1. Problem Gambling: The Hidden Addiction (Part 2) Victor Ortiz, MSW, LADC I, CADC II Presentation for: Residential Substance Abuse Treatment (RSAT) January 21, 2015

2. Acknowledgement o Harvard Medical School Division on Addiction o National Center for Responsible Gaming o Dr. Eunice Aviles

3. Learning Objectives Participants will be able to identify three effects of disordered gambling on mental health functioning Participants will be able to identify two theories of gambling addiction Participants will be able to identify two complementary services to gambling addiction treatment Participants will be able to identify two self help guide resources. Participants will be able to identify three common triggers experienced by problem gamblers in recovery

4. 4 Problem Gambling: The Hidden Addiction Part I Main Points The association of gambling disorders and psychiatric disorders Changes in the DSM-5 – Substance-Related Disorders Addiction Syndrome Model

5. Evidence Based Practice

6. 6 o Applying the best available research results (evidence) when making decisions about health care. Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences.

7. 7 Evidence Based Practice EVP + clinical expertise + patience values = positive outcomes

8. The Field of Gambling Disorders o It was not until 1972 that Dr. Robert Cluster, a physician working at the Veterans' Administration hospital in Brecksville, Ohio, first proposed a clinical entity, which he termed compulsive gambling. o In 1980, the American Psychiatric Association incorporated "pathological gambling" into its diagnostic and statistical manual (American Psychiatric Association, 1980) and thus legitimated this entity within the mainstream mental health field.

9. The Field of Gambling Disorders o The development of clinical strategies for the effective treatment of disordered gambling is in its very early stages (Korn, Shaffer, 2004) o The technological growth has added an additional dimensions to gambling.

10. The Gambling Environment is Evolving o Gambling has become more convenient and accessible. o Gambling is coming out of gambling environments and is converging with other technologies. o Gambling is becoming more anonymous and "asocial”. o Gambling is perceived as an ever more important source of public revenues. Sources include: Griffiths, M. (2012) Technological trends, behavioral tracking, and implications for social responsibility tools in gambling. [PowerPoint presentation] Retrieved from http://www.responsiblegambling.org/docs/discovery-2012/technology-trends-behavioural-tracking-and- implications-for-social-responsibility-tools-in-gambling.pdf?sfvrsn=8

11. 11 Problem Gambling: A Public Health Perspective

12. Non Gambling Range of Behaviors Framework for Public Health Action Range of Interventions Primary preventionSecondary preventionTertiary prevention Health Promotion Harm Reduction intensiveTreatmentbrief Range of Gambling Problems none mild moderate severe Healthy Gambling Unhealthy

13. Public Health Approach to Gambling Problem o For example, the classic public health model for communicable disease that examines the interaction among host, agent, environment and vector can be instructive for gambling. o A public health viewpoint also can lead to the design of more comprehensive and effective strategies for preventing and treating gambling related problems.

14. Clinical Practice

15. 15 The Case of Rita o 48 years old woman o First started gambling when she was 30 o Gambling intensified after her first divorce o Was previously diagnosed with a mood and anxiety disorder o 6 months free from a bet o Married with two children o Occasionally drinks, but has never used drugs

16. Rita Gambling of Choice o Casino Gambling o Scratch tickets Treatment/Services o Mental Health Counseling o Gambler Anonymous

17. 17

18. 18 Jose

19. 19 The Case of Jose o 40 years old o First started using drugs at 12 years old o Drug of choice is heroin o Was previously diagnosed with a mood and anxiety disorder o 9 months of sobriety o Married with two children o Currently resides in a Substance Abuse residential program

20. Jose Substance of Choice o Heroin Treatment/Services o Substance Abuse Counseling o 12 Step Programs

21. 21 Rita & Jose Missed Opportunities o Connecting mental health disorders, SUD, and/or symptoms to gambling behaviors o Education and awareness within clinical practice o Strengthen referrals and support services o Incorporating evidence within policy and practice

22. 22 A Clinical Perspective o People with gambling disorders are hesitant to enter treatment. o None of the participants in the National Comorbidity Survey Replication (Kessler & Merikangas 2004) with a PG diagnosis ever received treatment for a gambling problem; however, 49% were treated for other mental disorders (Kessler et al. 2008).These studies indicate that about half of the PGs received treatment for other psychiatric disorders. However, neither they nor their treatment providers recognized that their disordered gambling required treatment

23. Ranked Treatment Interventions Strong Evidence · Cognitive Behavioral Therapy · Behavioral Therapy Moderate Evidence · Relapse Prevention Weak Evidence · Psychodynamic Psychotherapy · Self Exclusion · Gamblers Anonymous

24. Cognitive Behavioral Therapy Research has demonstrated that cognitive factors are an important part of the development and maintenance of problem gambling (Lupu, 2008). Many pathological gamblers remember important winnings during their first gambling experiences. An individual absorbed by gambling loses sight of the hazardous dimension and concentrates on the possibility of controlling and influencing the game to his/her favor (Lupu, 2008).

25. Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT) has proven to be an effective way of treating problem gamblers (Fortune & Goodie, 2012). Positive outcomes of CBT can be seen as much as two years after termination of treatment (Gooding & Tarrier, 2009 in Fortune & Goodie, 2012).

