Download Treatment of Pathological Gambling

Problem Gambling and
Co-Occurring Disorders
Loreen Rugle, Ph.D. NCGC II
Director, Problem Gambling Services
Connecticut Department of Mental Health & Addiction Services
[email protected]
Joanna Franklin Ms NCGC II
President,
Maryland Council on Problem Gambling
[email protected]
MC
P G
Beginner’s Mind
In the beginner's mind there are many
possibilities, but in the expert's there are
few.
- Shunryu Suzuki
Psychiatric Comorbidity in Pathological
Gamblers
 Affect



Dysregulation/Negative Affect
Affective Disorders
Anxiety Disorders
Cluster C & A Personality Disorders
 Impulsivity/Disinhibition


Attention Deficit Hyperactivity Disorder
Cluster B Personality Disorders
 Substance
Abuse
Pathological Gambling and
Co-Occurring Disorders

Chicken and Egg

Risk Factor?

Interactive?

Consequence?

Independent Events?
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
PG First
Other Disorder
First
Onset at same
time
Any mood
Disorder
55.6%
23.1%
64.1%
11.7%
Any anxiety
disorder
60.3%
13.4%
82.1%
4.5%
Any impulse
control disorder
42.3%
0%
100%
0%
Any substance
use disorder
42.3%
36.2%
57.4%
6.4%
Problem Gambling and Mental Health
Disorders
Williams et al., 1998
Disorder
Recreational Gam
Vs. Non Gam
Prob Gam
Vs Non Gam
Major Depression
Dysthymia
Schizophrenia
Phobias
Somatization
Antisocial PD
Alcohol Use
Alcohol Abuse/Dep
Nicotine Use
Nicotine Dep
1.7 *
1.8 *
0.6
1.2
1.7 *
2.3 *
3.9 *
1.9 *
1.9 *
1.3 *
3.3 *
2.1
3.5 *
2.3 *
3.0 *
6.1 *
7.2 *
3.3 *
2.6 *
2.1 *
NS = Mania, Suicidality, OCD, Panic, GAD, Drug Use, Drug Abuse/Dep
*=p<0.05
Lifetime Co-morbidity
Kessler et al., 2008 (National Comoribidty Survey Replication)
 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.
Relationship between SA, Gambling
Problems and Mental Health
Rush et al., 2008

Results from Canadian
survey (N=365,885)


The presence of a lifetime
mental health disorder
(other than SA) almost
doubled rate of gambling
problems
The more severe the pastyear substance use
disorder the higher the
prevalence of gambling
problems
10
8
6
4
2
0
Abstainer
Subst. Dep.
Cravings in PG’s and Alcoholics
Tavares et al., 2008
Compared PG and Alcoholics on craving
rating (0 – 90)
 PG’s mean rating 49
 Alcoholics mean rating 35
 PG’s also more “spontaneous” on
impulsivity scale

Significance of Co-Occurring Disorders

Individuals with Co-Occurring PG and SUDs
Experience More Severe Symptoms Than Those
With SUDs Alone (Kaplan & Davis, 1997)



- Increased Rates of Admission for Detoxification
(> Two-Fold Rate)
- Increased Rates of Admission for Psychiatric
Stabilization (> 50% Increased Rate)
- More Suicidality (Federman et al, 1998)
Psychiatric Comoribity in Pathological
Gamblers: Summary of Research of PG’s in
Treatment
~50-80%
Affect
Disorders
~10-35%
~5-30%
Anxiety
Disorders
Trauma
Pathological
Gambling
~20-35%
Attention Deficit
Disorder
Substance Use
Disorders
Personality
Disorders
~20-93%
~25-63%
Substance Abuse, Mental Health and
Problem Gambling
Mental
Health
Center
Gambling
Screen
Screen
Negative
Interpret and
Follow Mental
Health Protocol
Gambling
Problems
Screen
Positive
Gambling
Assessment
Substance
Abuse
Treatment
Center
Screen
Gambling
Screen
Positive
Screen
Negative
Interpret and
Follow
SA Protocol
SOGS items









Has a problem with gambling.
Gambles more than intended.
Wants to stop but can’t.
Goes back to win lost money.
Claims to be winning when not.
Hides gambling signs from
others.
People criticize gambling.
Feels guilty about gambling.
Argue about gambling.






