Iowa Gambling Treatment Outcomes System: Year 4

Transcription

1 Iowa Gambling Treatment Outcomes System: Year 4 Prepared by Gene M. Lutz, Melvin E. Gonnerman Jr., Rod Muilenburg, Anne Bonsall Hoekstra, Karen Dietzenbach, & Ki H. Park Center for Social and Behavioral Research University of Northern Iowa With Assistance from Mollie Burke, Disa L. Cornish, & Kathryn Nelson Center for Social and Behavioral Research University of Northern Iowa Prepared for Iowa Department of Public Health Division of Behavioral Health Iowa Gambling Treatment Program August 2009

2 For further information, contact: Mark Vander Linden, MSW, Coordinator Iowa Gambling Treatment Program Iowa Department of Public Health, Lucas State Office Building, Sixth Floor 321 East 12th Street, Des Moines, IA (515) Gene M. Lutz, Professor and Director, Center for Social and Behavioral Research University of Northern Iowa, 2304 College St., Cedar Falls, IA ; ii

3 TABLE OF CONTENTS Page I. Background and Methodology...1 Purpose...1 Background...1 Data Sources...2 Sample Sizes: Questionnaire Data...3 Sample Sizes: GTRS Data...4 Presentation of Findings...5 II. Gambling Treatment System...7 Admissions Trend by Fiscal Year...7 Admissions, Services, and Discharges: 2008 Calendar Year...8 III. Main Findings...9 Highlights...9 Types and Locations of Wagering...10 Money Lost Gambling...17 Psychosocial Functioning...21 Recent Behaviors and Experiences...32 DSM-Problem Gambling Indicators...36 Intention to Change...41 Satisfaction with Treatment Services...45 IV. Summary...49 Wagering...49 Psychosocial Functioning...49 DSM-Problem Gambling Indicators...49 Behavior Change...50 Satisfaction with Treatment...50 Conclusions...50 Appendix A: Distance Treatment Program...51 Appendix B: Admission Questionnaire Tables Appendix C: One Month Questionnaire Tables Appendix D: Discharge Questionnaire Tables Appendix E: Six Month Follow-Up Questionnaire Tables Appendix F: GTRS Admission Form Tables iii

4 TABLE OF CONTENTS (Continued) Page Appendix G: GTRS Services Form Tables Appendix H: GTRS Discharge Form Tables Appendix I: GTRS Admission-Discharge Paired-Sample Tables Appendix J: IGTO Admission Questionnaire Appendix K: IGTO One Month Questionnaire Appendix L: IGTO Discharge Questionnaire Appendix M: IGTO Follow-Up Questionnaire Appendix N: GTRS Admission Form Appendix O: GTRS Services Form Appendix P: GTRS Discharge Form Appendix Q: Technical Notes iv

5 LIST OF TABLES Page Table 1: Types of Wagering: Admission...11 Table 2: Types of Wagering: One Month...11 Table 3: Types of Wagering: Discharge...12 Table 4: Types of Wagering: Follow-Up...12 Table 5: Gambling Locations: Admission...14 Table 6: Gambling Locations: One Month...14 Table 7: Gambling Locations: Discharge...15 Table 8: Gambling Locations: Follow-Up...15 Table 9: Monetary Loss from Gambling: Admission...18 Table 10: Monetary Loss from Gambling: One Month...18 Table 11: Monetary Loss from Gambling: Discharge...19 Table 12: Monetary Loss from Gambling: Follow-Up...19 Table 13: Financial Functioning: Admission...23 Table 14: Financial Functioning: One Month...23 Table 15: Financial Functioning: Discharge...24 Table 16: Financial Functioning: Follow-Up...24 Table 17: Emotional Functioning: Admission...26 Table 18: Emotional Functioning: One Month...26 Table 19: Emotional Functioning: Discharge...27 Table 20: Emotional Functioning: Follow-Up...27 Table 21: Interpersonal Functioning: Admission...29 Table 22: Interpersonal Functioning: One Month...29 Table 23: Interpersonal Functioning: Discharge...30 Table 24: Interpersonal Functioning: Follow-Up...30 Table 25: Recent Behaviors and Experiences: Admission...33 Table 26: Recent Behaviors and Experiences: One Month...33 Table 27: Recent Behaviors and Experiences: Discharge...34 Table 28: Recent Behaviors and Experiences: Follow-Up...34 Table 29: Current Intention to Change: Admission...42 Table 30: Current Intention to Change: One Month...42 Table 31: Current Intention to Change: Discharge...43 Table 32: Current Intention to Change: Follow-Up...43 v

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7 LIST OF FIGURES Page Figure 1: Sample Size for Questionnaire Data...3 Figure 2: GTRS Admissions for Fiscal Years Figure 3: Reason for Discharge: GTRS Discharge Forms....8 Figure 4: Any Type of Wagering During the Past 30 Days...10 Figure 5: Types of Wagering: Paired Sample...13 Figure 6: Locations of Wagering: Paired Sample...16 Figure 7: Lost Money Gambling During the Past 30 Days...17 Figure 8: Lost Money Gambling During the Past 30 Days: Paired Sample...20 Figure 9: Mean Number of Psychosocial Financial Problems During the Past 30 Days...21 Figure 10: Mean Number of Psychosocial Emotional Problems During the Past 30 Days...22 Figure 11: Mean Number of Psychosocial Interpersonal Problems During the Past 30 Days..22 Figure 12: Financial Indicators of Psychosocial Functioning During the Past 30 Days: Paired Sample...25 Figure 13: Emotional Indicators of Psychosocial Functioning During the Past 30 Days: Figure 14: Paired Sample...28 Interpersonal Indicators of Psychosocial Functioning During the Past 30 Days: Paired Sample...31 Figure 15: Felt Depressed or Hopeless During the Past 30 Days...32 Figure 16: Thoughts and Feelings During the Past 30 Days: Paired Sample...35 Figure 17: Current DSM Problem Gambling Indicators...36 Figure 18: Current DSM Problem Gambling Indicators: Admission...37 Figure 19: Current DSM Problem Gambling Indicators: One Month...37 Figure 20: Current DSM Problem Gambling Indicators: Discharge...38 Figure 21: Current DSM Problem Gambling Indicators: Follow-Up...38 Figure 22: Figure 23: Current DSM Problem Gambling Diagnosis at Admission and Discharge: Paired Sample Current DSM Problem Gambling Indicator at Admission and Discharge: Paired Sample...40 Figure 24: Intention to Change Problem Gambling Behavior...41 Figure 25: Current Intention to Change Gambling Behavior: Paired Sample...44 Figure 26 Overall Rating of the Services Received: Discharge...45 Figure 27: Overall Rating of the Services Received: Follow-Up...46 Figure 28: How Beneficial Was the Treatment Program: Follow-Up...46 Figure 29: Length of the Gambling Treatment: Discharge...47 Figure 30: Length of the Gambling Treatment: Follow-Up...47 Figure 31: Would Recommend the Program to Others: Discharge...48 Figure 32: Would Recommend the Program to Others: Follow-Up...48 vii

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9 EXECUTIVE SUMMARY Iowa Gambling Treatment Outcomes System: Year 4 Center for Social and Behavioral Research, University of Northern Iowa (August 2009) Project Description Project History. This is the fourth year that the Center for Social and Behavioral Research (CSBR) at the University of Northern Iowa (UNI) has conducted the Iowa Gambling Treatment Outcomes (IGTO) System. Since July 2005, the IGTO System has been in operation to collect and report information about the extent to which gambling treatment services provided via the Iowa Gambling Treatment Program (IGTP) are associated with positive outcomes in the lives of the clients who received services at treatment agencies contracted by the State of Iowa. The findings in this year s report are mainly about clients who received gambling treatment services during the 2008 calendar year. Protocol. The IGTO protocol has been modified over time in response to treatment provider feedback, client participation and analytic reviews. In general, the IGTO protocol relies on data from the Gambling Treatment Reporting System (GTRS) and from questionnaires completed at the time of admission, one month after admission, discharge, and six months after discharge. In July 2008, the agencies began offering distance treatment services to a small number of clients which required modifying the basic protocol to allow for the collection of additional data on these clients. The research protocol has been under continuous review from the University of Northern Iowa Institutional Review Board to ensure compliance with current legal and ethical considerations. Data Sources. Several data sources were used in preparing this year s report: GTRS Forms, questionnaire data, distance treatment telephone interviews, and a focus group. The report relies most heavily on the data from 262 Admission Questionnaires, 192 One Month Questionnaires, 106 Discharge Questionnaires, and 147 Six Month Follow-Up Questionnaires. The report also relies on GTRS forms for clients in the standard treatment program (461 GTRS Admission Forms, 484 Discharge Forms, and 2,481 Services Forms). These data sources are augmented by a limited amount of quantitative data from the clients who received distance treatment services and from qualitative data collected during a focus group with counselors and administrators discussing the distance treatment program. Limitations. A variety of factors can affect the representativeness and generalizability of findings regarding the outcomes of any intervention or treatment. In the present project, attrition and non-response bias are potentially limiting factors. Attrition occurs as clients leave without completing treatment. Because the discharge data are mainly available for only those who completed all or a substantial portion of treatment, these findings may be somewhat biased in terms of the positivity of outcomes and client attitudes if those who left treatment were less successful and less positive about their treatment. Non-response bias becomes an issue when the behaviors and opinions of those who completed the questionnaires systematically differ from those who did not complete the questionnaires. Non-response bias would occur if those with unfavorable outcomes had substantially different participation rates than those with favorable outcomes. Offering a $25 store certificate as compensation to follow-up respondents is an effort to help counteract this possibility. The effects of attrition and non-response bias on the representativeness and generalizability of the findings for this project are undetermined. ix

