problem gambling treatment for adolescents jeffrey l. derevensky, ph.d. professor & director of...
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Problem gambling treatment for adolescents
Jeffrey L. Derevensky, Ph.D.
Professor & Director of Clinical Training School/Applied Child Psychology
Professor, Psychiatry
International Centre for Youth Gambling Problems and High-Risk Behaviors
McGill Universitywww.youthgambling.com
Some context
The Changing Face of Gambling
Today! Our new field of dreams…
Problem Severity Continuum
No gambling
At-Risk
gambling
Social g
ambling
Problem gamblin
g
Pathologica
l gamblin
g
Compulsive gamblin
g
Disord
ered gambling
Today…GAMBLING (gaming) has become normalized in our society
Slots for kids Slots for adults
Gambling (gaming) has become glamorized
Gambling camp
Is gambling a problem?
Gambling campGambling camp
Gambling (gaming) has become Gambling (gaming) has become glamorizedglamorized
New Forms of Gambling: Concerns?
Poker’s heroes
Joe Cada, age 21, Community College dropout, winner World Series of Poker, 2009, $8.55 million
Jonathan Duhamel, age 23, University dropout, winner World Series of Poker, 2010, $8.944 million
Pius Heinz, age 22, University Student, winner World Series of Poker, 2011, $8.72 million
Greg Merson, age 24, University dropout, winner World Series of Poker, 2012, $8.528 million
Ryan Reiss, age 23, wins $8.36 million in 2013 WSP
recent college grad
“I’ve been dreaming about it a long time, ever since I was 14 and saw (Chris) Moneymaker win it.”
The new face of Internet gambling
Understanding youth problem gambling: Twenty+
years of research
Gambling
• Gambling is more popular amongst males than females
• Youth problem gambling prevalence rates range from 2%-10%
• Young adults (18-25) have the highest prevalence rates amongst adults
• Adolescent prevalence rates of problem gambling are 2-4 times that of adults
• Gambling has become a family activity
• Gambling venues are easily accessible
• Most individuals view gambling as a socially acceptable and enjoyable form of entertainment, significantly less harmful than alcohol, drugs or cigarettes
• People are easily influenced and lured by advertisements
• Young people believe gambling to be a relatively benign activity:
– 40% believe that playing cards for money is harmless even when played at least once a week
– 37% believe that teens should be allowed to use EGMs
– While 72% agree that gambling can be bad for you, there remains 28% of participants who either disagree or are neutral in this matter
• Few young people fear getting caught gambling
Percentage of young people who fear being caught while gambling (N=1294)
44
26
1710 9.1 8.6
0
10
20
30
40
50
60
70
80
90
100
grade 4 grade 6 grade 7 grade 8 grade 9 grade 11
(Gupta & Derevensky, 1998c)
• The majority of youth believe that tricks, strategies and practice will result in more success
– 56% agree that there are tricks or strategies associated with becoming a successful gambler
– 40% agree that the more you practice the better you get at gambling
• Individuals are bombarded with gambling advertisements
– 42% of young adults influenced by the ad-they want to try it
– 61% imagine/dream what winnings could buy
– 35% report wanting to gamble after viewing an ad
• 79% males; 57% age 16-18
• Perceptions– 68% of young people report winning is easy– 60% report probability of winning is high– 81% gambling can make you rich
Indiviudals experiencing gambling problems…
• are more likely to be males
• are greater risk-takers
• have poor general coping skills
• report beginning gambling at earlier ages, approximately 10 years of age
• move from social gambler to problem gambler quite quickly
• more likely to gamble after seeing an advertisement for gambling
• report lower self-esteem compared with others
• have higher rates of anxiety and depression
• dissociate more frequently when gambling
• are at heightened risk for suicide ideation and suicide attempts
• increased criminal behavior
• disruption of familial relationships
• decreased academic performance (if still in school)
• report having a support group, however, ‘old’ friends are often replaced by gambling associates
• score higher on measures of excitability, extroversion, impulsivity and anxiety & lower on conformity and self-discipline measures
• score lower on a measure of resiliency in light of risk factors
• remain at increased risk for the development of an addiction or multiple addictions
Reported percentage of substance use (past year) according to gambling severity (N=817))
0
10
2030
4050
6070
80
90100
alcohol drugs smoking
no problem gambler
social gambler
gambler with some problems
probable pathological gambler
* grades 7, 9, & 11
• have been shown to have experienced more major life events and early childhood traumas and abuse (physical, sexual, verbal)
• more likely to have parents with either a gambling problem, some form of mental health issues or substance abuse
• display significant cognitive distortions compared to peers when gambling
• see both the benefits AND risks associated with excessive gambling
Attitudes and perceptions of adolescent risky behaviors
40%
60%
64%
64%
66%
66%
73%
75%
81%
81%
82%
87%
Gambling (13)
Depression (12)
Excessive video game playing (10)
Negative body image (10)
Spending too much time online (8)
Obesity, eating disorders (8)
Smoking (7)
Violence in schools, bullying (6)
Unsafe sexual activities (3)
Drinking and driving (3)
Alcohol use (2)
Drug use (1)
Parental perceptions: Serious Youth Issues
A comparison of parents and teachers perceptions
concerning adolescent risky behaviours
Mental health professionals’ beliefs about the seriousness of youth issues
Figure represents responses “serious” and “very serious”
ProblemGambling
ConductDisorder
ADHD
DepressionDrug
Dependence
OtherDisorders
AlcoholDependence
Is Problem Gambling A Primary Disorder?
