Have the Conversation:Integrating Problem Gambling into Substance Use

Disorder and Mental Health Treatment

Loreen Rugle, PhD, NCGC-IILoreen Rugle, PhD, NCGC-II

Program DirectorProgram DirectorMaryland Center of Excellence on Problem GamblingMaryland Center of Excellence on Problem Gambling

University of MarylandUniversity of MarylandLrugle@psych.umaryland.eduLrugle@psych.umaryland.edu

OverviewOverview

Defining TermsDefining Terms

Why Bother? Evidence on the impact of Why Bother? Evidence on the impact of gambling gambling

Technology Transfer: Current PracticesTechnology Transfer: Current Practices

Screening and Integration StrategiesScreening and Integration Strategies

Maryland Center of Excellence on Problem Maryland Center of Excellence on Problem GamblingGambling

Mission Statement Mission Statement

The Maryland Center of Excellence on Problem Gambling The Maryland Center of Excellence on Problem Gambling promotes health and informed choices regarding gambling and promotes health and informed choices regarding gambling and problem gambling through problem gambling through treatment, prevention, training and treatment, prevention, training and education, outreach and public awareness, research and public education, outreach and public awareness, research and public policypolicy. It does so by working closely with appropriate state . It does so by working closely with appropriate state stakeholders and bringing together experts from a variety of stakeholders and bringing together experts from a variety of disciplines including psychiatry, medicine, epidemiology, social disciplines including psychiatry, medicine, epidemiology, social work, law and others. work, law and others.

Funded by DHMH/BHAFunded by DHMH/BHA

HOW MANY #1

WHAT PERCENTAGE OF ADULTS HAVE

GAMBLING EITHER IN THE PAST YEAR OR

LIFETIME?4

Funded by DHMH/BHAFunded by DHMH/BHA

HOW MANY #1

5Funded by DHMH/BHAFunded by DHMH/BHA

What is Gambling?What is Gambling?

If you bet on a horse, that’s gambling.If you bet on a horse, that’s gambling.

If you bet you can make three spades, that’s If you bet you can make three spades, that’s entertainment.entertainment.

If you bet cotton will go up three points, that’s business.If you bet cotton will go up three points, that’s business.

If you play bingo at your church, that’s charity.If you play bingo at your church, that’s charity.

What’s the difference?What’s the difference?

Gambling is any activity or game where you Gambling is any activity or game where you risk something of value or money on an risk something of value or money on an outcome that is not guaranteed.outcome that is not guaranteed.

HOW MANY #2

How many adults in Virginia have a

gambling problem?

7Funded by DHMH/BHAFunded by DHMH/BHA

++++

WHAT DOESWHAT DOES

REPRESENT?REPRESENT?Capacity 71,008 Capacity 71,008 x 3x 3 = 213,024= 213,024

RepresentsRepresents less than the estimated 219,107less than the estimated 219,107 Adult Problem Gamblers in VAAdult Problem Gamblers in VAAnd about double that number are likely to be at riskAnd about double that number are likely to be at risk

Funded by DHMH/BHAFunded by DHMH/BHA

Funded by DHMH/BHAFunded by DHMH/BHA

Youth Prevalence FindingsYouth Prevalence Findings

4-8 % Level III, Probable Pathological 4-8 % Level III, Probable Pathological gambler gambler (NRC, 1999)(NRC, 1999)

1.1 million youth 12-17 exhibit pathological 1.1 million youth 12-17 exhibit pathological gambling behavior gambling behavior (NGISC, 1999)(NGISC, 1999)

10-15% at-risk for Problem Gambling 10-15% at-risk for Problem Gambling (Shaffer & (Shaffer & Hall, 1996; Winters, Stinchfield, & Fulkerson, 1991; Wiebe, 1999; Hall, 1996; Winters, Stinchfield, & Fulkerson, 1991; Wiebe, 1999; Wynne, Smith, & Jacobs, 1996)Wynne, Smith, & Jacobs, 1996)

Youth Gambling 4 to 6 % Youth Gambling 4 to 6 % ((problem/pathologicalproblem/pathological))

Virginia Youth Estimated: 75,000 – 113,000 Virginia Youth Estimated: 75,000 – 113,000 ((problem/pathological based on 2014 census projectionsproblem/pathological based on 2014 census projections))

Defining Terms

Gambling: the act of risking something of value, including money and property, on an activity that has an uncertain outcome

Gambling Disorder: Current DSM5 diagnosis

Pathological Gambling: DSM- IV diagnosis

Problem Gambling: Characterized by difficulties in limiting money and/or time spent on gambling [impaired control] which leads to adverse consequences for the gambler, others, or for the community. (Neal, 2005).

At Risk Gambler: someone who is at risk for becoming a problem or pathological gambler because:

a) they evidence some adverse consequence(s) from gambling but no symptoms of loss of control; OR

b) they evidence some symptoms of loss of control but no adverse consequences; OR

c) they evidence some adverse consequences and loss of control, but not at a level sufficient to meet criteria for problem or pathological gambling; OR

d) they have a gambling frequency and/or expenditure that is significantly above average (especially in the context of their employment status, income, and debt).

