PROBLEM. IS the medical model used to reify "pathological" gambling?
METHODS. g qualitative field study of 12 subjects with the diagnosis "pathological" gambler.
FINDINGS. None of the 12 subjects being treated for "pathological" gambling fit neatly in the category of "pathological" gambler. An examination of the treatment center revealed institutional grounds for the use of this diagnosis.
CONCLUSIONS. Rather than a medical diagnosis, "pathological" gambling is a socially constructed phenomenon. Using the medical model serves clients interpersonally and clinicians occupationally.
Key words: Gambler, gambling, medicalization of deviance, medical model, "pathological" gambling, qualitative study, socially constructed disorder
The Diagnostic and Statistical Manual (DSM), in its various revisions, has come under criticism often. This criticism stems from alleged poor research, reductionism, and the "politics" that have influenced inclusion of certain disorders (Kirk & Kutchins, 1992; Zimmerman, Jampala, Sierles, & Taylor, 1991). Although "pathological" gambling is included in the DSM-IV (APA, 1994), some believe it should not be.
Following the trend described by Conrad and Schneider (1980), the medical model has been extended to include a number of areas of deviance including problem gambling. This model subsumes a disease concept of "pathological" or "compulsive" gambling (Blume, 1987), but there is no evidence that problem gambling is a disease (Dickerson, 1987; Hayano, 1982; Oldman, 1978; Rosecrance, 1985). As David Oldman wrote:
The "compulsive" gambler is an elusive creature.
Like the yeti we all know of his existence, yet his customary
habitat is localized and unfamiliar and there
is a lack of well-authenticated sightings. (p. 349)
I, like Oldman, believe that although patients coming into treatment do not fit the addictive disease conception of gambling behavior, the medical model is applied to the problem gamblers through political and institutional processes. To investigate this premise I conducted a field study of a program for "compulsive" gamblers.
For this study, Conrad and Schneider's (1980) definition of the medical model was used:
[T]he medical model of deviance locates the source
of deviant behavior within the individual, postulating
a physiological, constitutional, organic, or,
occasionally, psychogenic agent or condition that is
assumed to cause the behavioral deviance. The
medical model of deviance, usually, although not
always, mandates intervention by medical personnel
with medical means as treatment for the "illness." (p. 35)
Sheila Blume (1987), a psychiatrist who treats gamblers, argues that the medical model involves a "disease" or "illness" concept and that "compulsive" gambling fits the addictive disease model as well:
In order for a behavior pattern to fit a disease
model it must be reliably and repeatedly harmful to
the individual and/or others. The pattern must be
characteristic for the individual and outside of full
conscious control. (This differentiates kleptomania
from stealing and alcoholism from drinking.) It
must not be a symptom of some other disease, nor
an unconscious habit which can be changed by
merely paying attention to the behavior. Finally, the
behavior and accompanying internal state must follow
a predictable course which is common to other
individuals, yielding describable signs, symptoms,
stages of development, and patterns of harm. Thus
a single isolated episode of driving while intoxicated
may cause death to the driver, but the person
could not be diagnosed an alcoholic unless drinking
patterns over time matched those or others with
that diagnosis. …