Problem Gamblers
Helping adolescents with a gambling
disorder
Therapeutic Therapeutic approachesapproaches
Cognitive-Behavioral TherapyCognitive-Behavioral Therapy Motivational EnhancementMotivational Enhancement Psychodynamic/ Psychoanalytic TherapyPsychodynamic/ Psychoanalytic Therapy Pharmacological TreatmentsPharmacological Treatments Pathways ModelPathways Model
Attracting adolescents
Overarching philosophy (Pathways Model – Blaszczynski 2000; Nower & Blaszczynski, 2004)
• All problem gamblers are not alike.• There are different pathways to problem
gambling.• Gamblers in each pathway differ by the
presence or absence of psycho-social, biological factors and behavioral manifestations
• Gamblers in different pathways require different treatment strategies for success.
Common thread….. Maladaptive Coping
• Maladaptive coping styles tend to be associated with excessive involvement in gambling, regardless of pathway.
• People with gambling problems may use more emotion and distraction-oriented coping skills, and are less task-oriented in their problems-solving approach.
Coping as a mediating factor
Off-kilt physiological resting state Maladaptive coping
Psychological nature characterized by unhealthy
feelings, either due to trauma, loss, or poor
upbringing.
Addictive behavior
Phases of intervention
• Assessment
• Treatment
• Relapse prevention
AssessmentAssessment DSM-5 criteria -semi-structured interview DSM-5 criteria -semi-structured interview
(impaired control is important to assess)(impaired control is important to assess)
Establish baseline:Establish baseline:- frequency- frequency- length of play- length of play- money spent- money spent
Assess for comorbidity and relevant correlates• Conduct a thorough assessment of:
– personal history (i.e., traumas)
– family and educational history
– social/peer status
– underlying depression, anxiety, attention deficit disorder, substance use & other problems
• Identification of coping styles
• Identification of risk situations/ triggers
Assess for comorbidity and relevant correlates
• Identification of cognitive distortions
• Comorbidity
• Identification of gambling triggers
• Discussion of reasons underlying the need to gamble.
• Discussion of gambling as a consequence of the need to escape and feel better.
• Emphasize that it must be their decision to stop gambling.
• Discussion of abstinence vs. reduction.
Evaluate consequences
1. Effects on family
2. Impact on work, school
3. Change in mood and personality
4. Secrecy, rule- & law-breaking activities
Assess Motivation• It is important to assess the level of
motivation for change as this can help direct intervention. (DiClemente model)
• Match intervention to stage of change and identified skill deficit (if any)
Assessing readiness for change
Stage 1: Pre-contemplationgambling is not seen as a problemListen, acknowledge & validateContextualize problems & emphasize choice
Stage 2: Contemplationbeginning to think about modifying gambling Objective feedback on (-) consequencesPromote reflection (Pros & Cons)
Stage 3: Preparationdecided to change gambling behaviorProvide information about intervention optionsStick to their change agenda
Stage 4: Actiontakes steps to stop the gamblingSet incremental & feasible goalsDevelop strategies to reach goalsReinforce any positive change
Stage 5: Maintenancewillingness to accept continued work to sustain
initial changesReinforce gainsRelapse prevention
Stage 6: Terminationgambling no longer represents a temptation
or problem
ESSENTIAL THERAPEUTIC GOALS
• Understand motivations for gambling• Acceptance of gambling as a problem• Identifying underlying stressors• Enhance coping skills• Identifying and clarifying the irrationality of
thought processes when gambling • Facilitate the building of healthy support systems • Help with the structuring of free-time• Help create a debt repayment plan• Relapse prevention plan
Subgoals of therapySubgoals of therapy Reduce anxiety (restlessness,anxiety attacks…)Reduce anxiety (restlessness,anxiety attacks…)
Reduction of depressive symptoms (loss of Reduction of depressive symptoms (loss of appetite, difficulty sleeping, lack of activities…)appetite, difficulty sleeping, lack of activities…)
Reduction in antisocial behaviors (delinquent Reduction in antisocial behaviors (delinquent behaviors, lying, stealing, cheating… )behaviors, lying, stealing, cheating… )
