Iowa Gambling Treatment Outcomes System: Year 5

Transcription

1 Iowa Gambling Treatment Outcomes System: Year 5 Prepared by Gene M. Lutz Melvin E. Gonnerman, Jr. Rod Muilenburg Karen Dietzenbach Ki H. Park 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 2010 [Type text]

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 (319) ; ii

3 TABLE OF CONTENTS Page I. Executive Summary...v II. Section 1: Background and Methodology...1 III. Section 2.0: GTRS Forms ( )...7 Section 2.1 GTRS Admission Forms ( )...8 Section 2.2 GTRS Service Forms ( )...21 Section 2.3 GTRS Discharge Forms ( )...23 IV. Section 3.0: Questionnaire Data ( )...31 Section 3.1 Admission Alongside Discharge...32 Section 3.2 At Discharge...44 Section 3.3 At Follow-Up...50 V. Section 4: Distance Treatment...67 VI. Section 5: Summary & Conclusions...69 Appendix A: Forms & Questionnaires...73 Appendix A.1: GTRS Admission Form...75 Appendix A.2: Admission Questionnaire...79 Appendix A.3: GTRS Service Form...85 Appendix A.4: One-Month Questionnaire...89 Appendix A.5: GTRS Discharge Form...97 Appendix A.6: Discharge Questionnaire Appendix A.7: Six-Month Follow-Up Questionnaire Appendix A.8: Distance Treatment Telephone-Administered Questionnaires Appendix A.9: Follow-Up Informed Consent Form Appendix A.10: Distance Treatment Follow-Up Informed Consent Form Appendix B: 2009 Data Tables Appendix B.1: 2009 Admission Questionnaire Item Distributions Appendix B.2: 2009 One-Month Questionnaire Item Distributions Appendix B.3: 2009 Discharge Questionnaire Item Distributions Appendix B.4: 2009 Follow-Up Questionnaire Item Distributions Appendix C: DSM-IV Symptom Indicators Appendix D: Distance Treatment Tables Technical Notes Glossary iii

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5 EXECUTIVE SUMMARY Iowa Gambling Treatment Outcomes System: Year 5 Center for Social and Behavioral Research, University of Northern Iowa (August 2010) Project Description Project History. This is the fifth 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 collecting and reporting on 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. Purpose of Report. The Year 5 report of the Iowa Gambling Treatment Outcomes (IGTO) System summarizes findings for 2009 and highlights cumulative findings for Data Sources. The study includes only adult clients admitted to state-funded gambling treatment programs as gamblers, excluding crisis clients and concerned others. Data come from the State s electronic Gambling Treatment Reporting System (GTRS) and special questionnaires completed during treatment. There is also a follow-up questionnaire administered by CSBR approximately six months after clients were discharged from treatment. The data describe similarities and differences in gambling behaviors and life experiences of clients who completed treatment relative to those who did not complete treatment. The findings in this report were based on an analysis of (a) GTRS forms from 2006 through 2009, (b) admission and discharge questionnaires from July 2007 through December 2009, (c) follow-up questionnaires from July 2007 through June 2010, and (d) distance treatment data from August 2008 through June 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 can be an issue especially for the discharge data that 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 for whom questionnaire data are available systematically differ from those for whom data are not available. The specific effects of attrition and non-response bias on the representativeness and generalizability of the findings for this project are undetermined. Main Findings Places and Types of Gambling Activities. By far the most common type of gambling activity reported was playing slot machines. The other most common types of gambling activities were playing scratch tickets/pull tabs, casino table games, and lotteries. More wagering activities commonly took place at casinos and convenience stores than in other venues. v

6 Pathology at Admission. Data from the Admission Questionnaires (July December 2009) showed 93% of those admitted for treatment met the DSM-IV classification criteria for pathological or problem gambling based on their behaviors during the past 12 months. In terms of current pathology, 58% met these classification criteria based only behaviors during the past 30 days. Treatment Outcomes. Based on three years of data from respondents who completed the Six- Month Follow-up Questionnaire, those who completed treatment had more positive treatment outcomes and life experiences than did those who did not complete treatment. Specifically, at follow-up: Clients who completed treatment were 30% less likely than those who did not complete treatment to have gambled in the past 30 days (44% vs. 63%, respectively). Clients who completed treatment were 71% less likely than those who did not complete treatment to have given up important activities in order to gamble during the past 30 days (4% vs. 14%). Clients who completed treatment were 60% less likely than those who did not complete treatment to be classified as current pathological or current problem gamblers based on their behaviors during the past 30 days (10% vs. 25%). Clients who completed treatment were 42% more likely than those who did not complete treatment to say they reduced or quit their problem gambling behaviors for six months or longer (71% vs. 50%). Treatment Satisfaction. Over four years, most clients (55%) reported not waiting before being admitted into the gambling treatment program; however, the percentage who said they waited for 7 days or longer to be admitted increased from 13% in 2006 to 27% in Once in treatment, the vast majority of clients who responded to a questionnaire expressed favorable ratings of the treatment services they received and said they would recommend the treatment program to a friend or relative in need of similar help. At follow-up, 89% of respondents over a three year period rated the services as excellent or good. Those who completed treatment had the most favorable ratings (62% excellent and 35% good). Yet, even among those who did not complete treatment, the ratings were generally positive (42% excellent and 40% good). An important indicator of treatment satisfaction is whether someone would recommend the treatment program to a friend or family member in need of similar help. At follow-up, 82% of respondents said they definitely would recommend the treatment program, with 92% of completers and 73% of noncompleters expressing this opinion. Conclusions The Iowa Gambling Treatment Program provides state-funded gambling treatment services to Iowans with gambling problems. The findings in this report were based on an analysis of data from several sources spanning multiple years. Slightly more than one-third of clients completed all or a substantial portion of their treatment; however, about one-half of the clients who were admitted for treatment decided to leave before completing the treatment. Many of the respondents who participated in the six-month follow-up said their lives had improved since entering treatment. While many respondents who only partially completed their treatment plans experienced improvements in their lives, clearly those who completed treatment did better. This pattern suggests that keeping more clients in treatment would contribute to more adult Iowans experiencing successful recovery from problems associated with gambling. State investments in gambling treatment services are having successful effects. vi

