Lottery. The act of risking something of value, Including money and property, on an activity that has an uncertain outcome.

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1 DMHAS Commissioner Statewide Services Jeremy Wampler, LCSW, LADC, NCGC-II Director, DMHAS Problem Gambling Services Problem Gambling Services Susan McLaughlin M.P.A., C.P.P. Prevention Services Coordinator, DMHAS Problem Gambling Services RACs & CCPG Prevention Services Statewide Awareness Case Finding/ Outreach Clinical Services B/C Programs DiGIn Helpline (CCPG) Fiorigio (Fred) Fetta, LPC, NCGC-II Clinical Director, DMHAS Problem Gambling Services Connecticut Renaissance The Connection UCFS Wheeler MCCA The act of risking something of value, Including money and property, on an activity that has an uncertain outcome. Lottery 1

2 MORE GAMBLING OPPORTUNITIES? 66% Male, 34% Female Average Age: 37 Favorite Fantasy Sport: Football (73%) Fantasy Sports Players that Pay League Fee: 60% On average, fantasy sports players spend $465 a year on fantasy-related purchases (i.e. league costs, daily games, league-related materials) Billion dollar industry Blurring The Lines Is This Like Gambling? 2

3 The Future Casinos? Gambling behaviors are so normative that often certain activities are not even considered gambling. Many more grey areas when it comes to gambling DMHAS Problem Gambling Services 2010 Playing daily fantasy sports Being in a golf league tournament Betting sneakers on the outcome of a video game Risking a meal based on the outcome of a football game Bingo at church Investing in a mutual fund Putting your business card in a bowl to win a store gift certificate Playing free slots online Betting on who you think will be the next American Idol Playing a carnival game at the local fair Excitement Entertainment Escape (forget about their problems for a while) Economics (they want the money) Ego (the person s pride or reputation is on the line) 16 A gambler is nothing but a man who makes his living out of hope. ~William Bolitho DSM-III - Recognized as Psychiatric Disorder 1980 Diagnosis based on clinical experience and that of other treatment professionals. Criteria began with a statement about the individual experiencing progressive loss of control and then listed seven items, with an emphasis on damage and disruption to the individual s family, personal or vocational pursuits and money-related issues. 3

4 DSM-IV (1994) Criteria revised to reflect similarity to substance dependence, with the addition of repeated unsuccessful attempts to control, cut back or stop gambling. Noted excessive gambling behavior might be an indication of a manic episode and, therefore, bipolar disorder would be the primary diagnosis. (even at this early stage, the comorbidity of PG with other psychiatric problems was recognized) Impulse Control Disorders: DSM IV (1994) Classification DSM-5 moved to Substance-Related and Addictive D/O Impulse Control Disorder Renamed: Gambling Disorder Kleptomania Pyromania Intermittent Explosive Disorder Trichotillomania Pathological Gambling Impulse Control Disorder - NOS So far only Non-Substance-Related Disorder included Common elements with substance use disorders. Scientists and clinicians believe problem gamblers closely resemble alcoholics and drug addicts, not only from the external consequences of problem finances and destruction of relationships, but, increasingly, on the inside as well. The brain on gambling, reacts similar to the brain on substances. 4

5 A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period. 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement 2. Is restless or irritable when attempting to cut down or stop gambling 3. Has made repeated attempts to control, cut back, or stop gambling 4. Is often preoccupied with gambling (e.g. having persistent thoughts of reliving past gambling experiences, handicapping of planning the next venture, thinking of ways to get money with which to gamble) 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed) 6. After losing money gambling, often returns another day to get even ( chasing one s losses ) 7. Lies to conceal the extent of involvement with gambling 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 9. Relies on others to provide money to relieve desperate financial situations caused by gambling. B. The gambling behavior is not better explained by a manic episode Episodic: Met criteria at more than time pt. with sx s subsiding in between for several months Persistent Continuous sx s for multiple years Early Remission: no criteria for 3-12 mos. Sustained Remission: no criteria for 12 or more mos. Severity Mild: 4-5 Criteria Moderate: 6-7 Criteria Severe: 8-9 Criteria Nondisordered Gambling Professional Gambling Social Gambling Manic Episode Key Not better explained Person may exhibit manic like behavior during gambling episode Personality Disorders Other Medical Conditions 5

