Creating Gambling/Problem Gambling Informed Substance Use Disorder and Mental Health Treatment Programs Loreen Rugle, Ph.D., NCGCII Director, Problem Gambling Services State of Connecticut Department of Mental Health and Addiction Services Lori.Rugle@ct.gov
This isn t where our people are
What are we not doing right? Learning and listening project
Understand community attitudes and needs Increase community awareness Increase capacity to address problem gambling in community relevant ways
Community Readiness and Awareness Surveys Mental Health and Addiction Counselors Mental Health and Addiction Services Clients Community Groups Latino, African American, Non-Latino Caucasian
Focus Groups (formal and informal)
Training Clinical CAP Presentations Integration Integrated Assessments Brief Interventions Integrated Treatment Protocols
Community Awareness Posters Bus Signs Radio and TV PSA s? CAP Program
It is important to provide help for gambling problems 90 80 70 60 50 40 30 20 10 0 Str. Disag. Some Disag. Some. Ag. Str. Ag. C1T1 C1T2 C2T1 S1T1 S1T2 S2T1 If we all think this important, why doesn t it happen?
I am interested in learning more about problem gambling C1T1 90 80 70 60 50 40 30 20 10 0 Not at all True Slightly True Mod. True Very True C1T2 C2T1 S1T1 S1T2 S2T1
Budget Cuts DiGIn Buy In Trauma Informed Care Accreditation Co-Occurring Disorders Evidence-based Treatments Unfunded Mandates Recovery Oriented Care Wage Freezes 13
Principles of Drug Addiction Treatment NIDA (1999) Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. 14 14
So Why Bother? Evidence regarding the risk for gambling problems among individuals diagnoses with substance use and mental health disorders and the cost in particular for not addressing gambling issues in these individuals
Problem Gambling and Mental Health Disorders Williams et al., 1998 Odds of having a Mental Health or Substance Use Disorder Recreational Gambling Problem Gambling Disorder Compared to no Gambling Compared to no Gambling Major Depression 1.7 * 3.3 * Dysthymia 1.8 * 2.1 Schizophrenia 0.6 3.5 * Phobias 1.2 2.3 * Somatization 1.7 * 3.0 * Antisocial PD 2.3 * 6.1 * Alcohol Use 3.9 * 7.2 * Alcohol Abuse/Dep 1.9 * 3.3 * Nicotine Use 1.9 * 2.6 * Nicotine Dep 1.3 * 2.1 * NS = Mania, Suicidality, OCD, Panic, GAD, Drug Use, Drug Abuse/Dep *=p<0.05
Why Bother? Canadian Epidemiological Study The more severe the past year substance use disorder, the higher the prevalence of gambling problems Individuals with a lifetime history of a mental health disorder have 2 3 times the rate of problem gambling (PG). (Rush et al, 2008) PG in Methadone Maintenance 28% met criteria for problem or pathological gambling PG group more likely to have positive tox screen for cocaine 45.5% PG group dropped out early compared to 17.6% of non-gambling group Ledgerwood et al, 2002 Individuals with PG and SUD double the rates of admission for detoxification and significantly greater admissions for psychiatric stabilization (Kaplan & Davis, 1997) 10 8 6 4 2 0 Abstainer Subst. Dep. 17
Why Bother? Connecticut Study 19% of individuals in treatment with diagnosis of schizophrenia or schizoaffective disorder met criteria for problem or pathological gambling PG associated with depression, alcohol use problems, greater legal problems and higher utilization of MH treatment (this associated with recreational gambling as well) (Desai & Potenza, 2009) Health Problems and Medical Utilization with Gambling Disorders Gambling even 5 times a year (at risk) is associated with adverse health consequences, increased medical utilization and health care costs. At risk gamblers more likely to be diagnosed with hypertension, receive ER treatment, experienced severe injury, be obese, have history of mood or anxiety disorder, have an alcohol use disorder and nicotine dependence. At risk group comprises 25% of the population. National Epidemiologic Survey on Alcohol and Related Conditions (Morasco et al, 2006) 18
Intimate Partner Violence (IPV) and Problem Gambling Study of 300 women, consecutive ER admissions (Muehlemann et al, 2002): 26% categorized as experiencing IPV IPV 10X as likely if partner was problem gambler IPV 6X as likely if partner was problem drinker IPV 50X as likely if partner was both Study of 248 Problem Gamblers (43 women, 205 men) (Korman et al., 2008) 63% experienced past year assault, injury and/or sexual coercion 55.6% perpetrated IPV 59.7% victims of IPV Presence of lifetime substance use disorder + anger problems increased likelihood of IPV US Nat l Comoribidity Survey Replication, N=3334 (Afifi et al., 2009) Problem and Pathological Gambling (PPG) among those reporting IPV and Child Abuse Dating Violence: 5X rate of PPG Severe Marital Violence: 40X rate of PPG Severe Child Abuse: 2.5X rate of PPG
Lifetime Co-morbidity Kessler et al., 2008 (National Comoribidty Survey Replication) Temporal Sequence (For those with PG and other disorder Disorder Prevalence of Disorder amg. PG First Other Disorder First Onset at same time PG Any mood Disorder Any anxiety disorder Any impulse control disorder Any substance use disorder 55.6% 23.1% 64.1% 11.7% 60.3% 13.4% 82.1% 4.5% 42.3% 0% 100% 0% 42.3% 36.2% 57.4% 6.4%
Why Bother Lifetime Co-morbidity 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 Kessler et al., 2008 (National Comoribidty Survey Replication) 21 40 30 20 10 0 CT PG Helpline Callers 2009 Report of Prior Treatment Female Male MH Tx PG Tx
Why address gambling problems in SUD and MH programs: Summary Individuals with substance use and mental health disorders are at higher risk for having a gambling problem Gambling (even at moderate levels) may have an adverse impact on treatment outcome Unaddressed gambling and gambling problems are likely to add to treatment costs and service utilization
Why address gambling problems in SUD and MH programs: Summary Gambling may become a sequential addiction for individuals recovering from a substance use disorder Gambling can be a relapse risk factor Gambling and problem gambling may exacerbate psychiatric symptoms Relationship violence and child abuse are related to problem gambling and severely aggravated if substance use is involved.
