1. Strategies For Addressing Behavioral and Financial Issues Related to Problem Gambling in Treatment Gina Hutto, LPC, MAC, CCJP, NCGC-I Esther Maddux, CFP, GCACII, KCGC-I

2. Introductions Name Work Location Position Any Experience Working with Gambling Clients

3. Goals/Objectives Learn How to Screen for Gambling Disorder Identify Treatment Strategies for Working with Problem Gamblers Learn How to Address Financial Issues Related to Problem Gambling

4. What is Gambling? Gambling is the wagering of money or something of material value (referred to as “the stakes”) on an event with an uncertain outcome with the primary intent of winning additional money and/or material goods.

5. 3 Elements Must Be Present Consideration Chance Prize

6. Outcome of Wager Is usually immediate- roll of the dice Longer time frames are also common- betting on a sports event

7. Card Sort Exercise 10 Cards Get in Groups and Work Together Place in Order from 1-10, with #1 having the highest potential to develop a gambling problem Report Out

8. Living 40 Miles From a Casino The rate of Pathological Gambling Doubles if a person lives within a 50 mile radius of a casino

9. Playing Bingo 2-3 Times a Week Indicates ProgressionWhat You Might Ask? How much do you spend each time you play Do you go with others or alone How long have you been playing What else do you do for fun Have you ever depended on winning to pay bills

10. A Middle-Aged Mom Who Plans Saturday Getaways to Play Her Favorite Slot Machine Women tend to begin gambling later in life compared to men, but, develop problems with gambling faster Over 25% of women Problem Gamblers have dependent at home Don’t need a “big win” to get hooked

11. Purchase a Lottery Ticket Every Time You Pump Gas Households with an average income of $100,000/year spend an average of $300/year College graduates spend under $200/year White people spend an average of $210/year Households with an average income of $25,000/year spend an average of $600/year People who never graduated from college spend $700/year African-Americans spend an average of $998/year Seen as Solution

12. Placing a $500 Bet On The Kentucky Derby Every Year How many years have you placed these bets Have you ever won anything Do you bet solely on the Kentucky Derby Have you ever engaged in Off Track Betting (OTB)

13. Having A Parent Who Has A Gambling Problem Family History plays a role Problem Gamblers report growing up in a family with: Alcohol Abuse-38% Gambling Problem-30% Drug Abuse-26% Abusive Behavior -25%

14. Teenagers Getting Together Once A Month For Poker Night Is it Legal? Youth Most Vulnerable to Developing Gambling Problems: Have problems with impulsivity/hyperactivity Have been diagnosed with ADHD Have a need for excitement, are truant, or are early used of alcohol/drugs Have emotional vulnerabilities such low self- esteem, depression, feelings of loneliness

15. A 10 Year-Old Winning $50 On The First Scratch Ticket Ever Given To Him Age of Onset? “The earlier people begin gambling, the more likely they are to experience problems from gambling”, National Academy of Sciences, 2001 33% of students classified as possible “problem or pathological gamblers” reported starting gambling at age 8 of younger, CT Youth Gambling Report 2008

16. Playing Nightly, Online On A Free Gambling Website Often not free- 99 cents to keep playing Are you losing sleep Are you spending time with others If win- can often lead to casino with real money

17. Placing One $25 Bet On The NFL Each Week Adopted in 1992, the Professional & Amateur Sports Protection Act (PASPA) bans betting on sports events except in those states where betting was legal at the time the law was approved, or in any state that legalized sports betting within a year of that date. 4 States Qualify for Exemption- Nevada, Oregon, Delaware & Montana. Nevada is only state where betting on sports is taking place, but other states have taken steps to legalize sports betting, American Gaming Association, 2012

18. Personality Types of Gamblers ACTION Tend to be men Like games of “skill”- poker, dice, horse/dog racing, sports betting Believe they can beat other individuals or the “house” Tend to be confident, assertive and have large egos ESCAPE Tend to be women Like games such as bingo, slot machines, video poker Gamble to get relief/self- medicate from emotional or psychological pain Usually not outgoing or narcissistic- caring and responsible for most of their lives

19. DSM-5 Gambling Disorder Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting 4 (or more) of the following in a 12 month period.

20. Gambling Disorder- At Least 4 Of The Following Needs to gamble with increasing amounts of money in order to achieve the desired excitement Is restless or irritable when attempting to cut down or stop gambling Has made repeated unsuccessful efforts to control, cut back, or stop gambling Is often preoccupied gambling (e.g. Having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)

21. Gambling Disorder- At Least 4 Of The Following Often gambles when feeling distressed (e.g. helpless, guilty, anxious, depressed) After losing money gambling, often returns another day to get even (“chasing” one’s losses) Lies to conceal the extent of the involvement with gambling Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling Relies on others to provide money to relieve desperate financial situations caused by gambling

22. DSM-5 Gambling Disorder Continued The gambling behavior is not better explained by a manic episode. Specify if: Episodic or Persistent Specify if: In Early Remission or In Sustained Remission Specify Current Severity: Mild: 4-5 Criteria Met Moderate: 6-7 Criteria Met Severe: 8-9 Criteria Met

23. Differences Between DSM-IV and DSM 5 DSM-IV Pathological Gambling Under Impulse Control Disorders Not Elsewhere Classified DSM 5 Gambling Disorder Under Substance-Related and Addictive Disorders Criterion “has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling” eliminated

24. Lie/Bet Questionnaire 2 Question Screening Tool Useful in determining if a longer screening or further assessment is needed If “Yes” to one or both items- further assessment is needed Have you ever had to lie to people important to you about how much you have gambled? Have you ever felt the need to bet more and more money?

