Assailing problem gambling, brick by brick
This year the institute changed its name and ended its direct affiliation with the Division on Addictions. Why?
Reilly: For two reasons. We started this new initiative called the Centers of Excellence in Gambling Research. We thought that we needed to give people more time and more money to work on really basic issues so that we could continue to move the field forward. And because Howard Shaffer’s group [Shaffer, of Harvard Medical School, is the director of the Division on Addictions] has been doing that type of work for so long we felt it was more appropriate for the institute to oversee the work of the centers; and being part of the division made it difficult to evaluate their work; so we moved the institute to an independent status. … The reason we came to the name was because “pathological gambling” is the term that’s used in the [Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association], and it’s a diagnostic code that doesn’t really account for all the people who have subclinical, or Level II, forms of the disorder - what in alcohol might be called “problem drinking”. And since our research is really focused on all aspects of problem gambling we felt the new name was more reflective of newer research, which has questioned the fact that the definition is really very limited right now.
What would be a more accurate definition?
Reilly: We think that is going to be changing, and it’s going to be changing a lot because of the research we’ve been funding. But that’s what science is all about. You’re constantly questioning where you’ve been before, because every new investigation can show a different side of things or enlighten you in a different way. … Part of the problem is, we’re building the knowledge base; it’s like building blocks, and we’re still putting together all the building blocks to figure out why some people get into trouble with this disorder and most do not. You look at our research and you’ll notice it’s very varied. And the reason why it’s so varied is because the field is still very young, and we are still trying to put together all the pieces so that we can understand it better. Because you really can’t develop effective ways to eliminate the disorder if you don’t really understand the disorder.
How far are we from understanding it?
Reilly: We’ve made a lot of progress in recent years, and it’s simply because the NCRG did two important things: One, it supplied money for research. There was no real money for research before, and that infusion of money has made a huge difference. And the second thing that was important, it wasn’t just that the NCRG threw money at the problem but they demanded higher standards in the field. We want our investigators to go on and compete with everyone else and get money at the national level.
How do the Centers of Excellence fit into this?
Reilly: It’s simply more money and a longer period, and with the emphasis on being seminal, that’s what’s really important. There is a lot of important research going on, but it’s not seminal, it doesn’t really change the way you look at things. And although we still do specific project grants we felt there was a place to give people like Mark Potenza [of Yale University] and Jon Grant [of the University of Minnesota], for example, the opportunity and the time and the money. They’re both working with human subjects, and it is incredibly time-consuming. And they’re collecting original data. So it seemed to make more sense to give them a chance to really focus on basic issues - one on factors that influence treatment, and the other on similarities in impulsive behavior in young people, which may help us predict who will have a gambling problem. So much the better if we can figure out why some people get into trouble and we can stop them before they get into trouble.
Another of your project grants this year also is focusing on behavioral issues in young people.
Reilly: Yes. That’s an interesting grant. It’s a New Investigator grant. These have really two purposes. We do want to get publishable research. And [the recipient, Dr. Serena King of Hamline University] is approaching the issue from a new perspective and probably will produce some really important work. Dr. King will be mentored by Ken Winter [of the University of Minnesota], who is one of the leading people in the field. But it’s also important for her as a new investigator to have support so she can go on to [the National Institutes of Health] and get a career development grant. So we’ll not only be getting interesting research from her, but we’re also going to be cultivating the next generation of researchers.
There are other specific grant categories as well. It’s “very varied,” as you mentioned.
Reilly: There is a lot of variety. Drug trials, testing out new treatment strategies, brief interventions. A lot of Howard Shaffer’s work has been extremely important for taking a new look at what addiction really is and how gambling fits into all of that.
Where is that research headed?
