Gambling Disorders:

Co-occurring Issues and Recovery

Lynn Burkey PC, LICDC-CS/ICCS, NCGC II/BACCBryan Traband PC, LICDC, NCGC(pending)

Bruce Jones BSW, LSW, NCGC IMarch 5, 2014

Issues to be Addressed

• Mental health • Addictions• Health • Developmental Disabilities • Behaviors• Family• Finance• Spiritual • Harm to self and others

Nature Nurture

•Birth right•Genetic•Chemical •Brain Function

•Environment•Learned•Modeled•Family oriented

A Chronic & Fatal disease.

Remember: A Gambling Disorder• Is treatable but not curable.

• If left untreated it will get worse.

• The end result will be death , insanity, institutionalization, financial destruction & family break up.

Pressure Relief ( is not just a financial issue)

Instability created by co-occurring issues create a large portion of emotional & physical complications for recovery. If not addressed ,success in recovery is limited or at times impossible.• Emotional Instability• Health issues.• Co- occurring Chemical dependencies.• Developmental & disability Concerns• Behavioral issues • Family turmoil.• Legal Consequences• Financial pressures • Grief/Loss• Loneliness• Loss of purpose• Spiritual voids

CO-OCCURRING ISSUES

Comorbidity is the medical term used to describe the co-occurrence of two or more disorders in a single individual. Two types, a) lifetime- may describe a situation in which the diagnostic criteria for two or more illnesses were met at some time, although not necessarily at the same time during one’s lifetime. b) simultaneous comorbidity- occurs when criteria for two or more illnesses are met at the same time.

CO-OCCURRING ISSUES

• Reminder and note* DSM IV indicated clinician should exclude diagnosis of pathological gambling when symptoms were better accounted for by a manic episode.

• The treatment consideration(s) for pathological gambling can be substantiated through knowledge of who is at risk and the co-occurring illnesses. (Committee on the Social and Economic Impact of Pathological Gambling, p. 129, Pathological Gambling)

• Any clinicians familiar with our conference calls may recollect discussions regarding co-occurring issues when questions arise such as “does gambling escalate in presence of the other disorders?”, “is someone more likely to engage in problem or pathological gambling when consuming alcohol or other drugs?”

Chemical Addictions• Several interesting studies can be located related to the correlation(s)

between AoD addiction(s) and pathological and/or problem gambling

• - just alcohol usage – heavy alcohol usage was highly associated with increased gambling spending and multiple gambling problems (Crockford and El-Guebaly, 1998;Smart and Ferris, 1996; Spunt et al., 1995).

• -Lesieur et al. (1986) demonstrated that the rate of pathological gambling increased with the number of substances used.

• Persons admitted to chemical dependence treatment programs are three to six times more likely to be problem gamblers than people from the general population (Lesieur and Heineman, 1988; Lesieur et al., 1986; Steinberg et al., 1992; Lesieur and Rosenthal, 1998).

Chemical Addictions• A 2008 national telephone survey on problem gambling and other

disorders shows that approximately: 75% of all pathological gamblers have had problems with alcohol and 38% of all pathological gamblers have had problems with other drugs. (masscompulsivegambling.org)

• *phone surveys may be misleading due to factors including limited willingness to divulge issues over a telephone with other people present or truthfully answer questions in honest fashion, serve to continue gambling behaviors without knowledge of spouse, friend(s), co-worker, etc.

• In the addiction syndrome model, to become addicted the following must occur: risk factors, experience with the object, and enjoyment from the feeling or mood produced by the gambling or object (Shaffer, 2004)(masscompulsivegambling.org).

Chemical Addictions

• SIMILARITIES BETWEEN GAMBLING AND AOD ADDICTION(S)• Preoccupation with the activity- *reality based acknowledgement of these

thoughts could be beneficial with support of counselor, support network, journaling towards benefits and disadvantages, pros and cons, advantages and limitations caused through past or future gambling, usage

• Intense cravings (decision making difficulties)*contact with support network, journaling, reading recovery literature, attending a support activity

• Usage to medicate uncomfortable feelings*play the tape through, proactive approach vs. reactive approach and different type of thought process in recovery vs active addiction

• Increased tolerance (need more to achieve desired effect)*education has proved beneficial towards how tolerance relates to both gambling and AoD addiction-first time winning $5 seemed wonderful and then became used to that and wanted a new “high, rush,” etc.