7 SECTION 1 BACKGROUND AND METHODOLOGY What is the history of this project? This is the fifth year the Center for Social and Behavioral Research (CSBR) at the University of Northern Iowa (UNI) has conducted the Iowa Gambling Treatment Outcomes (IGTO) System study. The IGTO system is designed 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 clients who received services at treatment agencies contracted by the State of Iowa. What is the purpose of this report? The purpose of this report is to provide a summary of several outcomes of adult Iowans who were admitted into the Iowa Gambling Treatment Program. The study includes only adult clients admitted to state-funded gambling treatment programs as gamblers, excluding crisis clients and concerned others. The report highlights cumulative findings from several data sources covering the time period of 2006 through 2009 with some limited data from The report is not intended to be an exhaustive summary of all Gambling Treatment Reporting System (GTRS) form data or IGTO questionnaire data available during this time period. In addition to the cumulative findings, the report includes information presented separately for data available from the 2009 calendar year (i.e., Year 5). Specifically, the findings in this report were based on an analysis (a) of GTRS data from 2006 through 2009, (b) admission and discharge questionnaire data from July 2007 through December 2009, (c) follow-up data from July 2007 through June 2010, and (d) distance treatment client data from August 2008 through June How are the data collected? The IGTO protocol has been modified over time, with substantive revisions of the questionnaires and protocol in July 2007 (see Lutz et al and 2007 for additional details). In general, the protocol relies on data from GTRS forms and questionnaires completed at admission, one month into treatment, at discharge, and also at follow-up six months after leaving treatment. The data collection protocol is as follows: (a) counselors submit the GTRS form data electronically to the Iowa Department of Public Health, (b) counselors administer the admission, one-month, and discharge questionnaires with their clients and the counselors mail the questionnaires to CSBR for data processing, (c) clients are offered the opportunity to confidentially complete questionnaires about their treatment experiences at one-month and discharge using business reply envelopes mailed to CSBR for data processing, and (d) counselors distribute consent forms (i.e., recruitment forms giving CSBR permission to contact clients to conduct the follow-up) to clients to indicate whether or not they want to participate in the follow-up data collection conducted by CSBR approximately six months after completing or leaving treatment (see Technical 1

8 Note 1). The primary method of conducting the follow-up is a mailed questionnaire, but respondents are also provided the option of completing it by phone if they prefer. Respondents are offered a $25 gift card when they complete the follow-up questionnaire. This project has been under continuous review by the Institutional Review Board (IRB) at UNI to ensure compliance with current legal and ethical considerations regarding human participants. GTRS Admission Form The findings in this report are based on an analysis of 2,293 GTRS Admission Forms (see Appendix A.1 for the form) with activity dates from January 1, 2007 through December 31, 2009 for clients admitted into the gambling treatment program. The unit of analysis is the form, not the client, because some clients had multiple admissions during this time period. Admission Questionnaire The findings in this report are based on an analysis of 678 Admission Questionnaires (see Appendix A.2 for the questionnaire) completed with clients admitted for treatment from July 1, 2007 through December 31, The unit of analysis is the questionnaire, not the client, because some clients had multiple admissions during this time period. Ideally, the Admission Questionnaires are completed with the client during the first session, or soon thereafter. GTRS Service Form The findings in this report are based on an analysis of 2,477 GTRS Service Forms (see Appendix A.3 for the form) with service dates from January 2006 through December 2009 for clients admitted into the gambling treatment program. Service forms are completed monthly. The unit of analysis is the form, not the client, because clients typically have multiple service forms submitted during their treatment. One-Month Questionnaire This report includes a limited analysis of 185 One-Month Questionnaires (see Appendix A.4 for the questionnaire) and 156 One-Month Insert Questionnaires (i.e., one-page questionnaire completed confidentially by the client regarding their views about the treatment services they are receiving) for the 2009 calendar year (see Appendix B.3 for findings). The unit of analysis is the questionnaire, not the client. Ideally, One-Month Questionnaires are completed with the clients after they have been in the program for approximately four weeks; however, the actual timing of questionnaire administration varies depending on the clients circumstances and treatment schedules. 2