Recreational Gambler : someone who is able to maintain control over amounts of time and money spent gambling and who does not experience any adverse effects from gambling.

Diagnostic Changes DSMIV to DSM5Diagnostic Changes DSMIV to DSM5

K le p to m a n ia P yro m a n ia In te rm itte n tE xp lo s iveD is o rd e r

T rich o tillo m a n ia P a tho lo g ic a lG a m b ling

Im pu lseC o n tro l

D is o rd e r - N O S

Im p u lse C o n tro l D iso rd er

DSM IVDSM IV

DSM 5

• Reclassified under: Substance-Related and Addictive Disorders

• So far only “Non-Substance-Related Disorder included

• Renamed: Gambling Disorder

Funded by DHMH/BHAFunded by DHMH/BHA

Diagnostic CriteriaDiagnostic Criteria

A. Persistent and recurrent problematic gambling behavior …as A. Persistent and recurrent problematic gambling behavior …as indicated by 4 or more in a 12 month period.indicated by 4 or more in a 12 month period.

1.1.Needs to gamble with increasing amounts of money in order to Needs to gamble with increasing amounts of money in order to achieve the desired excitementachieve the desired excitement

2.2.Is restless or irritable when attempting to cut down or stop Is restless or irritable when attempting to cut down or stop gamblinggambling

3.3.Has made repeated attempts to control, cut back, or stop Has made repeated attempts to control, cut back, or stop gamblinggambling

4.4.Is often preoccupied with gambling (e.g., having persistent Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with planning the next venture, thinking of ways to get money with which to gambling).which to gambling).

Diagnostic CriteriaDiagnostic Criteria

5.5. Often gambles when feeling distressed (e.g., Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed)helpless, guilty, anxious, depressed)

6.6. After losing money gambling, often returns After losing money gambling, often returns another day to get even (“chasing one’s losses”)another day to get even (“chasing one’s losses”)

7.7. Lies to conceal the extent of involvement with Lies to conceal the extent of involvement with gamblinggambling

8.8. Has jeopardized or lost a significant relationship, Has jeopardized or lost a significant relationship, job, or educational or career opportunity because job, or educational or career opportunity because of gamblingof gambling

9.9. Relies on others to provide money to relieve Relies on others to provide money to relieve desperate financial situations caused by gamblingdesperate financial situations caused by gambling

B. The gambling behavior is not better explained by B. The gambling behavior is not better explained by a manic episode.a manic episode.

SpecifiersSpecifiersEpisodic: Episodic: – Met criteria at more than one time pt. with sx’s subsiding in Met criteria at more than one time pt. with sx’s subsiding in

between for several monthsbetween for several months

PersistentPersistent– Continuous sx’s for multiple yearsContinuous sx’s for multiple years

Early Remission: no criteria for 3-12 mos.Early Remission: no criteria for 3-12 mos.Sustained Remission: no criteria for 12 or more Sustained Remission: no criteria for 12 or more mos.mos.SeveritySeverity– Mild: 4-5 CriteriaMild: 4-5 Criteria– Moderate: 6-7 CriteriaModerate: 6-7 Criteria– Severe: 8-9 CriteriaSevere: 8-9 Criteria

Differential DiagnosisDifferential Diagnosis

Nondisordered GamblingNondisordered Gambling– Professional GamblingProfessional Gambling– Social GamblingSocial Gambling

Manic EpisodeManic Episode– Key – Not better explainedKey – Not better explained– Person may exhibit manic like behavior during Person may exhibit manic like behavior during

gambling episodegambling episode

Differential DiagnosisDifferential Diagnosis

Personality DisordersPersonality Disorders– If criteria met for both, both can be dx’dIf criteria met for both, both can be dx’d

Other Medical ConditionsOther Medical Conditions– Dopaminergic medicationsDopaminergic medications

Gambling Disorder 4/9 Substance Use Disorder 2/11

1. Tolerance2. Withdrawal3. Control4. Preoccupation5. Relieve6. Chasing7. Lying8. Impact on life9. Bailouts

1. Using more or longer than intend

2. Control3. Time spent in obtaining/use

substance4. Craving or strong desire/urge5. Failure to meet obligations 6. Continued use despite social

or interpersonal problems7. Important activities given up

or reduced8. Recurrent use in physical

hazardous situations9. Continued use despite phys

and psych consequences10. Tolerance a. Increasing amount - or b. Diminished effect11. Withdrawal a. Withdrawal syndrome for

alcohol - or b. Alcohol taken to relieve

or avoid withdrawal

Why Bother Screening for Why Bother Screening for Gambling Disorder?Gambling Disorder?

Evidence of high risk of gambling Evidence of high risk of gambling problems among individuals diagnosed problems among individuals diagnosed with substance use and mental health with substance use and mental health disorders.disorders.

