Problem Gambling

1. Problem Gambling: Allied Professionals OverviewCynthia Dunn (B.Psych Hons)Assoc MAPS, Gambling CounsellorQld

2. Problem Gambling • To gamble means staking something of value (usually money) on the outcome of an event or game. • The outcome is ‘chance’. • We speak of Problem Gambling when gambling behaviour causes harm in a person’s life, for their family or in the community.

3. Introduction: • Recent evidence suggests that the construct of Problem Gambling as a chronic and progressive disorder is highly questionable! • Many people mature out of Problems • Only 1 in 4 YP continue to keep gambling • Little consistency in activities from year to year -this study & others (Abbott, 2006; Delfabbro et al., 2009; Shaffer et al., 2004; Slutske, 2006; Wiebe et al., 2003 Westphal, 2008)

4. Introduction: Is Addiction a Useful Concept • This has led to an array of Gambling Screens with varying degrees of reliability and validity. • Watering down of inclusion criteria to include “at-risk” individuals. • Increase use of pharmacological treatments; and politico-legal sanctions of ‘gambling as disease’

5. Pathological Gambling: Chronic & Progressive? • DSM IIIR – Impulse Control Disorder (based on substance/alcohol syndrome criteria) • DSM IV – Impulse Control Disorder (with indemnifier precluding its use as insanity plea, i.e. not a mental illness or disease) • DSM V – Substance Abuse i.e. Addiction or -OCD Spectrum Disorder- sound biological links (Westphal, 2007) ? • Gambling is seen as “deviance”; sin, vice, now disease. • Despite findings that most people self-remit without treatment & practice-informed treatments are effective! The DoDo Bird Effect? All Rt are effective & all win a prize!

6. Moral Jeopardy • Recent evidence suggests that the construct of Problem Gambling as a chronic and progressive disorder is highly questionable (Westphal, 2008). • This has led to a proliferation of Gambling screens; watering down of inclusion criteria to include “at-risk” individuals; increase use of pharmacological treatments; and politico-legal sanctions of ‘gambling as disease’ • Thus, the “gambling problem” is big business which creates a moral jeopardy for governments, service providers, researchers and the community who benefit from ever increasing gambling revenue (Adams, 2009).

7. The G-MAP • The Maroondah Assessment Profile for Problem Gambling (G-MAP) (Loughnan, Pierce & Sagris-Desmond, 1999). • 85 item Questionnaire which corresponds to 5 groups of 17 factors. Scores are transposed onto a profile which provides a graphic representation. • Takes about 20 minutes to complete, 10 min to score and about 10 minutes to analyse. This can also be sensitively done in collaboration with the client.

8. The PANAS THE POSITIVE AND NEGATIVE AFFECT SCALE (Watson et al., 1988). • Low PA=Depression; High NA=Anxiety • Highly reliable normed in large samples in clinical, large normal samples and cross-cultural samples. • Normal Range of PANA Scores is: • PA Mean=32; SD=7; • NA Mean=19.5; SD= 7 • for a non-clinical sample of reliable norms (Watson et al., 1988)

9. Presentation by Cynthia Dunn, JCU, NAGS 09The G-MAP: The Maroondah Assesment Profile for Problem Gambling(Loughnan, Pierce &Sagris-Desmond, 1999) 17 factors divided into 5 groups: • Beliefs about Winning • Feelings • Situations • Attitudes to Self • Social

10. G-MAP (1. Beliefs about Winning) • Control - the extent to which the person is using a ‘system’. • Prophecy - the extent to which ideas about luck and intuition influence the individual. • Uninformed - believes gambling can be a reliable way of making money.

11. G-MAP (2. Feelings) • Good Feelings - managing feelings of depression. • Relaxation - managing feelings of anxiety or worry. • Boredom - managing feelings of boredom. • Numbness - dissociative state while gambling.

12. G-MAP (3. Situations) • Oasis - gambling as a reward and/or escape from the perceived demand of others. • Transition - gambling behaviour coincides with significant transitional life events. • Desperation - only way to escape situation is to have a big win, chasing losses and may be considering illegal activities to obtain money. • Mischief - gambling as an expression of rebellion against the perceived constraints of others, or for a ‘thrill’.

13. G-MAP (4. Attitudes to Self) • Low Self Image - regards self as loser and that others also see them as a loser and gambling as a way of becoming a winner. • Winner - relies on the identity of being a winner at gambling and relies on maintaining the image in the eyes of others. • Entrenchment - see gambling as a lifelong disease which can only be overcome by abstinence. • Self Harm - gambling as a conscious and deliberate way to harm themselves.

