IOM Conceptualization and Problem Gambling Public Health Interventions

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1 Evidence of high risk of gambling problems among individuals diagnosed with substance use and mental health disorders. Not addressing gambling issues decreases treatment effectiveness and adds to treatment costs Early intervention and treatment work Per DSM5, those with gambling disorder have high rates of SUD s, depressive disorders, anxiety disorders and personality disorders. One-third (Ledgerwood et al, 2002) to nearly ½ (Himelhoch et al, 2015) of individuals in SUD treatment identified as problem gamblers The more severe the past year SUD, the higher the prevalence of gambling problems (Rush et al, 2008) Individuals with lifetime history of mental health disorder had 2-3 times rate of problem gambling (Rush et al, 2008) Higher rates of medical problems among those with at risk and problem gambling (this group may be 25% of adults) 1

2 IOM Conceptualization and Problem Gambling Public Health Interventions No gambling Social gambling At Risk Gambling Problem Gambling Gambling Disorder For those who screen positive provide brief intervention Brief Specialized Treatment Universal Selective Indicated Prevention Then inform of and offer referral to treatment 2

3 9 NODS 1 NODS 8 NODS 10 NODS 14 Have there ever been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences or planning out future gambling ventures or bets? Have you ever gambled as a way to escape from personal problems? Has there ever been a period when, if you lost money gambling one day, you would return another day to get even? Has your gambling ever caused serious or repeated problems in your relationships with any of your family members or friends? 3

4 PG Screening

5 The following questions are about gambling. By gambling, we mean when you bet or risk money or something of value so that you can win or gain money or something else of value. For example, buying lottery tickets or scratch-offs, gambling at a casino, playing bingo, shooting dice, betting on sports, or playing keno. Risk Levels for Gambling Disorder and Brief Interventions Low Risk: An individual has answered no to all questions. Provide individuals with their score, give feedback on their risk level and give literature regarding Gambling Disorder in case their behavior worsens or they have affected family/friends with whom they want to share. Moderate Risk: An individual has responded yes to question 1, but has said no to all other questions. Give the low risk intervention. Additionally, the clinician should discuss with the participant the continuum of gambling behaviors (e.g., recreational, at risk, problem disorder), risk factors associated with moderate and problem gambling (e.g., medical issues), and guidelines to reduce risk for gambling problems. High Risk: An individual has responded yes to question 1 and has said yes to at least one other question. Combine low and moderate risk intervention. Additionally, review risk factors for problem gambling and options for further assistance including self-help materials, referral for further evaluation and referral to Gamblers Anonymous or a recovery support specialist. 5

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7 Perspective Change: Disordered Gambling Integration (DiGIn) Addressing gambling and gambling problems for individuals presenting with a primary concern of a substance use or mental health disorder is not just about making a diagnosis or finding cases of pathological gambling. Rather this approach involves assuring that the impact of gambling on mental health and substance use recovery is an ongoing topic of conversation in treatment, recovery and prevention settings. 26 Assessing Impact on Recovery Integrated Assessment Beyond diagnosis and labeling Integrate gambling throughout the assessment in addition to specific screening items In what ways does gambling support or detract from mental health or substance abuse recovery? In what ways does gambling support or detract from life goals? The key to this approach is to raise the issue of gambling and its role in your client s recovery in multiple contexts and repeatedly over time. Also it is key to include the topic of gambling in a non-judgmental or labeling manner, in order to minimize defensiveness or resistance

8 Integrated Assessment Incorporating into existing assessments How might you ask questions related to gambling in each of these sections of your intake or assessment? Medical Financial Family History Substance Use Psychiatric Recreation Screening Best Practices Include brief screen on intake (and don t expect much) Also use subtle questions about gambling activities. Be Creative. Just begin the conversation. Don t Pounce Repeat screen after relationship and trust established (at treatment plan updates?) Conduct screen in conjunction with psychoeducation on impact of gambling on recovery/problem gambling 29 GP s thought it was inappropriate to ask patients out of the blue if they gamble (Tolchard et al, 2007) If we ask about gambling and someone has a problem we would have to do something with it so we don t ask. If we ask, we don t know what to do with it. Counselor I can see from your response during your assessment that you were being really honest and open. That shows how motivated you are to work on your recovery. Some of your responses about gambling suggest that gambling may have a negative effect on your recovery and I d like to give you some feedback and information that we can talk about. How does that sound to you? 8