10 Main Findings Places and Types of Wagering. The two most frequently mentioned places where clients reported gambling were casinos and convenience stores. The most common types of wagering activities were slot machines, lottery scratch tickets and pull-tab games, casino table games, and lottery tickets. Treatment Outcomes: Six Month Follow-Up. Based on the data from clients who responded to the six month follow-up questionnaire, more positive treatment outcomes were observed among those who completed treatment as compared to those who did not complete treatment. Specifically: Treatment completers were 42% less likely to have gambled in the past 30 days than noncompleters (41% vs. 71%). Treatment completers were 80% less likely to have given up important activities due to gambling in the past 30 days than non-completers (2% vs. 10%). Treatment completers were 53% less likely to be classified as pathological gamblers in the past 30 days than non-completers (7% vs. 15%). Treatment completers were 51% more likely to have reduced or quit gambling for six months or longer (77% vs. 51%). Treatment Satisfaction. Six months after leaving treatment, respondents who completed treatment rated the quality of the treatment services favorably. Specifically, 33% of respondents who completed treatment rated the treatment as good and 63% rated the treatment as excellent. Among those who completed treatment, 93% said they would recommend the treatment program to a friend or family member with a gambling problem. Conclusions There are many positive outcomes for clients of the publicly funded gambling treatment program. About one-third of the clients who were admitted into the program during 2008 completed all or a substantial portion of treatment. Generally, these clients expressed high levels of satisfaction with the treatment services they received and thought the treatment was beneficial to their recovery. Six months after being discharged, there were positive treatment outcomes in several areas of the lives of clients who completed treatment. x

11 BACKGROUND & METHODOLOGY Purpose This is the fourth year that the Center for Social and Behavioral Research (CSBR) at the University of Northern Iowa (UNI) has conducted the Iowa Gambling Treatment Outcomes (IGTO) System. Since July 2005, the IGTO System has been in operation to collect and report information about the extent to which gambling treatment services provided via the Iowa Gambling Treatment Program (IGTP) are associated with positive outcomes in the lives of the clients who received services at treatment agencies contracted by the State of Iowa. The findings in this year s report are mainly about clients who received gambling treatment services during the 2008 calendar year. Background The IGTO protocol has been modified over time in response to treatment provider feedback, client participation and analytic reviews (see Lutz et al., 2006 and 2007 for discussions of the project s initial and revised protocols 1 ). In general, the IGTO protocol relies on questionnaire data completed at the time of admission, one month after admission, at discharge, and six months after discharge and also on data from the Gambling Treatment Reporting System (GTRS). The research protocol has been under continuous review from the University of Northern Iowa Institutional Review Board to ensure compliance with current legal and ethical considerations. Year One. The first year of the IGTO monitoring system project focused on developing the protocol and the measurement instruments which could be used to provide the State of Iowa with information about the outcomes and treatment experiences of clients receiving gambling services within the publically funded treatment system. Year Two. The second year of the IGTO monitoring system project involved evaluating and adjusting the system with the aim of improving the effectiveness and efficiency of the process while considering the needs and concerns of the clients, providers, state, and research unit. This led to revised questionnaires and administration protocol which went into effect in July Year Three. No major changes were made to the protocol during this year. The amount of data collected from the questionnaires continued to improve in the third year of the IGTO monitoring system project. The analysis for the third year focused on questionnaire data for clients in the system during the 2007 calendar year. 1 Lutz et al. (2006). Iowa Gambling Treatment Outcomes System: Year 1. University of Northern Iowa: Cedar Falls, IA. Lutz et al. (2007). Iowa Gambling Treatment Outcomes System: Year 2. University of Northern Iowa: Cedar Falls, IA. 1

12 Year Four. A major system-level change for the fourth year was the addition of providing distance treatment services starting July By the end of June 2009, there were eight agencies certified to provide distance treatment services. At present, the number of clients who have enrolled in the distance treatment program is small, and many of the enrolled clients are receiving a combination of standard and distance treatment services. In April 2009, CSBR conducted a focus group to provide qualitative information about provider experiences and perceptions of the distance treatment program. Findings related to the distance treatment program are included in Appendix A. Data Sources In this year s report, the main outcome areas of interest are financial consequences, gambling locations, type of wagering, psychosocial functioning, problem behaviors, DSM-problem gambling indicators, intention to change, and satisfaction with treatment. The narrative relies on the analysis of questionnaire data for the main outcome areas (see Appendix B-E for additional findings). 2 For many outcomes, results of paired-sample analyses (i.e., data for the admission and discharge questionnaires) are matched by client number. Because not every client completed an admission and discharge questionnaire during the 2008 calendar year, the sample size for paired-analysis is smaller than the analysis for all admission and discharge questionnaires. Although the main narrative primarily relies on questionnaire data, the GTRS data were also analyzed and summarized as part of the report (see Appendix F-I for additional findings). 3 Questionnaires and GTRS forms associated with distance treatment clients are not included in the counts or analyses in this report, with the exception of the sections dealing directly with the distance treatment program (see Appendix A for information about the distance treatment program). The questionnaires and GTRS forms are included in Appendix J-P. 2 Additional findings: Admission Questionnaire (see Appendix B), One Month Questionnaire (see Appendix C), Discharge Questionnaire (see Appendix D), and Six Month Follow-Up Questionnaire (see Appendix E). 3 Additional findings: GTRS Admission Form (see Appendix F), GTRS Services Form (see Appendix G), GTRS Discharge Form (see Appendix H), and GTRS Admission-Discharge Paired-Sample (see Appendix I). 4 Forms and questionnaires are found in the following appendixes: IGTO Admission Questionnaire (see Appendix J), IGTO One Month Questionnaire (see Appendix K), IGTO Discharge Questionnaire (see Appendix L), IGTO Follow-Up Questionnaire (see Appendix M), GTRS Admission Form (see Appendix N), GTRS Services Form (see Appendix O), and GTRS Discharge Form (see Appendix P). 2

13 Samples Sizes: Questionnaire Data Admission Questionnaire. A total of 262 Admission Questionnaires were completed and returned for the 2008 calendar year. Some clients were admitted two or more times during the year. There were 252 unique respondents for whom Admission Questionnaire data were available. One Month Questionnaire. A total of 192 One Month Questionnaires were completed and returned for the 2008 calendar year. Some respondents completed two or more such questionnaires during the year, so data were available for 186 unique respondents. Discharge Questionnaire. A total of 106 Discharge Questionnaires were completed and returned for the 2008 calendar year. Some respondents completed two or more such questionnaires during the year, so data were available for 104 unique respondents. Generally, data for the discharge questionnaire were available only for respondents who completed all or a substantial portion of their treatment. Six Month Follow-Up Questionnaire. A total of 147 Six Month Follow-Up Questionnaires were completed. Unlike the other questionnaires which correspond to the 2008 calendar year, the Six Month Follow-Up Questionnaires are for the time period of June 1, 2008 through May 30, This allows for the necessary lag period so that the follow-up data correspond to the same cohort as completed the other questionnaires. Of the 147 respondents who completed the Six Month Follow-Up Questionnaire, 41% had completed all or a substantial portion of treatment. One respondent completed two questionnaires during this period. When mailed questionnaires are not returned, respondents were contacted by telephone and the information was collected by CSBR telephone interviewers. The follow-up findings are typically presented separately for those who completed and those who did not complete treatment, which was determined by matching the client s follow-up questionnaire with the corresponding GTRS Discharge Form. Questionnaire: Paired-Sample Analysis. There were 59 respondents for whom data were able to be matched between their admission and discharge questionnaires. One Month (192) Admission (262) Discharge (106) Follow Up (147) Figure 1. Sample Size for Questionnaire Data. 3