9 GTRS Discharge Form The findings in this report are based on an analysis of 2,285 GTRS Discharge Forms (see Appendix A.5 for the form) with activity dates from January 1, 2006 through December 31, 2009 for clients admitted into the gambling treatment program. The activity date is the date the client last received a treatment service. The unit of analysis is the form, not the client, because some clients were discharged from treatment more than once during this time period. Discharge Questionnaire The findings in this report were based on 249 Discharge Questionnaires (see Appendix A.6 for the questionnaire) and 196 Discharge Insert Questionnaires completed for clients with discharge activity dates between July 1, 2007 and December 31, The unit of analysis is the questionnaire, not the client, because some clients were discharged from treatment more than once during this time period. Most of the Discharge Questionnaires are for clients who completed all or a substantial portion of treatment because the clients are not usually available to complete the questionnaires if they have stopped attending treatment. In addition to the Discharge Questionnaires are the Discharge Insert Questionnaires which are one-page questionnaires completed confidentially by the client regarding their views about the treatment services they received. These brief questionnaires are completed by the clients confidentially and then mailed to CSBR for data processing. There were 197 inserts from clients discharged between July 1, 2007 and December 31, Follow-Up Questionnaire The findings in this report were based on 384 Follow-Up Questionnaires (see Appendix A.7 for the questionnaire) completed with respondents between July 1, 2007, and June 30, Unlike the other questionnaire data which was included through December 2009, findings based on the six-month follow-up include questionnaires completed through June 30, During the time period of interest for this report, there were 577 respondents who were eligible for contact. This equates to a 67% completion rate. The unit of analysis is the questionnaire, not unique respondents, because there are a few respondents who completed two or more follow-up questionnaires during this time period. Of these respondents, 175 had completed treatment and 209 left without completing treatment. Follow-Up Questionnaires ideally are completed by respondents approximately six months after they are discharged from treatment; however, in a number of instances, the actual time lag is longer because of the difficulty reaching potential respondents. 3

10 Distance Treatment Although distance gambling treatment services are available through all of the statefunded treatment providers, there have been only a small number of clients who have enrolled in this program (see p. 67). The findings in this report include brief summaries of information obtained from telephone phone interviews (see Appendix A.8 for interview instruments) with these clients approximately one month and two months into treatment. When possible, clients are also interviewed by telephone soon after being discharged from treatment. Differences from Previous Single Year Reports. The sample sizes, frequencies, and percentages reported in this cumulative analysis vary somewhat from those reported in earlier single year reports. The magnitude of these differences varies by year and data source. These differences can occur for a variety of reasons including, but not limited to, the following: (a) submission of forms or receipt of questionnaires after the data were processed for a given time period, (b) whether analyses in previous years focused on unique clients versus unique forms within the system, (c) improvements by CSBR, over time, in the methods and effectiveness of data management procedures used to combine and update monthly data submissions of GTRS forms and processing of questionnaire data, (d) changes in decision rules per report concerning whether data with activity dates within a calendar year but received during the subsequent calendar year were included or excluded from the dataset used in the analysis of a yearly report, and (e) whether data for distance treatment and hybrid clients (see Glossary p. 239 for definitions) were included in the primary dataset or analyzed separately (see Technical Note 2 for additional information). Organization of the Report and Presentation of Findings Organization of Findings: The findings are organized in the following manner: (a) Section 2 includes cumulative findings from the GTRS Admission, Service, and Discharge Forms, (b) Section 3 includes cumulative findings from the Admission, Discharge, and Follow-Up Questionnaires, (c) Section 4 includes cumulative findings for distance treatment clients, (d) Appendix B includes findings from the Admission, One-Month, Discharge, and Follow-Up Questionnaires for the 2009 calendar year. Color Scheme. To aid the reader in interpreting the findings from the various data sources, findings corresponding to different data sources are color coded. Admission data are green, one-month data are light blue, discharge data are orange, and follow-up data are blue. 4

11 Percentages. Total percent is based on a denominator of all respondents. Unless otherwise noted, the percentages presented in this report generally do not correspond to the total percents, but instead refer to valid percents. A valid percent is based on a denominator of respondents for whom the questions were relevant and data were available. Typically, it omits no response and not applicable options. In this report, valid percent is sometimes also referred to as subgroup percent. The number of cases in the denominator is shown as n in tables and figures. Rounding. Values are rounded to whole percentages. 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 values reported in the narrative due to the cumulative effect of rounding when summing across multiple response options. Comparisons Across Data Sources. In this report, there are findings from various data sources. It is important to note that the individuals whose responses are depicted using one data source are not the exact same set of individuals whose responses are depicted using another data source. For example, 58% of those responding to the Admission Questionnaire met the classification criteria for current pathological or problem gambling. In comparison, 10% of those responding to the Discharge Questionnaire (and who completed treatment) met the classification criteria for current pathological or problem gambling. These values represent group aggregates and are not based on a denominator that includes the exact same set of individuals for a variety of reasons. For instance, some people who responded to the Discharge Questionnaire were admitted for treatment prior to July Also, not everyone who was admitted between July 2007 and December 2009 was discharged by the end of the calendar year. In addition, in order to more clearly identify treatment outcomes, the discharge values in the main body of the report are based only on the subgroup of people responding to the Discharge Questionnaire who completed all or a substantial portion of their treatment. In other words, the example above should be interpreted as follows: Of those admitted for treatment between July 2007 and December 2009 and who responded to the Admission Questionnaire, 58% met the classification criteria for current pathological or problem gambling. In contrast, of those who (a) completed treatment, (b) were discharged between July 2007 and December 2009, and (c) responded to the Discharge Questionnaire, 10% met the classification criteria for current pathological or problem gambling. From a statistical perspective, this corresponds to conceptualizing the results as between-group comparisons rather than paired-sample comparisons. In conclusion, the findings across data sources reflect changes in the aggregate or group level, but they do not provide information about change at the individual-level. 5

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13 SECTION 2 GTRS Forms ( ) The findings in this section are based on data from the State s electronic Gambling Treatment Reporting System (GTRS) submitted by agencies providing state-funded gambling treatment services in Iowa. These findings are only for adult clients admitted to state-funded gambling treatment programs as gamblers. These findings exclude forms for crisis clients and concerned others. The findings are based on cumulative data from GTRS forms submitted for the period of 2006 through In addition to the cumulative summary, the data are usually shown in tables with each year reported separately. 7