9 Client OK I guess. I never really thought much about my gambling. My drinking has always been the problem that seems to get me into trouble. Counselor That s great. I appreciate your willingness to talk about an area that you haven t thought about before and look at how it might effect your recovery. Counselor Tell me about your gambling and how you think it fits in your life and your recovery. Client Well I like playing cards with my buddies. We ve been getting together once a week for years. We do drink at the games. Hadn t thought about that. Do you think that s a real problem? Cost Benefit Analysis Counselor That s a great connection you just made. I think that is something to think about. One way we can look at your card playing is to look at the pros and cons. Is that something you d be willing to do? Please list all the benefits you receive from gambling and on a scale of 1-9 list how important each benefit is to you (1= not important; 9 = extremely important) and lists the costs of gambling (emotional, physical, relational etc as well as financial) and how distressing that cost is on a 1-9 scale (1 = not distressing; 9 = extremely distressing) Gambling Benefits Importance Gambling Costs Distress After you have made your Cost-Benefit list, look over the list and write down any feelings arise when you think about the balance of benefits and costs of gambling: Do any of these costs seem too expensive or too distressing? Are there alternative ways of getting any of the benefits? 9

10 Counselor: You did a great job of looking clearly at the things you enjoy about gambling and that you see as benefits as well as some of the downside or costs of gambling. What do you make of that? Client: Yeah, I think I see what you are getting at. Gambling is fun, but it always seems to lead to drinking. I know how drinking is messing me up, but I never thought about the gambling. Counselor: I think it is really good that you are able to see both sides of what gambling is about for you. You do have fun gambling, but you can see that it also interferes with your goal of not drinking. Client: Yeah, I just always thought it was something fun to do. I didn t really look at the connection to my drinking. On Scale of 1-10 how important On Scale of 1-10 how confident On Scale of 1-10 how willing 40 10

11 Jessie is a 57 year old female, presents due to marijuana use. Lives with adult daughter and her 3 children (X2 yrs). Grandson told teacher about her marijuana use and teacher reported to DCF. Significant conflict with daughter about house cleaning and child rearing. Reported on intake that she plays bingo 4-5 x per week. Takes her 82 year old mother. Feels it is a good way to get out of house and avoid conflict with daughter. Stated she spent $5000 in past 6 months Charles is a 34 year old male in medication assisted treatment program. Has been abstinent from opiates on methadone x 4 months. Reports significant cocaine cravings X 1 month. In initial assessment reported only occasional purchase of lottery tickets. In recent group discussion stated he has been buying $100 worth of lottery tickets per week rather than buying crack with that money. Linda is 42 year old female. On intake did not report any concerns about gambling. However, during group discussion, she was very quiet and did not make eye contact after viewing video on family consequences of gambling. When asked about her reaction, she acknowledged that her boyfriend with whom she is living, becomes abusive when he loses gambling or when they fight about money. She has been playing the lottery as she thinks winning will be the only way she can get enough money to leave this abusive situation. 11

12 First gambling experience Family and gambling Attitudes toward gambling Role in family activities and traditions Cultural Forms of gambling Role in cultural traditions Cultural attitudes towards gambling Cultural views toward help and help-seeking Gambling was done to meet needs Served an important function The best alternative at the time 12

13 What strengths/skills have you used to cope with gambling problems? Which have worked best? What strengths/skills have you used in other areas or times in your life? 13

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18 ~50-80% Affect Disorders ~10-35% Anxiety Disorders Pathological Gambling Trauma ~5-30% Attention Deficit Disorder ~20-35% Personality Disorders Substance Use Disorders ~20-93% ~25-63% 18

19 Maintenance Action Lapse or Relapse Planning Precontemplation Contemplation 75 19