Integrating Treatment for Gambling and CoOccurring Disorders Loreen

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

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

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

Why address gambling problems in SUD and MH programs: Summary • 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 • 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.

Co-Morbidity • Per DSM 5, 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)

DSM-5 GAMBLING DISORDER 46. 2% met DSM-5 criteria for Gambling Disorder

DSM-5 GAMBLING DISORDER 75. 2% identified as Moderate or Severe Gambler

• Most common types of gambling – Lottery Tickets – Scratch Offs – Games of Skill – Casino (81. 1%) (71. 8%) (40. 5%) (9. 2%)

Lottery Ticket Example: Purchased lottery tickets Not at alla Less than 10 times in total At least once a month At least once a week Avg. monthly spent ($) (M±(SD))b All Participants N = 185 Gambling Disorder No n = 99 Gambling Disorder Yes n = 85 18. 9% 7. 6% 4. 9% 68. 6% 178. 5 (357. 4) 30. 3% 12. 1% 8. 1% 49. 5% 72. 3 (159. 1) 5. 9% 2. 4% 1. 2% 90. 6% 302. 5 (469. 2)

• 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)

Impact of Co-Occurring Disorders Hodgins & el-Guebaly (2010) • 5 Year Follow-up of 101 subjects with GD who recently quit Disorder During Study Lifetime Mood Disorder 51% 72% Alcohol Use Disorder 62% 79% Drug Use Disorder 16% 55% • Complex combination of factors related to positive treatment outcome including problem gambling severity, treatment involvement, substance use and mood disorder

Impact of Co-Occurring Disorders Hodgins & 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

Impact of Co-Occurring Disorders Hodgins & 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

Temporal Sequence (For those with PG and other disorder Disorder Prevalence of Disorder amg. PG PG First Other Disorder Onset at same First time Any mood Disorder 55. 6% 23. 1% 64. 1% 11. 7% Any anxiety disorder 60. 3% 13. 4% 82. 1% 4. 5% Any impulse control disorder 42. 3% 0% 100% 0% Any substance use disorder 42. 3% 36. 2% 57. 4% 6. 4%

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

GAMBLING DISORDE AND CHRONIC MENTAL ILLNESS • 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.

• 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.

REMEMBERING THE MOST IMPORTANT ISSUES • 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.

Motivational Recycling Substance Use Disorder Problem Gambling Mental Health Disorder 21

Intimate Partner Violence (IPV) and Problem Gambling Study of 300 women, consecutive ER admissions (Muehlemann et al, 2002): • 26% categorized as experiencing IPV • IPV 10 X as likely if partner was problem gambler • IPV 6 X as likely if partner was problem drinker • IPV 50 X 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: 5 X rate of PPG Severe Marital Violence: 40 X rate of PPG Severe Child Abuse: 2. 5 X rate of PPG

Mental Health Center Gambling Screen Negative Interpret and Follow Mental Health Protocol Screen Positive Gambling Problems Gambling Assessment Substance Abuse Treatment Center Screen Positive Gambling Screen Negative Interpret and Follow SA Protocol

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

Perspective Change: Disordered Gambling Integration (Di. GIn) • 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.

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)

• 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.

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

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.

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

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

The Gambling Treatment Program Capability Index Organizational Commitment Continuity of Care Benchmarks Staffing Problem Gambling Treatment Program Capability . 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. Criteria & Metrics Clinical Process Community Engagement Program Structure Marotta and Coe, 2018

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

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.

• 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

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Providing Feedback and Enhancing Motivation Provide 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?

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.

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?

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?

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

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.

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.

Personally Normative Feedback Ø The average Canadian loses just under $600 per year, or about $50 per month, through all forms of gambling Ø Percentage of gross family income (total monthly pre-tax income divided by amount you gamble in a month Ø The average American loses just under $400 per year, or about $30 per month, through all forms of gambling Ø 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 Ø 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

Recovery/Life Goals 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. •

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

Goals for Gambling in Recovery • • • 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?

My Plan for Gambling in Recovery • 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:

Identify Your Warning Signs 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?

Making a Plan • 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 _________

Case 1 • Jessie is a 57 year old female, presents due to marijuana use. Lives with adult daughter and her 3 children (X 2 yrs). Grandson told teacher about her marijuana use and teacher reported to DCF. Significant conflict with daughter about house cleaning and child rearing. Reported on intake that she plays bingo 4 -5 x per week. Takes her 82 year old mother. Feels it is a good way to get out of house and avoid conflict with daughter. Stated she spent $5000 in past 6 months.

Case 2 • Charles is a 34 year old male in medication assisted treatment program. Has been abstinent from opiates on methadone x 4 months. Reports significant cocaine cravings X 1 month. In initial assessment reported only occasional purchase of lottery tickets. In recent group discussion stated he has been buying $100 worth of lottery tickets per week rather than buying crack with that money.

Case 3 • Linda is 42 year old female. On intake did not report any concerns about gambling. However, during group discussion, she was very quiet and did not make eye contact after viewing video on family consequences of gambling. When asked about her reaction, she acknowledged that her boyfriend with whom she is living, becomes abusive when he loses gambling or when they fight about money. She has been playing the lottery as she thinks winning will be the only way she can get enough money to leave this abusive situation.

Group Members • • Jasmine – Doesn’t gamble and never has George – Bets his favorite team for $5 once a week Sally – likes going to casinos when she goes on vacation. Tries to stick to her budget but sometimes goes over Sam – plays poker on line several times a week, mostly wins but has had losing streaks when got behind on bills. Joann – hardly waiting for the casino to open, loves playing the slots, makes all her stress go away. Loves the excitement, bells and whistles Jeff - plays dice on the street and cards in private games. Has been in trouble with loan sharks in the past. Avoids the really rough games. Kathy – plays bingo as often as she can. Takes all her “extra” money and sometimes borrows from friends to keep playing Bob – his wife has a serious problem with gambling. They used to go to casinos together, but he won’t go with her anymore .

• Design a group psychoeducation for this group • Tell me about gambling in your community • What would a person with a gambling problem look like? • Who is at higher risk for gambling problems • Self-Assessment and Normative Feedback • Discussion of Low and High Risk Gambling • Benefits and Costs of Gambling (Personal/community) • Thoughts about goals for gambling in recovery

Thank You Questions? 57