GAMBLING SCREENING: HOW TO MAKE IT FUN! Tracy McPherson, PhD - - PDF document

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GAMBLING SCREENING: HOW TO MAKE IT FUN!

PRESENTED BY: THE BIG SBIRT INITIATIVE, NATIONAL SBIRT ATTC, and NORC at THE UNIVERSITY OF CHICAGO

March 16, 2016

Webinar Moderator

Tracy McPherson, PhD

Senior Research Scientist Public Health Department NORC at the University of Chicago 4350 East West Highway 8th Floor, Bethesda, MD 20814 esap1234@gmail.com

Produced in Partnership…

www.sbirteducation.com

2016 SBIRT Webinar Series

¨

January 27th – Mini-Guide to SBIRT: An Overview of SBIRT and Resources – NOW ON-DEMAND

¨

February 17th – Integrating Adolescent SBIRT in Nursing and Social Work Education

¨

March 9th – Reducing Teen Substance Misuse: What Really Works

¨

March 16th – Gambling Screening: How to Make it Fun!

¨

April 27th – Integrating Motivational Interviewing Techniques for Brief Intervention into the Curriculum

¨

May 4th – Part IV: Using Case Studies for Integrating SBIRT into Curriculum

¨

May 23rd – Preventing Prescription Drug Abuse and Doctor Shopping: Prescribing Guidelines and Intervention Skills for Nurses and Healthcare Professionals

¨

June 22nd – Intimate Partner Violence SBIRT: The WINGS Intervention Model

hospitalsbirt.webs.com/webinars.htm

Access Materials

http://hospitalsbirt.webs.com/problem-gambling

¨ PowerPoint Slides ¨ Materials and

Resources

¨ Recording ¨ Certificate of

Completion

Ask Questions

Ask questions through the “Questions” Pane Will be answered live at the end

3/14/16 ¡ 2 ¡

Technical Facilitator

Misti Storie, MS, NCC

Technical Consultant misti.storie@gmail.com www.mististorie.com

Webinar Presenter

Jody Bechtold, LCSW, NCGC-II, BACC

Private clinician jody@jodybechtold.com & VP Clinical Affairs, Wellbridge Health, Inc. jody@wellbridgehealth.com

What is Gambling? What is Gambling?

Webster's New World Dictionary as the following:

— to play games of chance for money or some other stake,

• r

— to take a risk in order to gain some advantage.

Gambler’s Anonymous definition of gambling: “Any betting

• r wagering for self or others, whether for money or not, no

matter how slight or insignificant, where the outcome is uncertain or depends upon chance or “skill”, constitutes gambling.” (Gambler’s Anonymous, March 1994, Handbook)

What Does a Gambler Look Like?

The New Face of Gambling

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Which one of these activities is NOT considered gambling?

• Buying lottery tickets
• Playing fantasy football for money
• Playing free blackjack online
• Stock Market trading/investing
• Buying raffle tickets

Polling Question #1

15

Why Do People Gamble?

¨ Excitement ¨ Entertainment ¨ Escape (forget about

their problems for a while)

¨ Economics (they

want the money)

¨ Ego (the person’s

pride or reputation)

Gambling and Problem Gambling

No gambling Social gambling Problem Gambling

Gambling Disorder

None Mild Moderate Severe

Gambling Continuum

Korn & Shaffer , 99

Brief Intensive Treatment Secondary Prevention Primary Prevention Harm Reduction

At-Risk

Continuum of Gambling

¨ No Gambling ¤ A person does not gambling on any forms of gaming

(lottery, scratch offs, raffles, fund raisers, etc. )

¨ Social Gambling (Recreational) ¤ One form of entertainment; typically with others, time &

money is limited. No adverse consequences.

¨ At-Risk Gambling ¤ Increasing frequency & duration of gambling;

increasing total money and per bet money.