Reilly: One thing they’ve done which is very interesting is they tested a brief intervention based on their booklet “Your First Step to Change”. Most people that have addictions are very ambivalent about changing their behavior, no matter how bad their consequences are, and we don’t think that ambivalence always gets honored in this process, and that as clinicians and health care providers we all need to remember that. So they tested interventions in Nevada and, I believe, Massachusetts. And they’ll be coming out with a publication on that which examines whether for some people with a gambling problem it is easier or more appropriate to give them a self-help booklet and have them work with someone on that, rather than, say, being in therapy once a week. … One of the interesting things they looked at is the issue of symptoms. The current diagnostic approach holds that people are on a very slippery slope when they get this disorder, and there’s no way but down, and it’s a chronic, persistent disorder. But Howard’s faculty has discovered that the population studies just don’t bear that out, that people move back and forth between health and less healthy, and that we need to recognize the dynamic nature of the disorder.
Outreach also is becoming a larger part of the institute’s work. There are a number of online programs, all fairly recent, all of which appear to speak to the practical results of a lot of this research. The webinar series you’ve developed, to take an example. Who is that aimed at?
Reilly: They’re open to anybody. We do it at a level so that it is available to anybody. But we have slightly different audiences depending on the topic. Our very first one was on treating gambling disorders and the two new ways of doing treatment, one of which is cognitive behavioral therapy, and the other is motivational interviewing. So we recruited two of the scientists who have done a lot of work in this area; and although it wasn’t entirely clinicians who attended, it was heavily clinicians.
EMERGE, the online training, what has been the response to that?
Reilly: We just did some training with the San Manuel Tribe in California, and we’ve had an excellent response. I think people were a little scared off at first - “Oh, it’s science-based and was developed by Harvard professors” - but when people get into it they realize that the way we talk about it and the way we use the video clips and everything that it’s a very friendly, accessible program. And people will learn a lot about addiction, as well as gambling, and that is important for employees to know.
Any employee can access this?
Reilly: Yes, if your company decides to participate in it. But they have to contract with us. We can do in-person, but it’s primarily an online program. It was really designed for the large companies that have a lot of people to run through the program. You can run so many people through because it’s available 24/7, and that really fits well with casino employee schedules. And it’s very easy to stylize the program for a company’s needs. Like with San Manuel, we had a lot of slides about what they’re already doing. And they already have a fabulous program, so this reinforces what the company is doing.
As the research itself becomes more varied and more sophisticated, as our body of knowledge grows, as you’ve mentioned, is it becoming more expensive to fund?
Reilly: Not because of inflation, but because certain kinds of research are just more expensive. For example, when you fund a study where you use FMRI brain-imaging equipment to look at people while they’re doing a gambling test; we’ve done a lot of research with that, and that is very expensive. Drug trials are very expensive because you not only have to recruit a certain number of human subjects - recruitment alone can be very expensive - but you have to have doctors there; you have to have people to administer the drugs. There is a lot involved in those kinds of projects. But those are the kinds of projects we need to be doing. And our investigators have been extremely cost-efficient.
How far ahead do you look in this respect? Can you provide a glimpse into the direction the research will be taking in 2010 and beyond?
Reilly: I really can’t yet. Because we are industry-funded it’s really important to keep the industry and the donors separate from our decisions about what kinds of research we fund. Even I’m not allowed to see the research findings until they’ve been accepted by a publication. Another firewall is built around the fact that the institute is governed by a scientific advisory board. They’re going to look back and look ahead, see what the field needs, and they’re going to make recommendations to the NCRG board. For example, should we continue with neuroscience? Should we continue with New Investigators, all of these things. These are the decisions that need to be made by scientists. What’s best for the field? That is the priority. And ultimately what’s best to help these people who have this problem? That’s what we need to keep in the forefront, the person who is suffering with this disorder. We need to never lose sight that that’s why we’re doing this.
Christine Reilly has served as executive director of the Institute for Research on Gambling Disorders since its inception in 2000 as the Institute for Research on Pathological Gambling and Related Disorders. She served from 1997 to 2000 as the first executive director of the National Center for Responsible Gaming. Prior to that she was executive director of the Missouri Humanities Council, the state affiliate of the National Endowment for the Humanities. She is a former associate director of the Alabama Humanities Foundation and a former director of continuing studies at Vanderbilt University Divinity School. She holds a master’s degree from Vanderbilt in American religious history.