Problem gambling treatment for adolescents

Jeffrey L. Derevensky, Ph.D.

Professor & Director of Clinical Training School/Applied Child Psychology

Professor, Psychiatry

International Centre for Youth Gambling Problems and High-Risk Behaviors

McGill Universitywww.youthgambling.com

Some context

The Changing Face of Gambling

Today! Our new field of dreams…

Problem Severity Continuum

No gambling

At-Risk

gambling

Social g

ambling

Problem gamblin

g

Pathologica

l gamblin

g

Compulsive gamblin

g

Disord

ered gambling

Today…GAMBLING (gaming) has become normalized in our society

Slots for kids Slots for adults

Gambling (gaming) has become glamorized

Gambling camp

Is gambling a problem?

Gambling campGambling camp

Gambling (gaming) has become Gambling (gaming) has become glamorizedglamorized

New Forms of Gambling: Concerns?

Poker’s heroes

Joe Cada, age 21, Community College dropout, winner World Series of Poker, 2009, $8.55 million

Jonathan Duhamel, age 23, University dropout, winner World Series of Poker, 2010, $8.944 million

Pius Heinz, age 22, University Student, winner World Series of Poker, 2011, $8.72 million

Greg Merson, age 24, University dropout, winner World Series of Poker, 2012, $8.528 million

Ryan Reiss, age 23, wins $8.36 million in 2013 WSP

recent college grad

“I’ve been dreaming about it a long time, ever since I was 14 and saw (Chris) Moneymaker win it.”

The new face of Internet gambling

Understanding youth problem gambling: Twenty+

years of research

Gambling

• Gambling is more popular amongst males than females

• Youth problem gambling prevalence rates range from 2%-10%

• Young adults (18-25) have the highest prevalence rates amongst adults

• Adolescent prevalence rates of problem gambling are 2-4 times that of adults

• Gambling has become a family activity

• Gambling venues are easily accessible

• Most individuals view gambling as a socially acceptable and enjoyable form of entertainment, significantly less harmful than alcohol, drugs or cigarettes

• People are easily influenced and lured by advertisements

• Young people believe gambling to be a relatively benign activity:

– 40% believe that playing cards for money is harmless even when played at least once a week

– 37% believe that teens should be allowed to use EGMs

– While 72% agree that gambling can be bad for you, there remains 28% of participants who either disagree or are neutral in this matter

• Few young people fear getting caught gambling

Percentage of young people who fear being caught while gambling (N=1294)

44

26

1710 9.1 8.6

0

10

20

30

40

50

60

70

80

90

100

grade 4 grade 6 grade 7 grade 8 grade 9 grade 11

(Gupta & Derevensky, 1998c)

• The majority of youth believe that tricks, strategies and practice will result in more success

– 56% agree that there are tricks or strategies associated with becoming a successful gambler

– 40% agree that the more you practice the better you get at gambling

• Individuals are bombarded with gambling advertisements

– 42% of young adults influenced by the ad-they want to try it

– 61% imagine/dream what winnings could buy

– 35% report wanting to gamble after viewing an ad

• 79% males; 57% age 16-18

• Perceptions– 68% of young people report winning is easy– 60% report probability of winning is high– 81% gambling can make you rich

Indiviudals experiencing gambling problems…

• are more likely to be males

• are greater risk-takers

• have poor general coping skills

• report beginning gambling at earlier ages, approximately 10 years of age

• move from social gambler to problem gambler quite quickly

• more likely to gamble after seeing an advertisement for gambling

• report lower self-esteem compared with others

• have higher rates of anxiety and depression

• dissociate more frequently when gambling

• are at heightened risk for suicide ideation and suicide attempts

• increased criminal behavior

• disruption of familial relationships

• decreased academic performance (if still in school)

• report having a support group, however, ‘old’ friends are often replaced by gambling associates

• score higher on measures of excitability, extroversion, impulsivity and anxiety & lower on conformity and self-discipline measures

• score lower on a measure of resiliency in light of risk factors

• remain at increased risk for the development of an addiction or multiple addictions

Reported percentage of substance use (past year) according to gambling severity (N=817))

0

10

2030

4050

6070

80

90100

alcohol drugs smoking

no problem gambler

social gambler

gambler with some problems

probable pathological gambler

* grades 7, 9, & 11

• have been shown to have experienced more major life events and early childhood traumas and abuse (physical, sexual, verbal)

• more likely to have parents with either a gambling problem, some form of mental health issues or substance abuse

• display significant cognitive distortions compared to peers when gambling

• see both the benefits AND risks associated with excessive gambling

Attitudes and perceptions of adolescent risky behaviors

40%

60%

64%

64%

66%

66%

73%

75%

81%

81%

82%

87%

Gambling (13)

Depression (12)

Excessive video game playing (10)

Negative body image (10)

Spending too much time online (8)

Obesity, eating disorders (8)

Smoking (7)

Violence in schools, bullying (6)

Unsafe sexual activities (3)

Drinking and driving (3)

Alcohol use (2)

Drug use (1)

Parental perceptions: Serious Youth Issues

A comparison of parents and teachers perceptions

concerning adolescent risky behaviours

Mental health professionals’ beliefs about the seriousness of youth issues

Figure represents responses “serious” and “very serious”

ProblemGambling

ConductDisorder

ADHD

DepressionDrug

Dependence

OtherDisorders

AlcoholDependence

Is Problem Gambling A Primary Disorder?