Continuum of Gambling

¨ Problem Gambling ¤ Experiencing difficulties in some major areas of life;

having more difficulty cutting back or stopping; continued despite consequences

¨ Disordered Gambling ¤ DSM – 5 criteria

Gaming Psychology

Understanding the “Hook”

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Independence of Turns: A Fundamental Concept

Independence of Turns: Coin Toss

1 2 3 4 5 6 7 8 9 10

Heads Heads Tails Heads Tails Heads Heads Tails Heads _________

Skill vs Chance

¨ “What is the definition of skill?” ¨ “The more you practice, the better you will be” ¨ “What is the definition of chance?” ¨ “All unforeseen or unpredictable events over which a person

has no control.” Which of the following is a game of SKILL?

• Lottery
• Sports betting
• Bingo
• Poker / Blackjack

Polling Question #2

Chance Skill

slots Poker (table games) bingo card games lottery Sports(?)

Illusions of Control

3/14/16 ¡ 5 ¡ Recognizing Traps – Illusions of Control

¨ Slot Machines Illusions ¨ Lottery Illusions ¨ Bingo Illusions ¨ Blackjack Illusions ¨ Roulette Illusions ¨ Horse Racing Illusions

Which lottery ticket do you want?

1 2 3 4 5 11 4 7 28 32

Type “A” or “B” into the Chat Box A B

Understanding “Randomness” Reinforcement/Punishment

Type of Event Positive Event Aversive Event Presented Positive reinforcement Punishment Removed Punishment Negative reinforcement

Reinforcement/Punishment

Type of Event Positive Event Aversive Event Presented Get what you want Get what you don’t want Removed Take away what you want Take away what you don’t want

Reinforcement/Punishment

Type of Event Positive Event Aversive Event Presented Gamble and win $$ (+/+) Gamble and Debt (+/+) Removed Gamble and lose $ $ (+/-) Gamble and bailout (+/-)

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The “Hook”

¨ Independence of Turns ¨ Chance vs. Skill ¨ Illusions of Control ¨ Randomness ¨ Reward/Punishment

(Intermittent Reward)

Gambling: Myths & Assumptions Gambling: Myths & Assumptions

¨ If you can afford it, gambling is not a problem. ¨ Playing the lottery is not gambling. ¨ People that are home bound don’t gamble. ¨ Poor people don’t gamble. ¨ Playing bingo at the retirement community isn’t

gambling.

¨ The Deaf don’t gamble at casinos.

Impact: Myths & Assumptions

¨ S/He doesn’t look like a gambler ¨ Countertransference issues

Prevalence DSM-5 criteria

Gambling : Clinical Gambling in the US

¨ Approximately 85% of US Adults gambled at least

• nce in their lives; 60% in the past year.

¨ 2 million (1%) of US Adults are estimated to meet

criteria for disordered gambling in a given year.

¨ Another 4-6 million (2-3%) would be considered

Problem Gamblers.

¨ Source: National Council on Problem Gambling

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DSM – 5 Addictive Disorders: Behavioral Addiction

Gambling DISORDER: DSM-5 Criteria 312.31

¨ Preoccupation

¤ Is often preoccupied with gambling (e.g. having persistent thoughts or

reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble)

¨ Tolerance

¤ Needs to gamble with increasing amounts of money in order to achieve

the desired excitement

¨ Withdrawal

¤ Is restless or irritable when attempting to cut down or stop gambling

Gambling DISORDER: DSM-5 Criteria 312.31

¨ Escape

¤ Often gambles when feeling distressed (e.g. helpless, guilty, anxious,

depressed)

¨ Chasing

¤ After losing money gambling, often returns another day in order to get

even (chasing one’s losses)

¨ Lying

¤ Lies to conceal the extent of involvement with gambling

Gambling DISORDER: DSM-5 Criteria 312.31

¨ Loss of control

¤ Has made repeated unsuccessful efforts to control, cut back, or stop

gambling

¨ Risked significant relationship

¤ Has jeopardized or lost a significant relationship, job, education or

career opportunity because of gambling

¨ Bailout

¤ Relies on others to provide money to relieve a desperate financial

situation caused by gambling

Gambling DISORDER: DSM-5 Criteria 312.31

¤ The gambling behavior is not better explained by a manic

episode.