Reduction in excessive use of alcohol or drugsReduction in excessive use of alcohol or drugs
Address Underlying Issues
• ADHD/Impulse control problems• Low-self esteem• Learning problems• Mood disorders (depression/anxiety)• Substance abuse disorders• Dysfunctional family• Loss
ESTABLISH IMMEDIATE CAUSES OF STRESS & ANXIETY
• Conflict with spouse/ parents/ friends/ peers/significant others
• Fears• Post traumatic stress reactions• Inability to conform to norms (i.e., sitting still at a
desk all day)
TRIGGERSTRIGGERS
EMOTIONAL REACTIONS AND RATIONALIZATIONSEMOTIONAL REACTIONS AND RATIONALIZATIONS
BEHAVIORBEHAVIOR
CONSEQUENCESCONSEQUENCES
Analysis of A Gambling EpisodeAnalysis of A Gambling Episode
Increase repertoire of coping & problem solving skills through cognitive behavioral therapy
• Role playing
• Assignments
ADDRESSING COGNITIVE DISTORTIONS
• Negative expected winnings (Law of D.R.)Believing that persistence will pay offDiscounting house cut
• Independence of events/turnsMaking links between key events (near miss)
• Illusion of controlBelief that outcome can be influencedPicking lottery numbers
FAMILY INVOLVEMENT• Strengthening of relationships with family
members.
• Building social support systems for the adolescent. This can include involving parents, siblings, and close friends in the treatment process.
RESTRUCTURE FREE TIME & SUBSTITUTE ACTIVITIES
Lifestyle
WeekWeek Independent Independent thinkingthinking
Proper Proper nutritionnutrition ExerciseExercise SchoolSchool WorkWork SocializingSocializing TotalTotal
Sept Sept
8-148-148/108/10 7/107/10 10/1010/10 6/106/10 8/108/10 8/108/10 78%78%
SeptSept
15-2115-219/109/10 8/108/10 7/107/10 8/108/10 0/100/10 10/1010/10 70%70%
SeptSept
22-2822-289/109/10 9/109/10 10/1010/10 8/108/10 7/107/10 9/109/10 87%87%
Money Management Skills
• Reframing the value of money
• Budgeting skills
• Debt repayment
Therapeutic tools• Incorporate an eclectic and flexible approach.
• Use significant individuals (i.e., parents, siblings, friends) in the adolescent’s environment as a support network.
• Work in conjunction with a psychiatrist or general physician.
• Provide a “reality check”. Adolescents have a distorted perception of the amount of money and time they spend gambling.
Create therapeutic tools to monitor change
Gambling activity
$-253$-253 5 Days5 Days VLT and VLT and cardscards BaselineBaseline
$ -300$ -300 3 Days3 Days VLTVLT Improvement on Improvement on frequencyfrequency
Amount # daysSpecific games Progress
Sept 10- 16
Sept 17- 23
Progress ChartWeekWeek Staying Staying
awakeawakeProper Proper nutritionnutrition
ExerciseExercise School School workwork
WorkWork SocializingSocializing TotalTotal
Feb Feb
7-137-13
3/103/10 4/104/10 2/102/10 0/100/10 6/106/10 1/101/10 25%25%
April April 8-148-14
8/108/10 7/107/10 10/1010/10 6/106/10 8/108/10 8/108/10 78%78%
April April 15-2115-21
9/109/10 8/108/10 7/107/10 8/108/10 0/100/10 10/1010/10 70%70%
AprilApril
22-2822-28
9/109/10 9/109/10 10/1010/10 8/108/10 7/107/10 9/109/10 87%87%
Final outcome• Once therapy is completed the adolescent
should be abstinent for several months.
• Success is not complete until the adolescent had adopted a healthy lifestyle. This includes maintaining friendships with individuals who would not be considered to be a ‘negative’ influence. Newly acquired coping skills should result in enhanced emotional stability.
• The adolescent should be aware of his or her ongoing high risk for relapse. In the ideal setting the individual will choose abstinence over controlled gambling.
• Relapse prevention is critical-problem solving, coping and adaptive behaviors.
• Minimizing stress (which is a non-specific activation of a variety of problems, including relapse) – some clinicians believe that uncontrollable stress may be particularly disruptive.
• Reducing proximity to gambling venues, which serve as a cue
• Avoiding association with gambling friends or those still involved in the lifestyle, who may serve as a cue
Models of relapse prevention Models of relapse prevention frequently emphasize the following:frequently emphasize the following:
• Moderating conversation about gambling, since conversation can serve as a cue for craving or relapses
• Time management
• Information about where people can go for help or more information on problem gambling (i.e., treatment agencies, 24-hour hotlines)