Problem Gamblers

Helping adolescents with a gambling

disorder

Therapeutic Therapeutic approachesapproaches

Cognitive-Behavioral TherapyCognitive-Behavioral Therapy Motivational EnhancementMotivational Enhancement Psychodynamic/ Psychoanalytic TherapyPsychodynamic/ Psychoanalytic Therapy Pharmacological TreatmentsPharmacological Treatments Pathways ModelPathways Model

Attracting adolescents

Overarching philosophy (Pathways Model – Blaszczynski 2000; Nower & Blaszczynski, 2004)

• All problem gamblers are not alike.• There are different pathways to problem

gambling.• Gamblers in each pathway differ by the

presence or absence of psycho-social, biological factors and behavioral manifestations

• Gamblers in different pathways require different treatment strategies for success.

Common thread….. Maladaptive Coping

• Maladaptive coping styles tend to be associated with excessive involvement in gambling, regardless of pathway.

• People with gambling problems may use more emotion and distraction-oriented coping skills, and are less task-oriented in their problems-solving approach.

Coping as a mediating factor

Off-kilt physiological resting state Maladaptive coping

Psychological nature characterized by unhealthy

feelings, either due to trauma, loss, or poor

upbringing.

Addictive behavior

Phases of intervention

• Assessment

• Treatment

• Relapse prevention

AssessmentAssessment DSM-5 criteria -semi-structured interview DSM-5 criteria -semi-structured interview

(impaired control is important to assess)(impaired control is important to assess)

Establish baseline:Establish baseline:- frequency- frequency- length of play- length of play- money spent- money spent

Assess for comorbidity and relevant correlates• Conduct a thorough assessment of:

– personal history (i.e., traumas)

– family and educational history

– social/peer status

– underlying depression, anxiety, attention deficit disorder, substance use & other problems

• Identification of coping styles

• Identification of risk situations/ triggers

Assess for comorbidity and relevant correlates

• Identification of cognitive distortions

• Comorbidity

• Identification of gambling triggers

• Discussion of reasons underlying the need to gamble.

• Discussion of gambling as a consequence of the need to escape and feel better.

• Emphasize that it must be their decision to stop gambling.

• Discussion of abstinence vs. reduction.

Evaluate consequences

1. Effects on family

2. Impact on work, school

3. Change in mood and personality

4. Secrecy, rule- & law-breaking activities

Assess Motivation• It is important to assess the level of

motivation for change as this can help direct intervention. (DiClemente model)

• Match intervention to stage of change and identified skill deficit (if any)

Assessing readiness for change

Stage 1: Pre-contemplationgambling is not seen as a problemListen, acknowledge & validateContextualize problems & emphasize choice

Stage 2: Contemplationbeginning to think about modifying gambling Objective feedback on (-) consequencesPromote reflection (Pros & Cons)

Stage 3: Preparationdecided to change gambling behaviorProvide information about intervention optionsStick to their change agenda

Stage 4: Actiontakes steps to stop the gamblingSet incremental & feasible goalsDevelop strategies to reach goalsReinforce any positive change

Stage 5: Maintenancewillingness to accept continued work to sustain

initial changesReinforce gainsRelapse prevention

Stage 6: Terminationgambling no longer represents a temptation

or problem

ESSENTIAL THERAPEUTIC GOALS

• Understand motivations for gambling• Acceptance of gambling as a problem• Identifying underlying stressors• Enhance coping skills• Identifying and clarifying the irrationality of

thought processes when gambling • Facilitate the building of healthy support systems • Help with the structuring of free-time• Help create a debt repayment plan• Relapse prevention plan

Subgoals of therapySubgoals of therapy Reduce anxiety (restlessness,anxiety attacks…)Reduce anxiety (restlessness,anxiety attacks…)

Reduction of depressive symptoms (loss of Reduction of depressive symptoms (loss of appetite, difficulty sleeping, lack of activities…)appetite, difficulty sleeping, lack of activities…)

Reduction in antisocial behaviors (delinquent Reduction in antisocial behaviors (delinquent behaviors, lying, stealing, cheating… )behaviors, lying, stealing, cheating… )