Not addressing gambling issues Not addressing gambling issues decreases treatment effectiveness and decreases treatment effectiveness and adds to treatment costsadds to treatment costs

Early intervention and treatment work!Early intervention and treatment work!

Co-MorbidityCo-Morbidity

Per DSM5, those with gambling disorder have high rates Per DSM5, those with gambling disorder have high rates of SUD’s, depressive disorders, anxiety disorders and of SUD’s, depressive disorders, anxiety disorders and personality disorders.personality disorders.

Up to nearly 1/3 to 1/2 of individuals in SUD treatment Up to nearly 1/3 to 1/2 of individuals in SUD treatment identified as problem gamblers (Himmelhoch et al, in identified as problem gamblers (Himmelhoch et al, in press; Ledgerwood et al, 2002)press; Ledgerwood et al, 2002)

The more severe the past year SUD, the higher the The more severe the past year SUD, the higher the prevalence of gambling problems (Rush et al, 2008)prevalence of gambling problems (Rush et al, 2008)

Individuals with lifetime history of mental health disorder Individuals with lifetime history of mental health disorder had 2-3 times rate of problem gambling (Rush et al, had 2-3 times rate of problem gambling (Rush et al, 2008)2008)

OSAM SurveyOSAM Survey

27.6% gambled more when using alcohol 27.6% gambled more when using alcohol or other drugsor other drugs

16.7% used more alcohol or drugs when 16.7% used more alcohol or drugs when gamblinggambling

15.6% gambled to buy alcohol or drugs15.6% gambled to buy alcohol or drugs

Effect on Cost and Treatment Effect on Cost and Treatment OutcomeOutcome

For individuals diagnosed with serious For individuals diagnosed with serious mental health disorder, PG associated with mental health disorder, PG associated with depressiondepression, , alcohol usealcohol use problems, greater problems, greater legal problemslegal problems and and higher utilizationhigher utilization of MH of MH treatment (this associated with recreational treatment (this associated with recreational gambling as well) (Desai & Potenza, 2009)gambling as well) (Desai & Potenza, 2009)

Why BotherWhy Bother

Lifetime Co-morbidityLifetime Co-morbidityAlthough Although nearly halfnearly half (49%) of those with (49%) of those with lifetime pathological gambling received lifetime pathological gambling received treatment for mental health or substance treatment for mental health or substance abuse problems, abuse problems, nonenone reported treatment reported treatment for gambling problems for gambling problems

Kessler et al., 2008 (National Comoribidty Survey Replication)Kessler et al., 2008 (National Comoribidty Survey Replication)

2525

Health Problems and Medical Health Problems and Medical UtilizationUtilization

2626

• 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)

Per DSM5, “Gambling disorder is associated with poor general health...Some specific medical diagnoses, such as tachycardia and angina are more common than in the general population.

Intimate Partner Violence (IPV) and Intimate Partner Violence (IPV) and Problem GamblingProblem 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 PPGSevere Marital Violence: 40X rate of PPGSevere Child Abuse: 2.5X rate of PPG

PG ScreeningPG Screening

Good NewsGood News– South Oaks Gambling Screen (SOGS)South Oaks Gambling Screen (SOGS)

– NORC DSM Screen for Gambling Problems (NODS)NORC DSM Screen for Gambling Problems (NODS)

– GA 20 Questions GA 20 Questions

– Lie/BetLie/Bet

– NODS-CLiPNODS-CLiP

– NODS-PERCNODS-PERC

– Brief Biosocial Gambling Screen (BBGS)Brief Biosocial Gambling Screen (BBGS)

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Lie BetLie BetJohnson, Hamer, Nora et al., 1997Johnson, Hamer, Nora et al., 1997

– Have you ever felt the need to bet more and Have you ever felt the need to bet more and more moneymore money

– Have you ever had to lie to people important Have you ever had to lie to people important to you about how much you gambledto you about how much you gambled

NODS CLiPNODS CLiPToce-Gerstein, Gerstein & Volberg, 2009Toce-Gerstein, Gerstein & Volberg, 2009

– Loss of Control: Loss of Control: Have you ever tried to stop, Have you ever tried to stop, cut down, or control your gambling?cut down, or control your gambling?

– Lying: Lying: Have you ever lied to family Have you ever lied to family members, friends or others about how much members, friends or others about how much you gamble or how much money you lost on you gamble or how much money you lost on gambling?gambling?

– Preoccupation: Preoccupation: Have there been periods Have there been periods lasting 2 weeks or longer when you spent a lasting 2 weeks or longer when you spent a lot of time thinking about your gambling lot of time thinking about your gambling experiences, or planning out future gambling experiences, or planning out future gambling ventures or bets?ventures or bets?

The NODS-PERCThe NODS-PERCVolberg, Munck & Petry, 2008Volberg, Munck & Petry, 2008

NODS 1NODS 1 Have there ever been periods lasting 2 weeks or longer Have there ever been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling when you spent a lot of time thinking about your gambling experiences or planning out future gambling ventures or experiences or planning out future gambling ventures or bets?bets?