Diagnosis / Terminology

¨ Gambling Disorder: 4 or more of the DSM-5 criteria ¤ 4-5 Mild ¤ 6-7 Moderate ¤ 8-9 Severe ¨ Problem Gambling: more than 1 but fewer than 4 of the

DSM-5 criteria

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Drug / Alcohol Mental Health

Co-Occurring Rates

Disordered Gambling:

Comparison to Substance Abuse

Similarities

¨ Preoccupation with the activity and a loss of control ¨ Abuse of drugs/alcohol and problem gambling can

both be progressive

¨ Denial is the hallmark of both: the problem resides

• utside the person who is exhibiting the disordered

behavior

Disordered Gambling:

Comparison to Substance Abuse

Similarities

¨ Continued behavior despite negative consequences in

major life areas

¨ Tolerance develops – more of the substance or

gambling is needed to attain same feelings

¨ Urges and cravings develop among problem

gamblers too

¨ Similar psychological drives including escape,

excitement, self-medication and avoidance

Disordered Gambling:

Comparison to Substance Abuse

Differences

¨ Gambling is not self-limiting ¨ Behavior not attributable to intoxication ¨ More intense sense of shame and guilt ¨ Greater denial and stronger defenses

Disordered Gambling:

Comparison to Substance Abuse

Differences

¨ Fantasies of success ¨ Unpredictable outcome ¨ Easier to hide (no biological tests) ¨ Problem gambler’s financial situation is often critically

damaged and must be addressed as part of treatment

Disordered Gambling:

Comparison to Substance Abuse

Differences

¨ Intensity of family anger ¨ There is much less public awareness about problem

gambling

¨ Acceptance of gambling is even more widespread

than for alcohol

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Gambling: Co-Occurring

According to the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC):

¨ 73.2% of pathological gamblers had an alcohol use

disorder

¨ 38.1% had a drug use disorder ¨ 60.4% had nicotine dependence ¨ 49.6% had a mood disorder ¨ 41.3% had an anxiety disorder ¨ 60.8% had a personality disorder ¨ 15-20% attempt suicide

Petry, NM, et al. (2005)

Gambling: Co-Occurring

Meta-Analysis (Lorains, Cowlishaw, & Thomas, 2011)

¨ Mean prevalence with problem and disordered

gambling:

¤ Nicotine Dependence (60.1%) ¤ Substance Use Disorder (57.5%) ¤ Any Mood Disorder (37.9%) ¤ Any Anxiety Disorder (37.4%)

Implications: Co-occurring

¨ ACA: Increase coverage and access, reduce

disparities

¤ More people, more issues ¨ Improve patient/client care and their experience in

the healthcare/treatment setting

¨ You already have people that are at-risk or have a

problem with gambling….you just might not be asking or looking

Getting Treatment

Addicted Problematic At-Risk

Getting Help Sooner

Addicted Problematic At-Risk

Technology: Why Discuss

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It’s In The Clues

¨ Ring tones (Monday Night Football) ¨ Apps with slots, bingo, poker (for fun) ¨ Real-time updates on the scores (sports) ¨ More and more have “devices” that can potentially

become the pathway to problem gambling Yet

¨ No wide spread social responsibility / Prevention /

“Keeping it Safe” Gambling initiatives

Technology

¨ Cell phones ¤ Smart phones ¤ Regular cell phones ¨ Devices ¤ Tablets (iPad, Kindle,

Samsung)

¤ Laptops & Computers ¤ Smartphones ¨ GPS ¤ Maps, locations, tracking

Example: iPhone

ü Transcends all socio-economic

classes

ü All age groups ü Text messaging – transformative ü The “App” store ü FaceBook & Twitter ü Check-in on Yelp or Foursquare ü Google: An Era of specific,

localized information

ü Video gaming spanning multiple

generations

All from a device formally used to dial and talk to someone

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Near Miss or Near Win?

Gambling

Screens & Assessments

LIE-BET Problem Gambling Screen

1.

Have you 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?

A YES answer to one or the other of the following two questions,

• r a YES to both questions, should indicate a need for full

assessment for problem and pathological gambling. A NO to both may indicate no gambling concerns.

