Summer Institute Gambling Presentation 2010 by AkuZ95V

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									 Tom Litwicki, M.Ed., LISAC
    Emergent Recovery
   emergentrecovery.com
        520.977.3201
emergentrecovery@gmail.com
   Gambling is a socially acceptable form of
  entertainment practiced by most adults and a
    increasingly significant number of youth.

Increased Opportunity = Increased Prevalence of
             Gambling Problems.

 Correlation between Gambling Problems and
  Substance Use/Behavioral Health Disorders =
 Need for Clinicians to Screen for the Disorder,
   Have an Awareness of Symptomology, and
          Available Treatment Options.
 Placing something of value on an event that has a
 possibility of resulting in a larger, more beneficial
 outcome (Petry).
 Dice found in an Egyptian tomb (3000 B.C.E.)
 Gaming board cut into a step of the Acropolis at
    Athens.
   Hebrews divided the Promised Land through the
    drawing of lots.
   Colony of Virginia financed through lotteries.
   Early Universities (Harvard) funded through lotteries.
   Prohibition by 1910 in U.S. – to include Nevada
   1968 – first lottery in New Hamshire.
   Today – 38 state lotteries, 32 casino style gambling.
     Legal in every state except Utah and Hawaii
 Internet Gambling – 8 Billion (2006)
 North America
   (1.6%) 2.2 Million Adults with pathological gambling
   3.9% at risk for developing
 Degree of Involvement and Problems
 Level 0: No Lifetime Gambling
 Level 1: Social or Recreational
 Level 2: At Risk Gambling (Problem)
 Level 3: DSM IV Pathological Gambling




National Research Council, 1999
 Initiation Phase
   Often initial win
 Obsessive Thoughts
   Chasing After Wins
 Compulsion to Continue Gambling
   Impact Quality of Life
 Losing Phase
   Violation of Previous Norms/Rules in order to continue
    gambling
 Persistent and recurrent maladaptive gambling behavior as indicated
  by five (or more) of the following
      (1) is preoccupied
      (2) needs to gamble with increasing amounts
      (3) unsuccessful efforts to control, cut back, or stop
      (4) restless or irritable when attempting to cut down
      (5) gambles as a way of escaping from problems or of relieving a
       dysphoric mood
       (6) chasing losses
      (7) lies to conceal the extent of gambling
      (8) committed illegal acts
      (9) jeopardized or lost a significant relationship, job, or educational or
       career opportunity
      (10) relies on others to provide money to relieve a desperate financial
       situation caused by gambling
 B. The gambling behavior is not better accounted for by a Manic
  Episode
 U.S. Range of Lifetime Gambling by state is 81% to
  89%.
 Arizona is 89%.
   69% last year,
   23% monthly,
   10% weekly.
 Problem Gambling - 2.3% Overall
 Pathological .7%, Problem 1.6%


2003 Arizona Gambling Prevalence Study
   Questionnaire 2,750 AZ Residents Age 18 and older.
 Between 14,600 and 38,000 Pathological Gamblers in
    AZ
   Between 42,600 and 78,000 Problem Gamblers in AZ
   Most likely male age 35 – 54.
   Overrepresented Among Hispanic, Unemployed, and
    Disabled.
   70% Casino or Lottery.
   33% Horse, Dog, Sports, Private Games.
 Women
  32% of all pathological gamblers
  Start later in life – 30
  Telescoping
     Problem – Pathological in one year
     Men = 4.5 years
 2008 Arizona Youth Survey: Overview and Results
   The Arizona Criminal Justice Commission (ACJC) is
    mandated to measure the attitudes and prevalence of
    substance use, as well as the prevalence of gang activity
    among Arizona youth. The 2008 Arizona Youth Survey
    (AYS) administered to 8th, 10th and 12th grade students
    during the spring of 2008.
 54,734 Valid Results
 319 Schools
 Representative State and County Samples
 21% of persons seeking treatment have been charged
 with a crime.
 Primarily gambling behavior to relieve boredom, be
  active, engage in social activity.
 Primarily slots, bingo, lottery.
 Three times more likely to gamble daily.
 Nursing Home Survey
   23% engage in games onsite more than once a week.
Nixon, Petry
 76% Major Depression
 Antisocial Personality Disorder 15 – 40%
   (general population 3% males, 1% females)
 7 times more likely to have substance abuse concerns
 Lifetime Level 2 – 15.01%
 Lifetime Level 3 – 14.23%




     Shafer, Hall, Vander Bilt (1999)
 South Oaks Gambling Screen
 NORC
 Behavioral Theories
   Positive Reinforcement – variable reward schedule.
   Negative Reinforcement
      Initiating but not completing a habitual behavior leads to
       uncomfortable states of arousal. Chasing until you win.
   Vicarious Learning
      Imitate behaviors that are followed by reinforcers.
 Cognitive Theories
 Thinking Errors
   Superstition – Luck
   Interpretive Bias Win = skill Loss = fluke
   Temporal Telescoping
      Expecting wins sooner for self than others
   Selective Memory – ignore losses
   Illusory Correlations
      I won because of X

 Sunk-cost Effect: Willingness to engage in behavior
 because of money or time already in behavior.
 Dispositional Theories
   Personality Factors increase risk
      Extroversion
      Neuroses
      Impulsivity
      Low ego strength
      Over or under arousal
 Neurobiological Systems
   Differing reinforcement sensitivity
 Serotonin
   Possible impact on impulse control
   2 out of 3 studies found low levels
 Dopamine Imbalance
   Rewarding and reinforcing behaviors
 8% of Level 3 gamblers get treatment (NRC, 1999)
 Why don’t they come into treatment?
   80% wished to handle problem on their own.
   50% embarrassment
   Other
      Gambling not perceived as a problem
      Unaware treatment is available
      Unable to share problems with others
      Concern over stigma
   Only a minority of patients identified cost of treatment
    as a barrier.
 Lifetime v. Last Year
   40% of persons with pathological gambling in lifetime,
    do not meet criteria for pathological gambling in the last
    year (Higins, 1999).
   36% to 46% Level 3 gamblers considered in recovery
    (NRC, 1999).
 Why did they Stop?
   Financial loss and emotional pain.
 Motivational Interviewing/MET
 Motivational interviewing is a goal directed, client-
  centered counseling style for eliciting behavior change
  by helping clients to explore and resolve ambivalence.
   Miller, Rollnik (1991)
 3 Randomized Clinical Trials
 Managing Cravings
   Naltrexone – Opioid receptor antagonist
      Inhibits dopamine release and blocks the effect of
       endogenous endorphines (not as rewarding)
      Better than placebo in short term pathological gambling
       treatment.
      Increased outcome for those with unusually strong urges.

 Antidepressents
   Inhibits serotonin reuptake
   Fluvoxamine
 Mood Stabilizers
 12 Step
   Loss of Control
   Solution - spiritual and character renewal
 Cognitive Behavioral
   Thinking = Emotions = Behaviors
   Solution – modify thinking
 CRA
   Skill Building – refusal skills
   Reward Positive Behavior – Social Events
 Contingency Management
   Variable Reward Schedules
 Gamblers Anonymous
   Stuart and Brown (1988) followed 232 GA attendees
   7.5% received 1 year pin
   25% only attended 1 meeting
   75% attended 10 or fewer
 SMART Recovery
 Christian Recovery Groups
 Bi-polar and Depression Peer Support Groups
 ?
 Arizona Office of Problem Gambling
   Treatment Administrator
   Education and Prevention
 1-800-Next Step
 Treatment Assistance Program

								
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