NODS 8NODS 8 Have you ever gambled as a way to escape from Have you ever gambled as a way to escape from personal problems? personal problems?

NODS 10NODS 10 Has there ever been a period when, if you lost money Has there ever been a period when, if you lost money gambling one day, you would return another day to get gambling one day, you would return another day to get even? even?

NODS 14NODS 14 Has your gambling ever caused serious or repeated Has your gambling ever caused serious or repeated problems in your relationships with any of your family problems in your relationships with any of your family members or friends?members or friends?

Brief Biosocial Gambling ScreenBrief Biosocial Gambling ScreenGebauer, LaBrie & Shaffer, 2010Gebauer, LaBrie & Shaffer, 2010

During the past 12 months, have you become During the past 12 months, have you become restless, irritable or anxious when trying to restless, irritable or anxious when trying to stop/cut down on gambling?stop/cut down on gambling?

During the past 12 months, have you tried to During the past 12 months, have you tried to keep your family or friends from knowing how keep your family or friends from knowing how much you gambled?much you gambled?

During the past 12 months, did you have such During the past 12 months, did you have such financial trouble as a result of your gambling that financial trouble as a result of your gambling that you had to get help with living expenses from you had to get help with living expenses from family, friends or welfare?family, friends or welfare?

PG ScreeningPG Screening

Bad NewsBad News– Screens don’t work Screens don’t work

well in clinical practicewell in clinical practice– Give illusion of Give illusion of

addressing issueaddressing issue

3333

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%)

Gambling Disorder among Individuals Attending Outpt. Gambling Disorder among Individuals Attending Outpt. Substance Abuse TreatmentSubstance Abuse Treatment

(Himelhoch et al)(Himelhoch et al)

Individuals Meeting DSM5 Criteria Individuals Meeting DSM5 Criteria (n=203)(n=203)

3535

Yet in actual clinical practice only 2.5% of clients in SUD treatment screen positive for any gambling problems

Typical Results of Use of Brief Typical Results of Use of Brief Screens Screens

What happens in actual clinical practiceWhat happens in actual clinical practice

Use screenUse screen

No one endorses itemsNo one endorses items

What does counselor thinkWhat does counselor think– None of my clients have any gambling problemsNone of my clients have any gambling problems– Don’t care about the research, my clients are Don’t care about the research, my clients are

differentdifferent– NIMBY (Not in my back yard or treatment NIMBY (Not in my back yard or treatment

program)program)

Motivation Motivation

Individuals coming into treatment for a Individuals coming into treatment for a substance use or mental health disorder may substance use or mental health disorder may have any or all of the following attitudes toward have any or all of the following attitudes toward their gambling:their gambling:– Never thought of it as a problem or potential problemNever thought of it as a problem or potential problem– Believe it is a solution to their problems (emotional Believe it is a solution to their problems (emotional

and or financial)and or financial)– Realize it may be a problem, but don’t want to think Realize it may be a problem, but don’t want to think

about giving up “all their fun.”about giving up “all their fun.”– Feel overwhelmed by dealing with just one problem, Feel overwhelmed by dealing with just one problem,

don’t want to have to think about any others.don’t want to have to think about any others.

Barriers to Help SeekingBarriers to Help Seeking(Pulford et al, 2008; Evans & Delfabbr, 2005; McMillen et al (2004); Taveres, 2002)(Pulford et al, 2008; Evans & Delfabbr, 2005; McMillen et al (2004); Taveres, 2002)

Person-Centered Factors PredominantPerson-Centered Factors Predominant– Want to resolve problem on own and prideWant to resolve problem on own and pride– Shame and embarrassmentShame and embarrassment– Reluctance to admit problemReluctance to admit problem– Too overwhelmed to get helpToo overwhelmed to get help

Service Centered FactorsService Centered Factors– Bad help seeking experienceBad help seeking experience– Being treated like “addict” or mentally-ill personBeing treated like “addict” or mentally-ill person– Couldn’t get service at time or place wantedCouldn’t get service at time or place wanted

PG ScreeningPG ScreeningHave 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

3939

Barriers to Effective Screening: Barriers to Effective Screening: Training and WorkloadTraining and Workload

Another issue is the questions themselves Another issue is the questions themselves and way questions are addressed by and way questions are addressed by counselors and other health care counselors and other health care providers.providers.

Many factors including provider workload, Many factors including provider workload, length of intake assessments, provider length of intake assessments, provider priorities and comfort with problem priorities and comfort with problem gambling all may contribute to minimizing gambling all may contribute to minimizing importance of gambling questions.importance of gambling questions.

PG Screening: What often happens

I can save time on theseGambling questions…That’s not why she is hereanyway

You’ve never liedAbout gambling or Wanted to spend moreMoney on it, have you? Phew! Nobody

Cares about gambling

here!

