Problem Gambling and Co-Occurring Disorders

1. Problem Gambling and Co-Occurring Disorders Loreen Rugle, Ph.D. NCGC II Director, Problem Gambling Services Connecticut Department of Mental Health & Addiction Services Lrugle@hotmail.com Joanna Franklin Ms NCGC II President, Maryland Council on Problem Gambling Jfranklin.ipg@gmail.com MC PG

2. Beginner’s Mind In the beginner's mind there are many possibilities, but in the expert's there are few. - Shunryu Suzuki

3. 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

4. Pathological Gambling and Co-Occurring Disorders Chicken and Egg Risk Factor? Interactive? Consequence? Independent Events?

5. Lifetime Co-morbidityKessler et al., 2008 (National Comoribidty Survey Replication)

6. Problem Gambling and Mental Health DisordersWilliams et al., 1998 Recreational Gam Prob Gam Disorder Vs. Non Gam Vs Non Gam Major Depression 1.7 * 3.3 * Dysthymia 1.8 * 2.1 Schizophrenia 0.6 3.5 * Phobias 1.2 2.3 * Somatization 1.7 * 3.0 * Antisocial PD 2.3 * 6.1 * Alcohol Use 3.9 * 7.2 * Alcohol Abuse/Dep 1.9 * 3.3 * Nicotine Use 1.9 * 2.6 * Nicotine Dep 1.3 * 2.1 * NS = Mania, Suicidality, OCD, Panic, GAD, Drug Use, Drug Abuse/Dep *=p<0.05

7. Lifetime Co-morbidityKessler 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.

8. Relationship between SA, Gambling Problems and Mental HealthRush 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 past-year substance use disorder the higher the prevalence of gambling problems

9. Cravings in PG’s and AlcoholicsTavares 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

10. 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)

11. Psychiatric Comoribity in Pathological Gamblers: Summary of Research of PG’s in Treatment Affect Disorders ~50-80% Anxiety Disorders Trauma ~10-35% ~5-30% Pathological Gambling Attention Deficit Disorder Substance Use Disorders Personality Disorders ~20-35% ~25-63% ~20-93%

12. Substance Abuse, Mental Health and Problem Gambling Substance Abuse Treatment Center Mental Health Center Gambling Problems Screen Positive Gambling Screen Gambling Assessment Screen Positive Gambling Screen Screen Negative Screen Negative Interpret and Follow Mental Health Protocol Interpret and Follow SA Protocol

13. 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. Peoplecriticize 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. SOGS items

14. The NODS-PERC

15. 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

16. 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?

17. 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?

18. Assessment/Diagnosis Positive Screen? Then What?

19. Feedback Score = 0 Score = 0 Score = 1-2 Score = 3-4 Score > 5

20. Brief Education Low and High Risk Gambling Risk Factors High Risk Situations Life Goals – Discrepancy Analysis Cost Benefit Analysis Establishing personal guidelines

21. 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 SELF-WORTH ARE COMPROMISED BY THE GAMBLING

22. 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

23. PROBLEM GAMBLING AMONG SMI CLIENTS GAMBLING AS SELF-MEDICATION Antidepressant Stimulant Helps “numb out” Enhances dissociation Anxiolitic

24. 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

25. 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

26. Treatment Issues

27. Prioritizing Treatment: Where to Begin Immediate Life Threat/Safety Stabilization/Obstacles to Psychosocial Treatment Abstinence/Most Significant Relapse Risk Factors Most Distressing Most Motivated

28. WHAT DOES TREATMENT WITH THIS POPULATION LOOK LIKE? WHERE DO YOU START AS THE THERAPIST AND WHERE DO YOU GO?

29. 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.

30. Making Connections Medication compliance and gambling Diet and gambling Sleep and gambling Alcohol and/or drug use and gambling

31. Coping Skills Relapse Prevention Affect Tolerance and Emotional Regulation Interpersonal Skills Mindfulness Skills

32. PG and Co-Occurring Disorders Family Issues Denial and mislabeling Increased co-dependency and enabling Spouse increased stress and resentment Intimacy issues Communication problems

33. 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

34. How Can Client Feel Safe without the Wall? Befriending the Dragon 34

35. Identifying Multiple Risky Behaviors Sex Eating Substances Spending Self-Mutilation/Cutting Relationships

36. Motivational Recycling Substance Use Disorder Mental Health Disorder Problem Gambling 36

37. Progress or “The Joy of Chasing Cats”

38. Developing Healthy Behaviors Healthy Eating Sleep Exercise Health Maintenance Living Environment Sunlight Connection and Relationships Fun and Play Spiritual Practices

39. 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

40. COD and Pathological GamblingTreatment 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

41. COD and Pathological GamblingTreatment 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

42. 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

43. 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

44. 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

45. 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

46. PG and Co-Occurring Disorders Family Issues Denial and mislabeling Increased co-dependency and enabling Spouse increased stress and resentment Intimacy issues Communication problems

47. 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

48. 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

49. Fully Integrated Treatment for PG and Co-Occurring DisordersModified 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

50. Fully Integrated Treatment for PG and Co-Occurring DisordersModified 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