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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

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+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 - Family Functioning Financial - Productivity Social - Mental health Physical Occupation Education Interpersonal/Social Support System Self-maintenance

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 ForPathological 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

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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

0

10

20

30

40

50

60

70

SUDsAffectiveAnxietyICDs

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.

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?)

Motivation to Quit Gambling

DAILY SELF-MONITORING DIARYDate:

/ /

/ /

1. To what extent do I perceive that my gambling is under control?0---10---20---30---40---50---60---70---80---90---100not 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---100nonexistent 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---100Not 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 (depressed, bored, frustrated, happy, and anxious).

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.

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 ExampleDon

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 episodes. He endorses fleeting suicidal thoughts but no plan.

Case ExampleDon

Thoughts? What should be done first with Don? Next steps? Do we modify the homework based on Don’s

learning disability?

Case ExampleDon

Case ExampleBank 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 ExampleBank 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 ExampleBank Robber

Very personable to interview Accepts guilt Wants “treatment” instead of incarceration States he won’t gamble ever again

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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

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.

Controlling Gambling Triggers

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 StudyThe 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 gamblingClient and Therapist will develop an imaginal exposure script that includes all the relevant internal and external triggers that relate to your gamblingClient will complete first imaginal exposure in session with therapist

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.

Exposure Therapy: Background/Rationale

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)

Pre-tape Urge Peak Level of Urge

Post-tape Urge

Practice 1 (am)

Practice 2 (am)

Practice 1 (pm)

Practice 2 (pm)

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 (urge, emotion) and influence gambling

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 LogDate/Time

AActivating

Event(ICD

Trigger)

B(Belief)

(Rate certainty 0-100)

C(Consequen

ce) (Rate intensity 0-

100)

D(Dispute)

Rate certainty 0-100

E(Effect Change) (Re-rate B certainty and

C emotio

n 0-100)

Urge(_____)OutcomeI did __Ordid not__ engage in impulsive behavior

Antecedent (Triggers)

Behavior Consequence

A B C

Particular people

Environment

Feelings

e.g., urges, argument with spouse, boredom, anxiety

Positive

e.g., I gambled and I forgot about that argument with my wife

Negative

e.g., the next day, I felt like I’m a failure.l

Gambling/alternate behavior

e.g., I drove by the bar, next think I knew it was last call

Abstinence

e.g., I thought about the effect it would have on my family, and took a different route home

Thoughts/Feelings

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

Continue to use a financial budget and adhere to long-term plan of paying down debt

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.

Problem-solving training

Relapse prevention

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

jongrant@uchicago.edu