Integrating Treatment for Gambling and Co-Occurring Disorders

1. Integrating Treatment for Gambling and Co-Occurring Disorders Loreen Rugle, PhD, ICGC-II, BACC Maryland Center of Excellence on Problem Gambling Lrugle@som.umaryland.edu

2. Problem Gambling as a Co-Occurring Issue: So Why Bother? Evidence regarding the risk for gambling problems among individuals diagnoses with substance use and mental health disorders and the cost in particular for not addressing gambling issues in these individuals

3. Substance Use Disorders Mental Health Disorders Gambling Disorders Primary Care Funded by DHMH/BHA

4. Individuals with substance use and mental health disorders are at higher risk for having a gambling problem Gambling (even at moderate levels) may have an adverse impact on treatment outcome Unaddressed gambling and gambling problems are likely to add to treatment costs and service utilization Why address gambling problems in SUD and MH programs: Summary

5. Gambling may become a sequential addiction for individuals recovering from a substance use disorder Gambling can be a relapse risk factor Gambling and problem gambling may exacerbate psychiatric symptoms Relationship violence and child abuse are related to problem gambling and severely aggravated if substance use is involved. Why address gambling problems in SUD and MH programs: Summary

6. Co-Morbidity • Per DSM5, those with gambling disorder have high rates of SUD’s, depressive disorders, anxiety disorders and personality disorders. • Up to nearly 1/3 to 1/2 of individuals in SUD treatment identified as problem gamblers (Himelhoch et al, 2015; Ledgerwood et al, 2002) • The more severe the past year SUD, the higher the prevalence of gambling problems (Rush et al, 2008) • Individuals with lifetime history of mental health disorder had 2-3 times rate of problem gambling (Rush et al, 2008)

7. DSM-5 GAMBLING DISORDER 46.2% met DSM-5 criteria for Gambling Disorder

8. DSM-5 GAMBLING DISORDER 75.2% identified as Moderate or Severe Gambler

9. Most common types of gambling • Lottery Tickets (81.1%) • Scratch Offs (71.8%) • Games of Skill (40.5%) • Casino (9.2%)

10. Lottery Ticket Example:

11. Few people discussed gambling with their health provider (6.5%) • Those with a DSM-5 Gambling Disorder were significantly more likely to discuss gambling with health provider compared to those without (12% vs. 2%, p<0.05)

13. Impact of Co-Occurring DisordersHodgins & el-Guebaly (2010) • 5 Year Follow-up of 101 subjects with GD who recently quit • Complex combination of factors related to positive treatment outcome including problem gambling severity, treatment involvement, substance use and mood disorder

14. Impact of Co-Occurring DisordersHodgins & el-Guebaly (2010) • Only 2 of the initial 101 subjects maintained abstinence during the follow-up • 68% had at least 3 mos. abstinence • 47% - 6 mos. abstinence • 21% - 1 yr. abstinence • Mean SOGS scores decreased from 11.6 to 6.9 • 70% continued to score above 5 on SOGS • 43% above 5 on NODS

15. Impact of Co-Occurring DisordersHodgins & el-Guebaly (2010) • Co-morbid MH and SUD predictive of short term but not long term outcomes. • Those with Drug Use Disorder less likely to achieve short term abstinence (3 mo and trend for 6 mo) • Those with mood disorder slower to achieve period of abstinence • Involvement in treatment and AUD predictive or relapse • Treatment involvement predictive of 12 mo abstinence

17. Why Bother? Impact on Treatment and Recovery of Serious Mental Illness 19% of individuals in treatment with diagnosis of schizophrenia or schizoaffective disorder met criteria for problem or pathological gambling PG associated with depression, alcohol use problems, greater legal problems and higher utilization of MH treatment (this associated with recreational gambling as well) (Desai & Potenza, 2009) 17

18. THE INITIAL ISSUES MOST OFTEN ARE ABOUT THE EMOTIONAL IMPACT OF THE GAMBLING MONEY IS OFTEN CONTROLED BY SOMEONE IN THE PERSON’S LIFE, EITHER A MENTAL HEALTH AGENCY OR FAMILY MEMBER, SO FINANCIAL DAMAGE MAY BE MINIMAL. THE DREAM OF THE “BIG WIN” AND GAMBLING AS UNDOING THEIR MENTAL ILLNESSNEEDS TO BE TALKED ABOUT IN THERAPY AND ADDRESSED. THE SADNESS AND SENSE OF LOSS OF DEALING WITH A CHRONIC ILLNESS MUST BE ADDRESSED. GAMBLING DISORDE AND CHRONIC MENTAL ILLNESS