Johnson, Nora et al Las Vegas VA Hospital, Nevada

Brief Biosocial Screen

Gebauer, LaBrie & Shaffer, 2010

1.

During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling?

2.

During the past 12 months, have you tried to keep your family

• r friends from knowing how much you gambled?

3.

During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare? A “yes” answer to any of the questions means the person is at risk for developing a gambling problem.

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“Do you gamble?”

¨ Not a good question to ask ¨ What does “gamble” mean to the person? ¨ Answer: “No” ¨ Question: Do you play the lottery? ¨ Answer: Every day!

“You don’t smoke, use illegal substances, or have a problem with gambling, do you?” Don’t Do This

SBIRT : A Review SBIRT

¨ (S)creen ¨ (B)rief (I)ntervention ¨ (R)eferral to (T)reatment ¨ Screening quickly assesses the severity of substance use and

identifies the appropriate level of treatment.

¨ Brief intervention focuses on increasing insight and

awareness regarding substance use and motivation toward behavioral change.

¨ Referral to treatment provides those identified as needing

more extensive treatment with access to specialty care.

GBIRT : A Response GBIRT: What is it?

¨ DIRECT ¨ Easy to administer and score ¨ “Actionable” for the professional ¨ Addresses “Gambling”

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Hooray!

GBIRT: Having the Conversation

¨ How often do you gamble? ¨ For example, buy lottery tickets, go to the casino,

play cards with friends? (endorsing any gambling activity at all – ask next series

• f questions)

GBIRT: Screen

¨ For the purpose of the next questions, “gambling”

means buying lottery tickets, gambling at a casino, playing cards or dice for money, betting on sports games, playing slot machines, video poker or other video gambling, gambling on the internet, betting on horses or dogs, playing bingo or keno. During the past 12 months have you gambled 5 or more times? ___ Yes ___ No If yes, continue to next 3 questions ---

GBIRT

In the past 12 months:

• 1. Have you tried to hide how much you have

gambled from your family or friends? Yes No

• 2. Have you had to ask other people for

money to help deal with financial problems that had been caused by gambling? Yes No

• 3. Have you ever felt restless, on edge or

irritable when trying to stop or cut down on gambling? Yes No If yes to any of these 3 questions, continue with the next 6 questions.

GBIRT: Brief Intervention

Action to Take:

¨ A “yes” response to any of questions 1, 2 or 3

results in asking all questions (4-9) and Gambling Brief Intervention

What is a Gambling Brief Intervention?

¨ Dispel myths about gambling problems ¨ Reducing Gambling (Harm Reduction) ¨ Keeping it Fun (4 of the 10 Rules) ¨ Independence of Turns / Illusions of Control exercise or

conversation

¨ Continuum (Social to At-Risk to Problem to Disordered) -

educate

¨ Discussion about technology, apps, internet ¨ Barrier: How do professionals learn this information?

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GBIRT

In the past 12 months:

4. Have you tried to cut down or stop your gambling? Yes No 5. Have you increased your bet or how much you would spend, in order to feel the same kind of excitement as before? Yes No 6. Did you think about gambling even when you were not doing it? (Remembering past gambling experiences, or planning future gambling?) Yes No 7. Did you go to gamble when you were feeling down, stressed, angry or bored? Yes No 8. Did you ever try to win back the money that you had recently lost? Yes No 9. Has your gambling caused problems in your relationships

• r with work?

Yes No

Total “YES” responses:

GBIRT: Referral to Treatment

Action to Take:

¨ A “yes” response to a total of 4 questions (out of 9)

results in a potential Gambling Brief Intervention AND Referral to Gambling Treatment

What is a Gambling Brief Intervention?