6 Personality Disorders If criteria met for both, both can be dx d Other Medical Conditions Dopaminergic medications John is a 40-year-old African American male, who comes into treatment after being spouse mandated (i.e. his wife tells him he either gets help for gambling, or they are going to get a divorce). Upon Intake, you learn that John has $75, worth of gambling-related debts and has been gambling problematically for years. John reported that he has gambled since adolescence. John s father gambled regularly, so when John had the opportunity he would gamble on card games or sporting events at school. John reported that he spends most days thinking about gambling and can gamble daily most weeks. John often lies to his wife, telling her he is working late, but instead goes to the casino to play blackjack, poker or craps. John knows he has lost a lot of money gambling, but feels he can get his money back, because he has won big in the past. John s wife found out about his gambling after family members complained to her, because they loaned John money, but he hasn t paid them back. What criteria of Gambling Disorder does John meet? Gloria is a 54-year-old Caucasian female, who is mandated by probation to seek treatment after she embezzled $200, from work. Gloria is tearful as she describes her illegal acts upon intake: I never intended to steal from my employer. I was only borrowing. I was planning on putting that money back. Gloria reported that she started gambling once Foxwoods opened up in 1992, and would gamble 20 bucks, here and there. All that changed five years ago, after her divorce. Gloria found that she would go to the casino to play slots whenever she felt stressed, or depressed. Gloria stated that she gets lost in the slot machines, and doesn t have to think about her worries. Gloria says that she could spend hundreds of dollars each visit to the casino. Gloria reported that she has tried to stop gambling on several occasions, but the urges to gamble were too powerful. The few times she was gambling free, she found herself up all night thinking about gambling; during these times, she would become very irritable with others. So Gloria went back to gambling, because nothing helped her cope with life like her favorite slot machines. What criteria of Gambling Disorder does Gloria meet? Tolerance Withdrawal Loss of Control Preoccupation Distressed gambling Chasing Losses Lying behaviors Jeopardized or lost a significant relationship, job, education or career opportunity Bailouts Continuum?? No Gambling Social Gam. Serious Social Gam. Problem Gam. Disordered???? Professional Gambler Antisocial Gambler Pathways Model (Blaszczynski & Nower, 2002) Pathway 1 Gambler 1. Gambling linked to learning and environment 2. No pre-existing pathology 3. May have early big wins, intermittent wins, enjoy excitement 4. 1,2 &3 combine to form a gambling habit 5. Cognitive distortion contribute to habitual pattern 6. Anxiety, depression, substance use likely secondary to gambling consequences 36 6

7 Pathway 2 Gambler Proposes that some individuals vulnerable to problem gambling due to psychological problems such as difficulty managing stress or dealing with crisis situation Key feature is pre-existing psychological problem that creates emotional vulnerability Gambling viewed as way to escape or potential solution Poor coping and problem solving due to inadequate role models or past trauma May be anxious, depressed, isolated Gambling may instill a sense of hope, increasing desire to gamble. Pathway 3 Gambler Predisposing biological factors that contribute to problem gambling Likely history of wide range of impulsive behaviors from early age May have difficulties concentrating and learning May have history of attention deficit disorder May be overactive with a need for a lot of stimulation May do things on impulse without considering consequences The above behaviors point to biological disorders related to neurological deficits Similarities Loss of Control Preoccupation Negative impact on major life areas Tolerance Similarities Withdrawal Symptoms Self-help groups Biopsychosocial/spiritual disorders Family involvement Differences Fantasies of success No biological test Easier to hide Unpredictable outcome 7

8 Differences Gambling is not self-limiting Behavior not attributable to intoxication More intense sense of shame and guilt Greater denial and stronger defenses Differences Greater financial problems Intensity of family anger Less public awareness and acceptance Problem and Pathological Gamblers (NORC study) Poorer health More mental health treatment More depressed More manic symptoms More alcohol/drug dependence More family arguments and higher divorce rate More arrests File more bankruptcy Higher job loss and unemployment Financial/Legal Total amount of larceny/embezzlement charges of 38 PGS clients=$7,810,600 (nearly $8 million). This is about $205,500 per person. PGS, 2005 CT leads US in increase in embezzlements

9 Although nearly half (49%) of those with lifetime pathological gambling received treatment for mental health or substance abuse problems, none reported treatment for gambling problems Do you gamble much? Buying a few lottery tickets isn t really gambling. No not at all Have you ever borrowed money to gamble, gambled more than you intended to, or lied about how much you gambled? Have you or someone else ever thought that gambling might be causing problems in your life? It s bad enough I have to talk about my drug use, I m not ready to deal with gambling I can save time on these Gambling questions That s not why she is here anyway You ve never lied About gambling or Wanted to spend more Money on it, have you? Phew! Nobody Cares about gambling here! No No, that s not a problem Bad News Screens don t work in the current standard of clinical practice Give illusion of addressing issue Individuals coming into treatment for a substance use or mental health disorder may have any or all of the following attitudes toward their gambling: Never thought of it as a problem or potential problem Believe it is a solution to their problems (emotional and or financial) Realize it may be a problem, but don t want to think about giving up all their fun. Feel overwhelmed by dealing with just one problem, don t want to have to think about any others. 53 9