Chemical Addictions

• SIMILARITIES BETWEEN GAMBLING AND AOD ADDICTION(S)• Continued usage despite negative consequences* cognitive distortions

may result in return to gambling in attempt to solve related problems and education may assist in identifying these potential, destructive methods in which return may occur. Support and encouragement for recovery over period of time and this process vs instant results can be beneficial (promotes pride and reward for efforts to address addiction)

• Significant withdrawal symptoms *may complain of fatigue and lack of motivation similar to AoD withdrawal , irritability. Education of what she/he is experiencing as a result of the activity and the impact the activity of gambling on the brain may normalize this experience with support through acknowledging hope and reality that the experience will pass over time through a recovery process. *floor- what ideas prove beneficial in encouraging recovery based actions vs simply staying busy?

Chemical Addictions

• GAMBLING DISORDERS DIFFER FROM AOD ADDICTION(S)• No actual substance is ingested• No obvious signs such as an odor, bloodshot eyes, slurred speech, or

impaired body movement- aka – invisible addiction• Gambling provides a legitimate hope that the next episode will yield a

reward (ideas on therapy to identify irrational thought process of anticipating win)

• Loved ones/friends are often willing to provide a bailout for what appears to be a money problem

• ~note the similarities and differences here were supported through review at the website of masscompulsivegambling.org and the addition of potential clinical considerations was not (marked with a *)

Emotional Issues• When discussing emotional issues related to pathological or problem

gamblers, important to cultivate a relationship with the following characteristics in mind:

• - patient, understanding, accepting, supportive and warm• -while still being able to confront with the issues, problems and goals

(Custer and Milt, p. 233, When Luck Runs Out)• Research indicates gambling can provide a relief for emotional difficulties,

resulting from various scenarios including: • too much or too little parenting and early nurturing causing emotional

needs to be unmet, bringing about reliance on omnipotence and magical thinking.

• Environment where a parent(s) was unable to furnish appropriate or adequate care. Parents with addictions to AoD, gambling, emotional problems themselves.

Emotional Issues• Scenarios which may provide insight into how people seek gambling to relieve

emotional issues (cont)• Parents, especially father, may be exceedingly critical or demanding, or may reject

the gambler during his childhood or young adulthood. Others are passive and ineffectual, emotionally absent. (Berman, Siegel, p. 42, Behind the 8-Ball)

• When a person (particularly a male) feels lonely, empty, rejected, guilty, depressed, or anxious, or suffers from unresolved mourning, low self-esteem, or sadistic feelings, he may see gambling as a chance to finally “prove himself.” (Berman, Siegel, p. 42, Behind the 8-Ball)

• Isn’t compulsive gambling basically a financial problem?No, compulsive gambling is an emotional problem. A person in the grip of this illness creates mountains of apparently unsolvable problems. Of course, financial problems are created, but they also find themselves finding marital, employment, or legal problems. Compulsive gamblers find friends have been lost and relatives have rejected them. The most difficult and time consuming problem with which they will be faced is that of bringing about a character change within themself. (Gamblers Anonymous, p. 12)

Emotional Issues• Clinical considerations may include the identification of various feelings.

Consideration towards working on developing an ability to identify various feelings can be beneficial. Using the feelings list (with the faces) and spending time picking out one or two of the feelings and the events which provoked or related to the feelings may be beneficial.

• When previously referenced situations/scenarios may have been present (neglect, excessive criticism, too much or too little parenting, unmet emotional needs), one can understand the difficulty in identifying and dealing with various feelings.

• Acknowledging the “right” to feel anyway she/he does has been beneficial in working with problem gamblers. Regard for what others may perceive occasionally interferes with expression or “owning” feelings. This can lead to a build up of unresolved feelings and escape through gambling.

Emotional Issues

• The therapist’s attitude and approach are critical. When the compulsive gambler comes for treatment he is frightened, depressed, mistrustful, shaken. He will react negatively to a cold, judgmental approach. The therapist needs to be patient, understanding, accepting, supportive and warm, while still being able to confront the gambler with the issues, problems and goals. (Custer, R., Milt, H, p. 232-233 When Luck Runs Out).