Loses time from school or work
due to gambling.
Borrows money from friends,
spouse, or household for
gambling.
Borrows from banks or credit
cards to gamble.
Cashes in stocks/bonds or sells
property to gamble.
Writes bad checks to gamble.
Borrows from loan sharks to
gamble.
The NODS-PERC
NODS 1
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?
NODS 8
Have you ever gambled as a way to escape from
personal problems?
NODS 10
Has there ever been a period when, if you lost money
gambling one day, you would return another day to get
even?
NODS 14
Has your gambling ever caused serious or repeated
problems in your relationships with any of your family
members or friends?
Screening Issues
 Self-report
 How
you ask as well as what you ask
 Need to ask multiple times and in multiple
contexts
 Decrease defensiveness
 Involve family/significant others
Family Screening
 Does
Family Have Significant Financial
Problems
 Are Financial Problems Related to
Gambling (Either causing them or seen as
solution)
 Have You Been Concerned About Extent
of Gambling of Family Member?
Family Screening




Do family activities involve gambling?
What does the family do for fun?
What activities do you enjoy at family get
togethers?
Has gambling ever created problems for your
family?
Assessment/Diagnosis
 Positive
Screen?
 Then What?
Feedback
No Gambling
Score = 0
Social Gambling Score = 0
At Risk
Score = 1-2
Problem
Score = 3-4
Pathological
Score > 5
Brief Education
 Low
and High Risk Gambling
 Risk Factors
 High Risk Situations
 Life Goals – Discrepancy Analysis
 Cost Benefit Analysis
 Establishing personal guidelines
PROBLEM GAMBLING AMONG
SMI CLIENTS
 WHAT
DEFINES A PROBLEM GAMBLER
AMONG THE MENTALLY ILL
 OFTEN SOMEONE WHO GAMBLES
VERY LITTLE MONEY
 BUT WHOSE SELF-ESTEEM AND SELFWORTH ARE COMPROMISED BY THE
GAMBLING
PROBLEM GAMBLING AMONG
SMI CLIENTS
MONEY IS OFTEN CONTROLLED BY SOMEONE IN THE PERSON’S
LIFE, EITHER A MENTAL HEALTH AGENCY OR FAMILY MEMBER, SO
FINANCIAL DAMAGE MAY BE MINIMAL.
BASIC BILLS ARE BEING PAID, THEREFORE,
AND THERE MAY BE NO ACCESS TO CREDIT CARDS
BECAUSE OF LIMITED INCOME.
HOWEVER MAY CAUSE CONFLICTS AROUND MONEY WITH FAMILY,
PEERS, IN TREATMENT AND GROUP LIVING SETTINGS
COGNITIVE DEFICITS MAY CAUSE SERIOUS IMPAIRMENT IN
JUDGMENT
PROBLEM GAMBLING AMONG
SMI CLIENTS