25. Screening Tools South Oaks Gambling Screen (SOGS) Gamblers Anonymous (GA) 20 Questions

26. Entering Treatment Who is the Client? Person with problem or significant other Is treatment mandated by someone such as court, family members or is it voluntary Source of funds for payment: State funds, Insurance, Self-Pay

27. Presenting Issues At Treatment Is Gambling Primary or Secondary? Role of Gambling in client’s life: Social/Recreational Source of Income

28. ASAM Press Release August 15, 2011 ASAM is not just for alcohol and drugs, but for other addictions such as gambling, sex, etc.

29. ASAM Levels of Care Outpatient Level 1 is most common 11 states have Intensive Outpatient Level 2.1 programs 9 states have Residential Level 3 programs

30. Is Treating Gambling Different From Substance Abuse? 80% Similar 20% Different But the 20% is very significant…

31. Similarities Between Substance Abuse and Gambling Loss of Control Preoccupation Tolerance Withdrawal Depression Anxiety Triggers Need for Immediate Gratification Cravings Heredity 12 Step Family Involvement Chasing Progressive Responds to Treatment Can have multiple addictions

32. Differences Between Substance Abuse and Gambling The only addiction with the potential to make life better Cannot overdose Much higher suicide rate- 17-21% Greater financial issues Slower progression to addiction- 12-18 months for slots, 3-5 months for table games Magical thinking and superstition

33. More Differences Between Substance Abuse and Gambling No physical intoxication to explain bad behavior Hidden addiction- can’t test for it Feelings of guilt/shame/hopelessness more intense Stronger defenses and denial Direct impact on family- financial issues Fewer self-help & treatment options

34. Future Issues- Internet Gaming Disorder In DSM-5 Section III as a condition warranting more clinical research and experience New science- gamers place compulsively to the exclusion of other things in their lives resulting in impairment or distress. Also experience symptoms of withdrawal. Pathways in the brain are triggered in same way a drug addict’s brain is affected by a substance- same pleasure and reward.

35. Issues With Internet Gaming Freemium Model- Free to play, but have to pay to upgrade Only a few monetize, but enough to make lots of money One player $13,000 over 3 months on free to play games Not regulated- take away prize, chance or consideration Very aggressive- will contact you if haven’t played

36. Issues With Internet Gaming I am who I say I am- Age and other things often verified through Facebook Virtual games are often easier to win- give a false sense of security- odds are better, but bad odds when playing for real

37. The State Of Our State- Gambling In Georgia In 2012, Georgia ranked 12th out of 50 states and the D.C. in combined lottery sales, commercial casino gaming revenues, and Indian gaming revenues with $3.83 billion reported. In 2012, legalized gambling in Georgia included a traditional state lottery and charitable gaming.

38. Georgia On My Mind The 11 states that rank above Georgia and the 14 states that are immediately below Georgia in the rankings, all have Casino and/or Tribal Gaming Revenue. Georgia is the only state in the top 36 that only has the lottery.

39. Prevalence of Gambling Problems in Georgia An estimated 1.7% of Georgia adults (125,805 citizens) are believed to manifest a gambling disorder

40. Funding For Problem Gambling In Georgia In 2013, the State of Georgia enacted HB08-487, which created the opportunity for greater funding for problem gambling. In 2013, Georgia ranked 26th out of the 50 U.S. states in terms of per capita public funds plus unduplicated NCPG affiliate funds invested in problem gambling services. The average per capita allocation of public funds for problem gambling services in the 39 states with publicly funded services was 32 cents; Georgia’s per capita public investment was 2 cents.

41. Current Resources GA Meetings- 15 in Georgia- mostly Metro Georgia Gambling Helpline- 1-800-699-7717- run by HODAC, Inc. Website www.gagamblinghelpline.orgwww.gagamblinghelpline.org Directory of Pathological and Problem Gambling Treatment Providers and Gambler’s Anonymous/Gam-Anon meetings in Georgia by region- GA State 2010

42. Additional Resources National Council on Problem Gambling (NCPG)- list of certified counselors Georgia Council on Problem Gambling (new)

43. Contact Information Gina Hutto Director, Accountability Courts View Point Health (404) 557-1110 Gina.hutto@vphealth.org