14 SECTION 2.1 GTRS Admission Forms ( ) The findings in this section are based on the analysis of 2,293 GTRS Admission Forms with activity dates between January 1, 2006 and December 31, These forms do not always correspond to unique clients because some clients were admitted more than once during this time period. These forms are only for clients who were admitted as gamblers into the gambling treatment program. This does not include all of the Iowans who were served by the state-funded treatment providers because the agencies also provide assistance to concerned others and provide additional services (e.g., screenings) and treatment activities (e.g., crises interventions). A map showing admissions by county from 2006 through 2009 is shown in Figure 1. (A map of Iowa including county names is included in the glossary under Map of Iowa.) Figure 1. The number of GTRS Admission Forms by county of client residency between January 1, 2006, and December 31, Note. See Technical Note 3 on p. 236 for map displaying the number of forms per county. 8

15 GTRS ADMISSION FORMS There were 2,293 GTRS Admission Forms submitted with activity dates within the four-year period from 2006 through The number of admissions per year tends to be around 500 apart from the unusually high number in The number of admissions in 2009 rebounded somewhat after two years of decline from the high in Admission Forms Figure 2. Number of GTRS Admission Forms by calendar year. (GTRS Admission Forms ) Note. Values obtained from a cumulative analysis will not always correspond to those previously reported for individual calendar years (see Technical Note 2 for explanation). 9

16 Background Characteristics of Clients Admitted for Treatment Background characteristics of the clients admitted for gambling treatment from 2006 through 2009 are shown below. These data show that 53% were men, 72% had children in their household or were financially responsible for children, 50% had attended or graduated from college, 52% were employed full-time, and 65% had health insurance coverage. Compared to the general population in Iowa, clients in the gambling treatment program were more likely to be divorced (and not currently married) and to be unemployed. They were less likely to be married (currently), have bachelor s or graduate degrees, and have private health insurance coverage. Gender Children Marital Status Education Employment Health Insurance Primary Source of Payment 53% Male 47% Female 72% Children in household or financially responsible for one or more children 28% No children in household or not financial responsible for any children 39% Married 24% Single 22% Divorced 07% Cohabitating 05% Separated 03% Widowed 18% College graduate (bachelor s degree or higher) 32% Some college 42% High school/ged 08% Less than high school 52% Employed full-time 12% Employed part-time 13% Unemployed in past 30 days and looking for work* 23% Not in labor force 65% Have private health insurance (not including Medicare or Medicaid) 35% Do not have private health insurance (may be covered by Medicare or Medicaid) 94% State unit reimbursement 03% Self pay or other private pay 02% Other government (e.g., Medicaid, Medicare, State non-unit reimbursement) <1% Private health insurance <1% No charge Note. * This corresponds to an unemployment rate of 17% using a formula of (Unemployed/(Employed + Unemployed))*100. General population estimates were based on information from the American Community Survey 3-Year Estimates. Census data are based on the following age groups: 15 and older for marital status, 25 and older for education, and 16 and older for employment status. Additional demographic information about health insurance was based on tables prepared by the State Library of Iowa, State Data Center using information from the U.S. Bureau of the Census, Housing and Household Economic Statistics Division s Health Insurance Historical Tables HI-4, HI-5, and HI-6, dated 9/10/09. The general population data for Iowa were as follows: (a) gender: 51.3% male, 48.7% female; (b) 29.2% households with own children under 18; (c) marital status: 54.9% now married, 27.1% never married, 10.1% divorced, 1.2% separated, 6.7% widowed; (d) education: 7.5% graduate or professional degree, 16.8% bachelor s degree, 9.3% associate s degree, 21.1% some college, 35.0% high school or equivalency, 10.4% less than high school; (e) employment: 69.4% in the labor force, 66.2% employed, and 4.5% unemployment rate; and (f) health insurance: 78.9% adults have private health insurance. 10

17 Table 1 Background Characteristics of Clients Admitted for Treatment Background Characteristic 2006 (n =717) 2007 (n = 552) 2008 (n =476) 2009 (n = 548) Total (n =2,293 ) Male 54% 52% 54% 52% 53% Female 46% 48% 46% 48% 47% Children in Household 75% 71% 72% 69% 72% No Children in Household 25% 29% 28% 31% 28% Married 40% 41% 42% 35% 39% Single 23% 21% 23% 29% 24% Divorced 20% 23% 22% 22% 22% Cohabitating 08% 06% 06% 07% 07% Separated 06% 05% 05% 04% 05% Widowed 02% 03% 02% 03% 03% College Graduate 16% 16% 20% 18% 18% Some College 31% 33% 35% 30% 32% High School/GED 42% 43% 38% 43% 42% Less than High School 10% 08% 06% 09% 08% Employed Full-Time 56% 54% 51% 46% 52% Employed Part-Time 12% 09% 14% 12% 12% Unemployed (Looking) 12% 14% 12% 16% 13% Not in Labor Force 19% 23% 23% 26% 23% Have Private Health Insurance Without Private Health Insurance 68% 65% 66% 59% 65% 32% 35% 34% 41% 35% State Unit Reimbursement (Primary Source of Payment) 97% 96% 92% 91% 94% Note. Gender was not reported on 3 forms in 2006, 24 in 2007, 4 in 2008, and 6 in Number of children in household was not reported on 1 form in 2006 and 1 form in Primary source of payment was not reported on 4 forms in The percent unemployed when excluding those not in the labor force from the denominator was 15% in 2006, 18% in 2007, 15% in 2008, and 21% in