19. HOWEVER, THIS DOES NOT MEAN THAT MONEY DOES NOT MATTER. IN FACT, MONEY ISSUES CAN SPARK THE ILLNESS TO RECUR, AS OFTEN CLIENTS FEEL “CHEATED” BY HAVING THEIR MONEY MANAGED BY ANOTHER AND THIS ANGER CAN TURN TO OTHER SYMPTOMS. 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. COORDINATION WITH OTHER AGENCIES AND/OR PROVIDERS ESSENTAIL SO THAT ALL ARE WORKING ON SIMILAR GOALS.

20. SELF-ESTEEM: HOW TO FEEL RESPECTFUL OF YOURSELF IN A SOCIETY WHERE MENTAL ILLNESS IS STILL STIGMATIZED AND POVERTY IS SEEN AS A PERSONAL WEAKNESS. SADNESS: HOW TO HELP THE CLIENT ACCEPT THE ILLNESS, COPE WITH THE EFFECTS OF IT ON HER/HIS LIFE, AND GO ON WITHOUT LOSING HER/HIMSELF IN GAMBLING. FAMILY: HOW TO HELP CLIENT AND FAMILY DEAL WITH THE ILLNESS, THE MONEY ISSUES, THE PAIN, AND THE HOPE OF RESOLUTION. REMEMBERING THE MOST IMPORTANT ISSUES

21. Motivational Recycling Substance Use Disorder Mental Health Disorder Problem Gambling 21

22. Intimate Partner Violence (IPV) and Problem 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 PPG • Severe Marital Violence: 40X rate of PPG • Severe Child Abuse: 2.5X rate of PPG

23. 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

24. PG Screening Bad News Screens don’t work well in clinical practice Give illusion of addressing issue 24

25. Perspective Change: Disordered Gambling Integration (DiGIn) • Addressing gambling and gambling problems for individuals presenting with a primary concern of a substance use or mental health disorder is not just about making a diagnosis or finding cases of gambling disorder. • Rather this approach involves assuring that the impact of gambling on mental health and substance use recovery is an ongoing topic of conversation in treatment, recovery and prevention settings.

26. Typical Results of Use of Brief Screens What happens in actual clinical practice Use screen No one endorses items What does counselor think None of my clients have any gambling problems Don’t care about the research, my clients are different NIMBY (Not in my back yard or treatment program)

27. Another issue is the way questions are addressed by counselors. Many factors including counselor workload, length of intake assessments, counselor priorities and counselor comfort with problem gambling all may contribute to minimizing importance of gambling questions.

28. You’ve never lied About gambling or Wanted to spend more Money on it, have you? Phew! Nobody Cares about gambling here! I can save time on these Gambling questions… That’s not why she is here anyway No, that’s not a problem 28

29. Motivation Individuals coming into treatment for a substance use or mental health disorder may have any or all of the following attitudes toward their gambling: Never thought of it as a problem or potential problem Believe it is a solution to their problems (emotional and or financial) Realize it may be a problem, but don’t want to think about giving up “all their fun.” Feel overwhelmed by dealing with just one problem, don’t want to have to think about any others.

30. No Wrong Door Substance Abuse Treatment Center Mental Health Center Gambling Problems Gambling Screen Gambling Screen Screen Positive Screen Positive Gambling Specific Assessment Pos or Neg Pos or Neg Gambling Integrated Assessment Gambling Integrated Assessment Pos or Neg Pos or Neg Pos or Neg Pos or Neg PG Enhanced Treatment PG Enhanced Treatment Gambling Specific Treatment 30

31. Commitment to agency From – • Brief training to screen and refer • No ongoing involvement • No funding To – • Funding support (sustained) • Ongoing training and collaboration • Individualized TA

32. The Gambling Treatment Program Capability Index .The GTPCI evaluates 20 program elements that are subdivided into 6 dimensions.The GTPCI establishes benchmarks for providing treatment services to people with gambling disorders. The indexes ask questions about six dimensions. Benchmarks Criteria & Metrics Marotta and Coe, 2018

33. Integrated Assessment Incorporating into existing assessments How might you ask questions related to gambling in each of these sections of your intake or assessment? Medical Financial Family History Substance Use Psychiatric Recreation

34. Integrated Assessment • Hopefully the previous sections helped you see how gambling may be incorporated in each section of your typical intake or assessment. • The key to this approach is to raise the issue of gambling and its role in your client’s recovery in multiple contexts and repeatedly over time. • Also it is key to include the topic of gambling in a non-judgmental or labeling manner, in order to minimize defensiveness or resistance.

