Transcript Self-Exclusion from Gambling Venues

+
Evidence-Based Psychosocial
Treatment Approaches for
Disordered Gambling
Jon E. Grant, JD, MD, MPH
Professor
University of Chicago
Pritzker School of Medicine
Source: Look Magazine; March, 1963
Public Health Significance
 Problem and Pathological Gambling Are
Associated with High Rates of:
- Divorce
-
Poor General Health
-
Mental Health Problems
- Job Loss and Lost Wages
- Bankruptcy, Arrest and Incarceration
+
+
Intake and Gambling History
Intake First Steps
 Source of referral: From Where?
 What is the gambler’s presenting issue as it relates to
gambling?
 What is the real motivator?
Why now?
 Focus on how / what / when / why of getting into




treatment
Focus on past year
What medical problems? Medications?
Current family / living / employment situation
Financial / legal problems
Gambling History: First Signs
 Examine the first recognized sign of problem from
gambling; Big win?
 Explore reasons for continued gambling after that
 Listen for an early win or some positive
reinforcement from gambling
 How have losses affected them?
Early Wins
 First big win
 When did it occur
 How much
 Emotional impact
 Cognitive impact
Losses
 When did they start to happen?
 What was the main reason this happened?
 What was the reason it did not stop?

Change in strategy / bankroll or a matter of time?
 How were they dealt with initially?
Functional Impact: Now
 Focus on impact, not frequency
 Legal
 Financial
 Social
- Family Functioning
- Productivity
- Mental health
 Physical
 Occupation
 Education
 Interpersonal/Social
 Self-maintenance
Support System
Current Gambling Patterns
 Where
 When
 How much
 With whom
 Why
 Types
 Bankroll / source of money
How Does The Gambler
View Gambling?
 Not a problem (denial)
 Is a problem (ambivalence)
 Used to be a problem (minimizing)
 Not sure (denial, again)
What is the Gambler Looking
For?
Be aware of what the gambler is looking for:
The action gambler may be looking for the “fix”
The escape gambler is often looking for “hope”
BOTH may be trying to appease someone
important
Review Attempted Solutions
 Financial Fixes (Bailouts)
 Medical Fixes (Medications)
 Therapy Fixes (Mental Health, Family, Couples
Therapy)
 GA (Peer Support)
 Will power (Just Quit)
Social and Family History
 Current family / living environment/ academic /
employment status:
 Family History

Based on Genogram, Time Line; with emphasis on
history as related to present problems
 Recovery environment;
 Strength and recovery assets;
Family History
 Alcohol Abuse
 Substance Abuse
 Child Abuse/Neglect
 Sexual Abuse
 Domestic Abuse
 Suicide Attempt
 Significant Health Issues
Educational and
Vocational
History
 Last grade Completed
 Number of Jobs in the Last 5 Years
 Length of time on Current Job
 Current Occupation
 Career goals
 Barriers to achieving those goals
Past Psychiatric History
 Hospitalizations
 Medication Trials
 Number of therapists
 Treatments that worked or did not work
 Diagnoses as they understand it
Special Concerns
 Suicide Ideation
 Suicide Attempt
 Threat of Violence to Others
 Significant Loss/Grief
 Traumatic Event
 Other
Commonalities of Suicide For
Pathological Gamblers
 To
seek a solution (Quick fix)
 Goal is to seek cessation of consciousness
(Escape)
 Stressor in suicide is unendurable psychological
pain (Critical Self Talk)
 Emotions in suicide is hopelessness &
helplessness
+
Comorbidity
Social/Personal Consequences
 Family dysfunction and domestic violence
- spousal and child abuse
 Alcohol and other drug problems
 Psychiatric conditions
- major depression and anxiety disorders
 Suicidal thoughts and attempts
 Significant financial problems
- bankruptcy, unemployment, poverty)
 Criminal behavior
- theft, prostitution, homicide, fraud, embezzlement)
Co-Occurring Disorders in PG
70
60
50
40
30
20
10
0
SUDs
Affective
Anxiety
ICDs
Other Health Issues
Health concerns of pathological gamblers:






Heart disease
Liver disease
Hypertension
More likely to have had an injury
More likely to have needed ER visit
28% of homeless people had gambling
problem
Motivational Interviewing
Definition
 A directive, client-centered method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence (Miller & Rollnick, 2002)
 Style vs. therapy
 Client centered – listening and reflecting
 Focused on ambivalence
 Focused and goal directed
Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. New York: Guilford Press; 2002.
Spirit of MI
Miller and Rollnick (2002)