18 Source of Referral The two most common sources of referral to the gambling treatment program were self (34%) and the BETSOFF helpline (31%). For some of the referrals by self or others, the helpline may have been called during the process of entering treatment system even though it may not have been considered the primary source of referral. Source of Referral Self Helpline 34% 31% Clinic or Health Care Provider Criminal Justice -- Court 11% 9% Other Community Organization Spouse-Partner Other Individual Employer/School 3% 3% 8% <1% 0% 20% 40% 60% 80% 100% Figure 3. Source of referral for gambling treatment program. (GTRS Admission Forms ) Table 2 Source of Referral for Gambling Treatment Program Source of Referral 2006 (n = 715) 2007 (n = 552) 2008 (n = 476) 2009 (n = 548) Total (n = 2,291) Self 29% 33% 41% 35% 34% Helpline 34% 34% 24% 31% 31% Clinic or Health Care Provider 13% 09% 11% 13% 11% Criminal Justice or 08% 10% 08% 08% 09% Court Other Community 03% 04% 04% 02% 03% Organization Spouse or Partner 02% 03% 04% 03% 03% Other Individual 10% 06% 07% 08% 08% Employer/School 01% <1% <1% <1% <1% Note. Some of the self referrals may have also called the helpline. Some of the categories were combined for the charts and tables in this report. Specifically, for the combined four-year period, the sub-category counts were as follows: (a) clinic and health care provider includes health care provider (n = 42), community mental health clinic (n = 60), and alcohol & drug abuse provider (n = 160); (b) other community organization includes other community agency which would cover both government, community, and religious organizations (n = 69) and debt counselors (n = 7); and (c) other individual includes GA and Gamanon members (n = 22) and other individuals (n = 159). Subcategory values are not separated for the individual years. 12

19 Days Waited Before Admitted for Treatment A slight majority (55%) of clients were admitted for treatment on the same day they were screened or sought treatment. A few days wait was reported for about 25% of the clients and an additional 20% of clients waited one week or longer to be admitted for treatment. The percentage of clients who had no wait has been declining from 65% in 2006 to 45% in Likewise, the percentage of clients who have waited one week or longer has risen from 13% in 2006 to 27% in Days Waited Before Admission Week or Longer 20% 4-6 Days 8% No Wait 55% 1-3 Days 17% Figure 4. Number of days client waited to be admitted for treatment. (GTRS Admission Forms ) Table 3 Number of Days Waited Before Admission Days Waited 2006 (n =717) 2007 (n = 552) 2008 (n =476) 2009 (n = 548) Total (n = 2,293) No Wait 65% 58% 49% 45% 55% (0 Days) 1 to 3 Days 17% 14% 21% 17% 17% 4 to 6 Days 05% 08% 09% 11% 08% 7 Days or Longer 13% 20% 21% 27% 20% Note. The proportion of clients who said they had to wait one or more days was significantly greater in both 2008 and 2009 compared to 2006 and The difference between 2008 and 2009 was not statistically significant. The proportion who reported waiting 7 or more days was greater in 2009 compared to the previous three years. 13

20 Other Treatment Experiences Forty-two percent of the clients had previously sought help to address their gambling problem. Prior treatment for alcohol or drug problems was reported by 29% of the clients when they were admitted to the gambling treatment program. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 58% First Time Seeking Help for Gambling Problem Other Treatment Experiences 42% Prior Help Sought for Gambling Problem 29% Prior Treatment for Alcohol or Drug Problem Figure 5. Treatment experiences for gambling, alcohol, and drug problems. (GTRS Admission Forms ) Table 4 Other Treatment Experiences Other Treatment Experiences (% Yes) Total (n = 717) (n = 552) (n = 476) (n = 548) (n = 2,293) First Time Seeking Help for Gambling Problem 62% 57% 52% 59% 58% Prior Help Sought for Gambling Problem 38% 43% 48% 41% 42% Prior Treatment for Alcohol or Drug Problem 32% 26% 29% 29% 29% 14

21 Filed for Bankruptcy Gambling problems can have detrimental effects on a person s financial well-being. About onethird of those admitted for gambling treatment said they had filed bankruptcy. Filed for Bankruptcy Yes 32% No 68% Figure 6. Filed for bankruptcy. (GTRS Admission Forms ) Table 5 Filed for Bankruptcy Total Bankruptcy (n = 715) (n = 552) (n = 476) (n = 548) (n = 2,291) Filed Bankruptcy (% Yes) 31% 33% 36% 30% 32% 15

22 Total Debt About one-third (35%) of clients admitted for gambling treatment said they had total debt of $50,000 or more. Total debt may include mortgages, car loans, educational loans, credit cards, overdue bills, and so forth which are not necessarily the consequence of problem gambling behaviors. The median amount of total debt was $24,110. Total Debt None $1 - $1,999 $2,000 - $4,999 $5,000 - $9,999 $10,000 - $19,999 6% 6% 8% 10% 13% $20,000 - $49,999 21% $50,000 - $99,999 14% $100,000 or more 21% 0% 20% 40% 60% 80% 100% Figure 7. Total debt. (GTRS Admission Forms ) Table 6 Total Debt Total Debt Total (n = 717) (n = 552) (n = 475) (n =547) (n =2,291) None 06% 07% 05% 09% 06% $1 - $1,999 07% 05% 06% 06% 06% $2,000 - $4,999 09% 08% 07% 09% 08% $5,000 - $9,999 10% 08% 10% 10% 10% $10,000 - $19,999 12% 14% 14% 14% 13% $20,000 - $49,999 20% 22% 23% 18% 21% $50,000 - $99,999 15% 15% 16% 12% 14% $100,000 or more 20% 21% 21% 21% 21% Median $25,000 $28,000 $25,000 $20,000 $24,110 Note. The mean amounts of total debt were as follows: $55,509 (2006), $63,720 (2007), $63,841 (2008), $60,463 (2009), and $60,396 ( total). Total debt can include credit card debt: 65% of clients said they had at least some credit card debt and about 5% said they had credit card debt of $50,000 or more with a mean of $9,468 and median of $1,600 ( total). As a measure of central tendency the mean is sensitive to the influence of outliers, which in this case included 6 clients who reported credit card debt of $200,000 or more excluding these extreme scores the mean was $8,815 and the median was $1,500. Total debt can include overdue bills: 55% of clients said they had at least some overdue bills and about 3% said they had overdue bills of $50,000 or more with a mean of $7,424 and median of $424 ( total). As a measure of central tendency the mean is sensitive to the influence of outliers, which in this case included 15 clients who reported overdue bills of $200,000 or more excluding these extreme scores the mean was $5,536 and the median was $400 ( total). 16