35. Goals of screening and assessment: • Open the conversation • Increase curiosity • Begin to move from pre-pre contemplation • Give permission to talk about gambling • Begin to make connections between gambling and other major life areas

37. Providing Feedback and Enhancing MotivationProvide affirmation Counselor I can see from your response during your assessment that you were being really honest and open. That shows how motivated you are to work on your recovery. Some of your responses about gambling suggest that gambling may have a negative effect on your recovery and I’d like to give you some feedback and information that we can talk about. How does that sound to you?

38. Providing Feedback and Enhancing Motivation Client –OK I guess. I never really thought much about my gambling. My drinking has always been the problem that seems to get me into trouble. Counselor – That’s great. I appreciate your willingness to talk about an area that you haven’t thought about before and look at how it might effect your recovery.

39. Feedback Open – ended questions Counselor – Tell me about your gambling and how you think it fits in your life and your recovery. Client – Well – I like playing cards with my buddies. We’ve been getting together once a week for years. We do drink at the games. Hadn’t thought about that. Do you think that’s a real problem?

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

41. Cost – Benefit Analysis Benefits Fun Relaxation Camaraderie Win money Costs Drink at games Wife sometimes upset at time away and coming home drunk Borrow money

42. Pre-contemplation to Contemplation • Counselor: You did a great job of looking clearly at the things you enjoy about gambling and that you see as benefits as well as some of the downside or costs of gambling. What do you make of that? • Client: Yeah, I think I see what you are getting at. Gambling is fun, but it always seems to lead to drinking. I know how drinking is messing me up, but I never thought about the gambling.

43. Addressing Ambivalence Counselor: I think it is really good that you are able to see both sides of what gambling is about for you. You do have fun gambling, but you can see that it also interferes with your goal of not drinking. Client: Yeah, I just always thought it was something fun to do. I didn’t really look at the connection to my drinking.

44. Personally Normative Feedback • The average Canadian loses just under $600 per year, or about $50 per month, through all forms of gambling • Percentage of gross family income (total monthly pre-tax income divided by amount you gamble in a month • The average American loses just under $400 per year, or about $30 per month, through all forms of gambling • People who gamble more than 5% of their gross family income per month are 3 times more likely than those who gamble less than 1% to experience serious problems from their gambling • 27.1% of people who report spending more than 5% of their gross family income per month on gambling report serious negative consequences from their gambling

45. List 5 important goals in your life (things you would like to have in your life or accomplish) for the next 2-5 years. Goal One: Goal Two: Goal Three: Goal Four: Goal Five: 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 that goal. Ways Gambling will Help Ways Gambling might Interfere 1. 2. 3. 4. 5. Recovery/Life Goals

46. Motivation On Scale of 1 -10 how important On Scale of 1-10 how confident On Scale of 1-10 how willing 46

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

48. I will spend no more than __% of my budget which is $____ per month. I will gambling no more than ____ times/wk/mo/yr. I will spend no more than ____ hours per time I gamble. I will only gamble at the following activities: I will only gamble in the following situations: I will be sure to be accountable to the following people about my gambling: I will safeguard my money from excessive gambling in the following ways: My Plan for Gambling in Recovery

49. 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 of and monitor. Some Common Warning Signs of Gambling Problems Any increase in gambling behaviors Noticing an increase in cravings for other addictive behaviors in connection with gambling Using gambling as an alternative to other additive behaviors Gambling to relieve boredom, anxiety or depression Feeling the same kind of rush or high when gambling as when using substances What are any other signs that you might notice to indicate that gambling might be becoming a problem for you or putting your recovery at risk? Identify Your Warning Signs

50. What is your plan if you notice any warning signs of problem gambling? Talk to sponsor Talk with counselor Stop gambling Attend GA meeting Develop plan to protect my money Other _________________ Making a Plan