Collaboration
Evocation
Respectful
Miller WR, Rollnick S. Motivational interviewing: Preparing people for change. New York: Guilford Press; 2002.
Motivation to Quit Gambling
1) Positive aspects of
impulsive behavior (what are
the positive things gambling
gives me?)
2) Negative aspects of quitting
(what do I lose if I stop
gambling?)
3) What are the negative
consequences of gambling
(current and future?)
4) What are the advantages of
quitting gambling (what do I
have to gain?)
DAILY SELF-MONITORING DIARY
Date:
1. To what extent do I perceive that my gambling is under control?
0---10---20---30---40---50---60---70---80---90---100
not at all a little
moderately very much completely
2. What is my desire to act on gambling today?
0---10---20---30---40---50---60---70---80---90---100
nonexistent weak
average
high
very high
3. To what extent do I perceive myself as being able to abstain from
gambling?
0---10---20---30---40---50---60---70---80---90---100
Not at all a little moderately very much completely
4. Did I engage in gambling today?
5. How much time (hours & minutes) did I spend on gambling?
6. How much money did I spend on gambling, excluding wins for
gamblers?
7. Specify your state of mind or the particular events of the day
/
/
/
/
Homework
Review motivation to quit gambling form daily as reminder of the
consequences of your gambling.
Daily self-monitoring diary:
Most gamblers underestimate their problem, this grid helps to make
you more conscious of the gambling, of the intensity your urge to
gambling, and of the numerous negative consequences.
Grid enables clients to monitor progress. Clients can better quantify
changes taking place throughout therapy.
Case Example
Don
 Don is a 55 year old, single man. He works in
a factory on an assembly line, doing the
same job for the past 35 years. Don has a
history of depression and a suicide attempt at
22 years of age that he attributes to ‘a stupid
impulsive decision’. He reports that he
dropped out of school at the age of 14 due to
‘troubles with teachers and getting bad
grades’. Further probing, he indicates that he
was diagnosed with a severe learning
disability at the age of 8 and had always had
a problem with school.
Case Example
Don
 Don reports gambling starting gambling at the
age of 17 but that it has only become a
problem in recent years. He plays the lottery
and slot machines. Although he gamblers
several times a week on the lottery, he goes
to the casino about once a week to play the
slots, especially after getting his paycheck.
 Due to his gambling, he has had to work
overtime to pay his bills and his boss has put
him on probation for several errors he has
made in recent weeks due to exhaustion from
working too much and late night gambling
Case Example
Don
 Thoughts?



What should be done first with Don?
Next steps?
Do we modify the homework based on Don’s
learning disability?
Case Example
Bank Robber
 22 year old Caucasian
 No prior legal problems
 Worked in a bank
 Problem gambling onset at age 20
 Ran up debts; borrowing from family
 Impulsively “robbed” a bank
Case Example
Bank Robber
 Court-ordered for an examination
 Results reveal no other psychopathology
other than PG
 Neurocognitive testing showed attentional
and impulsivity impairments
 No brain imaging
Case Example
Bank Robber
 Very personable to interview
 Accepts guilt
 Wants “treatment” instead of incarceration
 States he won’t gamble ever again
+
Special Topics:
Self-Exclusion
The Prototypical Program
 Pamphlets and/or website explain program
 Individuals can sign up at casinos

Fill out application and have photo taken

Are advised that help is available
 May apply to all casinos in jurisdiction, does not apply to
other gambling venues
 Names and photographs of individuals are distributed to
casinos in jurisdiction
Prototypical Program, Cont’d
 Individuals removed from mailing lists
 Casinos refer to list before issuing player cards,
cashing cheques, paying jackpots, etc
 Usually irrevocable, requirements for re-entry vary
 Self-exclusion enforced by security personnel
 Many casinos also have involuntary exclusion lists
Session on Finances
Goals:
 Identify and plan for using specific strategies for
managing finances (for clients with debt)
 Client will understand the importance of using a
financial budget
Suggestions
 Restrict your access to money (cash, credit, and ATMs);
 Temporarily assign the management of your finances to a significant