23 Gambling Related Debt One in five clients admitted for gambling treatment said they did not have any gambling related debt; however, nearly one in three clients said they had $20,000 or more of debt due to their problem gambling. The median level of gambling-related debt was $6,000. Gambling Related Debt None 20% $1 - $1,999 $2,000 - $4,999 $5,000 - $9,999 $10,000 - $19,999 $20,000 - $49,999 $50,000 - $99,999 $100,000 or more 12% 13% 13% 13% 18% 8% 4% 0% 20% 40% 60% 80% 100% Figure 8. Gambling-related debt. (GTRS Admission Forms ) Table 7 Gambling Related Debt Gambling Related Debt Total (n = 717) (n = 552) (n = 476) (n = 547) (n = 2,292) None 21% 19% 14% 22% 20% $1 - $1,999 14% 10% 10% 11% 12% $2,000 - $4,999 15% 15% 10% 12% 13% $5,000 - $9,999 12% 11% 17% 14% 13% $10,000 - $19,999 12% 13% 16% 13% 13% $20,000 - $49,999 14% 22% 19% 17% 18% $50,000 - $99,999 08% 08% 09% 07% 08% $100,000 or more 04% 03% 05% 05% 04% Median $4,700 $6,150 $9,000 $6,000 $6,000 Note. The mean values are highly influenced by the presence of extreme sources. Those clients who reported especially high levels of gambling related debt skew the distributions. The mean levels of gambling-related debt were as follows: $19,003 (2006), $19,917 (2007), $24,321 (2008), $22,975 (2009), and $21,276 ( Total). 17

24 Types of Gambling Activities (Past 6 Months) More than two-thirds (69%) of clients said they had wagered on slot machines during the past 6 months, with one-fourth indicating that they wagered exclusively on slot machines. Slot machines were by far the most commonly reported type of gambling activity. About one-fourth of clients said they had wagered money during the past 6 months on casino table games, scratch tickets/pull tabs, and lottery numbers. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 26% 69% 1% Types of Gambling Activities (Past 6 Months) 14% 8% 6% 28% 25% 4% 7% <1% 6% 9% Figure 9. Types of gambling activities in the past 6 months. (GTRS Admission Forms ) Note. Clients were asked to assign the percentage of all money wagered for each activity. The values above show the percent of clients who said at least 1% of their money was wagered on a particular activity. Table 8 Types of Gambling Activities: Past 6 Months Types of Gambling Activities (% yes) 2006 (n = 717) 2007 (n = 552) 2008 (n = 476) 2009 (n = 548) Total (n = 2,293) Casino Table Games 24% 26% 31% 22% 26% Slot Machines 67% 69% 70% 70% 69% Live Keno 02% <1% 03% <1% 01% Video: Poker/Keno/Blackjack 13% 14% 15% 13% 14% Non-Casino Cards 10% 07% 08% 06% 08% Bingo 05% 06% 06% 05% 06% Scratch Tickets & Pull Tabs 25% 27% 35% 26% 28% Lotteries 25% 26% 27% 21% 25% Racetrack 04% 04% 06% 02% 04% Sports 10% 06% 08% 04% 07% Stocks/Commodities/Futures <1% <1% 01% <1% <1% Other 15% 04% 01% 02% 06% No Wagering Reported 05% 12% 08% 10% 09% Note. Clients were asked to assign the percentage of all money wagered for each activity. The values above show the percent of clients who said at least 1% of their money was wagered on a particular activity. No wagering activities were reported in the past 6 months for 9% of clients; however, the dates they said they last gambled were within the past 6 months for 13% of these clients (i.e., 1% of total). 18

25 Percent of Wagering on Gambling Activities Table 9 Percent of Gambling Activities: Past 6 Months 2006 (n = 717) 2007 (n = 552) 2008 (n = 476) 2009 (n = 548) Total (n = 2,293) Casino Table Games None (0%) 76% 74% 69% 78% 74% Some (1% 99%) 21% 24% 25% 18% 22% Only type (100%) 03% 02% 06% 04% 04% Slot Machines None (0%) 33% 31% 30% 30% 31% Some (1% 99%) 42% 45% 50% 40% 44% Only type (100%) 25% 25% 19% 29% 25% Live Keno None (0%) 98% 99% 97% 100% 99% Some (1% 99%) 01% <1% 02% <1% 01% Only type (100%) <1% <1% <1% 00% <1% Video: Poker/Keno/Blackjack None (0%) 87% 86% 85% 87% 86% Some (1% 99%) 10% 12% 13% 12% 12% Only type (100%) 03% 02% 02% 02% 02% Non-Casino Cards None (0%) 90% 93% 92% 94% 92% Some (1% 99%) 09% 06% 08% 06% 07% Only type (100%) 01% 01% <1% <1% <1% Bingo None (0%) 95% 94% 94% 95% 94% Some (1% 99%) 05% 06% 06% 05% 06% Only type (100%) 00% 00% 00% 00% 00% Scratch Tickets & Pull Tabs None (0%) 75% 73% 65% 74% 72% Some (1% 99%) 24% 26% 33% 24% 26% Only type (100%) 02% <1% 02% 02% 01% Lotteries None (0%) 75% 74% 73% 79% 75% Some (1% 99%) 24% 26% 26% 21% 24% Only type (100%) <1% <1% <1% <1% <1% 19