• The referenced attitude and approach are similar to the same qualities which are ultimate goals for the gambler.

Behavioral Issues• But right along with that we had to deal with the personality and

behavior problems- the dishonesty, impatience, intolerance and manipulation, inability to plan and make decisions, avoidance of responsibility, insensitivity to the feelings and needs of others, poor problem-solving ability. (Custer, R., Milt, H, p. 221, When Luck Runs Out).

• Many gamblers find gambling helps them feel less depressed. Symptoms of depression through the following behaviors may be a tip-off of current and potential gambling activities: moody, tired, indecisive, less interested and involved in family, work, social activities, and hobbies. Even a change in sleeping or eating patterns. (Berman, L., Siegel, M., p.85, Behind The 8-Ball).

Behavioral Issues

Dishonesty• education towards how

dishonesty has proved to further relationship with gambling and block ability to reach out for and receive assistance.

• Identify 2 examples when being dishonest proved to cause continued consequences and continued gambling.

Honesty• importance of education

towards honesty and how honesty allows for accessing and receiving help.

• Identify 2 examples of how being honest could have or did access assistance from others and proved beneficial.

Behavioral Issues

Impatience• Characteristic of active

addiction, serves to avoid asking for help and make decisions prior to gaining support or knowledge of what may be in the best interest towards recovery.

Patience• Benefits of being patient in

making decisions and education towards how to practice patience through some breathing exercises and accepting situations regardless of potential outcomes. Scheduling is a potential objective to develop patience.

Behavioral Issues

Intolerance and Manipulation• Identification of being

intolerant or manipulative as a tool for continued addiction-problem gambling.

• Identify 2 situations in which non-acceptance and/or manipulating served to continue gambling and related consequences.

Acceptance • Acceptance- the action or

process of being received as adequate or suitable, typically to be admitted into a group.

• What are 2 specific ways acceptance may serve to promote growth in recovery from problem gambling?

• Ideas on perfection?

Behavioral Issues

Avoidance of Responsibility• Identify 2 previous

situations of how avoidance of responsibilities towards various areas- family, employment, health, finances, being honest with yourself and others, keeping your “word” promoted continued gambling and consequences.

Moving towards being Responsible

• Identify 2 actions to promote responsibility in 3 most important areas of life.

• May include family, employment, health, finances, relationships, recovery efforts to address problem gambling.

Behavioral IssuesInsensitivity to Feelings or Needs of Others

• Identify 3 ways problem gambling has negatively impacted others.

• Education towards impact of non-acknowledgement of others feelings and needs can further gambling activity and is considered “non-recovery characteristic.”

Consideration, Compassion for Others

• Identify and report 3 ways in which considering others feelings and needs may benefit efforts towards addressing problem gambling.

• Learn from others• Access and receive

assistance in any area.

Behavioral Issues

Problem –Solving on Own• Identify how decision

making without consulting anyone else has lead to consequences, 3 ways.

• Identify 3 specific examples of how asking for input prior to making decisions could have improved outcome(s).

Problem-Solving with Help• Identify 3 ways to access

assistance in problem-solving ability.

• Identify benefits of maintaining, developing, and using a “recovery contact list”.

• Various resources may benefit various areas-acceptance of imperfection through understanding how some have strengths others don’t.

THE ADDICTIVE PERSONALITY

• OBSESSIVE • COMPULSIVE• IMPULSIVE• REPULSIVE

Behavioral Addictions•Work•Success•Action•Danger•Body image•Looking good•Money•Spending•Hoarding•Religion

•Sex•Sports•Exercise•Helping•Control•Cleaning•Crime•Illness•Anger•Perfection

The Impact of Gambling Addiction on Health

Bruce Jones, BSW, LSW, NCGC-IMaryhaven Problem Gambling

Program

Health Considerations

• The science of gambling• The Mirapex/Requip issue• Gambling as self-medication• Gambling and chronic illness• Gambling’s impact on resources and access to

care• Physical withdrawal symptoms

The Science of Gambling

• There is no specific gene associated with Pathological Gambling

• PG subjects display decreased activity in the frontal and orbitofrontal cortex, basal ganglia and thalamus (Potneza et al, 2003)

• Similar neuropathology as seen in obsessive compulsive and addictive disorders (Cavedini et al, 2002).