14 Samples Sizes: GTRS Data GTRS Admission Form. A total of 461 Admission Forms were available for analysis with activity dates in These forms corresponded to 420 unique clients during the 2008 calendar year. GTRS Services Form. A total of 2,481 Services Forms were available for analysis with activity dates in These forms corresponded to 579 unique clients during the 2008 calendar year. GTRS Discharge Form. A total of 484 Discharge Forms were available for analysis with activity dates in These forms corresponded to 442 unique clients during the 2008 calendar year. GTRS: Paired-Sample Analysis. Data from a total of 305 matched admission-discharge sets were available for analysis. Merging Questionnaire and GTRS Forms. By merging information available from the IGTO monitoring system questionnaires and the GTRS forms, the attitudes and behaviors of clients who completed treatment verses clients with other discharge dispositions can be examined six months after their discharge form has been processed. This provides important information to help contextualize the information obtained in the Discharge Questionnaire and GTRS Discharge Form because most of the data associated with these two data sources are obtained from those who successfully completed all or a substantial portion of treatment. Thus, the findings associated with discharge data may be somewhat biased in terms of the positivity of outcomes and client attitudes because those who left treatment may possibly have been less successful in the program and been less positive about their treatment. The six month follow-up data may be similarly biased if clients with less successful outcomes were less likely to respond to the questionnaire than those with more favorable outcomes. The extent to which the generalizability of the questionnaire data may be affected by attrition and non-response bias is undetermined. 4

15 Presentation of Findings Organization. This report is organized in a way that balances presenting the maximum amount of information from various data sources with the need to present the findings in a clear and concise manner. The findings are presented for the following topic areas: Money Lost Gambling Places Gambled Types of Wagering Psychosocial Functioning Recent Behaviors and Experiences DSM-Problem Gambling Indicators Intention to Change Satisfaction with Treatment Color Coding. Color coding and Venn diagrams were used to aid the reader in interpreting the findings from the various data sources. For instance, findings using the IGTO monitoring system questionnaires are color-coded as follows: green for Admission Questionnaire data, light blue for One Month Questionnaire data, orange for Discharge Questionnaire data, and dark blue for Six Month Follow-Up Questionnaire data. In each section, the tables show findings for admission, one month, discharge, and six month followup. These tables are typically followed by a graph showing findings from the paired-sample analyses for respondents for whom an Admission Questionnaire and Discharge Questionnaire could be matched. Explanation of Terms. The term respondents refers to those clients who completed the questionnaires. The term clients is used for the results based on the GTRS data. Clients sometimes is also used to more broadly refer to people who received IGTP services. When discussing GTRS data, the terms admissions and discharges typically refer to forms processed rather than clients, per se. The phrase six months after leaving treatment refers to a time period starting with six months after the activity date recorded on the client s GTRS Discharge Form and ending with when the Six Month Follow-Up Questionnaire was completed. In some cases, this represents a time period of greater than six months. The term completed treatment is used to refer to respondents who completed all or a substantial portion of treatment according to their GTRS Discharge Form. The data shown in the main report are based on forms and questionnaires associated with those admitted for and receiving the standard treatment which refers to treatment-as-usual (TAU) (i.e., non-distance treatment). 5

16 Based on self-reported questionnaire responses to 10 indicators of gambling pathology, respondents were classified as current pathological gamblers, problem gamblers, at-risk gamblers, or they received an indefinite diagnosis. Using this questionnaire data, respondents were classified as current pathological gamblers if they said they had experienced 5 or more of the 10 DSM indicators during the past 30 days. Respondents were classified as problem gamblers if they said that during the past 30 days they had experienced 3 or 4 of the 10 DSM indicators provided that at least one of the indicators was (a) committing illegal acts to finance gambling, (b) losing or almost losing a significant relationship, job, educational or career opportunity because of gambling, or (c) relying on others to provide money to relieve a desperate financial situation caused by gambling. Respondents were classified as at-risk gamblers if they said that during the past 30 days they had experienced 3 or 4 of the 10 DSM indicators but none of them involved (a) committing illegal acts to finance gambling, (b) losing or almost losing a significant relationship, job, educational or career opportunity because of gambling, or (c) relying on others to provide money to relieve a desperate financial situation caused by gambling. Respondents were classified with an indefinite diagnosis if they said that during the past 30 days they had experienced 2 or fewer of the 10 DSM indicators. An indefinite diagnosis does not necessarily mean the person does not have a gambling problem, but it means that there was insufficient evidence of current pathology based on self-reported questionnaire responses. A professional treatment provider may be aware of additional information beyond what is assessed in the self-report questionnaire that could indicate the client would benefit from receiving gambling treatment services. The classifications reported in this document were made based upon the respondents reports of the gambling-related thoughts and behaviors they are currently (i.e., during the past 30 days) experiencing. This is a more restrictive classification than recent or past-year pathology or lifetime pathology. The term significantly or statistically significant means that the subgroup differences were statistically significant at the 95% confidence level using an appropriate inferential statistical test. The 95% confidence level means that one can be 95% confident that observed differences were not due to chance alone but represent actual differences between the demographic subgroups or treatment groups. Tables and Figures. In this report, the values presented generally correspond to valid percent unless otherwise noted. The valid percent is based on a denominator of respondents for whom the question was relevant and data were available. Typically, it omits no response and not applicable options. In some cases, this differs from the total percent which is based on a denominator of all respondents. (The number of cases in the denominator is shown as n in tables and figures.) Rounding. Values are rounded to the nearest whole percent in the narrative and to one decimal place in the appendixes. In some cases, the values may appear not to sum to 100% due to the effect of rounding. Also, the sum of values presented in graphs may differ by a percentage point from the cumulative value reported in the narrative due to the cumulative effect of rounding. Technical Notes. Technical notes about data processing are discussed in Appendix Q. 6

17 GAMBLING TREATMENT SYSTEM Admission Trend by Fiscal Year The historical trend of admissions for gambling treatment services are shown in Figure 2 by fiscal year FY1998 FY1999 FY2000 FY2001 FY2002 FY2003 FY2004 FY2005 FY2006 FY2007 FY2008 Figure 2. GTRS Admissions for Fiscal Years

18 Admissions, Services, and Discharges: 2008 Calendar Year For clients in the standard treatment program, there were 461 GTRS Admission Forms with activity dates in 2008 (see Appendix F for additional information). Based on GTRS Service Forms submitted, the treatment agencies provided approximately 9,750 gambling treatment sessions corresponding to more than 11,800 hours of treatment to 579 clients during the 2008 calendar year (see Appendix G for additional information). Specifically, the treatment service agencies provided slightly more than 4,500 hours of individual counseling and approximately 5,750 hours of group counseling (excluding crisis counseling, family counseling, and continuing care services). The counselors recommended to 76% of the clients that they should attend Gamblers Anonymous or some similar recovery group. Slightly more than one-half (58%) of the clients either received or were recommended to receive debt management or financial counseling. For clients in the standard treatment program, there were 484 GTRS Discharge Forms with activity dates in 2008 (see Appendix H for additional information). About one-third of discharge forms indicated that the client completed all or a substantial portion of treatment, but about one-half (49%) of the forms indicated that the client left before completing treatment (see Figure 3). 6% 10% 20% Treatment Plan Completed Treatment Plan Substantially Completed Client Left 15% Referred Outside 49% Other Figure 3. Reason for Discharge: GTRS Discharge Forms. 8

19 MAIN FINDINGS Highlights Places and Types of Wagering. The two most frequently mentioned places where clients reported gambling were casinos and convenience stores. The most common types of wagering activities were slot machines, lottery scratch tickets and pull-tab games, casino table games, and lottery tickets. Treatment Outcomes: Six Month Follow-Up. Based on the data from clients who responded to the six month follow-up questionnaire, more positive treatment outcomes were observed among those who completed treatment as compared to those who did not complete treatment. Specifically: Treatment completers were 42% less likely to have gambled in the past 30 days than noncompleters (41% vs. 71%). Treatment completers were 80% less likely to have given up important activities due to gambling in the past 30 days than non-completers (2% vs. 10%). Treatment completers were 53% less likely to be classified as pathological gamblers in the past 30 days than non-completers (7% vs. 15%). Treatment completers were 51% more likely to have reduced or quit gambling for six months or longer (77% vs. 51%). Treatment Satisfaction. Six months after leaving treatment, respondents who completed treatment rated the quality of the treatment services favorably. Specifically, 33% of respondents who completed treatment rated the treatment as good and 63% rated the treatment as excellent. Among those who completed treatment, 93% said they would recommend the treatment program to a friend or family member with a gambling problem. 9

20 Types and Locations of Wagering Prior to being admitted for treatment, 68% of respondents said they had gambled during the past 30 days (see a related discussion about people s readiness to change in the Intention to Change section on page 41). In contrast, 22% of respondents said they had gambled during the 30 days prior to being discharged. Six months after treatment, respondents who had completed treatment were less likely than those who had not completed treatment to report having gambled during the past 30 days. Specifically, 41% of respondents who completed treatment and 71% of those who did not complete treatment said they had gambled at least once during the past 30 days. The most common types of wagering activities were slot machines, lottery scratch games and pull-tabs, casino table games, and lottery tickets (see Tables 1-4). Casinos and convenience stores were the two most frequently mentioned places at which respondents gambled (see Tables 5-8). 100% 80% 60% 68% 71% 40% 20% 31% 22% 41% 0% Admission One Month Discharge Follow Up (Completed) Follow Up (Did Not Complete) Figure 4. Any Type of Wagering During the Past 30 Days. 10