No, that’s not a problem

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Training NeedsTraining Needs

Counselors and health care providers Counselors and health care providers need specific training to:need specific training to:– Understand the impact of gambling on Understand the impact of gambling on

recovery, health and well-beingrecovery, health and well-being– Feel comfortable and competent to talk about Feel comfortable and competent to talk about

gamblinggambling– Know that they have tools and resources for Know that they have tools and resources for

brief interventions and referralbrief interventions and referral

Training NeedsTraining Needs

GP’s thought it was “inappropriate” to ask GP’s thought it was “inappropriate” to ask patients “out of the blue” if they gamble patients “out of the blue” if they gamble (Tolchard et al, 2007)(Tolchard et al, 2007)

If we ask about gambling and someone If we ask about gambling and someone has a problem we would have to do has a problem we would have to do something with it – so we don’t ask.something with it – so we don’t ask.

If we ask, we don’t know what to do with it.If we ask, we don’t know what to do with it.

Need to Define “Gambling”Need to Define “Gambling” Next I’m going to ask you a few questions about gambling. For example, by gambling I mean buying lottery tickets, playing cards with friends, betting on sports, betting at the casino. Would you say you do any of those things 5 times a year or more?

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.

Possible StrategyPossible StrategyAdapted by Illinois SBIRT from DSM5, BBGS, and Elizabeth Hartney, PhDAdapted by Illinois SBIRT from DSM5, BBGS, and Elizabeth Hartney, PhD

For the purpose of the next questions, “gambling” means For the purpose of the next questions, “gambling” means buying lottery tickets, gambling at a casino, playing cards or buying lottery tickets, gambling at a casino, playing cards or dice for money, betting on sports games, playing slot dice for money, betting on sports games, playing slot machines, video poker or other video gambling, gambling on machines, video poker or other video gambling, gambling on the internet, betting on horses or dogs, playing bingo or the internet, betting on horses or dogs, playing bingo or keno.keno.

During the past 12 months have you gambled 5 or During the past 12 months have you gambled 5 or more times? ___ Yes ___ Nomore times? ___ Yes ___ No

If yes continue to next 3 questions ---If yes continue to next 3 questions ---

Screening StrategyScreening StrategyDURING THE PAST 12 MONTHS:

1. Have you tried to hide how much you have gambled from your family or friends?

Yes No

 

2. Have you had to ask other people for money to help deal with financial problems that had been caused by gambling?

Yes No

 

3. Have you ever felt restless, on edge or irritable when trying to stop or cut down on gambling?

Yes No 

If yes to any of the above proceed to next 6 questions

Brief InterventionBrief Intervention

• A “yes” response to any of questions 1, A “yes” response to any of questions 1, 2, or 3 results in asking all the questions 2, or 3 results in asking all the questions (4-9) and Gambling Brief Intervention.(4-9) and Gambling Brief Intervention.

• A “yes” response to a total of 4 questions A “yes” response to a total of 4 questions (out of 9) results in a Gambling Brief (out of 9) results in a Gambling Brief Intervention and Referral to Gambling Intervention and Referral to Gambling TreatmentTreatment

DURING THE PAST 12 MONTHS:

4. Have you tried to cut down or stop your gambling? Yes No 

5. Have you increased your bet or how much you would spend, in order to feel the same kind of excitement as before?

Yes No 

6. Did you think about gambling even when you were not doing it? (Remembering past gambling experiences, or planning future gambling?)

Yes No 

7. Did you go to gamble when you were feeling down, stressed, angry or bored?

Yes No 

8. Did you ever try to win back the money that you had recently lost?

Yes No 

9. Has your gambling caused problems in your relationships or with work?

Yes No 

Total “Yes” Responses 

 

Training NeedsTraining Needs

Counselors and health care providers Counselors and health care providers need specific training to:need specific training to:– Understand not their job to “catch” clients in Understand not their job to “catch” clients in

“bad” behavior“bad” behavior

– Be able to utilize motivational strategies to Be able to utilize motivational strategies to elicit curiosity and open conversationelicit curiosity and open conversation

Brief Advice on Reducing GamblingBrief Advice on Reducing Gambling• Feedback on personal gamblingFeedback on personal gambling• Define levels of gambling and gambling disorderDefine levels of gambling and gambling disorder• Risk Factors for Problem Gambling/Gambling Risk Factors for Problem Gambling/Gambling

DisorderDisorder• Four steps to reduce risk for gambling problemsFour steps to reduce risk for gambling problems

• Limit moneyLimit money• Limit timeLimit time• Don’t view gambling as way to make moneyDon’t view gambling as way to make money• Spend time on other recreational activitiesSpend time on other recreational activities

Brief Advice on Reducing Gambling Brief Advice on Reducing Gambling (Petry, 2005)(Petry, 2005)

9%

7%

1%

1%

82%

Providing Feedback and Enhancing Providing Feedback and Enhancing MotivationMotivation

Provide affirmationProvide affirmationCounselorCounselor– I can see from your response during your I can see from your response during your

assessment that you were being really honest assessment that you were being really honest and open. That shows how motivated you are and open. That shows how motivated you are to work on your recovery.to work on your recovery.

