Evidence-Based Psychosocial Treatment Approaches for Disordered Gambling - PowerPoint PPT Presentation


PPT – Evidence-Based Psychosocial Treatment Approaches for Disordered Gambling PowerPoint presentation | free to view - id: 716150-ZTQ4Y


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Evidence-Based Psychosocial Treatment Approaches for Disordered Gambling


Title: Self-Exclusion from Gambling Venues Author: SUSANNAH CARLSON Last modified by: Grant, Jon [BSD] - PSY Created Date: 3/5/2012 1:20:28 PM Document presentation ... – PowerPoint PPT presentation

Number of Views:51
Avg rating:3.0/5.0
Slides: 67
Provided by: SUSANN196


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Evidence-Based Psychosocial Treatment Approaches for Disordered Gambling

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

(No Transcript)
Intake and Gambling History
Intake First Steps
  • Source of referral From Where?
  • What is the gamblers presenting issue as it
    relates to gambling?
  • What is the real motivator?
  • Why now?
  • Focus on how / what / when / why of getting into
  • 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

  • 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
  • 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
  • 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
  • Stressor in suicide is unendurable psychological
    pain (Critical Self Talk)
  • Emotions in suicide is hopelessness helplessness

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,

Co-Occurring Disorders in PG
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?)

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 (depressed, bored, frustrated, happy, and anxious).
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

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 episodes. He
    endorses fleeting suicidal thoughts but no plan.


Case Example Don
  • Thoughts?
  • What should be done first with Don?
  • Next steps?
  • Do we modify the homework based on Dons learning

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 wont 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, Contd
  • Individuals removed from mailing lists
  • Casinos refer to list before issuing player
    cards, cashing cheques, paying jackpots, etc
  • Usually irrevocable, requirements for re-entry
  • 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

  • Restrict your access to money (cash, credit, and
  • 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
  • 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
  • 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
  • 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
  • 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
  • Cant 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
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
  • 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
  • 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

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
  • Therapist will provide a recording for you to
    listen to in between sessions.

Script for PG
  • Its 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 dont 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

  • 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 cant fall asleep
    and I continue to replay the gambling in my head.
    I cant believe that I didnt 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
  • The next step in the process is helping you to
    understand that behind every action there is a
  • 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 ABCs 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

Date/ Time A Activating Event (ICD Trigger) B (Belief) (Rate certainty 0-100) C (Consequence) (Rate intensity 0-100) D (Dispute) Rate certainty 0-100 E (Effect Change) (Re-rate B certainty and C emotion 0-100)
Urge (_____) Outcome I did __ Or did not__ engage in impulsive behavior
Thoughts/ Feelings
Antecedent (Triggers)
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
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 Im a failure.l
Case Study
  • 21 year old college student brought in by parents
    for online gambling because they discovered
    excessive amounts of money withdrawn from bank
  • He says he gambles 2-3 times per week at online
    poker and his net losses over last few months are
    200 per week. His GPA is 2.5, he isolates but
    says he has gambling friends. He reads about
    gambling odds and loves video games.
  • He reports several gambling rituals that he
    engages in prior to and during any gambling
  • Making three green lights on his way home from
    work is a sign that he will win if he goes
  • Taps the slot machine with a lucky coin prior
    to every bet

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
  • List strategies for coping with these or similar
  • Ongoing self-monitoring of urge and behaviors
    will serve to maintain self-awareness of
    Activating events (triggers) and the clients
  • 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
  • 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?

  • Group CBT 3 studies
  • Cognitive restructuring
  • Coping skills and identification of high-risk
  • 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

About PowerShow.com