gambling in an aod context...beating the odds: how carolyn hirsh overcame her pokies addiction as a...
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Gambling in an AOD Context
Dr. Jane Oakes
DANA 2018 Australasian Conference
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I would like to acknowledge the traditional
owners of the land we meet on and pay respect
to Elders past and present and any Aboriginal
people present today
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Session Objectives
• Overview of gambling and problem gambling
• The identification of problem gambling
• Implication of AOD and gambling
• Practical ways to support people with problem gambling
behaviors
• Help referral options
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Beating the odds: How Carolyn Hirsh overcame her pokies addiction
As a psychologist and a state MP, Carolyn Hirsh warned of the addictive nature of poker machines –then herself fell under their powerful spell
https://www.smh.com.au/lifestyle/beating-the-odds-how-carolyn-hirsh-overcame-her-pokies-addiction-20151001-gjzbfp.html
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Gaming machines takeover peoples’ minds
Larry PA
“The damn machines take your mind over, your body and soul over, and that’s probably the reason why people commit suicide, because it just takes control. But it’s – what would you call it, it’s being delirious.”
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Background
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Gambling
To stake or risk money or anything of value on the
outcome of something involving chance
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Australian Gambling
• Gambling participation 63.9%
• Total gambling expenditure AUD$23.648 billion
• Land-based gambling expenditure declining
• Interactive gambling growing
• Approx AUD$1.1 billion per year gambled on regulated sites
(Dowling et al., 2015; Roy Morgan Research 2012)
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Types of gambling
Type Risk of harm
EGMs High
Racing High
Casino - Black Jack, Poker, Roulette Moderate
Sports bet Moderate
Lotteries Low
Cultural – Mahjong, Bingo, Two up Low
Rowe, C., White, M., Long, C., Roche, A., Orr, K. (2015)
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EGMS - Most addictive
• accessibility & advertising
• lights, colors, noises, alcohol
• game variety and bonuses
• frequent wins -intermittent rewards
• illusion of skill – near misses
• capacity for uninterrupted rapid play
• use of bill acceptors / easy access to funds
Finlay, Marmurek, Kanetkar, & Londerville, 2010; Reith, 2006 Dowling et al., 2005
Abbott, 2006; Dowling, Smith, & Thomas, 2005; Gainsbury, Russell, Hing, et al.,
2014a; Wardle, Moody, Spence, et al., 2011
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Problem gambling
“Problem gambling is characterised by difficulties in limiting
money and/or time spent on gambling which leads to adverse
consequences for the gambler, others or for the community”
Neal, Delfabbro and O’Neal (2005)
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Australian
• Problem gambling 0.4%
• Moderate-risk gambling 1.9%
• Low-risk gambling 3.0%
Dowling et al., (2015)
Victoria
• Problem Gambling O.8 %
• 12% total population experiencing harms
(Hare et al 2015)
Gambling Prevalence
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Vulnerable Populations
• young males
• people with debt
• low socio-economic status
• mental health issues
• indigenous
• poor physical health
• Alcohol problems
Thomas & Jackson,(2008). Delfabbro, (2002). Delfabbro, (2007).
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• financial
• relationship
• emotional or psychological distress
• decrements to health
• cultural
• reduced performance at work or study
• criminal activity
Legacy harms - occur later in life, or transferred between generations - parental poverty impacts on children over lifespanBrowne, M, Langham, E, Rawat, V, Greer, N, Li, E, Rose, J, Rockloff, M, Donaldson, P, Thorne, H, Goodwin, B, Bryden, G & Best, T (2016)
Gambling Harms
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Gambling -shame & stigma
• more publicly stigmatised than alcoholism, obesity,
schizophrenia, depression- but not drug addiction
• gamblers fault - lack of self-control
Therefore:
• significant shame, self-stigma, disappointment in self,
embarrassed, weak
• secrecy main coping mechanism - self-help most common
• relapse worsens self-stigma and shameHing, N., Russell, A., Nuske, E., Gainsbury, S. (2015)
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• The gambling behavior is not better explained by a manic
episode
• Persistent /recurrent problematic gambling behavior – clinically
significant impairment / distress, as indicated by the individual
exhibiting 4+ of following in a 12-month period:
DSM-5 Diagnostic Criteria: Gambling Disorder
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• Needs to gamble with increasing amounts of money
• Restless or irritable when attempting to cut down or stop gambling.