21 Table 1 Types of Wagering: Admission During the past 30 days, did you gamble at the following? (n =244) Casino table games 19 Slots 44 Live keno 1 <1 Video: Poker/keno/blackjack 1 8 Touch play machines 1 1 Cards not in a casino 5 Bingo 4 Scratch tickets and pull tabs 20 Lotteries 17 Racetrack <1 Sports 1 3 High risk trading <1 Other 2 Internet 2 4 Note. 1 (n = 243), 2 (n = 242). Admission One Month Follow Up Discharge Slightly less than one-half of the respondents (44%) said they had gambled using slot machines during the 30 days prior to being admitted for gambling treatment. Table 2 Types of Wagering: One Month During the past 30 days, did you gamble at the following? (n =171) Casino table games 4 Slots 18 Live keno 0 Video: Poker/keno/blackjack 4 Touch play machines 0 Cards not in a casino 1 Bingo 2 Scratch tickets and pull tabs 6 Lotteries 7 Racetrack 0 Sports 1 High risk trading <1 Other 1 2 Internet 1 Note. 1 (n = 170). Admission One Month Follow Up Discharge About one month into treatment, 18% of respondents had gambled using slot machines during the past 30 days. 11

22 Table 3 Types of Wagering: Discharge During the past 30 days, did you gamble at the following? (n = 92) Casino table games 6 Slots 10 Live keno 0 Video: Poker/keno/blackjack 3 Touch play machines 1 Cards not in a casino 1 Bingo 2 Scratch tickets and pull tabs 6 Lotteries 8 Racetrack 0 Sports 0 High risk trading 0 Other 2 Internet 1 Admission One Month Follow Up Discharge At discharge, 10% of respondents said they had gambled using slot machines during the past 30 days. Table 4 Types of Wagering: Follow-Up () During the past 30 days, did you gamble at the following? Completed (n = 60) Did Not Complete (n = 87) All Respondents (n = 147) Casino table games Slots Live keno <1 Video: Poker/keno/ blackjack Touch play machines Cards not in a casino Bingo Scratch tickets and pull tabs Lotteries Racetrack Sports High risk trading Other Internet Note. Statistically significant differences: table games, video poker/keno/ cards, and scratch tickets. 1 (n = 86 not completed, 146 total). 2 (n = 84 not completed, 144 total). 3 (n = 59 completed, 85 not completed, 144 total). 4 (n = 59 completed, 146 total). 5 (n = 85 not completed, 145 total). 6 (n = 59 completed, 81 not completed, 140 total). Admission One Month Follow Up Discharge Six months after leaving treatment, 32% of respondents said they had gambled using slot machines during the past 30 days. 12

23 Paired-Sample. Among those respondents who completed both an Admission and a Discharge Questionnaire, there were significant decreases in wagering using casino table games, slot machines, lottery tickets, and lottery scratch games during the past 30 days. Admission One Month Discharge Follow Up Casino table games Slots Live keno Video:Poker/keno/blackjack Touch play machines Cards not in a casino Bingo Scratch tickets and pull tabs Lotteries Racetrack Sports High risk trading stocks Internet Other 25% 8% 35% 12% 0% 0% 10% 6% 4% 2% 6% 2% 4% 2% 27% 12% 21% 6% 2% 0% 2% 0% 0% 0% 8% 2% 4% 4% 0% 20% 40% 60% 80% 100% Admission Discharge Figure 5. Types of Wagering: Paired Sample (n = 59). 13

24 Table 5 Gambling Locations: Admission In the past 30 days, did you at any time (even once) gamble at the following? (n =243) Casino 56 Racetrack 2 Sporting event 1 Bar or restaurant 5 School <1 Work 3 Home or a friend s home 6 Convenience store 24 On the Internet 4 Other 3 Admission One Month Follow Up Discharge More than one-half (56%) of respondents said they had gambled at casinos during the 30 days prior to being admitted for gambling treatment. Table 6 Gambling Locations: One Month In the past 30 days, did you at any time (even once) gamble at the following? (n =171) Casino 21 Racetrack 0 Sporting event 1 Bar or restaurant 0 School 0 Work 2 Home or a friend s home 2 Convenience store 10 On the Internet 1 Other 2 Admission One Month Follow Up Discharge About one month into treatment, 21% of respondents said they had gambled at a casino during the past 30 days. 14

25 Table 7 Gambling Locations: Discharge In the past 30 days, did you at any time (even once) gamble at the following? (n = 92) Casino 13 Racetrack 0 Sporting event 0 Bar or restaurant 3 School 0 Work 2 Home or a friend s home 0 Convenience store 10 On the Internet 1 Other 2 Admission One Month Follow Up Discharge At discharge, 13% of respondents said they had gambled at a casino during the past 30 days. Table 8 Gambling Locations: Follow-Up () In the past 30 days, did you at any time (even once) gamble at the following? Completed (n = 58) Did Not All Complete Respondents (n = 84) (n = 142) Casino Racetrack 0 1 <1 Sporting event 0 1 <1 Bar or restaurant School Work Home or a friend s home Convenience store On the Internet Other Note. Statistically significant differences: casino and convenience store. Admission One Month Follow Up Discharge Six months after leaving treatment, respondents said the places they had gambled at most frequently during the past 30 days were casinos and conveniences stores. 15

26 Paired-Sample. Among respondents who completed both an Admission and a Discharge Questionnaire, 44% said they had gambled at casinos during the 30 days before entering treatment and 16% said they had gambled at casinos during the 30 days prior to leaving treatment. At discharge, these respondents were significantly less likely to report having gambled at casinos or convenience stores. Admission One Month Follow Up Discharge Casino 16% 44% Racetrack Sporting events Bar or restaurant School Work Home or a friend's home 4% 0% 2% 0% 6% 6% 0% 0% 4% 4% 4% 0% Admission Discharge Convenience store 12% 27% Internet Other 6% 2% 4% 2% 0% 20% 40% 60% 80% 100% Figure 6. Locations of Wagering: Paired Sample (n = 59). 16

27 Money Lost Gambling Respondents were asked how much money (if any) they had lost gambling during the past 30 days. At admission, about two-thirds of respondents said they had lost money gambling during the past 30 days. In comparison, about one-fifth of respondents said they had lost money gambling during the past 30 days at discharge. Six months after leaving treatment, there were clear differences between those who completed treatment and those who were discharged without completing treatment. Respondents who did not complete treatment were nearly twice as likely as those who completed treatment to have lost money gambling during the past 30 days (61% vs. 34%). 100% 80% 34% 24% 4% 6% 5% 8% 13% 29% $1,000 + $1 $999 60% 53% None 34% 40% 73% 81% 66% 20% 33% 39% 0% Admission One Month Discharge Follow Up (Completed) Follow Up (Did Not Complete) Figure 7. Lost Money Gambling During the Past 30 Days. Note. Sums may appear not to sum to 100% due to the effect of rounding. 17

28 Table 9 Monetary Loss from Gambling: Admission In the past 30 days, how much money did you lose gambling? (n = 242) Did not lose in the past 30 days 33 $1 to $ $250 to $499 8 $500 to $ $750 to $999 1 $1,000 to $1, $2,000 to $2,999 8 $3,000 to $3,999 4 $4,000 to $4,999 2 $5,000 to $7,499 3 $7,500 to $9,999 2 $10,000 to $12,499 1 $12,500 or more 2 Note. The sum of the percentages for the $1-$999 categories was 33.5% which was rounded to 34% in Figure 7. Admission One Month Follow Up Discharge At admission, 67% of respondents had lost money gambling during the past 30 days, with 34% having lost $1,000 or more during that time period. Table 10 Monetary Loss from Gambling: One Month In the past 30 days, how much money did you lose gambling? (n = 166) Did not lose in the past 30 days 73 $1 to $ $250 to $499 2 $500 to $749 3 $750 to $999 1 $1,000 to $1,999 3 $2,000 to $2,999 <1 $3,000 to $3,999 0 $4,000 to $4,999 0 $5,000 to $7,499 0 $7,500 to $9,999 0 $10,000 to $12,499 0 $12,500 or more 0 Admission One Month Follow Up Discharge About one month into treatment, 27% of respondents said they had lost money gambling during the past 30 days with 4% having lost $1,000 or more during that time period. 18

29 Table 11 Monetary Loss from Gambling: Discharge In the past 30 days, how much money did you lose gambling? (n = 90) Did not lose in the past 30 days 81 $1 to $ $250 to $499 1 $500 to $749 0 $750 to $999 2 $1,000 to $1,999 3 $2,000 to $2,999 1 $3,000 to $3,999 0 $4,000 to $4,999 0 $5,000 to $7,499 0 $7,500 to $9,999 0 $10,000 to $12,499 0 $12,500 or more 1 Note. The sum of the percentages for the $1,000 or more categories was 5.5% which was rounded to 6% in Figure 7. Admission One Month Follow Up Discharge At discharge, 19% of respondents said they had lost money gambling during the past 30 days with about 6% having lost $1,000 or more during that time period. Table 12 Monetary Loss from Gambling: Follow-Up () In the past 30 days, how much money did you lose gambling? Completed (n = 59) Did Not Complete (n = 85) All Respondents (n = 144) Did not lose in the past 30 days $1 to $ $250 to $ $500 to $ $750 to $ $1,000 to $1, $2,000 to $2, $3,000 to $3, $4,000 to $4, $5,000 to $7, <1 $7,500 to $9, $10,000 to $12, <1 $12,500 or more Note. Respondents who completed treatment were significantly less likely than those who did not complete treatment to have lost money gambling during the past 30 days. Admission One Month Follow Up Discharge Respondents who did not complete treatment were nearly twice as likely as those who completed treatment to have lost money gambling during the past 30 days (66% vs. 39%). 19

