Focus on Anger in the Treatment of Gambling Problems

1. Focus on Anger in the Treatment of Gambling Problems Lorne Korman, Ph.D., C.Psych. Director of Research BC Provincial Youth Concurrent Disorders Program

2. Jane Collins BC Provincial Youth Concurrent Disorders Program

3. What is Anger? • Anger is a primary, basic emotion, with characteristic appraisal and action tendency1 • Anger is the blueprint for aggression, violence2 • Anger and violence frequently co-occur3 • Violence can also occur in the absence of anger 1 Fridja, 1986; Ekman, 1984; Ekman & Friesen, 1975, Izard 1977 2 Averill, 1993 3 Kassinove & Sukhodolsky, 1995

4. Self-Reported Anger and Aggression among Substance-Using Clients 18-month Period at ARF and CAMH • 4995 new patients seeking addictions tx • 40% reported anger problems at intake • 19% reported acts of physical aggression related to substance use • 9.7% reported acts of physical aggression in the last 90 days From Collins, Skinner, & Toneatto, 2005

5. Canadian Forensic Data: Violence and S.U.% of Alcohol and Drug Intoxication at Time of Perpetration of Index Violent Crime Source: Pernanen et al., 2002. Canadian Centre on Substance Abuse

6. The Co-occurrence of Substance Use and Violent Crime • Summary of 26 studies in 11 countries found on average, 61.5% of offenders drank at time of committing violent crime1 • Recent Swedish study found a 13.2-fold increase in the risk of criminal violence within 24 hours of alcohol consumption2 1 Murdoch, Pihl, & Ross, 1990 2 Haggard-Grann, Hallqvist, Langstrom, & Moller, 2006

7. Substance Use and Intimate Partner Violence • Very high rates of co-occurrence of substance abuse among perpetrators of IPV, particularly among male perpetrators1 • The relationship between substance use and IPV has been established both in cross-sectional and longitudinal studies2 • 1 c.f. Quigley & Leonard, 2000 • Heyman, O’Leary, & Jouriles, 1995; • Leonard & Senchak, 1996; Quigley & Leonard, 2000

8. Substance Use and Intimate Partner Violence:Recidivism • IPV recidivism higher among relapsed alcoholics than among remitted alcoholics1 • Following batterer intervention programs, individuals more likely to re-assault if they have substance use problems2 • 1 Stuart et al., 2003; Maiden, 1997 • DeMaris & Jackson, 1987; Gondolf, 1997; Jones & Gondolf, 2001

9. Anger and Addictions • High rates of co-occurrence of: • substance use and anger • substance use (especially alcohol) and violent crime • substance use and domestic violence • What about the co-occurrence of pathological gambling and anger/violence?

10. Anger Problems among Substance-Using Problem Gamblers • higher proportion of problem gamblers (61%) report anger management problems than non-problem gamblers (40%) 1 • severity of gambling problems associated with greater hostility in treatment-seeking substance users2 1 Collins, Skinner, & Toneatto, 2005 2 McCormick, 1993

11. Intimate Partner Violence and Problem Gambling • Research relatively sparse • Survey of 144 spouses of compulsive gamblers: 43% reported their spouses had physically or verbally abused them1 • Lorenz and Shuttlesworth, 1983

12. Intimate Partner Violence and Problem Gambling (continued) • In interviews with pathological gamblers, 23% reported having hit or thrown things at their partners at least once 1 • Survey of 300 women attending E.R. in Nebraska: those with spouses who had gambling problems more likely to be victims of IPV 2 1 Bland, Newman, Orn, & Stebelski, 1993 2 Muellerman, DenOtter, Wadman, Tran, & Anderson, 2002

13. Treating Comorbid Anger and Addictions • Much known about the high prevalence of concurrent anger, aggression and substance use (e.g., domestic violence & alcohol) • Many anger treatments screen out clients with active addictions • Lack of empirically tested integrated treatments for comorbid anger and addictions

14. Treat Concurrent Anger & AddictionsProblems Concurrently? • Are there benefits to addressing concurrent anger and addictions in an integrated treatment? • Theories posit emotion dysregulation as an underlying problem of (separately) gambling, anger, substance use problems1 • Is there utility in targeting emotion dysregulation for people with concurrent anger, gambling, and substance use problems? 1 Dutton, 1995; Greenberg & Paivio, 1997; Khantzian, 1985, 1997; Levinson, Gernstein & Maloff, 1983; Miller, 1980;Moran, 1970

15. RCT on Integrated Treatment for Comorbid Anger and Addictions • RCT study compared integrated gambling, anger and substance use treatment to a specialized addictions-only treatment

16. Randomized Control Trial of an Integrated Treatment for Concurrent Anger and Addictions Research Team Lorne Korman Jane Collins Nina Littman-Sharp Shelley McMain Wayne Skinner Project Consultant Tony Toneatto Research Assistant Virginia Mercado With Assistance from: Therapists of the Problem Gambling Service & the Anger and Addiction Clinic at CAMH Funded by a grant from The Ontario Problem Gambling Research Centre

17. Study Design • Participants: Problem gamblers (CPGI ≥ 8), all with self-identified anger problems, with or without concurrent substance use problem • RCT, 42 participants stratified by substance dependence disorder • Assessment periods: Intake (T1), 14 weeks (T2), 12-week follow-up (T3)

18. Treatment Conditions • Integrated Treatment Targeted both Anger & Addictions @ an Integrated Anger & Addiction Clinic • Addictions-Only Treatment-as-Usual (TAU) Only Targeted Addictions – Gambling & SU @ Specialized Gambling Clinic