26 Percent of Wagering on Gambling Activities Table 9 (Continued) Percent of Gambling Activities: Past 6 Months 2006 (n = 717) 2007 (n = 552) 2008 (n = 476) 2009 (n = 548) Total (n = 2,293) Racetrack None (0%) 96% 96% 94% 98% 96% Some (1% 99%) 04% 04% 06% 02% 04% Only type (100%) <1% 00% 00% 00% <1% Sports None (0%) 90% 94% 92% 96% 93% Some (1% 99%) 08% 05% 07% 04% 06% Only type (100%) 01% <1% 01% <1% 01% Stocks/Commodities/Futures None (0%) 100% 99% 99% 100% 99% Some (1% 99%) <1% <1% 01% <1% <1% Only type (100%) 00% 00% 00% 00% 00% Other None (0%) 84% 96% 99% 98% 94% Some (1% 99%) 13% 03% 01% 02% 05% Only type (100%) 02% <1% 00% <1% 01% 20

27 SECTION 2.2 GTRS Service Forms ( ) Presently, there are nine agencies providing state-funded gambling treatment services to Iowans. The main and satellite offices for these agencies are shown in Figure 10. During the four-year period of interest for this year report some agencies stopped providing services, some changed their names, and others changed their service areas. The agencies submit GTRS Service Forms documenting the number of sessions and minutes of various types of services they provide to gamblers admitted into the treatment program. Figure 11 is a map showing the total number of individual and group counseling sessions provided to clients by county. The agencies provide services in addition to individual and group counseling sessions, but the present study includes summaries only for these two major forms of treatment. Figure 10. Location of agencies providing state-funded gambling treatment services. Note. The office locations were based on information available to the public on the agencies websites as of November

28 Figure 11. Total number of individual and group counseling sessions provided to clients by the county in which the clients lived. (GTRS Service Forms ) During this four-year period, the treatment agencies provided (a) approximately 22,900 sessions corresponding to about 23,200 hours of counseling with gamblers admitted for treatment, and (b) approximately 19,200 sessions corresponding to about 28,600 hours of group counseling with gamblers admitted for treatment. Treatment providers may also recommend to their clients that they seek other types of treatment or counseling to support healthy lifestyle changes. During this four-year period, the following were recommended to those receiving gambling treatment services by counselors: (a) 81% Gambler Anonymous, Gamanon, or other support group meetings, (b) 65% debt management or financial counseling, (c) 15% substance abuse counseling, (d) 32% mental health counseling, (e) 4% domestic violence counseling, and (f) 2% sexual addiction counseling. Note. See Technical Note 3 for details on how sessions were assigned to counties and p. 237 for a map displaying the total number of sessions for clients within each county. For 2009, clients admitted into the gambling treatment program received approximately (a) 4,450 hours of individual counseling during 4,550 sessions, (b) 6,200 hours of group counseling during 4,300 sessions, (c) 200 hours of family counseling during 200 sessions, (d) 750 hours of individual continuing care during 750 sessions, and (e) 1,200 hours of group continuing care during 800 sessions. In 2009, additional services were recommended as follows: Gamblers Anonymous or similar group (73%), debt management/financial counseling (50%), substance abuse counseling (17%), mental health counseling (39%), domestic violence counseling (4%), and sexual addiction counseling (2%). 22

29 SECTION 2.3 GTRS Discharge Forms ( ) The findings in this section are based on the analysis of 2,285 GTRS Discharge Forms with activity dates between January 1, 2006 and December 31, These forms do not correspond to unique clients because some clients were discharged more than once during this time period. A map showing discharges by county from 2006 through 2009 is shown in Figure 12. Figure 12. The number of GTRS Discharge Forms between January 1, 2006 and December 31, 2009 per county based on where the clients lived. Note. See Technical Note 3 for details on how sessions were assigned to counties and p. 237 for a map displaying the number of forms per county. 23

30 GTRS DISCHARGE FORMS There were 2,285 GTRS Discharge Forms submitted with activity dates within the four-year period from 2006 through The numbers of discharges per year have been around 500 since The higher number of discharges in 2006 and 2007 are likely reflective of the higher number of admissions into the treatment program during Discharge Forms Figure 13. Number of GTRS Discharge Forms by calendar year. (GTRS Discharge Forms ) Note. The number of forms reported per year varies slightly from the numbers reported in earlier reports. This may occur for a variety of reasons (see Technical Note 2 for details). 24