30 Paired-Sample. Among the respondents who completed both an Admission and a Discharge Questionnaire, there was a substantial decrease in percent of clients from admission (60%) to discharge (22%) who reported having lost money gambling during the past 30 days. For these respondents, the mean amount of money lost gambling during the past 30 days was significantly less at discharge than it was at admission. Admission One Month Follow Up Discharge None 40% 78% $1 $999 16% 38% Admission Discharge $1,000 or More 6% 21% 0% 20% 40% 60% 80% 100% Figure 8. Lost Money Gambling During the Past 30 Days: Paired Sample (n = 59). Note. Sum of the percents for the three bars for admission data appear not to sum to 100% due to the effect of rounding. 20

31 Psychosocial Functioning Three areas of psychosocial functioning were assessed. The financial area included being late paying bills, declaring bankruptcy, losing a job due to gambling, losing a job for other reasons, and committing illegal acts to get money for gambling. The emotional area included expressing feelings, life satisfaction, and self-confidence. The interpersonal area included being arrested for something related to gambling, being arrested for some other reason, reduced participation in important activities, difficulty managing responsibilities at work/school, difficulty managing responsibilities at home, and having difficulties in important relationships. In all three areas, the mean number of problems was significantly lower among those who completed treatment than those who did not complete treatment Admission One Month Discharge Follow Up (Completed) Follow Up (Did Not Complete) Figure 9. Mean Number of Psychosocial Financial Problems During the Past 30 Days. (Maximum Score = 5) 21

32 Admission One Month Discharge Follow Up (Completed) Follow Up (Did Not Complete) Figure 10. Mean Number of Psychosocial Emotional Problems During the Past 30 Days. (Maximum Score = 3) Admission One Month Discharge Follow Up (Completed) Follow Up (Did Not Complete) Figure 11. Mean Number of Psychosocial Interpersonal Problems During the Past 30 Days. (Maximum Score = 6) 22

33 Psychosocial Functioning: Financial Table 13 Financial Functioning: Admission In the past 30 days, have you (n = 244) One Month Been late paying your bills 1 51 Declared bankruptcy 4 Lost a job due to a gambling problem 4 Admission Discharge Lost a job for some other reason 6 Committed illegal acts to get money to gamble with 2 12 Note. 1 (n = 238). 2 (n = 243). Follow Up About one-half of the respondents (51%) said they had been late paying bills during the 30 days prior to being admitted for gambling treatment. Table 14 Financial Functioning: One Month In the past 30 days, have you (n = 170) One Month Been late paying your bills 1 38 Declared bankruptcy 5 Lost a job due to a gambling problem <1 Admission Discharge Lost a job for some other reason 4 Committed illegal acts to get money to gamble with 1 2 Note. 1 (n = 169). Follow Up About one month into their treatment, 38% of respondents said they had been late paying bills during the past 30 days. 23

34 Table 15 Financial Functioning: Discharge In the past 30 days, have you (n = 88) One Month Been late paying your bills 23 Declared bankruptcy 3 Lost a job due to a gambling problem 1 Admission Discharge Lost a job for some other reason 4 Committed illegal acts to get money to gamble with 3 Follow Up At discharge, 23% of respondents said they had been late paying bills during the past 30 days. In the past 30 days, have you Table 16 Financial Functioning: Follow-Up () Completed (n = 58) Did Not Complete (n = 83) All Respondents (n = 141) Been late paying your bills Admission One Month Discharge Declared bankruptcy Lost a job due to a gambling problem Lost a job for some other reason Committed illegal acts to get money to gamble with <1 Note. 1 (n =57 completed, 82 not completed, 139 total). Although the mean was significantly different for the composite score, there were no statistically significant differences for any individual indicator. Follow Up Six months after leaving treatment, 33% of respondents who did not complete treatment and 23% of those who completed treatment said they had been late paying their bills during the past 30 days. 24

35 Paired-Sample. Respondents who completed both an Admission and a Discharge Questionnaire were asked about financial experiences during the past 30 days. Among these respondents, they were significantly less likely to report being late paying bills at discharge than they did at admission. Specifically, 41% of respondents at admission versus 21% of respondents at discharge said they had been late paying their bills during the past 30 days. Admission One Month Discharge Follow Up Been late paying bills 21% 41% Declared bankruptcy 0% 0% Lost job due to gambling Lost job due to other reason 4% 2% 6% 4% Admission Discharge Committed illegal acts to get money for gambling 10% 4% 0% 20% 40% 60% 80% 100% Figure 12. Financial Indicators of Psychosocial Functioning During the Past 30 Days: Paired Sample (n =59). 25

36 Psychosocial Functioning: Emotional Table 17 Emotional Functioning: Admission In the past 30 days, have you (n = 243) Recognized and expressed your feelings inappropriately 1 40 Felt generally dissatisfied with your life 73 Lacked self-confidence or felt bad about yourself Note. 1 (n =244). 76 Admission One Month Follow Up Discharge About three-fourths of respondents (76%) said they lacked self-confidence or felt bad about themselves during the 30 days prior to being admitted for gambling treatment. Table 18 Emotional Functioning: One Month In the past 30 days, have you (n = 170) Recognized and expressed your feelings inappropriately Felt generally dissatisfied with your life 1 43 Lacked self-confidence or felt bad about yourself Note. 1 (n = 169) Admission One Month Follow Up Discharge About one month into treatment, 61% of respondents said they lacked self-confidence or felt bad about themselves during the past 30 days. 26

37 Table 19 Emotional Functioning: Discharge In the past 30 days, have you (n = 88) Recognized and expressed your feelings inappropriately 1 22 Felt generally dissatisfied with your life 28 Lacked self-confidence or felt bad about yourself Note. 1 (n = 87) 32 Admission One Month Follow Up Discharge At discharge, 32% of respondents said they lacked self-confidence or felt bad about themselves during the past 30 days. Table 20 Emotional Functioning: Follow-Up () In the past 30 days, have you Completed (n = 58) Did Not Complete (n = 83) All Respondents (n = 141) Recognized and expressed your feelings inappropriately Felt generally dissatisfied with your life Lacked self-confidence or felt bad about yourself Note. (n = 81 not completed, 139 total). Statistically significant difference: lacked self-confidence or felt bad about yourself. Admission One Month Follow Up Discharge Six months after leaving treatment, 36% of respondents said they lacked self-confidence or felt bad about themselves during the past 30 days. 27

38 Paired-Sample. Respondents who completed both an Admission and a Discharge Questionnaire were asked about their emotional experiences during the past 30 days. Among these respondents, they were significantly less likely at discharge than at admission to report life dissatisfaction and feeling bad about themselves. Specifically, 65% of respondents at admission versus 34% of respondents at discharge said they had felt generally dissatisfied with their life at least once during the past 30 days. Admission One Month Follow Up Discharge Recognized and expressed feeling inappropriately 26% 36% Felt generally dissatisfied with your life 34% 65% Admission Discharge Lacked self confidence or felt bad about self 43% 71% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100% Figure 13. Emotional Indicators of Psychosocial Functioning During the Past 30 Days: Paired Sample (n = 59). 28

39 Psychosocial Functioning: Interpersonal Table 21 Interpersonal Functioning: Admission In the past 30 days, have you (n = 244) One Month Been arrested for gambling problems 2 Been arrested for some other reason 4 Given up or greatly reduced important activities so you could gamble Had difficulty managing your responsibilities at work or school 1 24 Had difficulty managing your responsibilities at home 2 55 Had difficulties with family and/or friends 2 57 Note. 1 (n = 242). 2 (n = 243). 28 Admission Follow Up Discharge More than one-half of the respondents (57%) said they had experienced difficulties with family and/or friends during the 30 days prior to being admitted for gambling treatment. Table 22 Interpersonal Functioning: One Month In the past 30 days, have you (n = 170) One Month Been arrested for gambling problems 1 Been arrested for some other reason 1 Given up or greatly reduced important activities so you could gamble Had difficulty managing your responsibilities at work or school 1 12 Had difficulty managing your responsibilities at home Had difficulties with family and/or friends 38 Note. 1 (n = 168) Admission Follow Up Discharge About one month into their treatment, 38% of respondents said they had experienced difficulties with family and/or friends during the past 30 days. 29