14. G-MAP (5. Social) • Shyness - socially lacking confidence and gambling is away of being amongst people. • Friendship - gambling as a social activity, problems may arise from peer pressure and/or competitiveness. (Loughnan,Pierce & Sagris-Desmond, 1999)

15. Profiles: Names & Details Changed Bob • Is a 35 yr old regular/heavy gambler who is employed and gambles on the pokies at the casino.He scores 7 on the SOGS (problem category) and reports problems with pokies for 3 yrs, he plays 1 day/wk @ $40/2 hr session and reports spending $80/week, not include winnings. • No AOD or Psych problems reported. Receives Gambling Treatment. PA – 34, NA – 46. • G – MAP groups: (1), 31; (2), 46; (3), 35; (4), 40; (5) 12. Factors: Uninformed (18); Good Feelings (17); Transition (15). • Expected gambling outcomes (Mode Descriptors): Forgets problems & feels like a loser angry, miserable & afraid (5). Urge-10, Preoccupation-6, Control-5. • No qualitative comment was made, but he has gambling related suicidal ideation and ceased gambling after treatment.

16. Profiles: Names & Details Changed Barb • Is a 35 yr old regular/heavy gambler who is employed and gambles on the pokies and lotto.She scores 11 on the SOGS (problem category) and reports problems with pokies for 3 yrs, she plays 1 day/wk @ $40/2 hr session and reports spending $80/week, not include winnings. • No AOD or Psych problems reported. No Gambling Treatment. PA – 37, NA – 14. • G – MAP groups: (1), 11; (2), 25; (3), 23; (4), 4; (5) 7. Factors: Uninformed (7); Good Feelings (7); Boredom (8); Transition (11);) Oasis (8). • Expected gambling outcomes (Mode Descriptors): Forgets problems & feels excited and broke (4). Urge-8, Preoccupation-5, Control-3. • No qualitative comment was made, but she does not feel gambling related suicidal ideation and has ceased gambling without treatment.

17. Profiles: Names & Details Changed Belinda • Is a 44 yr old regular/heavy gambler who gambles on the pokies at the Clubs, she was abstinent from gambling at interview . She scores 7 on the SOGS (problem category) and has gambled since she was 11, unemployed and reports problems for 4 years. She bets on mainly pokies (keno & lotto to a lesser degree, 2 days a wk and $80/ session and loses $60/wk (when gambling). • She has experienced AOD & Psych probs. Received Gambling Rt. PA – 36, NA – 20. • G - MAP Groups: (1), 0; (2), 19; (3), 18; (4), 0; (5) 9. • Factors: Good Feelings (7); Relaxation (7); Transition (9). • Expected outcomes (Mode): To forget problems & Excited (4). • Urge-3, Preoccupation-2, Control-9. • She made no qualitative comment qualitative comment, but has suicidal ideation and attempts for gambling and grief related issues.

18. Profiles: Names & Details Changed Ben • Is a 63 yr old heavy gambler who gambles on the pokies. He scores 10 on the SOGS (regular category) and has gambled since he was 16, he doesn’t work and reports problems on & off for 10 yrs. He bets on mainly pokies, twice a week, and reports betting whatever money he has on him, and claims to always lose. • Has recovered AOD & experiences Anxiety/Depression. Has sought Gambling Rt & follows 12 steps. PA – 21, NA – 48. • G - MAP Groups: (1), 13; (2), 42; (3), 0; (4), 35; (5) 0. Factors: Relaxation (14), Boredom (16, Transition (14), Entrenchment (13). • Expected outcomes (Mode): Forgets problems, Excited, Broke (5). Urge-10, Preoccupation-3, Control-3. • His qualitative comment was that the availability & promotion of Gambling induces sexual arousal, part. Symbols on pokies. He has regular suicidal ideation.

19. Profiles: Names & Details Changed Brad • Is a 36 yr old heavy gambler who gambles on the pokies. He scores 10 on the SOGS (regular category) and has gambled since he was 25, he is employed and reports problems for 7 yrs. He bets on pokies & casino games, once a week, for 4-6 hrs and reports betting $300-$600/session.He has now self-barred from the casino for 2 yrs. • No Alcohol or Psychiatric, but uses non-prescription drugs. Hasnotsought Gambling Rt. PA – 18, NA – 44. • G - MAP Groups: (1), 22; (2), 30; (3), 28; (4), 11; (5) 0. • Factors: Uninformed (12, Numbness (11), Transition (19). • Expected outcomes (Mode): Loser,Broke, Reckless & Afraid (5).Urge-7, Preoccupation-3, Control-2. • His qualitative comment was that ‘an early life change put him behind & he is gambling to catch up’. He has gambling related suicidal ideation.