31 Reason for Discharge Slightly more than one-third (36%) of the clients discharged had completed all or a substantial portion of their treatment; however, 50% of the clients left without completing treatment. The other reasons for discharge for the remaining clients were as follows: referral to outside agency (4%), program decision due to lack of progress (2%), incarceration (2%), death (<1%), and some other reason (6%). The percentage of discharges where the client left was 55% in 2006 as compared to 44% in During this time period, the percentage of clients who have completed treatment has been relatively consistent, ranging from 34% in 2008 to 38% in For every client who completed all or a substantial portion of their treatment there were 1.4 clients who left without completing treatment (excluding those who were referred elsewhere, released from the program for lack of progress, incarcerated, died, or other reasons). Reason for Discharge Completed Treatment 36% Client Left 50% All Other Reasons 14% Figure 14. Reason for discharge from the gambling treatment program. (GTRS Discharge Forms ) Reason for Discharge 2006 (n = 659) Table 10 Reason for Discharge: Summary 2007 (n = 615) 2008 (n = 499) 2009 (n = 512) Total (n = 2,285) Completed Treatment 35% 38% 34% 36% 36% Client Left 55% 49% 49% 44% 50% Other Reasons 10% 13% 17% 19% 14% Note. Completed treatment includes those who completed all or a substantial portion of treatment. Other reasons includes referrals to outside agencies, program decision due to lack of progress, incarceration, death, and all other reasons. The high percent of other reasons can be partially attributed to clients being discharged from one agency and transferred to another agency, and to clients with administrative discharges and subsequent admissions within an agency to clarify coverage service areas. 25

32 Reason for Discharge Completed Treatment (Plan Completed) Table 11 Reason for Discharge: Full Distribution 2006 (n = 659) 2007 (n = 615) 2008 (n = 499) 2009 (n = 512) Total (n = 2,285) 20% 26% 19% 21% 22% Completed Treatment (Plan Substantially Completed) 14% 12% 15% 15% 14% Referred to Outside Agency 02% 06% 06% 02% 04% Program Decision Due to Lack of Progress 02% 03% 03% 01% 02% Client Left 55% 49% 49% 44% 50% Incarcerated 02% 01% 01% 02% 02% Death of Client <1% 00% <1% 00% <1% Other 04% 03% 06% 13% 06% Note. Completed treatment includes those who completed all or a substantial portion of treatment. The high percent of all other reasons in 2009 can be partially attributed to clients being discharged from one agency and transferred to another agency, and to clients with administrative discharges and subsequent admissions within an agency to clarify coverage service areas. 26

33 Types of Gambling Activities Since Admission The most common types of gambling activities at discharge for those who completed treatment were generally the same as they were at admission; however, the percentages are much lower. Wagering on slot machines is by far the most common type of gambling activity reported. Most clients (60%) who completed treatment did not report any gambling activities since admission. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 8% 26% Types of Gambling Activities: Since Admission 5% 4% 9% <1% 2% 7% 1% 4% <1% 2% 60% Figure 15. Types of gambling activities: Since admission. (GTRS Discharge Forms for clients who completed treatment) Types of Gambling Activities (% yes) Table 12 Types of Gambling Activities: Since Admission (For those who completed treatment) 2006 (n = 230) 2007 (n = 234) (n = 172) 2009 (n = 186) Total (n = 822) Casino Table Games 06% 07% 12% 09% 08% Slot Machines 24% 28% 29% 24% 26% Live Keno <1% <1% <1% <1% <1% Video: 03% 05% 09% 02% 05% Poker/Keno/Blackjack Non-Casino Cards 06% 04% 02% 04% 04% Bingo 03% 02% 04% 01% 02% Scratch Tickets & Pull Tabs 04% 09% 13% 10% 09% Lotteries 06% 06% 10% 06% 07% Racetrack <1% <1% 01% 02% 01% Sports 04% 04% 04% 02% 04% Stocks/Commodities/Futures 00% 00% 00% <1% <1% Other 03% 02% 00% 01% 02% No Wagering Reported 63% 61% 54% 61% 60% Note. Clients were asked to assign the percentage of all money wagered for each activity. The values above show the percent of clients who said at least 1% of their money was wagered on a particular activity since being admitted into treatment.

34 Percent of Wagering on Gambling Activities Table 13 Percent of Gambling Activities: Since Admission (For those who completed treatment) 2006 (n = 230) 2007 (n = 234) 2008 (n = 172) 2009 (n = 186) Total (n = 822) Casino Table Games None (0%) 94% 93% 88% 91% 92% Some (1% 99%) 04% 07% 09% 04% 06% Only type (100%) 02% <1% 02% 05% 02% Slot Machines None (0%) 76% 72% 71% 76% 74% Some (1% 99%) 09% 13% 16% 09% 12% Only type (100%) 15% 15% 13% 15% 14% Live Keno None (0%) 100% 100% 99% 100% 100% Some (1% 99%) <1% <1% <1% <1% <1% Only type (100%) 00% 00% 00% 00% 00% Video: Poker/Keno/Blackjack None (0%) 97% 95% 91% 98% 95% Some (1% 99%) 02% 03% 07% 02% 03% Only type (100%) <1% 02% 02% <1% 01% Non-Casino Cards None (0%) 94% 96% 98% 96% 96% Some (1% 99%) 04% 03% 02% 04% 04% Only type (100%) 01% <1% 00% <1% <1% Bingo None (0%) 97% 98% 96% 99% 98% Some (1% 99%) 02% 02% 02% 01% 02% Only type (100%) <1% <1% 01% 00% <1% Scratch Tickets & Pull Tabs None (0%) 96% 92% 87% 90% 91% Some (1% 99%) 04% 07% 12% 07% 07% Only type (100%) <1% 01% 01% 03% 01% Lotteries None (0%) 94% 94% 90% 94% 93% Some (1% 99%) 04% 06% 08% 05% 06% Only type (100%) 01% <1% 02% 02% 01% 28