40 Table 23 Interpersonal Functioning: Discharge In the past 30 days, have you (n = 88) One Month Been arrested for gambling problems 0 Been arrested for some other reason 0 Given up or greatly reduced important activities so you could gamble 1 5 Had difficulty managing your responsibilities at work or school Had difficulty managing your responsibilities at home Had difficulties with family and/or friends 19 Note. 1 (n = 87) Admission Follow Up Discharge At discharge, 19% of respondents said they had experienced difficulties with family and/or friends during the past 30 days. Table 24 Interpersonal Functioning: Follow-Up () In the past 30 days, have you Completed (n = 58) Did Not Complete (n = 83) All Respondents (n = 141) Been arrested for gambling problems <1 Been arrested for some other reason Given up or greatly reduced important activities so you could gamble Had difficulty managing your responsibilities at work or school Had difficulty managing your responsibilities at home Had difficulties with family and/or friends Note. 1 (n = 57 completed, 140 total). Although the mean was significantly different for the composite score, there were no statistically significant differences for any individual indicator. Admission One Month Follow Up Discharge Six months after leaving treatment, respondents who did not complete treatment were more likely than those who completed treatment to have given up important activities to gamble during the past 30 days and also to have experienced difficulties managing responsibilities at work, school, or home during the past 30 days. 30

41 Paired-Sample. Respondents who completed both an Admission and a Discharge Questionnaire were asked about their social and interpersonal experiences during the past 30 days. Among these respondents, they were significantly less likely at discharge than at admission to report a nongambling arrest, giving up important activities to gamble, having difficulties at home, or having difficulties with friends or family. For instance, 58% of respondents at admission versus 19% of respondents at discharge said they had difficulties with family or friends at least once during the past 30 days. Admission One Month Follow Up Discharge Been arrested related to gambling 2% 0% Been arrested for other reasons 0% 12% Given up important activities to gamble 6% 27% Had difficulties at work or school 11% 23% Admission Discharge Had difficulties at home 15% 51% Had difficulties with family and/or friends 19% 58% 0% 20% 40% 60% 80% 100% Figure 14. Interpersonal Indicators of Psychosocial Functioning During the Past 30 Days: Paired Sample (n =59). 31

42 Recent Behaviors and Experiences Respondents were asked about a variety of other recent behaviors and experiences during the past 30 days. These included substance use (i.e., recent use of tobacco, alcohol, illegal drugs, and misuse of prescription medications), missing work or school because of a gambling-related problem, eating disorder behaviors (e.g., starving, binging, or purging), and thoughts and feelings (i.e., thinking about suicide, feeling depressed or hopeless). Feelings of depression and hopelessness were common (78%) among respondents admitted for gambling treatment. There was a substantial decrease in the percent of respondents experiencing feelings of depression and hopelessness by the time of discharge, with 32% saying they felt that way during the past 30 days. At the six month follow-up, respondents who completed treatment were significantly less likely than those who had not completed treatment to report having felt depressed or hopeless during the past 30 days (17% vs. 36%, respectively). 100% 80% 78% 60% 54% 40% 32% 36% 20% 17% 0% Admission (n = 245) One Month (n = 171) Discharge (n = 88) Follow Up (Completed) (n = 59) Follow Up (Did Not Complete) (n = 86) Figure 15. Felt Depressed or Hopeless During the Past 30 Days. 32

43 Table 25 Recent Behaviors and Experiences: Admission During the past 30 days, did you? (n = 244) Thoughts & Feelings One Month Feel depressed or hopeless 1 78 Think about suicide 24 Other Behaviors & Experiences Admission Discharge Starve yourself, binge, or purge 9 Miss work or school because of a gambling-related problem 2 16 Substance Use Use tobacco 63 Drink alcohol 41 Follow Up About three-fourths (78%) of respondents said they felt depressed or hopeless during the 30 days prior to being admitted for gambling treatment. Misuse prescription drugs 2 Use illegal drugs 1 5 Note. 1 (n = 245). 2 (n = 242). Table 26 Recent Behaviors and Experiences: One Month During the past 30 days, did you? (n = 171) Thoughts & Feelings One Month Feel depressed or hopeless 54 Think about suicide 10 Other Behaviors & Experiences Admission Discharge Starve yourself, binge, or purge 6 Miss work or school because of a gambling-related problem 1 4 Substance Use Use tobacco 58 Follow Up About one month into their treatment, 54% of respondents said they had felt depressed or hopeless during the past 30 days. Drink alcohol 37 Misuse prescription drugs 0 Use illegal drugs 5 Note. 1 (n = 168). 33

44 Table 27 Recent Behaviors and Experiences: Discharge During the past 30 days, did you? (n = 89) Thoughts & Feelings One Month Feel depressed or hopeless 1 32 Think about suicide 8 Other Behaviors & Experiences Admission Discharge Starve yourself, binge, or purge 7 Miss work or school because of a gambling-related problem Substance Use Use tobacco 57 Drink alcohol 32 Misuse prescription drugs 2 6 Follow Up At discharge, 32% of respondents said they had felt depressed or hopeless during the 30 days prior to being discharged. Use illegal drugs 1 2 Note. 1 (n = 88). Table 28 Recent Behaviors and Experiences: Follow-Up () During the past 30 days, did you? Thoughts & Feelings Completed (n = 59) Did Not Complete (n = 86) All Respondents (n = 145) Feel depressed or hopeless Admission One Month Discharge Think about suicide Other Behaviors & Experiences Starve yourself, binge, or purge Miss work or school because of a gambling-related problem Substance Use Use tobacco Drink alcohol Misuse prescription drugs Follow Up Six months after leaving treatment, 28% of respondents said they had felt depressed or hopeless during the past 30 days. Use illegal drugs Note. 1 (n = 87 not completed, 146 total) 2 (n = 55 completed, 79 not completed, 134 total). Statistically significant difference: feel depressed or hopeless. 34

45 Paired-Sample. Respondents who completed both an Admission and a Discharge Questionnaire were asked about negative thoughts and feelings they may have had during the past 30 days. Among these respondents, they were significantly less likely at discharge than at admission to report having suicidal thoughts or feeling depressed. For instance, 69% of respondents at admission versus 39% at discharge said they had felt depressed or hopeless during the past 30 days. Admission One Month Follow Up Discharge 100% 90% 80% 70% 60% 69% Admission Discharge 50% 40% 30% 27% 39% 20% 10% 0% 13% Think about suicide Feel depressed or hopeless Figure 16. Thoughts and Feelings During the Past 30 Days: Paired Sample (n =59). Note. Other recent behaviors and experiences at admission and discharge were: starve, binge, or purge (9% vs. 7%); miss work or school because of gamblingrelated problem (16% vs. 6%); use tobacco (63% vs. 57%); drink alcohol (41% vs. 31%); misuse prescription medications (2% vs. 2%); and use illegal drugs (5% vs. 2%). 35

46 DSM-Problem Gambling Indicators One way to assess the severity of someone s gambling problem is to use information that corresponds to the clinical guidelines of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the present study, respondents were classified as current pathological gamblers, problem gamblers, at-risk gamblers, or they received an indefinite diagnosis based on their responses to 10 indicators of pathology (see page 6 of the Explanation of Terms subsection for additional information about these classifications). An indefinite diagnosis simply means that based on the responses to a self-report questionnaire there is insufficient evidence of current pathology, but this does not necessarily mean that the person does not have a gambling problem or does not need treatment. A professional treatment provider may be aware of additional information beyond what is assessed in the self-report questionnaire that could indicate the client would benefit from receiving gambling treatment services. More than one-half (52%) of respondents were classified as current pathological gamblers at the time of admission as compared to 7% at discharge. This difference, however, must be understood within the context of the study design. Discharge data are generally available for those who completed all or a substantial portion of the treatment program, but often are not available for other types of clients (e.g., client left before completing their treatment). With this in mind, the six month follow-up data may provide a better picture of the treatment effectiveness. Based on their thoughts and behaviors during the past 30 days, 7% of respondents who completed treatment and 15% of those who did not complete treatment met the current pathological gambler criteria based on their thoughts and behaviors during the past 30 days. 100% 90% 80% 38% 70% 60% 50% 6% 4% 77% 89% 86% 74% Indefinite Diagnosis 40% At Risk Gambler 30% 20% 10% 0% 52% Admission (n = 239) 6% 12% 5% One Month (n = 170) 0% 5% 4% 2% 7% 7% Discharge (n = 89) Follow Up (Completed) (n = 58) 8% 15% 2% Follow Up (Did Not Complete) (n = 82) Problem Gambler Pathological Gambler Figure 17. Current DSM Problem Gambling Indicators. Note. Sums may appear not to sum to 100% due to the effect of rounding. 36

47 One Month 38% Admission Discharge 52% Follow Up 4% 5% Indefinite Diagnosis Problem Gambler At Risk Gambler Pathological Gambler More than one-half of respondents (52%) met the DSM-IV criteria to be a pathological gambler at the time of admission. Figure 18. Current DSM Problem Gambling Indicators: Admission (n = 239). 12% One Month 6% 5% Admission Discharge Follow Up 77% Indefinite Diagnosis Problem Gambler At Risk Gambler Pathological Gambler About one month into their treatment, 12% of respondents met the DSM-IV criteria to be a pathological gambler. Figure 19. Current DSM Problem Gambling Indicators: One Month (n = 170). Note. Sums may appear not to sum to 100% due to the effect of rounding. 37

