr. Custer's continuing efforts, pathological gambling was added to the American Psychiatric Association's list of mental disorders. Eventually we were able to publish research showing that formal recognition and treatment of gambling problems pays for itself. It wasn't long before others were showing that they could do it better and cheaper, working pretty much with outpatients. And we learned to do it better and cheaper, too.

In time, Congressman Ron Mottl lost an important election as national priorities changed. However, he did very well exactly what elected officials are supposed to do; he represented the special interests of his local constituency.

In time, veterans of Vietnam began to get help, too.

In my opinion, our United States Congress does exactly what it is supposed to do. It represents the needs of each important group in our nation, and tries to find workable compromises we can all accept. Democracy is slow and painful; it takes time and effort to produce less than perfect results. But democracy is still the best way. The virtues of Congress reflect the virtues of the people, as its sins and failures also accurately reflect our own. Congress tries to make sense out of the conflicting demands of hundreds of special-interest groups. So voters have a responsibility. Let us be very careful, because we are likely to get what we ask from Congress.

At Brecksville we settled into a treatment routine that was, of course, never routine. Our patients were always articulate. They demanded an active role in their own treatment, and they struggled very hard to avoid real personal change. They taught me an important rule: People who most need to change always prefer to work on what they are already good at; and they least want to change what they most need to change. It's true for all of us, isn’t it? We want to be better at doing what has failed us in the past, and we refuse to learn those strange, new habits upon which a better life may be built.

For the next seven years, the problems of gamblers took me all around the country, into many courts of law, and even into the homes and lives of gamblers' families. I spent hundreds of hours studying psychological test results, life histories, medical records, and family histories; hundreds more hours went to individual and group therapy, as well as to screening interviews. But the most fascinating journey of all was into mind of the gambler. Nothing I ever saw on the outside compelled my interest as much as the dark and distorted landscape of thought, the thinking that underlies the appalling behavior known as pathological gambling.

If problem gambling is to be called an illness, it is in every important respect a mental illness. Let us make no mistake about that.

Like it or not, call them what we will, these gamblers—these charming, intelligent, energetic people—are, in common language, crazy.