¨ Dispel myths about gambling problems ¨ Reducing Gambling (Harm Reduction) ¨ Keeping it Fun (4 of the 10 Rules) ¨ Independence of Turns / Illusions of Control exercise

• r conversation

¨ Continuum (Social to At-Risk to Problem to

Disordered) - educate

¨ Discussion about technology, apps, internet

Referral to Treatment Issues

¨ Where to refer? ¨ National Helpline - 1-800-522-4700 ¨ State Problem Gambling Departments ¨ Is treatment paid for? ¤ commercial insurance ¤ government funding (Medicaid, Medicare) ¨ Multiple providers helping 1 person ¤ Communication issues (HIPAA, consents) ¤ Transportation issues ¤ Time commitment issues

Start Simple

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Prime the Environment Indirect and Passive

¨ Prime the environment (posters, helpline) just like we

do for DV/IPV

¤ Message: We can talk about gambling here! ¨ Screen ¨ Assess (integrated): part of primary assessment ¨ Intervene (as part of other services) ¤ Examples during session, groups, & handouts ¨ Train professionals & additional referrals

How to “Keep It Fun” before it becomes a problem

10 Rules of Responsible Gaming Top 4 Rules of Responsible Gaming

¨ Gambling is viewed as 1 form of entertainment ¨ Set a dollar limit and stick to it ¨ Set a time limit and stick to it ¨ Don’t gamble on credit, borrow, or use income

meant for necessities

• 1. If you choose to gamble…

¨ Do so for entertainment purposes. ¨ If your gambling is no longer an enjoyable event,

then ask yourself why you are still “playing.”

• 2. Treat the money you lose…

¨ As the cost of your entertainment.

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• 3. Set a dollar limit

¨ …and stick to it. ¨ Decide before you go not only what you can

“afford” to lose, but how much you want to spend. Don’t change your mind after losing.

• 4. Set a time limit

¨ . . . and stick to it. ¨ Decide how much of your time you want to allow for

• gambling. Leave when you reach the time limit

whether you are winning or losing.

• 5. Expect to lose…

¨ The odds are that you will lose.

• 6. Make it a private rule…

¨ Never to gamble on credit. ¨ Do not borrow money to gamble.

• 7. Create balance in your life…

¨ Gambling should not interfere with or substitute for

friends, family, work, or other worthwhile activities.

• 8. Avoid “chasing”

¨ Lost money. ¨ Chances are the more you try to recoup your losses,

the larger your losses will be.

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• 9. Don’t gamble as a way to cope…

¨ With emotional or physical pain. ¨ Gambling for reasons other than entertainment can

lead to problems.

• 10. Become educated…

¨ About the warning signs of problem gambling. ¨ The more you know, the better choices you can

make. When GBIRT doesn’t work as intended

FUN: One Approach Digital Health Program – a pilot

¨ Targeted high risk Medicaid and Medicare individuals

with Chronic Conditions (CHF, T2D, COPD)

¨ Average age (54) ¨ Poor and vulnerable (money and health) ¨ Cultural Mistrust is High towards “professionals” ¨ Received an iPad (data plan) & weight scale during in-

home assessment

¨ Weekly video chats promoting health and education ¨ Duration: 6 months

Concerns

¨ Providing access to iPad and internet ¨ Already vulnerable population ¨ Where is the education about gambling and at-risk

gambling?

¨ Where is the social responsibility of the

• rganization if we are providing access to the

Internet and ability to download apps (bingo, slots)?

In-Home Assessment

Everyone received the GBIRT in addition to at least 10 other screens and assessments

¤ Already answering a lot of questions n Risk for falls n Depression n Cognitive impairments n Substance use & history (including nicotine) ¤ Voluntarily participating in the program n No cost to participate ¤ We have “eyes” into the person’s home (lifestyle)

3/14/16 ¡ 19 ¡

GBIRT Results – 4%

“YES” to the first question of gambling 5 or more times in the past 12 months.

Could this by right?

Cultural Mistrust: Revealed

¨ 2 months into the program ¤ Clues during video chats ¤ Celebrating birthdays ¤ Saturday Night Outings ¤ Increased data usage due to Internet-dependent

gaming (bingo via apps)

In development: Jody Bechtold, Christine Gallagher, & Karey Kerns-Yonich

FUN Assessment

FUN Assessment

¨ Series of questions with “open-ended” responses ¨ Professional codes each question based on At-Risk

behaviors (alcohol, gambling, drugs/tobacco, sex, lifestyle, etc.)