26. Cognitive Behavioral Therapy Experts have agreed that cognitive distortions play a key role in triggering and maintaining gambling behaviors despite negative outcomes. (Jacobsen, Knudsen, Krogh, Pallesen, & Molde, 2007 in Fortune & goodie, 2012). The purpose of CBT with pathological gamblers is to “identify negative thoughts, cognitive distortions and erroneous perceptions about gambling that are responsible for continued gambling” (Tavares, Zilberman, el-Guebaly, 2003 in Fong, 2005). In doing so the aim is to correct cognitive distortions about gambling to achieve complete abstinence (Fong, 2005).

27. Principles of Drug Abuse Treatment for Criminal Justice Population 7. Treatment should target factors that are associated with criminal behavior o “Criminal thinking” is a combination of attitudes and beliefs that support a criminal lifestyle and criminal behavior, such as feeling entitled to have things one’s own way, feeling that one’s criminal behavior is justified, failing to accept responsibility for one’s actions, and consistently failing to anticipate or appreciate the consequences of one’s behavior. o This pattern of thinking often contributes to drug use and criminal behavior. Treatment that provides specific cognitive skills training to help individuals recognize errors in judgment that lead to drug abuse and criminal behavior may improve outcomes.

28. 28

29. 29 Screening Tools

30. 30 Screening Tools  SOGS-South Oak Gambling Screen  MAGS-  Lie/Bet Screening Tool  BBGS- Brief Biosocial Gambling Screen

32. Screening Tools -LIE/BET Have you ever felt the need to bet more and more money? Have you ever had to lie to people important to you about how much you gamble?

33. 33 Resources

34. Gambling Problems: An Introduction for Behavioral Health Services Providers www.samha.gov

36. 36 First Step to Change: Gambling o Many people are able to change their excessive behavior patterns without entering formal treatment. The Division on Addiction, Cambridge Health Alliance, an affiliate of Harvard Medical School has created a series of self-change toolkits. These toolkits are designed to do three things: www.basisonline.org/selfhelp_tools o They will help people gain information about addiction-related problems. o They will help people evaluate their own addiction-related behavior. o They will help people develop change strategies, should they decide that change is the best course.

37. 37 First Step to Change: Gambling o Section 1: Facts About Gambling will explain how gambling works and how it can become a problem for some people. o Section 2: Understanding Your Gambling, will help you think about how you gamble and your reasons for gambling. o Section 3: Thinking About Change, will lead you through the process of change.

38. 38 National Council on Problem Gambling www.ncpg.org Massachusetts Council on Compulsive Gambling www.masscompulsivegambling.org Harvard School Division on Addiction www.divisiononaddiction.org National Center for Responsible Gaming www.ncrg.org

39. 39 Massachusetts Council on Compulsive Gambling Victor Ortiz, MSW, LADC I, CADC II Sr. Director of Programs and Services victor@masscompulsivegambling.org Twitter- @Victor_Ortiz21 617-426-4554

40. Work Cited Petry, NM, et al. (2005) Comorbidity of DSM-IV pathological gambling and other psychiatric disorders: Results from the national epidemiologic survey on alcohol and related conditions. Journal of clinical Psychiatry. 66:564-574 Grant, J.E. J.D. Potenza, M. MD, Weinstein, A. PhD., Gorelick, D. MD, PhD. (2010) The American Journal of Drug and Alcohol Use, Early Online 1-9. DOI: 10.3109/00952990.2010.491884 Petry, NM, et al. (2013). An Overview of and Rationale for Changes Proposed for Pathological Gambling in DSM-5. J Gambl Studies. Howard J. Shaffer, PhD, CAS, Debi A. LaPlante, PhD, Richard A. LaBrie, EdD, Rachel C. Kidman, BA, Anthony N. Donato, MPP, and Michael V. Stanton, BA; Toward a Syndrome Model of Addiction: Multiple Expressions, Common Etiology, Harv Rev Psychiatry 2004;12:367–374. 2004 Shaffer HJ, Martin R. Disordered gambling: etiology, trajectory, and clinical considerations. Annu Rev Clin Psychol. 2011; 7: 483-510. Shaffer HJ. On the nature and meaning of addiction. Natl Forum 1999;79(4):10–4.67

41. Work Cited Shaffer HJ. The most important unresolved issue in the addictions: conceptual chaos. Subst Use Misuse 1997;32:1573–80. Shaffer HJ. Rethinking addiction: how gambling and other behavioral addictions are changing the concept and treatment of alcohol and substance use disorders. Acad News 2003(2):1,3,7. American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013 Grant JE, Potenza MN. Commentary: illegal behavior and pathological gambling. J Am Acad Psychiatry Law. 2007;35(3):302–305.

42. Next Presentation The Neurobiology of Addiction & Effective Treatment February 18, 2015 2:00 – 3:00 p.m. ET This webinar will provide an overview of the scientific basis for viewing drug addiction as a disease that affects the brain and behavior. Evidence-based interventions and principles for addressing substance use disorders, including psychosocial treatments and medications will be discussed. Presenter: Redonna K. Chandler, Ph.D.