GAMBLING AS SELF-MEDICATION
Antidepressant
Stimulant
Helps “numb out”
Enhances dissociation
Anxiolitic
PROBLEM GAMBLING AMONG SMI
CLIENTS
IT’S NOT ABOUT THE AMOUNTS OF MONEY GAMBLED; IT’S
ABOUT SEEING YOURSELF AS NORMAL AND IT’S ABOUT
CONNECTING WITH THE REST OF THE POPULATION ON
EQUAL FOOTING.
PROVIDES “SAFE” SOCIALIZING, ILLUSION OF ACCEPTANCE
AND BELONGING, RELIEVES LONELINESS AND BOREDOM.
CAN SEEM LIKE A SUBSTITUTE FOR EMPLOYMENT. FEELING
USEFUL AND PRODUCTIVE
PROVIDES STRUCTURE FOR LIFE. SOMETHING TO DO WITH
TIME
PROBLEM GAMBLING AMONG SMI
CLIENTS
IT’S ABOUT FEELING STIGMATIZED AND
DISENFRANCHISHED BY A
CONSUMER ORIENTED, “HEALTHY”
ORIENTED SOCIETY THAT DIMINISHES
THE UNHEALTHY AND THE POOR
Treatment Issues
Prioritizing Treatment: Where to Begin

Immediate Life Threat/Safety

Stabilization/Obstacles to Psychosocial
Treatment

Abstinence/Most Significant Relapse Risk
Factors

Most Distressing

Most Motivated
WHAT DOES TREATMENT WITH
THIS POPULATION LOOK LIKE?
WHERE DO YOU START AS THE
THERAPIST AND WHERE DO YOU
GO?

THE DREAM OF THE “BIG WIN” NEEDS TO BE TALKED
ABOUT IN THERAPY AND ADDRESSED. THE SADNESS
AND SENSE OF LOSS OF DEALING WITH A CHRONIC
ILLNESS MUST BE ADDRESSED.

FAMILY STRAIN CAN BE IMMENSE IF THE FAMILY IS
HANDLING THE MONEY, AND OFTEN THE FAMILY IS
IN NEED OF COUNSELING AS MUCH AS OR MORE
THAN THE GAMBLER. THE FAMILY SHOULD BE
INVOLVED FROM THE BEGINNING.

OTHER AGENCIES AND/OR TREATERS NEED TO BE
CONTACTED, RELEASES SIGNED AND
RELATIONSHIPS ESTABLISHED SO THAT ALL ARE
WORKING ON SIMILAR GOALS. REMEMBER THAT
OFTEN THIS POPULATION HAS LESS “THERAPY” AND
MORE “CASE MANAGEMENT” FROM MENTAL HEALTH
AGENCIES.
Making Connections
 Medication
compliance and gambling
 Diet and gambling
 Sleep and gambling
 Alcohol and/or drug use and gambling
Coping Skills
 Relapse
Prevention
 Affect Tolerance and Emotional
Regulation
 Interpersonal Skills
 Mindfulness Skills
PG and Co-Occurring Disorders
 Family





Issues
Denial and mislabeling
Increased co-dependency and enabling
Spouse increased stress and resentment
Intimacy issues
Communication problems
Uncovering Co-occurring Disorders:
Need for Ongoing Assessment

Gambling stops and Co-morbidity Starts
Avoidance
Anger
Identity Confusion
Fear
Anxiety
Trauma
Depression
G
A
M
B
L
I
N
G
33
How Can Client Feel Safe
without the Wall?
 Befriending
the Dragon
34
Identifying Multiple Risky Behaviors
 Sex
 Eating
 Substances
 Spending
 Self-Mutilation/Cutting
 Relationships
Motivational Recycling
Substance Use
Disorder
Problem
Gambling
Mental
Health
Disorder
36
Progress or “The Joy of Chasing
Cats”
12
10
Gambling
Substance Use
Cutting
Eating Problems
Sex
Spending
Shop Lifting
8
6
4
2
9
e
8
Ti
m
e
7
Ti
m
e
6
Ti
m
e
5
Ti
m
e
4
Ti
m
e
3
Ti
m
e
2
Ti
m
e
Ti
m
Ti
m
e
1
0
Developing Healthy Behaviors









Healthy Eating
Sleep
Exercise
Health Maintenance
Living Environment
Sunlight
Connection and Relationships
Fun and Play
Spiritual Practices
Co-occurring Disorder (COD) and Problem
Gambling Treatment Implications