48 4% 7% 0% One Month Admission Discharge Follow Up Indefinite Diagnosis Problem Gambler 89% At Risk Gambler Pathological Gambler At discharge, 7% of respondents met the DSM-IV criteria to be a pathological gambler. Figure 20. Current DSM Problem Gambling Indicators: Discharge (n = 89). 7% 2% 11% One Month Admission Discharge Follow Up Indefinite Diagnosis Problem Gambler 79% At Risk Gambler Pathological Gambler Six months after leaving treatment, 11% of respondents could be classified as pathological gamblers. Based on their thoughts and behaviors during the past 30 days, 7% of respondents who completed treatment and 15% of respondents who did not complete treatment met the criteria as a pathological gambler (see Table E-21B on page 187 for details). Figure 21. Current DSM Problem Gambling Indicators: Follow-Up (n = 140). Note. Sums may appear not to sum to 100% due to the effect of rounding. 38

49 Paired-Sample. Among those respondents who completed both an Admission and a Discharge Questionnaire, they were significantly less likely to be classified as current pathological gamblers based on their thoughts and behaviors during the past 30 days. Specifically, 44% of them met the criteria to be classified as current pathological gamblers when they were admitted for treatment as compared to 8% at discharge. Admission One Month Discharge Follow Up 0% 8% 8% 44% 50% 0% 6% 83% Indefinite Diagnosis At Risk Gambler Indefinite Diagnosis At Risk Gambler Problem Gambler Pathological Gambler Problem Gambler Pathological Gambler Admission Discharge Figure 22. Current DSM Problem Gambling Diagnosis at Admission and Discharge: Paired Sample (n =59). 39

50 Find yourself thinking a lot about gambling, such as past gambling experiences, future gambling ventures, or ways of getting money for gambling 23% 56% Need to gamble with larger amounts of money or with larger bets in order to get the same feeling of excitement 6% 31% Repeatedly try to cut down or stop your gambling but have been unsuccessful 6% 45% Feel restless or irritable when you tried to cut down or stop gambling 23% 51% Gamble to run away from problems or to get relief from feeling depressed, anxious, or bad about yourself 12% 42% Admission After losing money gambling, often return another day in order to win back your losses 8% 45% Discharge Lie to family members, friends, or others in order to hide your gambling from them 15% 44% Commit any illegal acts to finance your gambling, such as writing bad checks, theft, forgery, embezzlement, or fraud 4% 12% Lose or almost lose a significant relationship, job, or an educational career opportunity because of gambling 10% 23% Rely on others to provide money to relieve a desperate financial situation caused by gambling 8% 29% 0% 20% 40% 60% 80% 100% Figure 23. Current DSM Problem Gambling Indicator at Admission and Discharge: Paired Sample (n =59). Note. Differences between admission and discharge are statistically significant for all indicators except committing illegal acts to finance gambling. 40

51 Intention to Change One s readiness to change problem behaviors is an important aspect of the treatment process. Some people seek help during a time when their problem gambling behaviors are at their worst and other people seek help after they have been trying, with mixed results, to reduce or quit on their own for a period of time. For instance, 57% of respondents who entered the gambling treatment program said they had already begun to reduce or quit their gambling behaviors in the past six months, and an additional 7% had maintained this level of progress for more than six months. There were significant differences between respondents who did versus did not complete treatment in terms of their ability to maintain changes for six or more months. Six months after leaving treatment, 77% of respondents who completed treatment and 51% of those who did not complete treatment were significantly more likely to say that they had reduced or quit their problem gambling behaviors. 100% 80% 60% 64% 7% 92% 92% 14% 48% 95% 77% 88% 51% 40% 20% 0% 57% 78% 44% 18% Admission One Month Discharge Follow Up (Completed) 37% Follow Up (Did Not Complete) I have already begun to reduce or quit my problem gambling behaviors within the past six months. I reduced or quit my problem gambling behaviors over six months ago and have been able to maintain these changes during this period of time. Figure 24. Intention to Change Problem Gambling Behavior. 41

52 Table 29 Current Intention to Change: Admission Which one of the following statements best applies to you right now? (n = 245) I have no intentions of changing my problem gambling behaviors. I am seriously considering reducing or stopping my problem gambling behaviors in the next 6 months. I plan to reduce or quit my problem gambling behaviors in the next month. I have already begun to reduce or quit my problem gambling behaviors within the past 6 months. I reduced or quit my problem gambling behaviors over 6 months ago and have been able to maintain these changes during this period of time Admission One Month Follow Up Discharge More than one-half of respondents (57%) said they had already begun to reduce or quit their problem gambling behaviors before entering the gambling treatment program. An additional 7% had maintained these changes for at least 6 months. Table 30 Current Intention to Change: One Month Which one of the following statements best applies to you right now? (n = 169) I have no intentions of changing my problem gambling behaviors. I am seriously considering reducing or stopping my problem gambling behaviors in the next 6 months. I plan to reduce or quit my problem gambling behaviors in the next month. I have already begun to reduce or quit my problem gambling behaviors within the past 6 months. I reduced or quit my problem gambling behaviors over 6 months ago and have been able to maintain these changes during this period of time Admission One Month Follow Up Discharge About one month into their treatment, 78% of respondents said they had already begun to reduce or quit their problem gambling behaviors within the past 6 months, and an additional 14% said they had done so for more than 6 months. 42

53 Table 31 Current Intention to Change: Discharge Which one of the following statements best applies to you right now? (n = 89) I have no intentions of changing my problem gambling behaviors. I am seriously considering reducing or stopping my problem gambling behaviors in the next 6 months. I plan to reduce or quit my problem gambling behaviors in the next month. I have already begun to reduce or quit my problem gambling behaviors within the past 6 months. I reduced or quit my problem gambling behaviors over 6 months ago and have been able to maintain these changes during this period of time Table 32 Current Intention to Change: Follow-Up () Which one of the following statements best applies to you right now? I have no intentions of changing my problem gambling behaviors. I am seriously considering reducing or stopping my problem gambling behaviors in the next 6 months. I plan to reduce or quit my problem gambling behaviors in the next month. I have already begun to reduce or quit my problem gambling behaviors within the past 6 months. I reduced or quit my problem gambling behaviors over 6 months ago and have been able to maintain these changes during this period of time. Completed (n = 60) Did Not Complete (n = 87) All Respondents (n = 147) Note. Respondents who completed treatment were significantly more likely than those who did not complete treatment to say they have reduced or quit their problem gambling behaviors. Admission One Month Follow Up Discharge At discharge, 48% of respondents said they had reduced or quit their problem gambling behaviors for more than 6 months, and an additional 44% of respondents said they had begun to reduce or quit these behaviors. Admission One Month Follow Up Discharge Six months after leaving treatment, respondents who completed treatment were more likely than those who did not complete treatment to say they have reduced or quit their problem gambling behaviors for 6 or more months. 43

54 Paired-Sample. Among those respondents who completed both an Admission and a Discharge Questionnaire, respondents were significantly more likely at discharge (28%) than at admission (17%) to say they reduced or eliminated their problem gambling behaviors for more than six months. Admission One Month Discharge Follow Up I have no intentions of changing my problem gambling behaviors 0% 0% I am seriously considering reducing or stopping my problem gambling behaviors in the next 6 months 2% 6% I plan to reduce or quit my problem gambling behaviors in the next month 6% 25% Admission Discharge I have already begun to reduce or quit my problem gambling behaviors within the past 6 months 52% 64% I reduced or quit my problem gambling behaviors over 6 months ago and have been able to maintain these changes during this period of time 17% 28% 0% 20% 40% 60% 80% 100% Figure 25. Current Intention to Change Gambling Behavior: Paired Sample (n = 59). 44

55 Satisfaction with Treatment Services The Discharge and Six Month Follow-Up Questionnaires included questions assessing opinions about treatment experiences. Data at discharge are mainly available for those respondents who completed all or a substantial portion of treatment. At the time of discharge, 100% of respondents rated their treatment services as good (23%) or excellent (77%). Overall Rating of the Services Received 23% One Month Admission Discharge Follow Up 77% Excellent Good Fair Poor At discharge, 100% of respondents said the treatment services they received were either good or excellent. The discharge data, however, are usually available only for people who completed treatment. Figure 26. Overall Rating of the Services Received: Discharge (n = 66). 45