10 What happens in actual clinical practice: Use screen No one endorses items What does counselor think None of my clients have any gambling problems Don t care about the research, my clients are different NIMBY (Not in my back yard or treatment program) How often do you gamble? For example, buy lottery tickets, go to the casino, play cards with friends? I don t really gamble, but I do buy lottery tickets a few times a week and my friends and I go to the casino to celebrate our birthdays. Start with a lead in question: How much money did you spend on gambling in the past year (for example, lottery, scratch offs, betting on sports, cards, casino, etc.)? $ OR In the past year, have you participated in gambling (for example, lottery, scratch offs, betting on sports, cards, casino, etc.)? None Less Than Monthly Monthly Weekly Daily Then, the NODS CLIP Have you ever tried to stop, cut down, or control your gambling? Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling? Have there 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? A yes response to any of the three questions may indicate a problem with gambling. 1. During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling? Yes No 2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? Yes No 3. During the past 12 months, did you have such financial trouble that you had to get help from family or friends? Yes No *BBGS Scoring: Answering Yes to one or more questions indicates likely disordered gambling. 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. Source: Gebauer, L., LaBrie, R. A., & Shaffer, H. J. (2010). Optimizing DSM-IV classification accuracy: A brief bio-social screen for gambling disorders among the general household population. Canadian Journal of Psychiatry, 55(2),

11 Ask more than once! What do you like to do for fun? Ever win anything? Certain times of the year Superbowl pools, money on the game, etc. Big horse races (Kentucky Derby, Belmont, Preakness) When the lottery prize gets very high Fantasy leagues (Especially football) March Madness What impact has gambling had on your recovery? What impact has gambling had on your relationship/s? What impact has gambling had on your finances? Don t be afraid to talk about money!!! Someone who is unwilling to make changes with his/her gambling at this time. I m here to work on my depression. I m not interested in talking about how often I buy scratch tickets. Raising Awareness about gambling and providing education could be helpful. Keep gambling safe. Set a limit on how much time and money you spend gambling. Recreational Low Risk Gambling Limits on time, frequency and duration Learn about the games you choose to play. Not gambling alone, but in a social setting Balance gambling with other leisure activities. Gambling with money you can afford to gamble Raising Awareness / Education High Risk Gambling Gambling to cope with grief, loneliness, anger or depression. Gambling under financial pressure. Recovering from mental health or substance use disorders. Under the influence of drugs. Under the legal age. For concerns about gambling, please call New Senior Risk Reduction Wallet Card 11

12 Someone who is thinking about making changes with his/her gambling. When I go to the casino, the free drinks are a trigger for alcohol use. I don t know if I m ready to stop going, but I might think about it. Evaluating decisions may be helpful for someone contemplating change. 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) Benefits of Gambling Importance Costs of Gambling Distress Examples: Winning helps to pay 8 Losing hurts my family 9 the bills and puts my sobriety at risk. Gambling takes me 7 I can spend hours at the casino 9 away from my problems. when I m gambling. This takes time away from my kids. University of South Florida Co-occurring Disorders Problem Gambling Integrated Treatment Workbook Someone who is prepared to make changes. I believe that I am spending way too much time at the OTB, which makes me so tired that I go back to using cocaine to function. I need to focus on making changes. Having resources for success available could be helpful at this stage. Treatment Programs Bettor Choice Regional Gambling Awareness Teams 12 Step Meetings Gamblers Anonymous National Site CT / Western Mass Site (626) Harm Reduction Abstinence Utilizing Motivational Interviewing (MI) and Cognitive Behavioral Therapy (CBT). Gam-Anon (718) Advocacy Unlimited Problem Gambling Support Group CCAR Monthly Gambling Awareness Groups 12