Disordered Gambling Integration (DiGIn) Programs SUD Outpatient MAT Behavioral Health Counseling Center (MH) Young Adults Primary Care SUD Residential Dual Diagnosis Supportive Housing Recovery Centers
PG Screening Good News Lie/Bet BBGS NODS-CLiP NODS-PERC 25
The NODS-PERC 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?
Lie Bet Have you ever felt the need to bet more and more money Have you ever had to lie to people important to you about how much you gambled
Brief Bio-social Gambling Screen (BBGS) 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 pathological gambling. 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), 82-90
NODS CLiP Loss of Control: Have you ever tried to stop, cut down, or control your gambling? Lying: Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling? Preoccupation: 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?
PG Screening Bad News Screens don t work in clinical practice Give illusion of addressing issue 30
Typical Results of Use of Brief Screens 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)
Motivation 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.
Screening Client may not acknowledge in first interview either because they simply don t categorize these issues as problematic or because of shame and the desire to avoid talking about these issues
Iowa Study Data collected by 4 SA Block Grant Agencies Baseline 368 Lie/Bet 4 positives (1%) Follow-up 2 agencies switched to BBGS and 2 to NODS-CLiP BBGS: 267 Screens 6 positives (3%) NODS CliP: 89 screens 3 positives (3%)
You know one if you see one --- Director of Substance Abuse Treatment Program, Detroit VA
PG Screening 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 No 36
Screening Another issue is the way questions are addressed by counselors. Many factors including counselor workload, length of intake assessments, counselor priorities and counselor comfort with problem gambling all may contribute to minimizing importance of gambling questions.
If you really feel like you have to take a drink go gamble --- AA Sponsor
PG Screening Do you gamble much? Buying a few lottery tickets isn t really gambling. No not at all 39
PG Screening: What often happens 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, that s not a problem 40
Screening For example if you first ask someone how often they engage in specific forms of gambling How often do you: Buy lottery tickets Play cards for money Play slot machines Bet on sports Etc.. When you then ask the screening questions, people will endorse more problem gambling than if you just ask the screening questions.
Screening: Ideally 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.
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.
Assessing Impact on Recovery 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?
Integrated Assessment 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.
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
Case Examples: Stages of Change and Motivation Action Substance Use Disorder Problem Gambling Mental Health Disorder Precontemplation Contemplation 47
Screening Then What? If any indications of gambling problems are presented: Provide client feedback Assess further and provide menu of options
Feedback No Gambling Social Gambling At Risk Problem Pathological Score = 0 Score = 0 Score = 1-2 Score = 2-4 Score > 4
Remember Even though individuals in recovery from substance use and mental health disorders are at higher risk for gambling problems, this does not mean that gambling always has a negative impact on someone s recovery It is our job to help our clients be aware of and evaluate the risks as well as benefits that gambling can bring to their recovery, and to assist them in making the best informed decisions regarding the role of gambling in their lives and recoveries.
Brief Education Low and High Risk Gambling Risk Factors High Risk Situations Life Goals Discrepancy Analysis Cost Benefit Analysis Establishing personal guidelines
Low Risk Gambling Some Characteristics of Low Risk Gambling Done in social setting with friends or family As a form of recreation, not as a way to make money Within a set budget Within a set timeframe and with frequent breaks Done in balance with other social/recreational activities Done with discretionary money, not money needed for necessities Not done with borrowed money Accept that money lost is the cost of entertainment, don t chase losses What are characteristics of low risk gambling for you?
High Risk Gambling Some Characteristics of High Risk Gambling Viewed as a way to make money or fix financial problems Done in isolation Done to the exclusion of other activities Done in combination with alcohol or drug use Done in response to stress or emotional distress What are characteristics of high risk gambling for you?
Risky Situations Some Characteristics of High Risk Situations for Gambling When highly emotional: angry, lonely, depressed, under stress or feeling euphoric or overly optimistic When coping with loss or grief When coping with trauma When under financial pressure and stress During times of major life change When drinking or drugging What are characteristics of your high risk situations for gambling?