• Made repeated unsuccessful efforts to control, cut back, or stop gambling.
• Preoccupied with gambling
• Gambles when feeling distressed
• After losing money gambling, often returns another day to get even (“chasing”)
• Lies to conceal extent of gambling involvement
• Jeopardized or lost significant relationship, job, educational or career opportunity
because of gambling
• Relies on others to provide money to relieve desperate financial situations caused by
gambling
DSM-5 Diagnostic Criteria: Gambling Disorder
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The Problem Gambling Severity Index (PGSI)
Maximum=27
PGSI Score
Non-problem gambler
(0)
Low risk gambler
(1-2)
Moderate risk gambler
(3-7)
Problem gambler (8+)
1• Have you bet more than you could really afford to lose?
2• Have you needed to gamble with large amounts of money to get the same feeling of
excitement?
3• When you did gamble, did you go back another day to try to win back the money you lost?
4• Have you borrowed money or sold anything to get money to gamble?
5• Have you felt that you might have a problem with gambling?
6• Has gambling cause you any health problems, including stress or anxiety?
7• Have people criticized your betting or told you that you have a gambling problem, regardless
of whether or not you thought it was true?
8• Has your gambling caused any financial problems for you or your household?
9• Have you felt guilty about the way you gamble or what happens when you gamble?
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Early Detection
If your client is presenting with symptoms of depression and anxiety, addictions or family, social and financial problems, asking the following two questions can help in determining whether gambling may be a problem.
Screens need to be short and effective
Have you ever had an issue with your gambling?
Or
Has anyone in your family ever had an issue with gambling?
If the client answers yes undertake an assessment or refer for a more thorough assessment
(Thomas et al., 2008)
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Problem Gambling and Mental Health Problems
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Prevalence of mental health in Problem gamblers (PGs)
Systematic review & meta-analysis - PGs in general population • 57% substance use disorder
• 38% mood disorder (any)
• 37% anxiety disorder (any) (Lorains et al,. 2011)
Systematic review & meta-analysis - Treatment seeking studies• 75% of treatment seeking gamblers report co-morbid DSM Axis I disorders
• 23% co-morbid mood disorder
• 18% alcohol use disorder
• 7% substance (non-alcohol) use disorder
• 48% have a personality disorder (Dowling et al., 2015)
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PG prevalence - Victorian community-based mentalhealth services N = 837
• Gambling participation rate 41.6%
• Participants with current drug use disorder diagnosis - more-than-fourfold increase in risk of problem gambling
• Low-risk gamblers (highest proportion) identified as hazardous drinkers
Manning, V., Dowling, N. A., Lee, S., Rodda, S., Garfield, J. B. B., Volberg, R., ... & Lubman, D. I. (2017)
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One in Two
• One in two mental health patients who gamble experience gambling related harm
• 6 % mental health patients have problem gambling
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AOD and problem gambling
4 times more likely to have problems with alcohol
30-46% report drug use disorders
More than 25% experienced both alcohol use disorders and
severe mental health disorders
Thomas, S. A., & Jackson, A. C. (2008).
Townshend, P., Dowling, N., Rodda, S., & Legge, B. (2014).