– Some of your responses about gambling Some of your responses about gambling suggest that gambling may have a negative suggest that gambling may have a negative effect on your recovery and I’d like to give you effect on your recovery and I’d like to give you some feedback and information that we can some feedback and information that we can talk about. How does that sound to you?talk about. How does that sound to you?

Providing Feedback and Enhancing Providing Feedback and Enhancing MotivationMotivation

Client –OK I guess. I never really thought Client –OK I guess. I never really thought much about my gambling. My drinking much about my gambling. My drinking has always been the problem that seems has always been the problem that seems to get me into trouble.to get me into trouble.

Counselor – That’s great. I appreciate Counselor – That’s great. I appreciate your willingness to talk about an area that your willingness to talk about an area that you haven’t thought about before and look you haven’t thought about before and look at how it might effect your recovery.at how it might effect your recovery.

Feedback Feedback Open – ended questionsOpen – ended questions

Counselor – Tell me about your gambling Counselor – Tell me about your gambling and how you think it fits in your life and and how you think it fits in your life and your recovery.your recovery.

Client – Well – I like playing cards with my Client – Well – I like playing cards with my buddies. We’ve been getting together buddies. We’ve been getting together once a week for years. We do drink at the once a week for years. We do drink at the games. Hadn’t thought about that. Do games. Hadn’t thought about that. Do you think that’s a real problem?you think that’s a real problem?

Feedback Feedback Open – ended questionsOpen – ended questions

Counselor – That’s a great connection you Counselor – That’s a great connection you just made. I think that is something to think just made. I think that is something to think about. One way we can look at your card about. One way we can look at your card playing is to look at the pros and cons. Is playing is to look at the pros and cons. Is that something you’d be willing to do?that something you’d be willing to do?

Cost – Benefit AnalysisCost – Benefit Analysis

Please list all the benefits you receive from gambling and on a scale of 1-9 list 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 how important each benefit is to you (1= not important; 9 = extremely important) and lists the costs of gambling (emotional, physical, relational 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 = etc as well as financial) and how distressing that cost is on a 1-9 scale (1 = not distressing; 9 = extremely distressing)not distressing; 9 = extremely distressing)

Gambling Benefits Importance Gambling Costs DistressGambling Benefits Importance Gambling Costs Distress

After you have made your Cost-Benefit list, look over the list and write 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 down any feelings arise when you think about the balance of benefits and costs of gambling:costs of gambling:

Do any of these costs seem too expensive or too distressing?Do any of these costs seem too expensive or too distressing?

Are there alternative ways of getting any of the benefits?Are there alternative ways of getting any of the benefits?

Cost – Benefit AnalysisCost – Benefit Analysis

BenefitsBenefits– FunFun– RelaxationRelaxation– CamaraderieCamaraderie– Win moneyWin money

CostsCosts– Drink at gamesDrink at games– Wife sometimes upset Wife sometimes upset

at time away and at time away and coming home drunkcoming home drunk

– Borrow moneyBorrow money

Pre-contemplation to Pre-contemplation to ContemplationContemplation

Counselor: You did a great job of looking clearly at Counselor: You did a great job of looking clearly at the things you enjoy about gambling and that you the things you enjoy about gambling and that you see as benefits as well as some of the downside or see as benefits as well as some of the downside or costs of gambling. What do you make of that? costs of gambling. What do you make of that?

Client: Yeah, I think I see what you are getting at. Client: Yeah, I think I see what you are getting at. Gambling is fun, but it always seems to lead to Gambling is fun, but it always seems to lead to drinking. I know how drinking is messing me up, drinking. I know how drinking is messing me up, but I never thought about the gambling.but I never thought about the gambling.

Addressing AmbivalenceAddressing Ambivalence

Counselor: I think it is really good that you Counselor: I think it is really good that you are able to see both sides of what are able to see both sides of what gambling is about for you. You do have gambling is about for you. You do have fun gambling, but you can see that it also fun gambling, but you can see that it also interferes with your goal of not drinking. interferes with your goal of not drinking.

Client: Yeah, I just always thought it was Client: Yeah, I just always thought it was something fun to do. I didn’t really look at something fun to do. I didn’t really look at the connection to my drinking.the connection to my drinking.

Low Risk Gambling is Done:Low Risk Gambling is Done:As a form of recreation, not to make money or make up for previous As a form of recreation, not to make money or make up for previous

losses.losses.With limits on time, frequency, and duration.With limits on time, frequency, and duration.

In a social setting with others not alone.In a social setting with others not alone.With money you can afford to lose.With money you can afford to lose.

High Risk Gambling – Situations When You Are:High Risk Gambling – Situations When You Are:Coping with grief, loneliness, anger or depression.Coping with grief, loneliness, anger or depression.

Under financial pressure and stress.Under financial pressure and stress.Recovering from mental health or substance use disorders.Recovering from mental health or substance use disorders.

Using alcohol or other drugs.Using alcohol or other drugs.Under legal age to gamble.Under legal age to gamble.