The Science of Gambling

• PG is thought to be a result of the dysfunction of the serotonin, noradrenergic and dopaminergic systems– Norepinephrine (arousal) – is increased in the

brain of those with PG– Dopamine (reward) – dysregulated dopamine

neurotransmission (Strojanov et al, 2003)– Serotonin- compulsivity

Gambling as Self-Medication

• The casino environment/slot machines provide a welcome escape mentally and emotionally from pain, stress, and traumatic memories. Repetition of the machines can have hypnotic effect.

• Some may struggle with the conceptualization of gambling as addiction as they do not feel “high,” but they DO experience an absence of physical and emotional pain.

Self-Medication Cases

Gambling and Chronic Illness

• Apkarian, et al (2004) found that chronic pain patients show impairment on emotional decision-making tasks. This leaves them vulnerable to poor risk/benefit decisions.

• Casinos provide accessibility, social acceptance and interaction, personal attention, free beverages, and a variety of other “comps.”

• Clients can be entertained and experience excitement while putting forth minimal physical effort.

Chronic Illness Cases

• 42 year old female with arthritis of an undiagnosed subtype, living with constant pain in her hands and arms. She stated she enjoys playing the slot machines because it makes time pass quickly and nearly pain-free.

Gambling and Access to Care

• The financial impact of gambling can complicate a client’s access to medical care. Clients may have lost their job and health insurance or may not be able to afford co-pays or their medication.

• Clients may need assistance short term, but many services require proof of low income, disqualifying the gambling client.

• Clients may be able to talk to their healthcare provider about samples or other assistance.

Access to Care Cases

• 67 year old female taking Celexa for 10 years could no longer afford her prescription due to gambling. Her retirement income disqualifies her for short-term assistance. Stopping her medication suddenly after such a long period of time caused a major depressive episode, which made it very difficult for her to keep her counseling appointments.

Withdrawal Symptoms• Restless/Irritable 91%• Insomnia 87%• Headache 50%• Digestive Problems 36%• Weakness 34%• Palpitations 27%• Shakes 26%• Muscle Aches 19%• Breathing Difficulty 17%• Sweats 12%• Chill/Fever 6%

Suicidality

• “Compulsive gambling is a serious disorder, as exhibited by extraordinarily high rates of suicide, severe depression, alcohol abuse and crime.”– House Armed Services Committee, 1989

Suicidality

• “Suicide attempts among pathological gamblers are higher than for any of the addictions and second only to suicide attempt rates among individuals with major affective disorders, schizophrenia and a few major hereditary disorders.”

-Dr. Rachel A. Volberg, President of Gemini Research, Ltd. (Gambling Research)12

Suicidality• 76% of those with Pathological Gambling had a diagnosis of Major

Depressive Disorder– 28% had recurrent episodes

• Suicide risk is very high, estimated at 17-24%• A University of California-San Diego sociologist found that “visitors to

and residents of gaming communities experience significantly elevated suicide levels.” According to Dr. David Phillips, Las Vegas “displays the highest levels of suicide in the nation, both for residents of Las Vegas and for visitors to that setting.” In Atlantic City, N.J., Phillips found that “abnormally high suicide levels for visitors and residents appeared only after gambling casinos were opened.”2

• Nevada had the highest suicide rate in the nation from 1990-1994, according to statistics from the Centers for Disease Control and Prevention.3

Suicidality• In Gulfport, Mississippi, suicides increased by 213 percent (from 24 to 75)

in the first two years after casinos arrived. In neighboring Biloxi, suicide attempts jumped by 1,000 percent (from 6 to 66) in the first year alone.4

• The National Council on Problem Gambling, citing various studies, reports that one in five pathological gamblers attempts suicide, a rate higher than for any other addictive disorder.5

• At least 140 clients at Minnesota’s six gambling addiction treatment centers have attempted suicide, according to the Minneapolis Star Tribune. The paper confirmed six gambling-related suicides in that state, but noted that the six are “almost certainly a fraction of the total number,” given that authorities often do not ascertain motives in suicide cases.6

