Oregon Problem Gambling Helpline
Mental Health Clinicians
ARE PROBLEM GAMBLERS IN YOUR CASELOAD?
Jeffrey Marotta, Ph.D.
If you are a practicing mental health clinician, chances are you’ve provided care to someone who has a gambling disorder – whether you knew it or not. Epidemiologic findings suggest that 1 in 10 persons with psychiatric disorders may have a gambling problem. 1Persons struggling with mental illness appear at high risk for using gambling as a mechanism to avoid the uncomfortable thoughts and feelings associated with mental illness.
During my years as a practicing clinician, I had very few clients with a presenting complaint of gambling too much. Even after clinical assessment and engagement I would not have portrayed 10% of my caseload having, or at high risk of developing, a gambling problem. Now that my professional focus is on problem gambling I better appreciate the pervasive and elusive nature of gambling disorders.
Clients with active gambling problems often seek therapy not for their gambling problem but for help with related symptoms such as depression, anxiety, sleep disturbances, or for functional problems with relationships, school, or job. These clients may not conceptualize gambling as part of the problem but rather as part of the solution. Gambling may be offering them hope and possibility – a big win to provide needed cash or needed validation. Gambling may create a feeling of normalcy – the excitement of gambling can change the perceived valence of underlying anxiety from feeling “bad” to feeling “good”. Gambling may serve as a powerful opioid with the ability to tame emotional and physical pain. Gambling may be viewed as “my only recreation” or an excuse to leave an unpleasant home or work environment. With so many reasons to hold on to gambling, it is understandable why few clients self-recognize the nature or extent of their gambling or, if they do, disclose it to their therapists.
Although most mental health providers are aware of problem gambling, studies find that very few clinician ask their clients about problem gambling.2,3 Increased awareness and early intervention are the keys to reducing the personal, family, and social costs of problem gambling. Psychologists and other mental health professionals can play an integral role in this process by educating clients about risks associated with gambling, recognizing early signs of problems, and by motivating clients to address unhelpful gambling behaviors.
How big is the problem?
Studies conducted in Oregon found past-year prevalence rates in an at-large community sample of adults at 1% for Pathological Gambling and an additional 1.7% for problem gambling.4 The prevalence of problem gambling among persons entering a primary care setting appears to be closer to 10% and for those entering an alcohol and drug treatment agency the rate is between 10% to 30%. 5 Based on this information, one can speculate that the prevalence of problem gamblers within a mental health setting could be at least 10%.
What is problem gambling?
Gambling is a widespread activity, with 86% of the general adult population having some gambling activity over a lifetime. 6 While the majority of people gamble, a small minority has a gambling problem. Pathological Gambling (Table 1) represents the most severe pattern of excessive or destructive gambling behavior and is the only gambling related disorder for which there are formal diagnostic criteria. 7 Problem gambling is a term that has different meaning depending on the context. Used colloquially, problem gambling describes any form of gambling that results in functional consequences. In the scientific literature, problem gambling refers to less-severe forms of dysfunctional gambling as differentiated from Pathological Gambling. This article uses the former meaning of the term except were noted otherwise.
The causes of problem gambling are complex and may emanate from diverse sources – a mix of individual traits, social and economic circumstances, and the overall community environment that presents or encourages gambling opportunities.6 Although Pathological Gambling had originally been conceptualized as a chronic and progressive disorder, new evidence suggests there are multiple courses the disorder can follow.9 Sometimes the gambling problem is transient; sometimes it plateaus and maintains for years; and sometimes it follows a progressive course. Regardless of the course, it is common for a problem gambler to experience mental and physical health problems.
Problem gambling treatment
At present there are no universally agreed upon “best practices” nor standardized models of treatment specific to gambling. A review of the best treatment studies indicates the following:
Cognitive-behavioral treatment (CBT) approaches, even when delivered via a manual and involving only minimal therapist contact, have the most empirical support, compared with no treatment. CBTs, generally brief and delivered on an outpatient basis, have been shown to strengthen motivation.
Pharmacotherapy (most commonly Nalmefene, Naltrexone, Welbutrin, and selective serotonin reuptake inhibitors [SSRIs]) may be an important adjunct to verbal interventions. However, the body of knowledge on problem gambling treatment has not determined which specific type of CBT or medication is most effective, for which individuals, under what circumstances, or whether other approaches have better efficacy.
The initial intervention should strive to increase the individual’s commitment to treatment and resolve treatment-disrupting ambivalence as much as possible. The relatively high rates of support group dropout and treatment non-completion among problem gamblers suggests that more effort should be made to strengthen the client’s commitment to change. Interventions consistent with the motivation stage of change model would be appropriate.
Gambling-treatment outcomes can be improved by addressing the factors contributing to treatment failure.10 Several predictors of poor treatment outcome include gambling-related cognitive distortions and beliefs about randomness, impulsivity or sensation seeking, biological vulnerabilities, and negative affect or mood symptoms.