KEEP GAMBLING FUN AND PROBLEM FREEKEEP GAMBLING FUN AND PROBLEM FREE

Set a limitSet a limit on how much time and money you will spend and stick on how much time and money you will spend and stick to itto it

Only gamble what you can Only gamble what you can afford to loseafford to lose

BalanceBalance gambling with other leisure activities gambling with other leisure activities

If you gamble and spend more time and money than you can afford, a If you gamble and spend more time and money than you can afford, a good strategy is to take a break and look at your gambling. good strategy is to take a break and look at your gambling.

Consider seeking help if this is a concern.Consider seeking help if this is a concern.

Problem Gambling Helpline, Toll-Free, Confidential, 24/7Problem Gambling Helpline, Toll-Free, Confidential, 24/7

1-800-Gambler or1-800-Gambler or

www.Mdproblemgambling.com

Perspective Change: Disordered Perspective Change: Disordered Gambling Integration (DiGIn)Gambling Integration (DiGIn)

Addressing gambling and gambling problems for Addressing gambling and gambling problems for individuals presenting with a primary concern of individuals presenting with a primary concern of a substance use or mental health disorder is not a substance use or mental health disorder is not just about making a diagnosis or finding cases of just about making a diagnosis or finding cases of pathological gambling.pathological gambling.

Rather this approach involves assuring that the Rather this approach involves assuring that the impact of gambling on mental health and impact of gambling on mental health and substance use recovery is an ongoing topic of substance use recovery is an ongoing topic of conversation in treatment, recovery and conversation in treatment, recovery and prevention settings.prevention settings.

Integrated AssessmentIntegrated Assessment

Incorporating into existing assessmentsIncorporating into existing assessments

How might you ask questions related to How might you ask questions related to gambling in each of these sections of your gambling in each of these sections of your intake or assessment?intake or assessment?– MedicalMedical– FinancialFinancial– Family HistoryFamily History– Substance UseSubstance Use– PsychiatricPsychiatric– RecreationRecreation

Integrated AssessmentIntegrated Assessment

The key to this approach is to raise the issue of The key to this approach is to raise the issue of gambling and its role in your client’s recovery in gambling and its role in your client’s recovery in multiple contexts and repeatedly over time.multiple contexts and repeatedly over time.

Also it is key to include the topic of gambling in a Also it is key to include the topic of gambling in a non-judgmental or labeling manner, in order to non-judgmental or labeling manner, in order to minimize defensiveness or resistance.minimize defensiveness or resistance.

Case Case

• Charles is a 34 year old male in medication Charles is a 34 year old male in medication assisted treatment program. Has been assisted treatment program. Has been abstinent from opiates on methadone x 4 abstinent from opiates on methadone x 4 months. Reports significant cocaine cravings months. Reports significant cocaine cravings X 1 month. In initial assessment reported only X 1 month. In initial assessment reported only occasional purchase of lottery tickets. In occasional purchase of lottery tickets. In recent group discussion stated he has been recent group discussion stated he has been buying $100 worth of lottery tickets per week buying $100 worth of lottery tickets per week rather than buying crack with that money. rather than buying crack with that money.

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Brief EducationBrief Education

Low and High Risk GamblingLow and High Risk Gambling

Risk FactorsRisk Factors

High Risk SituationsHigh Risk Situations

Life Goals – Discrepancy AnalysisLife Goals – Discrepancy Analysis

Cost Benefit AnalysisCost Benefit Analysis

Establishing personal guidelinesEstablishing personal guidelines

JessieJessie

Jessie is a 57 year old female, presents due to Jessie is a 57 year old female, presents due to marijuana use. Lives with adult daughter and her marijuana use. Lives with adult daughter and her 3 children (X2 yrs). Grandson told teacher about 3 children (X2 yrs). Grandson told teacher about her marijuana use and teacher reported to DCF. her marijuana use and teacher reported to DCF. Significant conflict with daughter about house Significant conflict with daughter about house cleaning and child rearing. Reported on intake cleaning and child rearing. Reported on intake that she plays bingo 4-5 x per week. Takes her that she plays bingo 4-5 x per week. Takes her 82 year old mother. Feels it is a good way to get 82 year old mother. Feels it is a good way to get out of house and avoid conflict with daughter. out of house and avoid conflict with daughter. Stated she spent $5000 in past 6 months.Stated she spent $5000 in past 6 months. 6767

Goals for Gambling in RecoveryGoals for Gambling in Recovery

How would you like to enjoy gambling?How would you like to enjoy gambling?What type of gambling would you like to do, if any?What type of gambling would you like to do, if any?How often would you like to gamble?How often would you like to gamble?How much money can you afford to gamble with?How much money can you afford to gamble with?Which people do you want to gamble with, if any?Which people do you want to gamble with, if any?Are there people who are higher risk than others?Are there people who are higher risk than others?

Life GoalsLife GoalsList 5 important goals in your life (things you would like to have in your List 5 important goals in your life (things you would like to have in your life or accomplish) for the next 2-5 years.life or accomplish) for the next 2-5 years.