Goals for Gambling in Recovery How would you like to enjoy gambling? What type of gambling would you like to do, if any? How often would you like to gamble? How much money can you afford to gamble with? Which people do you want to gamble with, if any? Are there people who are higher risk than others?
Cost Benefit Analysis 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?
Life Goals List 5 important goals in your life (things you would like to have in your life or accomplish) for the next 2-5 years. Goal One: Goal Two: Goal Three: Goal Four: Goal Five: For each of these goals write down any ways that gambling will help you reach that goal and ways that gambling will interfere with reaching that goal. Ways Gambling will Help Ways Gambling might Interfere 1. 2. 3. 4. 5.
Re-evaluating After looking at the Cost-Benefit Analysis and your Goal Assessment, are there any changes you would like to make in your personal goals for gambling? (Review page 3)
My Plan for Gambling in Recovery I will spend no more than % of my budget which is $ per month. I will spend no more than hours per time I gamble. I will only gamble at the following low risk activities: I will only gamble in the following low risk situations: I will be sure to be accountable to the following people about my gambling: I will not gamble when I am feeling: Angry Lonely Depressed Stressed Other
Identify Your Warning Signs If you chose to continue to gamble review the list of warning signs below and circle the ones that you think you need to be aware of and monitor. Some Common Warning Signs of Gambling Problems Any increase in gambling behaviors Noticing an increase in cravings for other addictive behaviors in connection with gambling Using gambling as an alternative to other additive behaviors Gambling to relieve boredom, anxiety or depression Feeling the same kind of rush or high when gambling as when using substances What are any other signs that you might notice to indicate that gambling might be becoming a problem for you or putting your recovery at risk?
Making a Plan What is your plan if you notice any warning signs of problem gambling? Talk to sponsor Talk with counselor Stop gambling Attend GA meeting Develop plan to protect my money Other
How Assess agency (staff and client) awareness of and readiness to address problem gambling through surveys Integrate gambling and problem gambling throughout the intake and assessment process Have staff who are adequately trained and have Problem Gambling Competency Certification (see CCB) Infuse gambling and problem gambling into existing intervention tools and practices Appreciate underlying common etiologies and processes and connect the dots Utilize Motivational Enhancement and Harm Minimization strategies to assist clients in addressing the role of gambling in their recoveries Develop gambling informed treatment resources, policies and procedures Evaluation using Problem Gambling Capability Scale
Connect the Dots Gambling Gambling
Sprinkle in just the right amount: A little can go a long way
Q6. For the following questions please check the response that best fits for you. Time 1 Time 2 4.0 3.5 3.0 2.5 2.0 1.5 1.0 2.75 2.55 If I had a gambling problem, I would know where to go or who to talk to for help*** I am not aware of any gambilng problems among people I know 1.77 1.85 I am interested in learning more about problem gambling* The trt/community program I am attending needs to do more to address problem gambling 2.91 3.05 If I had a gambling problem I would feel comortable talking to staff of this program about it** 1.81.92 Talking about problem gambling would be helpful for me** 2.77 2.53 If I had a family member with a gambling problem, I would know who to talk to about this or where to get help*** 1=Not at all true; 2=Slightly true; 3=Moderately true; 4=Very true * p<.05; ** p<.01; *** p<.001
Q7. For the following questions please check the response that best fits the program or agency [ ]. 4.0 Time 1 Time 2 3.5 3.0 2.5 3.03 3.07 3.07 3.13 2.69 2.76 2.68 2.86 2.76 2.99 2.63 2.83 2.0 1.5 1.0 The program believes it is important to address problem gambling*** Staff are knowledgeable about problem gambling*** Staff are aware of community programs that address prevention and treatment*** In general, staff know how to provide help *** Staff are currently learning how to address problem gambling*** This program/agency has a written policy concerning problem gambling** 1=Not at all true; 2=Slightly true; 3=Moderately true; 4=Very true * p<.05; ** p<.01; *** p<.001
Q8. [ ]that best fits for your organization. In the past six months Time 1 Time 2 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 3.23 3.26 2.93 2.96 My personal knowledge of resources for help with problem gambling has*** My personal awareness of problem gambling issues has*** 3.37 3.37 3.08 3.07 My understanding of risk factors for problem gambling has*** My awareness of how problem gambling can affect my mental and physical health has*** 1=Decreased a lot; 2=Decreased little; 3=Not changed; 4=Increased a little; 5=Increased a lot * p<.05; ** p<.01; *** p<.001
Gambling and Recovery CCAR Video
For Further Information http://www.ct.gov/dmhas/problemgambling Or Contact: Lori Rugle, Director PGS Lori.Rugle@ct.gov; 860.262.6610 Problem Gambling Services CT Valley Hospital, Vance Drive, Russell Hall, 1st Floor Middletown, CT 06457 Ph: 860-344-2244 Toll Free: 866-440-4375 69
Thank You Anyone can slay a dragon, he told me, but try waking up every morning and loving the world all over again. That s what takes a real hero. 70