¨ Questions are mostly worded as “positive” and

“fun”

¨ Information shared was more honest and stigma-

free

¨ Used to strengthen the therapeutic relationship

FUN Assessment Questions - example

¨ How do you calm

down, unwind, relax? (open-ended answer) “I like to go to the club and play the cherry machines…but I order diet coke – no alcohol now that I have diabetes” (grin)

Not At Risk Alcohol Risk Tobacco / Drugs Risk Gaming / Gambling Risk Sexual Behaviors Risk Shopping / Spending Risk Professional records at-risk behavior

3/14/16 ¡ 20 ¡

FUN Results

Approximately 50% benefited from continuing the conversation and receiving brief interventions related to At-Risk Gambling

FUN Assessment Questions - example

¨ What do you do for

entertainment? (open-ended answer) “It’s March and I love

• basketball. I have money
• n the March Madness
• bracket. I watch every

single game.”

Not At Risk Alcohol Risk Tobacco / Drugs Risk Gaming / Gambling Risk Sexual Behaviors Risk Shopping / Spending Risk Professional records at-risk behavior

FUN Assessment Questions - examples

¨ How do you like to

celebrate?

¨ How do you calm down,

unwind, relax?

¨ What games do you like

to play?

¨ What do you do for

entertainment?

¨ When do you have the

most energy?

¨ What do you do when

you are bored?

Not At Risk Alcohol Risk Tobacco / Drugs Risk Gaming / Gambling Risk Sexual Behaviors Risk Shopping / Spending Risk Professional records at-risk behavior

Conclusions

¨ Not every screen and assessment is 100% ¨ Highlight the importance of all “at-risk” behaviors,

not just the “one” they are seeing you for Or that you are most comfortable talking about

¨ Expand your vocabulary to include “gambling” and

“gaming”

¨ Pay attention to technology devices, ring tones, etc.

• f your clients AND Ask questions

Remember

¨ Understand the “Hook” of gambling ¨ Don’t ignore the high co-occurrence rates ¨ Be aware of how you ask screening questions ¨ Be interested in how your clients use technology ¨ Prime your office/agency setting with posters and

signs about gambling

¨ Find other ways to get at the “right” answers, even

if you already screen

¨ Know when to refer to a trained specialist NCPG (National Council on Problem Gambling) and PGAM (Problem Gambling Awareness Month)

Have the CONVERSATION

3/14/16 ¡ 21 ¡

Thank You!

Jody Bechtold, LCSW, NCGC-II, BACC

Private clinician jody@jodybechtold.com & VP Clinical Affairs, Wellbridge Health, Inc. jody@wellbridgehealth.com

Ask Questions

Ask questions through the “Questions” Pane Will be answered live at the end

In Our Last Few Moments…

¨ PowerPoint Slides ¨ Certificate of

Completion

¨ On-demand

Recording

¨ Evaluation Survey ¨ Follow-up Email

http://hospitalsbirt.webs.com/problem-gambling

2016 SBIRT Webinar Series

¨

January 27th – Mini-Guide to SBIRT: An Overview of SBIRT and Resources – NOW ON-DEMAND

¨

February 17th – Integrating Adolescent SBIRT in Nursing and Social Work Education

¨

March 9th – Reducing Teen Substance Misuse: What Really Works

¨

March 16th – Gambling Screening: How to Make it Fun!

¨

April 27th – Integrating Motivational Interviewing Techniques for Brief Intervention into the Curriculum

¨

May 4th – Part IV: Using Case Studies for Integrating SBIRT into Curriculum

¨

May 23rd – Preventing Prescription Drug Abuse and Doctor Shopping: Prescribing Guidelines and Intervention Skills for Nurses and Healthcare Professionals

¨

June 22nd – Intimate Partner Violence SBIRT: The WINGS Intervention Model

hospitalsbirt.webs.com/webinars.htm

SBIRT Technical Assistance

Do you have questions about SBIRT implementation, evaluation, or training? Schedule a free telephonic Technical Assistance session with Tracy McPherson, co- lead of The BIG SBIRT Initiative.

Email Dr. McPherson at esap1234@gmail.com

Thank You for Attending!

www.sbirteducation.com