Goal One:Goal One:Goal Two:Goal Two:Goal Three:Goal Three:Goal Four:Goal Four:Goal Five:Goal Five:

For each of these goals write down any ways that gambling will help 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 you reach that goal and ways that gambling will interfere with reaching that goal.that goal.

Ways Gambling will HelpWays Gambling will Help Ways Gambling might InterfereWays Gambling might Interfere1.1.2.2.3.3.4.4.5. 5.

Re-evaluatingRe-evaluating

After looking at the Cost-Benefit After looking at the Cost-Benefit Analysis and your Goal Assessment, are Analysis and your Goal Assessment, are there any changes you would like to there any changes you would like to make in your personal goals for make in your personal goals for gambling? gambling?

My Plan for Gambling in RecoveryMy Plan for Gambling in Recovery

I will spend no more than __% of my budget which is I will spend no more than __% of my budget which is $____ per month.$____ per month.I will spend no more than ____ hours per time I gamble I will spend no more than ____ hours per time I gamble and only gamble ____ times/month.and only gamble ____ times/month.I will only gamble at the following low risk activities:I will only gamble at the following low risk activities:I will only gamble in the following low risk situations:I will only gamble in the following low risk situations:I will be sure to be accountable to the following people I will be sure to be accountable to the following people about my gambling:about my gambling:I will not gamble when I am feeling:I will not gamble when I am feeling:– AngryAngry– LonelyLonely– DepressedDepressed– StressedStressed– Other __________Other __________

Identify Your Warning SignsIdentify Your Warning Signs

If you chose to continue to gamble review the list of 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 below and circle the ones that you think you need to be aware of and monitor.of and monitor.

Some Common Warning Signs of Gambling ProblemsSome Common Warning Signs of Gambling Problems

Any increase in gambling behaviorsAny increase in gambling behaviorsNoticing an increase in cravings for other addictive behaviors in Noticing an increase in cravings for other addictive behaviors in connection with gamblingconnection with gamblingUsing gambling as an alternative to other additive behaviorsUsing gambling as an alternative to other additive behaviorsGambling to relieve boredom, anxiety or depressionGambling to relieve boredom, anxiety or depressionFeeling the same kind of rush or high when gambling as when Feeling the same kind of rush or high when gambling as when using substancesusing substancesWhat are any other signs that you might notice to indicate that What are any other signs that you might notice to indicate that gambling might be becoming a problem for you or putting your gambling might be becoming a problem for you or putting your recovery at risk?recovery at risk?

Making a PlanMaking a PlanWhat is your plan if you notice any What is your plan if you notice any warning signs of problem gambling?warning signs of problem gambling?– Talk to sponsorTalk to sponsor– Talk with counselorTalk with counselor– Stop gamblingStop gambling– Attend GA meetingAttend GA meeting– Develop plan to protect my moneyDevelop plan to protect my money– Other _________________Other _________________

LindaLinda

Linda is 42 year old female. On intake did not report Linda is 42 year old female. On intake did not report any concerns about gambling. However, during any concerns about gambling. However, during group discussion, she was very quiet and did not group discussion, she was very quiet and did not make eye contact after viewing video on family make eye contact after viewing video on family consequences of gambling. When asked about her consequences of gambling. When asked about her reaction, she acknowledged that her boyfriend with reaction, she acknowledged that her boyfriend with whom she is living, becomes abusive when he whom she is living, becomes abusive when he looses gambling or when they fight about money. looses gambling or when they fight about money. She has been playing the lottery as she thinks She has been playing the lottery as she thinks winning will be the only way she can get enough winning will be the only way she can get enough money to leave this abusive situation.money to leave this abusive situation.

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RememberRemember

• Even though individuals in recovery from Even though individuals in recovery from substance use and mental health disorders are substance use and mental health disorders are at higher risk for gambling problems, this does at higher risk for gambling problems, this does not mean that gambling always has a negative not mean that gambling always has a negative impact on someone’s recoveryimpact on someone’s recovery

• It is our job to help our clients be aware of and It is our job to help our clients be aware of and evaluate the risks as well as benefits that evaluate the risks as well as benefits that gambling can bring to their recovery, and to gambling can bring to their recovery, and to assist them in making the best informed assist them in making the best informed decisions regarding the role of gambling in their decisions regarding the role of gambling in their lives and recoveries.lives and recoveries.

RESOURCES: RESOURCES:

Md. Problem Gambling Helpline 1-Md. Problem Gambling Helpline 1-800-Gambler800-Gamblerwww.mdproblemgambling.comwww.baltimoregambler.orgwww.facebook.com/BaltimoreGamblerwww.baltimoredicezombies.orgwww.gamblesafewomen.orgwww.gamblesafewomen.orgLori Rugle: Lori Rugle: Lrugle@psych.umaryland.edu

Questions and CommentsQuestions and Comments

Thank You!

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Anyone can slay a dragon, he told me, but Anyone can slay a dragon, he told me, but try waking up every morning and try waking up every morning and loving the world all over again. loving the world all over again.

That’s what takes a real hero.That’s what takes a real hero.