20. Profiles: Names & Details changed Betty • Is a 35 yr old regular/heavy gambler who is employed and gambles on the pokies and casino.She scores 10 on the SOGS (problem category), has gambled since 19yrs and reports problems with pokies for 3 yrs, she plays 4 day/wk @ $50/3 hr session and reports spending $100??/week, not include winnings. • No AOD or Psych problems reported. No Gambling Treatment. • PA – 42, NA – 19. • G – MAP groups: (1), 13; (2), 21; (3), 16; (4), 7; (5) 0. Factors: Uninformed (9); Good Feelings (7); Boredom (9); Entrenchment (7). • Expected gambling outcomes (Mode Descriptors): Feels excited and broke (5). Urge-8, Preoccupation-7, Control-3. • No qualitative comment was made, but she does not feel gambling related suicidal ideation and claims to have ceased gambling without treatment.

21. Results (Cases: Group 1)

22. Results (Cases: Group 2)

23. Results (Cases: Group 3)

24. Results (Cases: Group 4)

25. Results (Cases: Group 5)

26. The lack of evidence-based gambling treatment (Westphal, 2009) • Do practitioners actually agree with this? When there has been no measurable improvement in effectiveness in the last 30yrs. • Miller et al.-Practice-based evidence is practical, elegant and… rather than evidence-based practice which is governed by ‘Pax Medica’. • Motivational enhancement has provided evidence based results as well as, can be delivered in a client-focused approach.

27. Motivational Enhancement • Hodgins, Currie & el- Guebaly (2001) found Motivational Enhancement efficacious. • Stages of Change in PG Treatment efficacious (Petry, 2005). • Hodgins, Currie, el-Gubelay & Peden, (2004) Motivational Enhancement successful in treating PG’s at 24 mth follow-up. • Hodgins & el- Guebaly (2004) found the major reason for relapse was ‘optimism about winning’, ‘feeling lucky’ & ‘believing that winning were possible”.

28. The Prevalence of Pathological Gambling • Shaffer, 2004 states: “Measuring the distribution of a phenomenon (e.g. population pathological gambling) across segments involves identifying prevalence (that is, the proportion of people with the disorder at a specific time) and ‘incidence’ (that is, the proportion of people who acquire the disorder during a specific period)” What we don’t do???

29. The DSM IV (1994) criteria for pathological gambling is: A. Persistent and recurrent maladaptive gambling behaviour as indicated by five (or more) of the following: • is preoccupied by gambling (e.g. preoccupied by reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble). 2) needs to gamble with increasing amounts of money in order to achieve the desired excitement. 3) has repeated unsuccessful efforts to control, cut back, or stop gambling. 4) is restless or irritable when attempting to stop. 5) gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, depression). 6) after losing money gambling, often returns another day to get even (“chasing” one’s losses). 7) lies to family members, therapist, or others to conceal the extent of involvement with gambling. 8) has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling. Replace “GAMBLING” with: FASHION; EATING; SEX; EXCERCICE; WORK; MAKING MONEY, CARS/MOTOR BIKES; HOBBIES; EXTREME SPORTS

30. Motivational Interviewing:More recent evidence to support it’s use. • Evidence-based, Practice informed! • Can acknowledge the short-term benefits of gambling to gain greater insight • Commitment talk (more recent findings) • Client-focused, also can fit into various models • Emphasis on the role of choice/agency • Decisions “empower” the client • The ‘Therapuetic Alliance’ is strengthened

31. Conclusions • Multiple site trials show diffs with dif measures • Use of available simple measures to review client progress (i.e. One Question Screen by Thomas, 2008 has reliability/validity = others) • Lack of evidence for ‘Disease Concept’! • Strong evidence base for client-focused; outcome-informed approach instead of double blind placebos. • Strong evidence base for natural recovery and movement in and out of problems (Wiebe et al, 2003; Slutske et al., 2003; Delffabro, 2008; and many others).

32. Acknowledgements • I would like to acknowledge & thank Dr Christopher Wurm, Senior Consultant – Drug & Alcohol Resource Unit, Royal Adelaide Hospital; • Senior Medical Practitioner – Port Adelaide Community Treatment Centre • Visiting Fellow, University of Adelaide. (Author of “Is Addiction a Useful Concept: an existential view”; Psychotherapy in Australia, Vol 7, No 2, pp 20-25, February 2001.) • Stanton Peele’s paper “Addiction as a cultural concept” 1998 (see www.stantonpeele.com) • Thomas Szasz (1991). Diagnoses are not diseases. (Lancet, 338, 1574-1576.) • Michael Walker (1989). Some problems with the concept of “gambling addiction”: should theories of addiction be generalised to include excessive gambling? (The Journal of Gambling Behaviour, 5, (3). 179-200.) • Especially, I would like to acknowledge my participants for their views and candidness (The Case study names and some of their details have been changed to protect their identity).

33. Acknowledgements • A Special Thank You to my Clients • Structured Interview from Prof Blaszczynski. • Kind assistance from Sue Hutchinson-Phillips

34. Questions and Discussion For any further info or references please contact cynthia.dunn@jcu.edu.au

35. Appendix • THE G-MAP HANDOUT