19. Study Treatments Integrated Condition: Max. 12 individual weekly sessions (1 hour) Diary card of target behaviours Analyses of reported target behaviours (30-40 min.) Skills training, as relevant (20-30 min.), and exposure, response prevention, rehearsal

20. Study Treatments Addictions-Only TAU Treatment length varied as needed, 1 hour individual sessions Focused primarily on problem gambling and substance use using CBT relapse prevention

21. Study Measures • Canadian Problem Gambling Index (CPGI) • PGSI (9 items, 9-point lykert scale) • State-Trait Anger Expression Inventory (STAXI) • 44 items, yielding 2 scales, 6 subscales • Drug Use History Questionnaire (type, frequency and amount of substances used past 3 months) • SCID Substance Use/Substance Dependence Sections (T1 only)

22. Demographics

23. Treatment Engagement:% subjects attended at least 1 session

24. # Sessions Attended by Group

25. Sessions Attended = Covariate • Integrated treatment significantly better at engaging clients than addictions-only TAU • Because # of sessions attended in Integrative condition was greater, # of treatment sessions attended was used as a covariate in analyses of outcome. • Therefore observed treatment effects on all major outcome variables were not dependent on the number of treatment sessions attended • Also, patterns of change same for participants in TAU who had 4 or more sessions

26. Gambling: PGSI

27. % Meeting Criteria for Problem Gambling(PGSI≥8)

28. Gambling: % monthly income spent gambling

29. STAXI Trait Anger

30. STAXI Anger Expression

31. Clinical Significance of Changes: STAXI Anger Expression Problem Anger Threshold (expressed in percentiles, based on a standardized normal population)

32. Integrt. n=20 TAU n=22 Dependence 8 8 Abuse 2 1 Use not meeting disorder criteria 3 3 No use in past 90 days 7 10 Substance Use (at intake)

33. Substance Use: Days Used

34. Discussion • An integrated approach treating concurrent anger & gambling appears to improve both addictions & anger outcomes • The presence of anger may make gambling treatment less effective if anger not addressed. • Addictions clinicians need to assess & treat concurrent anger & other addictions problems. • Anger treatments need also to screen & target addictions.

35. Discussion • Addressing concurrent anger may provide a big bang for the buck in gambling treatment • Findings underscore importance of using engagement strategies with clients with concurrent anger and gambling problems • Integration & flexibility important- i.e., the ability to target multiple relevant problems concurrently.

36. Response to the Study (I) • Sample size (20/22 per group) • TAU was not a manualized treatment • Follow-up was relatively short (3 months)

37. Integrated Anger and Addiction Treatment Study: RCT # 2 – Just starting • N = 80 youth (40 per condition) • TAU is a manualized CBT with adherence monitoring • One-year follow-up Korman, Toneatto, Collins, & Cripps, in progress Funded by a grant from the Ontario Gambling Research Centre

38. Response to the Study (II) Findings may be less important because angry problem gamblers are a small “niche” population. So, are angry problem gamblers in fact a small “niche” population of problem gamblers?

39. Are Angry Problem Gamblers a Small, “Niche” Population of Problem Gamblers? Study examined the prevalence of problem anger, substance use and intimate partner violence among problem gamblers. n=248problem gamblers (43 females, 205 males) Korman, Collins, Littman-Sharp, Dutton, Cripps & Skinner, 2007 Funded by a grant from the Ontario Problem Gambling Research Centre

40. Angry Problem Gamblers not a “Niche” Population: They may be the Majority In a recently completed prevalence study of 248 problem gamblers in Canada, 64.5% found to have clinically significant anger problems on the STAXI-II Source: Korman, Collins, Littman-Sharp, Dutton, Cripps & Skinner, 2007 Funded by a grant from the Ontario Problem Gambling Research Centre

41. Problem Gamblers What about the prevalence of Intimate Partner Violence?

42. Intimate Partner Violence in the Past Year: CTS2 Data * either perpetrator or victim of physical assault, injury, and/or sexual coercion N = 248

43. "Minor" Physical Assault among Problem Gamblers: Perpetration CTS2 Minor Physical Assault: e.g. push, grab, shove * ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999) N = 248

44. “Severe" Physical Assault among Problem Gamblers Perpetration CTS2 Severe Physical Assault: e.g. punch, kick, use weapon * ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999) N = 248

45. "Minor" Physical Assault among Problem Gamblers Victimization CTS2 Minor Physical Assault: e.g. push, grab, shove * ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999) N = 248

46. “Severe" Physical Assault among Problem Gamblers Victimization CTS2 Severe Physical Assault: e.g. punch, kick, use weapon * ( male pop. norms from Kwong, Bartholomew, & Dutton, 1999) N = 248

47. Lifetime Substance Use Disorder in Problem Gamblers (N=185/248)

48. What Accounts for High Rates of Anger and IPV among Problem Gamblers? • Psychiatric Comorbidity? • And/or Impulsivity? • And/or general emotion dysregulation?

49. Axis II Comorbidity? • High rates of Axis II comorbidity among pathological gamblers 1 • Blaszczynski and Steel (1998): 92% of 82 treatment-seeking problem gamblers met criteria for at least one personality disorder • Cluster B most prevalent: 57.3% pathological gamblers met criteria for borderline, histrionic, and/or narcissistic PD • Note two of these PDs feature emotion dysregulation 1Black & Moyer, 1998; Blaszczynski and Steel, 1998; Fernandez-Montalvo & Echeburua, 2004; Lesieur & Blume, 1990

50. The Role of Emotion Regulation Are there functional relationships between anger and gambling?