56 About 90% of respondents rated their treatment as good (38%) or excellent (51%) six months after leaving treatment (see Figure 27). In addition, good or excellent ratings were significantly more likely from respondents who completed treatment (97%) than those who did not complete treatment (85%). 9% 1% One Month Admission Discharge 38% 51% Follow Up Excellent Good Fair Poor Six months after leaving treatment, about 90% of all respondents said the services they received were either good or excellent. Moreover, 97% of those respondents who completed treatment said the services they received were either good or excellent. Figure 27. Overall Rating of the Services Received: Follow-Up (n = 146). Beneficialness of Treatment At the six month follow-up, respondents who had completed treatment were significantly more likely than those who had not completed treatment to rate the treatment program as very beneficial. Yet, even among those who had not completed treatment, more than one-half said it was very beneficial (58%) and about one-third said it was beneficial. Ratings for individual types of services are shown in Appendix E. 23% 0% 9% 34% 58% 77% Very Beneficial Beneficial Not Beneficial Very Beneficial Beneficial Not Beneficial Completed (n = 80) Did Not Complete (n = 56) Figure 28. How Beneficial Was the Treatment Program: Follow-Up. Note. Sums may appear not to sum to 100% due to the effect of rounding. 46

57 Length of the Gambling Treatment The length of their treatment was about right according to 79% of respondents who completed Six Month Follow-Up Questionnaires (see Figure 30). Respondents who did not complete treatment were significantly more likely than those who did to say that the treatment was too short (31% vs. 5%, respectively). 9% One Month Admission Discharge Follow Up 91% Too Short About Right Too Long At discharge, 91% of respondents said the length of the treatment was about right. Figure 29. Length of the Gambling Treatment: Discharge (n = 65). 1% 20% One Month Admission Discharge Follow Up 79% Too Short About Right Too Long Six months after leaving treatment, 79% of respondents said the length of the treatment was about right. Figure 30. Length of the Gambling Treatment: Follow-Up (n = 145). 47

58 Would You Recommend the Program? Among respondents who completed Six Month Follow-Up Questionnaires, 80% said they definitely would recommend the gambling treatment program to a friend or relative who needed similar help (see Figure 32). Respondents who completed treatment were significantly more likely than those who did not complete treatment to say that they definitely would recommend treatment to a friend or relative (93% vs. 70%, respectively). 3% 2% One Month Admission Discharge Follow Up Definitely Yes Probably Not 95% Maybe Definitely Not At discharge, 95% of respondents said they definitely would recommend the gambling treatment program to a friend or family member with a similar need. Figure 31. Would Recommend the Program to Others: Discharge (n = 64). 18% <1% 1% One Month Admission Discharge Follow Up Definitely Yes Probably Not 80% Maybe Definitely Not Six months after leaving treatment, 80% of respondents said they definitely would recommend the gambling treatment program to a friend or family member with a similar need. Figure 32. Would Recommend the Program to Others: Follow-Up (n = 147). 48

59 SUMMARY Wagering The two most frequently mentioned places at which respondents said they gambled were casinos and convenience stores. The most common types of wagering activities were slot machines, lottery scratch tickets and pull-tab games, casino table games, and lottery tickets. Six months after leaving treatment, respondents who had completed the treatment program were significantly less likely to have gambled during the past 30 days than were respondents who had not completed treatment (41% vs. 71%, respectively). Six months after leaving treatment, the majority (59%) of respondents who completed the program said they had not gambled during the past 30 days. Psychosocial Functioning Six months after leaving treatment, respondents who completed treatment were less likely than those who had not completed treatment to report that they lacked self-confidence or felt bad about themselves (26% vs. 42%, respectively). Likewise, they were also less likely to report having felt hopeless or depressed during the past 30 days (17% vs. 36%). At the time of admission, 78% of respondents said they felt hopeless or depressed. DSM-Problem Gambling Indicators One way to assess the severity of someone s gambling problem is to use information that corresponds to the clinical guidelines of the Diagnostic and Statistical Manual of Mental Disorders (DSM). In the present study, respondents were classified as current pathological gamblers, problem gamblers, at-risk gamblers, or they received an indefinite diagnosis based on their responses to 10 indicators of pathology (see page 6 of the Explanation of Terms subsection for additional information about these classifications). Self-reports of gambling-related thoughts and behaviors experienced during the past 30 days were used to assess current gambling pathology. The current classification approach is more restrictive than classifications using experiences during the past 12 months (i.e., recent or past-year gambling pathology ) or having ever had these thoughts or experiences (i.e., lifetime gambling pathology ). More than one-half (52%) of respondents were classified as current pathological gamblers at admission versus 7% at discharge. This difference, however, must be understood within the context of the data collection protocol. Discharge data are generally available for people who completed all or a substantial portion of treatment, but unavailable for people who left treatment under other circumstances. With this in mind, the six month follow-up data may provide a better picture of the effectiveness of treatment. Six months after leaving treatment, 7% of respondents who completed treatment versus 15% of respondents who did not complete treatment met the criteria for a current pathological gamblers based on their thoughts and behaviors during the past 30 days. Although the majority of both groups of respondents were classified with an indefinite diagnosis at the six month follow-up, there were significant differences between the two groups on 4 of the 10 DSM indicators. Respondents who completed treatment were less likely to report that they (a) found themselves thinking a lot about gambling, past or future gambling ventures, or ways to get money to gamble; (b) repeatedly tried to cut down or stop gambling but have been unsuccessful during the past 30 days; (c) gambled to run away from problems or to get relief from feeling depressed, anxious, or bad about themselves during the past 30 days; and (d) lied to family members, friends, or others to hide their gambling during the past 30 days. 49

60 Behavior Change At the six month follow-up, there were significant differences between respondents who did versus did not complete treatment in terms having reduced or stopped their problem gambling behaviors. Specifically, 77% of respondents who completed treatment versus 51% of those who did not complete treatment said they had reduced or quit their problem gambling and maintained these positive changes for six months. An additional 18% of respondents who completed treatment said they had begun to reduce or quit their problem gambling behaviors during the past six months. Satisfaction with Treatment At the time of discharge, 100% of respondents completing the questionnaire rated their treatment services as good (23%) or excellent (77%). The data from the discharge questionnaire are mainly from those respondents who completed all or a substantial portion of treatment. At the six month follow-up, 77% of respondents who completed treatment and 58% of respondents who had not completed treatment said the program was very beneficial to them. Six months after leaving treatment, the majority of respondents said they would recommend the treatment program to a friend or relative who needed similar help. Specifically, 93% of respondents who completed the program and 70% of respondents who did not complete treatment said they definitely would recommend it to others. Conclusions There are many positive outcomes for clients of the publicly funded gambling treatment program. About one-third of the clients who were admitted into the program during 2008 completed all or a substantial portion of treatment. Generally, these clients expressed high levels of satisfaction with the treatment services they received and thought the treatment was beneficial to their recovery. Six months after being discharged, there were positive treatment outcomes in several areas of the lives of clients who completed treatment. 50

61 APPENDIX A Distance Treatment Program 51

62 [Space Left Blank Intentionally] 52

63 Distance Treatment Service Providers According to information available to CSBR at the time of this report, the following eight agencies have been approved to provide distance treatment: Alcohol & Drug Dependency Services of SE Iowa, Allen Hospital Gambling Treatment Program, MECCA Services, Compass Pointe, Substance Abuse Services Center, Heartland Family Service, Jackson Recovery Centers, Inc, and Prairie Ridge Addiction Treatment Services. Not all of these agencies were providing treatment services during the 2008 calendar year. Focus Group Summary CSBR conducted a distance treatment focus group on April 8, 2009, during the Iowa Governor s Conference on Substance Abuse. Staff members from five treatment agencies and from the Iowa Department of Public Health participated in the focus group session. Five of the participants had 5 or fewer years of experience with gambling treatment, 2 participants had 5-19 years of experience, and 2 participants had 20 or more years of experience. The participants also had varying levels of direct experience with providing treatment services to clients via distance treatment. Summary of Main Themes In the past, incorporation of other modes of contact have been necessary (in a limited manner) to accommodate clients who couldn t make appointments due to physical location, weather conditions, etc. As a result, many counselors have been using a hybrid approach to gambling treatment for several years, even prior to the start of the distance treatment program in Iowa. The overall flexibility of the distance treatment program is seen by counselors as both a benefit and a barrier. While many like having the flexibility to tailor the program to their specific agency and clients, others feel that the training did not provide them with adequate structure and direction for program implementation. The greatest barrier counselors asserted is the lack of marketing, and they would like to see more localized and targeted marketing. Technology issues, such as the cost and amount of time required to set-up encrypted servers and websites has also been a barrier to providing treatment via the Internet. As a result, most clients are treated via a hybrid approach (i.e. phone and face-to-face). Counselors believe the program has great potential for expanded reach but barriers must be addressed for the program to realize its full potential. 53

64 Flexibility Both a benefit and a barrier Some counselors like flexibility to tailor program to specific agency and clients Others dislike perceived lack of structure and direction for program implementation Sounds New, Actually Old Incorporation of phone contact has always been necessary in accommodating clients who couldn't make appointments due to location, weather, etc. Marketing Greatest perceived barrier to the program realizing its full potential Perceived need for localized marketing and targeted messaging Technology Time requirements and cost of setting up encryption services are a barrier for agencies Because of cost and time requirements, most counselors in the focus group had hybrid clients and no "pure distance treatment" clients Mostly phone being used in distance treatment Great Potential If barriers are addressed, counselors perceive program as having great potential for expanded reach 54