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• exacerbate gambling problems: increase amount prepared to
bet
• more disinhibited & have less cognitive control
• less likely to stop once started gambling
• ability to evaluate costs / benefits /understand games rules
compromised
• AOD – escape distress gambling losses
Ministerial Council on Drug Strategy. (2010)
French, M. T., Maclean, J. C., & Ettner, S. L. (2008)
AOD and Gambling
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• Higher levels depression, anxiety, suicidal ideation, and dissociation (Delfabbro, 2007)
• Suicidal ideation and suicide attempts among individuals with pathological gambling 20% to 40% (Kausch, 2003 Blaszczynski & Farrell, 1998; DeCaria et al., 1996)
• Suffer higher rates of depression
• Suicidal thoughts 48-79% in clients with problem gambling and co-morbidity
• Suicide attempts 12-20 % (Rugle, 2000)
Depression / Suicide
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Rates of suicidal ideation(thoughts and plan) but not lifetime attempts were significantly higher among gambling than substance use patients
Manning et al, 2015, Psychiatry Research
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Risk Assesment
“oh my God, you really, really did lose that amount of money”
“I got a bank statement which showed me what I’d earned and what I still
had in the account and it was like ‘oh my God, I can’t possibly have earned
that amount of money and spent that amount of money’ and I did ……. control
was gone and I didn’t realise it was gone until I had that bank
statement sitting in front of me going ‘oh my God, you really, really
did lose that amount of money”
Colleen
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Family violence andgambling-related harm
Family violence three times more likely to occur in families
where gambling is a problem
(Dowling, Ewin, Youssef, Thomas & Jackson In preparation)
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Differences Domain Alcohol Gambling
Reason for continued use Avoid withdrawal symptoms Desire to win back losses
Signs dependence Physiological signs eg smell No physical - secretive
Overdose/Excessive use Biological consequences Lose +++ money quickly
Service recognition Screened Unrecognised /unscreened
Help seeking Rates vary Low rates
Speed of harm Can take time for problems to
develop
Incur harms quickly
Rowe, C., White, M., Long, C., Roche, A., Orr, K. (2015). Slots and Shots: A Gambling Resource for AOD Workers. Odyssey House Victoria, Melbourne, Victoria.
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Dopamine and Gambling
• The behavioural, cognitive, and neurobiological profiles resemble those whom
have addiction to alcohol and/or substances, particularly stimulants
• Secretion of dopamine in the ventral striatum is a function of gambling severity
and excitement level
(van Holst et al., 2018)
• The neurotransmission of dopamine in the mesolimbic prefrontal cortex has been
implicated in gambling, which reinforces the conditioned relationship between
gambling and reward
(van Holst, van den Brink, Veltman, & Goudriaan, 2010)
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Harm Reduction
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Relapse Study (Battersby et al 2010)
Significant predictors of problem gambling and relapse
Relapse and continuing to gamble:
Gambling urge
Gambling related cognitions
Urges Powerful and overwhelming
(Blaszczyncki et al, 1986, Freidenberg et al, 2002 & Kushner et al, 2007)
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External Triggers:
Classical Conditioning
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Operant Conditioning –
reward learning
Tension relief
Money – winning
Free drinks and food
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Gambling
Uncontrollable urge
(Battersby et al., 2008)
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Gambling reduces the urge temporarily and reinforces the gambling behaviour
0
2
4
6
8
0 4 8 11.5 15 18.5
Urge
Time
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Allowing the urge to peak and subsidethe strength of the trigger is weakened
0
2
4
6
8
0 6.8 7.35 4.5 2 0
Urge
TimeTrigger
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0
2
4
6
8
0.00 6.80 7.35 4.50 2.00 0.00
Urge
Time
Each time the urge passes and the person resists gambling the power of the urge reduces and subsides with repeated practice
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Faulty Cognitions –Cognitive Therapy
PGs believe they can predict or control the outcome of a bet
• These types of thoughts may include
• Thinking the odds are in your favour
• Playing on certain machines increases your odds
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Changing the thoughts
• What evidence do I have for this thought?
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Harm Reduction
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Distress
level
Time with clinician
10
9
8
7
6
5
4
3
2
1
0
Workable Zone
Increased distress
Continued gambling
Self-harm
Severity of situation
minimised
Perceived permission to
continue gambling
Extreme distress
Relaxation
Managing Distress (Oakes et al 2016)
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Money Management
GHO – information • Financial counselling
• Weekly budget - a running tally of true wins and loses
• Have wages electronically paid into a bank account
• Unlink accounts, lower withdrawal limits 2 signatures
• Cancel the redraw facility on the home loan
• Keep money in a place that is difficult to access
• Visa Gift card
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Harm Reduction
• Negative affect / Risk Assessment
• Management of gambling urge
• Support Important - professional / personal
• Money / debts - financial assistance can be a problem
• Examination of permission giving cognition's
• GHO – information
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Gambling Help Online
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Gambling help Online provides free:
• 24 hour live counselling
• 24 hour email- based counselling
• Online peer support community
• Self Help Tools and Modules
• Range of web based self-help information and referral and support materials
• Blogs
• SMS support
• Face book site
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Contact Details
Dr Jane Oakes
M: 0432 224 939