Screening
Screening for gambling-related history and symptoms is justified because of the prevalence and potential severity of problem gambling, the potential to improve client outcomes, and the low costs and low risk associated with asking about problem gambling. Early intervention of problem gambling through screening and motivating help-seeking may reduce the harm of problem gambling on individuals and their families.
Problem gambling screening procedures
When conducting a biopsychosocial assessment , include questions on gambling. If gambling is a frequent activity, then consider utilizing a simple screening tool - the Lie-Bet Questionnaire.11 This questionnaire is valid and reliable for ruling out pathological gambling behaviors.
The Lie-Bet Questions
1) Have you ever felt the need to bet more and more money?
2) Have you ever had to lie to people important to you about how much you gambled?
If a client answers yes to one or both of the questions on the Lie-Bet questionnaire, further assessment is indicated. Either make an assessment, based on the clinical interview, using the DSM-IV criteria provided in Table 1 or provide self- assessments such as the South Oaks Gambling Screen (SOGS) at http://www.npgaw.org/tools/screeningtools.asp
If a client’s primary diagnosis is Pathological Gambling, the treating clinician should have specialized training and competence in working with problem gamblers. If not, a referral is warranted. When treating a client with a co-occurring gambling disorder, whether a gambling disorder is treated first, second or simultaneously is a matter of clinical judgment based on the relative intensity or emergent nature of the various disorders present. Counselors need to remain cognizant of the risk of underemphasizing a co-occurring gambling problem that is in need of immediate attention. When treatment planning for a client with a co-occurring gambling problem, seek consultation from a colleague with problem gambling expertise.
Resources for clinicians
Oregon operates a 24-hour confidential problem gambling helpline 1-877-MYLIMIT or 1877mylimit.org. Operators are certified problem gambling counselors and can assist with general information about problem gambling, crisis-intervention, motivational interviewing, and referrals to Oregon state-funded gambling treatment providers in their area. There is also an online version of the Helpline which offers help via chat/email/IM and can be accessed at 1877mylimit.org. Oregon has 25 outpatient problem gambling treatment centers, two short-term residential treatment programs, one residential treatment program, and a structured self-change program that utilizes workbooks and telephone counseling. Over 2,000 individuals are treated each year in Oregon’s system of state-funded problem gambling treatment. 12
Free clinician brochure download: egov.oregon.gov/DHS/addiction/gambling.shtml click on Resources
REFERENCES
1 Cunningham-Williams, R., Cottler, L, Compton, W, & Spitznagel, E (1998). Taking chances: Problem gamblers and mental health disorders – results from the St. Louis Epidemiologic Catchment Area Study, American Journal of Public Health, 88, 1093-1096.
2 Christensen, M.H., Patsdaughter, C.A., & Babington, L.M. (2001). Health care providers’ experiences with problem gamblers. Journal of Gambling Studies, 17 (1), 71-79.
3 Sullivan, S., Arroll, B., Coster, G., Abbott, M., & Adams, P. (2000). Problem gamblers: Do GP’s want to intervene? New Zealand Medical Journal, 113(1111), 204-207.
4 Volberg, R. (2001, February). Changes in gambling and problem gambling in Oregon: Results from a replication study, 1997 to 2000. Salem, OR: Oregon Gambling Addiction Treatment Foundation.
5 Pasternak IV AV, Fleming MF. Prevalence of gambling disorders in a primary care setting. Arch Fam Med 1999; 8: 515–20.
6 National Opinion Research Center (NORC). (1999). Gambling impact and behavior study, report to the national gambling impact study commission. Chicago, IL: Author.
7 American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, D.C.: Government Printing Office.
8 Potenza, M.N., Fiellin, D.A., Heninger, G.R., Rounsaville, B.J., & Mazure, C.M. (2002). Gambling: An addictive behavior with health and primary care implications. Journal of General Internal Medicine, 17, 721-732.
9 Abbott, M, Williams, M., Volberg, R. (1999). Seven years on: A follow-up study of frequent and problem gamblers living in the community. Wellington: Department of Internal Affairs.
10 Daughters SB, Lejuez CW, Lesieur HR, Strong DR, Zvolensky MJ. Towards a better understanding of gambling treatment failure: implications of translational research. Clin Psychol Rev 2003;23:573–86
11 Johnson, E.E., Hamer, R., Nora, R.M., Tan, B., Eistenstein, N., & Englehart, C. (1988). The lie/bet questionnaire for screening pathological gamblers. Psychological Reports, 80, 83-88.
12 Marotta, J. (2003). Oregon's Problem Gambling Services: Public health orientation in a stepped-care approach. Electronic Journal of Gambling Studies, 9, 129-133.