COD does not absolve of responsibility
 Treatment Compliance
 Resistance or COD
 Smaller Assignments
 Need for Assistance
 Financial Problems Serious Relapse Trigger
 Money Manager/Financial Counselor
 Keeping Budget Organized
COD and Pathological Gambling
Treatment Implications
 Inadequacy,
Avoidance and
Procrastination






Education on COD
Address Issue of Shame
Develop Effective Coping Strategies and skills
training
Acknowledging Need for Help and Coaching
Anxiety and Affect management techniques
Structure
COD and Pathological Gambling
Treatment Implications
 Help





with Organizing and Structuring
Sponsorship
Help with Problem Solving
Career and Work Issues
Values and Spiritual Structure
Role of Prolonged Probation to support and
structure therapeutic interventions
Psychotropic Medication Issues





Medication for comorbid risk factors or as
ancillary tool (naltrexone) to full treatment
program
Directed to diagnosed psychiatric disorders, not
insomnia or to medicate feelings
Fixed dose regimes, not PRN
Avoid addictive medications
Can use while actively gambling


Historical evidence of benefits
Work toward engagement in gambling treatment
Hospitalization

Inpatient hospitalization avoided whenever
possible
 Recommended when:



Patient is in a psychotic state and threatening suicide
Suicide threats escalating and patient does not want
to be hospitalized
Patient has history of serious medication
abuse/overdose and is having problems that require
close medication monitoring
43
Hospitalization
 Recommended



when:
Risk of suicide outweighs the risk of
inappropriate hospitalization
Therapeutic relationship is seriously strained
and is creating a suicidal risk and outside
consultation seems necessary
Patient is not responding to outpatient
treatment and is severely depressed or
anxious
44
Hospitalization
 Recommended

when:
The patient is in an overwhelming crisis, can’t
cope without significant risk of harm, and no
other safe environment available
45
PG and Co-Occurring Disorders
 Family





Issues
Denial and mislabeling
Increased co-dependency and enabling
Spouse increased stress and resentment
Intimacy issues
Communication problems
Continuing Care in Comorbid
Pathological Gamblers







Parallel process of gambling and mental
health/substance abuse treatment
Make connections continuously
May need multiple support groups
Educate and address motivation for all disorders
Family education on full diagnostic picture
Remember both/all can be recurring,
progressive disorders
Learning from relapses
Treatment Integration
 Integrated
Co-Occurring Disorder
Treatment Program
 Collaborative, concurrent problem
gambling, substance use and mental
health treatment
 Primary mental health and or substance
use treatment with adjunctive and/or
intermittent problem gambling treatment
48
Fully Integrated Treatment for PG
and Co-Occurring Disorders
Modified from TIP 42

One program provides treatment for both (all)
disorders
 Same clinicians treat PG and other addiction
and mental health disorders
 Clinicians are trained in psychopathology,
assessment and treatment strategies for PG,
PD, SA and MH disorders
49
Fully Integrated Treatment for PG
and Co-Occurring Disorders
Modified from TIP 42
 Emphasis
is placed on trust,
understanding and learning
 Long term perspective, slow pace
 Providers offer stagewise and motivational
counseling
 12 step groups available to those who
chose to participate and can benefit
50
Therapist Challenges
 Compassionate
Honesty
 Tolerating client’s emotional discomfort
 Balance between empathic support and
confrontation
 Acknowledging counter transference
reactions
 Patience and Self-Forgiveness
Going in Circles
Thich Nhat Hanh
O you who are going in circles,
please stop,
What are you doing it for?
“I cannot be without going,
Because I don’t know where to go.
That’s why I go in circles”
O you who are going in circles,
please stop
“But if I stop going,
I will stop being.”
Going in Circles
Thich Nhat Hanh
O my friend who is going in circles,
You are not one with
This crazy business of going in circles.
You may enjoy going,
But not going in circles
“Where can I go?”
Go where you can find your beloved,
Where you can find yourself.