Reduction in excessive use of alcohol or drugsReduction in excessive use of alcohol or drugs

Address Underlying Issues

• ADHD/Impulse control problems• Low-self esteem• Learning problems• Mood disorders (depression/anxiety)• Substance abuse disorders• Dysfunctional family• Loss

ESTABLISH IMMEDIATE CAUSES OF STRESS & ANXIETY

• Conflict with spouse/ parents/ friends/ peers/significant others

• Fears• Post traumatic stress reactions• Inability to conform to norms (i.e., sitting still at a

desk all day)

TRIGGERSTRIGGERS

EMOTIONAL REACTIONS AND RATIONALIZATIONSEMOTIONAL REACTIONS AND RATIONALIZATIONS

BEHAVIORBEHAVIOR

CONSEQUENCESCONSEQUENCES

Analysis of A Gambling EpisodeAnalysis of A Gambling Episode

Increase repertoire of coping & problem solving skills through cognitive behavioral therapy

• Role playing

• Assignments

ADDRESSING COGNITIVE DISTORTIONS

• Negative expected winnings (Law of D.R.)Believing that persistence will pay offDiscounting house cut

• Independence of events/turnsMaking links between key events (near miss)

• Illusion of controlBelief that outcome can be influencedPicking lottery numbers

FAMILY INVOLVEMENT• Strengthening of relationships with family

members.

• Building social support systems for the adolescent. This can include involving parents, siblings, and close friends in the treatment process.

RESTRUCTURE FREE TIME & SUBSTITUTE ACTIVITIES

Lifestyle

WeekWeek Independent Independent thinkingthinking

Proper Proper nutritionnutrition ExerciseExercise SchoolSchool WorkWork SocializingSocializing TotalTotal

Sept Sept

8-148-148/108/10 7/107/10 10/1010/10 6/106/10 8/108/10 8/108/10 78%78%

SeptSept

15-2115-219/109/10 8/108/10 7/107/10 8/108/10 0/100/10 10/1010/10 70%70%

SeptSept

22-2822-289/109/10 9/109/10 10/1010/10 8/108/10 7/107/10 9/109/10 87%87%

Money Management Skills

• Reframing the value of money

• Budgeting skills

• Debt repayment

Therapeutic tools• Incorporate an eclectic and flexible approach.

• Use significant individuals (i.e., parents, siblings, friends) in the adolescent’s environment as a support network.

• Work in conjunction with a psychiatrist or general physician.

• Provide a “reality check”. Adolescents have a distorted perception of the amount of money and time they spend gambling.

Create therapeutic tools to monitor change

Gambling activity

$-253$-253 5 Days5 Days VLT and VLT and cardscards BaselineBaseline

$ -300$ -300 3 Days3 Days VLTVLT Improvement on Improvement on frequencyfrequency

Amount # daysSpecific games Progress

Sept 10- 16

Sept 17- 23

Progress ChartWeekWeek Staying Staying

awakeawakeProper Proper nutritionnutrition

ExerciseExercise School School workwork

WorkWork SocializingSocializing TotalTotal

Feb Feb

7-137-13

3/103/10 4/104/10 2/102/10 0/100/10 6/106/10 1/101/10 25%25%

April April 8-148-14

8/108/10 7/107/10 10/1010/10 6/106/10 8/108/10 8/108/10 78%78%

April April 15-2115-21

9/109/10 8/108/10 7/107/10 8/108/10 0/100/10 10/1010/10 70%70%

AprilApril

22-2822-28

9/109/10 9/109/10 10/1010/10 8/108/10 7/107/10 9/109/10 87%87%

Final outcome• Once therapy is completed the adolescent

should be abstinent for several months.

• Success is not complete until the adolescent had adopted a healthy lifestyle. This includes maintaining friendships with individuals who would not be considered to be a ‘negative’ influence. Newly acquired coping skills should result in enhanced emotional stability.

• The adolescent should be aware of his or her ongoing high risk for relapse. In the ideal setting the individual will choose abstinence over controlled gambling.

• Relapse prevention is critical-problem solving, coping and adaptive behaviors.

• Minimizing stress (which is a non-specific activation of a variety of problems, including relapse) – some clinicians believe that uncontrollable stress may be particularly disruptive.

• Reducing proximity to gambling venues, which serve as a cue

• Avoiding association with gambling friends or those still involved in the lifestyle, who may serve as a cue

Models of relapse prevention Models of relapse prevention frequently emphasize the following:frequently emphasize the following:

• Moderating conversation about gambling, since conversation can serve as a cue for craving or relapses

• Time management

• Information about where people can go for help or more information on problem gambling (i.e., treatment agencies, 24-hour hotlines)