other;
Get help from a credit counselor or an agency that can help you with
your budget;
Develop a budget that fits your income and expenses;
Plan to pay off your debts (starting with the most urgent);
Keep very little money on you (strict minimum);
Cancel your credit cards; Cut up your debit cards;
Designate a co-signer for your bank withdrawals;
Give a clear message to friends and family not to give you personal
loans;
Arrange for an automatic deposit for your pay check;
Take someone with you when making bank deposits;
Plan non-gambling activities around pay day;
Inform a significant other about incoming money
Strategies I Will Use To Manage My Finances
Strategy
Others
Involved
Plan to Implement
Strategy
Case Example
 Gladys is a 75 year old widowed woman with three




adult children. She works part-time in a local school.
If no gambling, she can pay her bills with little left
over each month.
Currently reports significant financial problems due to
gambling
Family distrust due to lying
Can’t pay her bills
Session - Behavioral Interventions
Goals:
 Identify all Gambling Triggers
 Rate how challenging it is to resist gambling when
triggered (level of control)
 Identify healthy behaviors to implement in order to
manage gambling triggers
 Learn about and practice use of the problem solving
strategies handout
 Identify a minimum of 2 leisure skill goals and steps to
accomplish those goals
Controlling Gambling Triggers
Describe the Gambling Triggers that affect you the
most, and indicate how you might deal with them
Gambling Triggers
Healthy Behaviors
1.
1.
2.
2.
Here is a list of strategies that many people use to help
control their gambling habits. Read them carefully and
decide of those that might work for you:
 Avoid being near places where you can gamble
outside your designated hours;
 Change your route to ensure that a gambling venue
is not on your way;
 Avoid asking the staff or other clients how the slots
are paying out, about lottery results, or about results
from any other form of gambling;
 Avoid being alone in a gambling venue.
Case Study
The Businesswoman
 48 year old, self-employed businesswoman
 Lives alone, no kids, overweight
 Gambles regularly since college as a pastime
 Won jackpot in slots 4 years ago and been
chasing since
 Now, financial losses excessive
 Called Gambling Helpline because of bills
Case Study
The Businesswoman
 Gambles for escape
 Plays 3 machines at once
 Always gamblers alone
 Tried to stop many times but keeps going
back
Case Study
The Businesswoman
 Treatment plan



CBT to address cognitive distortions and to
develop alternative coping strategies
Supportive therapy to address financial loss
Motivational interviewing to alter lifestyle
choices and become more active in healthier
life pursuits.
Session - Imaginal Exposure
Goals:
Client will understand the rationale behind the use of
exposure therapy for treating gambling
Client and Therapist will develop an imaginal exposure
script that includes all the relevant internal and external
triggers that relate to your gambling
Client will complete first imaginal exposure in session
with therapist
Exposure Therapy:
Background/Rationale
 Purpose of imaginal exposure is to imagine yourself in




the situation and feel as if it were really happening to
you, aware of the thoughts, feelings, sights, sounds, and
sensations.
You may experience an urge to gamble. You are
expected to have an urge.
The therapist will read the script of your gambling
experience while you listen. While you are experiencing
an urge, your therapist will introduce the negative
consequences of your gambling, as reported by you,
followed by the use of healthy coping strategies.
You will be asked to rate your urge during the exercise.
Therapist will provide a recording for you to listen to in
between sessions.
Script for PG:

“It’s Friday and I have been looking forward to gambling all
week. As I am thinking about gambling right now, my urge = 75.
Work has been quite stressful and it will feel good to escape for a
while and have some fun at the casino. I am bringing $200 and I have
to leave the casino when that is gone, maybe 2-3 hours. I hope the
money can last a little while so I don’t have to leave so soon. I notice
my heart flutter slightly, have butterflies in my stomach, and I can
hardly wait to get there. I am hoping my favorite machine is available
and the traffic on the way to the casino is not too bad. I thought of an
excuse before today to tell my spouse where I will be, an after work
gathering. As I approach the casino, I notice the lights outside, my
excitement increases and I drive a little faster. I am walking into the
main entrance and feel a rush as I hear the noise of the casino, the
hustle and bustle of people, and I head over to my bank of slot
machines. My machine is open and I take it as a sign that I am going
to win tonight.
 … I am out the $200 I brought. I head over to the instant
cash machine and withdrawal $200 more. I continue to
lose on whatever machine I chose and make 2 more
trips back to the cash machine for $100 and $200
respectively. I continue to chase the losses, feeling
disgusted with myself for staying so long and not having
any control. My urge to gamble is now = 65 and the
excitement has gone down and I am now more focused
on my anxiety. I planned to get home by 9pm and it is
now midnight. As the gambling outing ends, I am walking
away from the casino in disbelief. I planned to stay for a
short time and gamble a small amount.
 When I get home, my spouse is upset with me and we
argue before going to bed. I can’t fall asleep and I
continue to replay the gambling in my head. I can’t
believe that I didn’t walk away. I am aware that bills will
be delayed due to recent gambling. The next day I am
not able to enjoy much, feel distant from my spouse and
guilty for lying about gambling. …
 “I can also imagine another scenario that did not result in
me gambling. I call my brother on Tuesday and let him
know I need to make plans for the weekend because I
am concerned about gambling. I will have dinner with my
brother and his family and watch some movies Friday
night. … I have to continue to remind myself of the
negative consequences of gambling and of the
opportunities (socializing, self improvement) I have when
I abstain from gambling.”
Imaginal Exposure Rating Form
Date
(Exercise)
Practice 1 (am)
Practice 2 (am)
Practice 1 (pm)
Practice 2 (pm)
Pre-tape Urge
Peak Level of
Urge
Post-tape Urge
Session - Cognitive Therapy
Goals:
 To understand beliefs that relate to gambling
 To learn how to evaluate objective evidence
that supports and contradicts gambling
beliefs
 To learn how to develop healthy, alternative
beliefs related to gambling
Assessment of Beliefs
 Clients will be asked to identify their specific
thought process before, during, and after an
episode of gambling
 Clients have learned behavioral interventions
to limit their exposure to cues that can trigger
gambling
 The next step in the process is helping you to
understand that behind every action there is
a thought
 You will learn in this session the emphasis
CBT places on evaluating beliefs and how
beliefs influence our reactions
 Keep in mind that it is the “thought that
counts” and that provokes our reactions
The ABC’s of Gambling
 You and your therapist will review the gambling
beliefs monitoring forms and will practice completing
the forms with in session





A = Activating event (Trigger)
B = Impulsive Beliefs
C = Consequence (urge and behavior)
D = Dispute Impulsive beliefs
E = Effect change
ABC Log
Date/
Time
A
Activating
Event
(ICD
Trigger)
B
(Belief)
(Rate certainty 0100)
C
(Consequen
ce) (Rate
intensity 0100)
Urge
(_____)
Outcome
I did __
Or
did not__
engage in
impulsive
behavior
D
(Dispute)
Rate certainty
0-100
E
(Effect
Chang
e) (Rerate B
certain
ty and
C
emotio
n 0100)
A
Thoughts/
Feelings
Antecedent
(Triggers)
B
Behavior
C
Consequence
Particular people
Gambling/alternate behavior
Positive
Environment
e.g., I drove by the bar, next
think I knew it was last call
e.g., I gambled and I
forgot about that argument
with my wife
Feelings
e.g., urges,
argument with
spouse,
boredom, anxiety
Abstinence
e.g., I thought about the effect
it would have on my family,
and took a different route
home
Negative
e.g., the next day, I felt
like I’m a failure.l
Case Study




What questions do you ask him?
What is the therapeutic approach?
What sort of treatment plans do you invoke?
How do we address the cognitive distortions?
SESSION - Relapse Prevention
Goals:
 Review of all skill areas to assess client
preparation for using skills independently
 Identify ongoing supports for maintaining
progress in management of gambling
Planning for Future Triggers
 List major life events that may occur in the near
future
 List strategies for coping with these or similar
situations
 Ongoing self-monitoring of urge and behaviors will
serve to maintain self-awareness of Activating events
(triggers) and the client’s reactions
 Make efforts to maintain plans for dealing with
Gambling Triggers. All clients will avoid all
unnecessary exposures to situational triggers and will
attempt to engage in healthy coping when
experiencing distress, boredom or struggling with
conflict
Case Example - Donna
 Donna is a 50 year old, working professional who
successfully completed treatment. She has been
abstinent from gambling for two months. Work stress
was her main trigger to engaging in slot machine
gambling.
 She recently was required to go on a work cruise
which had a casino onboard.
 She wants to know:


Should she go on the work trip?
What can she do to help prevent relapse?
 Donna gambles the first day on the cruise ship.
 What should she do now?
Groups
Group CBT – 3 studies
 Cognitive restructuring
 Coping skills and identification of high-risk
situations.
 Imaginary exposure with response
prevention.
 Financial limit setting and activity scheduling
of leisure activities.
Pathological Gambling Subtypes May Suggest Treatment
Directions for Individual Patients
• Problems with urges/cravings
• Problems with hypofrontality
• Comorbidity
• Using genetics and neuroimaging to refine subtypes
further
[email protected]