13 Counseling for gamblers and person s affected by gambling (i.e. spouse, family member, significant other). Individual, couples, family and group counseling. Medication Management (gambling often co-occurs with other mental health and substance abuse disorders). Peer Counseling Accept insurance with grant funding that reduces or eliminates treatment costs. Clients individual goals REGION 1 Southwest CT REGION 2 South Central CT REGION 3 Eastern CT CONNECTICUT RENAISSANCE Melodie Keen 4 Byington Place. Norwalk, CT Franklin Commons Stamford, CT , ext (All referrals) Fax: melodie@ctrenaissance.com POSITIVE DIRECTIONS Bob Vietro 420 Post Road, West Westport, CT , ext. 126 (All referrals) Fax: info@positivedirections.org THE CONNECTION, INC. BETTOR CHOICE PROGRAM Scott Nelson CVH, P.O. Box 351, Russell Hall Middletown, CT (All referrals) Fax: Orange Street New Haven, CT snelson@theconnectioninc.org UNITED COMMUNITY & FAMILY SERVICES Lisa Moon 47 Town Street, Meadows Plaza Norwich, CT (All referrals) Fax: Bayonet Street New London, CT LMoon@ucfs.org Plainfield and Jewett City REGION 4 North Central CT WHEELER CLINIC Patricia Devendorf 999 Asylum Avenue Hartford, CT , ext.104 (All referrals) Fax: pdevendorf@wheelerclinic.org 91 Northwest Drive Plainville, CT North Mountain Road New Britain, CT Region 5 Northwest CT MCCA Diane Desmarais Contact Diane for Inpatient and Outpatient Referrals Cell: Office: x 1813 Fax: ddesmarais@mccaonline.com Danbury, Waterbury, New Milford, Torrington, and Ridgefield Statewide Gambling Awareness Prevention Initiative: Moving towards Gambling Informed Prevention, Intervention and Treatment across the continuum of care and across the lifespan in the five Mental Health and Addiction Services Human Service Regions in Connecticut. Composed of prevention, treatment professional, recovery supports providers and community partners. Each region has a team that meets quarterly. 13

14 Special projects supported through this Initiative include: Gambling Awareness integration in schools and youth programs Financial Literacy with Older Adults, Women, People in Recovery and Youth Business community awareness Program evaluation and regional data collection Problem Gambling Awareness Month events Scholarships to attend today s event Fantasy Sports Awareness Upcoming Legislative Events Region 1 (Southwest CT) Communities 4 Action Ingrid Gillespie, Executive Director (203) igillespie@communities4action.org Region 2 (Central CT) South Central CT Substance Abuse Council Marlene F. McGann, Executive Director (203) mawsac@aol.com Region 3 (Southeast CT) South Eastern Regional Action Council Michele Devine, Executive Director (860) serac.ed@sbcglobal.net Region 4 (Northeast CT) East of the River Action for Substance Abuse Elimination Bonnie Weyland Smith, Executive Director (860) bonnie.smith@erasect.org Region 5 (Northwest CT) Central Naugatuck Valley Regional Action Council Jennifer Dewitt, Executive Director (203) cnvrac1@famintervention.com Someone making the steps towards change. I m starting to have some recovery time under my belt and I want to keep moving in the right direction, one day at a time. Interventions that help individuals work towards achieving their goals are helpful in this stage of change. Determine the frequency of visits to the gambling establishment: How often can you gamble without causing problems? Is it safe to gamble on a weekly basis? Is it safe to gamble on a monthly basis? I feel that it is safe for me to gamble days per week; or days per month. Set boundaries on playing time: What is a safe amount of time to gamble? When I gamble today, I will leave at o clock. Take care of important expenses first (i.e. rent, bills, basic needs, etc.) before gambling. Determine what money is left over to gamble and place it in your funding for entertainment. Only bring cash that you can afford to lose. Do not bring ATM cards, credit cards, check books, etc. What money do I have in my entertainment category? I will only bring $ cash to gamble and leave if I lose this amount. Remove all winnings from gambling. Hope to win, but always expect to lose. Plan to take home any extra winnings. Bring a friend or family member along, who is aware of the reduction plan. I will bring with me when I gamble. 14

15 Triggers Monitoring Make a list of your triggers for gambling, substance abuse and mental health disorders. When you experienced the trigger(s), did you gamble, use, or experience depressive symptoms? If not, what kept you from gambling, using, or experiencing improved mood? If so, how could you have prevented the relapse or depressed mood? Increasing Pleasant Activities When you experience urges to gamble, use, or your anxiety increases, what else can you do? Examples spend time with family or friends, get involved with a hobby, watch a movie, call a support, etc. Thought related interventions When you experience urges to gamble or use, how can you keep from relapsing? How can you work through trauma? Examples Think about the negative consequences of the behavior, using grounding techniques, put off gambling or using for 10 minutes at a time, etc. Create a budget Identify all your expenses Identify you list of creditors Identify all of your income sources Create a repayment plan I haven t gambled in over 6 months, and I m feeling great about my recovery. I m also coping better with the traumatic events I ve experienced in my life. For Further Information 1. Gambling is not a risk-free activity. 2. Know how to keep the problem out of gambling. 3. Help is available for those with gambling problems, as well as for those impacted by gambling. Problem Gambling Helpline CT DMHAS Problem Gambling Services Connecticut Council on Problem Gambling

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