Suicidality

• A survey of nearly 200 Gamblers Anonymous members in Illinois found that 66 percent had contemplated suicide, 79 percent had wanted to die, 45 percent had a definite plan to kill themselves, and 16 percent had actually attempted suicide.7

• Authorities in Montreal, Canada, officially linked four suicides and a murder-suicide to gambling problems at the Montreal Casino within the first three years of its opening.8

Suicidality

• The Illinois Council on Compulsive Gambling reports that more than 20 Illinois residents have killed themselves as a result of a gambling addiction since casinos arrived.9

• Multiple casino-related suicides also have been reported in various others states, including Iowa, Missouri and Connecticut.10

• An investigation by the Canadian Press found more than 10 percent of suicides in Alberta and 6.3 percent in Nova Scotia were linked to gambling (2001 through 2003).11

True or False?

• Aggressive advertising by casinos, lotteries and online poker sites is the reason for much of today’s problem gambling.

False

• The cause of a gambling problem is a person’s inability to control their impulses. This may be due in part to a genetic tendency to develop addiction, an inability to cope with normal life stress or other factors. A casino or lottery, however, only provides the opportunity for the person to gamble. It does not, in and of itself, create the problem any more than a liquor store would create an alcoholic.– NCPG

Emotional & Spiritual Vulnerability

• Filling the Voids for both action and escape gamblers

Co-occurring issues give fuel to Problem Gambling

• Boredom• Stress• Grief• Finances • Health Problems• Fear of Death• Isolation• Lack of Leisure

Activities/Hobbies

• Physical or Emotional Abuse

• Critical, Controling or Domineering Spouse• Relationship Difficulties• Chronic Pain• Loss of Youth• Loss of meaning &

purpose• Depression• Identity Issues• Loneliness

Issues leading to Spiritual Emptiness

Isolation ‘ Loneliness Lack of Intimacy Abandonment/ Isolation Hopelessness & Depression Significant Relationship break up Abusive Home Situation Neglected Death, Grief or loss Time on Hands Loss of Abilities/Skills/Mobility Loss of employment/ income Financial desperation Loss of home/ residence Accidents Injuries Trauma Aging Loss if leisure activity Empty nest

Living EnvironmentPressures of

Work/AchievementLow Self EsteemResistance to Change

Family Responsibility & Turmoil

Control IssuesEntitlementFear of change

Special Co- occurring Issues with gamblers

• Finances

• Domestic Abuse

• Lack of support group

– Spiritual voids

• Inadequate

• Unimportant

• Unlovable

Financial pressure“Stop The Bleeding”

Restitution Plan:Manageable BudgetEmploymentFinancial responsibilityMoney safetyMoney monitoring Debt reduction Restitution PaymentsFamily restitutionReward progress

Family & Domestic Issues

• Domestic abuse “the Gambler”• Anger , Resentment, Guilt , & Frustration • Potential to harm self & others.• Short fuse as the losses build up.

Domestic abuse “ the Family” Similar dynamics to gambler “But”Hurt Disappointment Wronged Cheated Lied to Abandoned

Finding purpose & meaning.• Filling empty spots

• Seeking a spiritual power outside of self.

• Willing to give up “illusion” of control.

• Asking for and accepting the help that is available.

• Abstaining from Gambling is not Recovery but is the Result of Recovery.

Balance

• Raise self-esteem

• Increase interpersonal relationships

• Work / volunteer

• Hobbies

• Fun

• Leisure

• Financial Stability

Getting Healthy

Be good to yourself.• Gratitude lists. • Reward for successes.• Look at problems as lessons.• Mistakes become opportunities.• Dilemmas become possibilities .• Have Goals but make them simple.• Learn patience.• Learn from the moment.• Grow spiritually.• See the big picture.

Being Active

Finding Balance Accepting ChangeDefining Limits

Don’t get too:H ungryA ngryL onely T ired

Rules for spiritual growth

• Have mind open to possibilities.• Change from demanding to giving.• Accept responsibilities for self.• Eliminate regrets• Make conscious contact with God.• Let go of past.• Think positive.• Give self affirmations• Know you are loved • Expect the good

“Don’t die with the music in you!! “

Slow and steady. Enjoy today!

• “Recovery is a Marathon and

Not a Sprint.”

GOAL:

INSTILL HOPE RAISE ESTEEM