PROBLEM GAMBLING. Education and Treatment in a Residential Setting. Facilitator s Guide

Transcription

1 PROBLEM Education and Treatment in a Residential Setting GAMBLING Facilitator s Guide

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3 Problem Gambling Education and Treatment in a Residential Setting Facilitator s Guide

4 ii Problem Gambling: Education and Treatment in a Residential Setting Problem Gambling: Education and Treatment in a Residential Setting Facilitator s Guide isbn: (PRINT) isbn: (PDF) isbn: (HTML) isbn: (epub) Printed in Canada Copyright 2009 Centre for Addiction and Mental Health, Toronto ON Facilitators offering this program have permission to download the manual and copy and distribute the handouts for use by participants. Otherwise, no part of this work may be reproduced or transmitted (for profit or otherwise) in any form or by any means electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system without written permission from the publisher except for a brief quotation (not to exceed 200 words) in a review or professional work. 4044/

5 Problem Gambling: Education and Treatment in a Residential Setting iii Contents Introduction 1 Why Is It Important to Talk about Gambling and Problem Gambling with Clients Who Have Mental Health and/or Substance Use Problems? 2 How Is the Program Delivered? 3 Screening for Problem Gambling 3 Program Evaluation 4 Acknowledgments Session-by-Session Guide 7 Session 1: Gambling and Problem Gambling 23 Session 2: Understanding Gambling 35 Session 3: Goal Setting and Identifying High Risk-Situations 41 Session 4: Developing Coping Strategies For High-Risk Situations 49 References

6 iv Problem Gambling: Education and Treatment in a Residential Setting Appendices 53 Appendix A: Problem Gambling Severity Index 55 Appendix B: Sessions 1 and 2: Pretest/Post-test 61 Appendix C: Problematic vs. Non-Problematic Gambling 63 Appendix D: Reducing the Risk 65 Appendix E: How to Choose Your Gambling Goal 67 Appendix F: My Goal Statement 69 Appendix G: Self-Monitoring Gambling or Urges to Gamble 71 Appendix H: Gambling Triggers 73 Appendix I: Facilitator s Evaluation

7 Problem Gambling: Education and Treatment in a Residential Setting 1 Introduction The Problem Gambling Project at the Centre for Addiction and Mental Health (camh), in collaboration with the Georgianwood Concurrent Disorders Program at the Mental Health Centre Penetanguishene, is delighted to offer this problem gambling education and early treatment program for clients who are in a residential mental health and/or substance use setting. This program is intended to help clinicians inform clients with mental health and/or substance use problems about the potential risks associated with gambling and to provide some preliminary interventions for those clients already engaging in problematic gambling behaviour. Why Is It Important to Talk about Gambling and Problem Gambling with Clients Who Have Mental Health and/or Substance Use Problems? Research shows a correlation between mental health problems, particularly depression and anxiety, and problem gambling. Research also shows a correlation between substance use problems and problem gambling. Gambling can be a potential trigger for substance use and/or mental health relapse. People tend to be unaware of the risks associated with gambling.

8 2 Problem Gambling: Education and Treatment in a Residential Setting How Is the Program Delivered? The program comprises four sessions delivered by clinicians in a group setting, and includes this facilitator s guide, PowerPoint presentations and participant handouts, all available free for download at You will also need a laptop computer, lcd projector, Internet access, flipchart and markers to deliver this program. Although a basic understanding of problem gambling is beneficial, it is not required to deliver this program. The facilitator s guide offers clinicians all the information needed to deliver the program. The content from the PowerPoint slides appears in bold in this guide, and is accompanied by supporting notes for the facilitator. In certain areas, the facilitator is also provided with additional information or is directed to further readings. Depending on the number of participants and the amount of group discussion, each session will take between 60 and 90 minutes. Sessions 1 and 2 take a prevention and education approach toward gambling and are intended for all clients. They provide information about gambling that is suitable for everyone, regardless of their involvement in gambling. Session 1 focuses on introductory information including: how gambling and problem gambling are defined; what activities are considered gambling; prevalence rates of gambling and problem gambling; risk factors for developing a gambling problem; the impact of problem gambling; how gambling and substance use are connected; how gambling and mental health are connected; and a comparison of problematic and non-problematic gambling. Session 2 focuses on: how games of chance work; false beliefs and superstitions associated with gambling; and strategies for reducing the risk of developing a gambling problem. Sessions 3 and 4, on the other hand, are intended for clients who are concerned about their gambling, or who have been identified as having problems related to their gambling. These sessions provide clients with a little more insight and awareness into their gambling difficulties, and help them to identify their personal triggers and learn new skills for how to deal with these triggers. Session 3 focuses on: how to set realistic gambling goals; and how to identify personal gambling triggers.

9 Problem Gambling: Education and Treatment in a Residential Setting 3 Session 4 focuses on: how to develop coping strategies to deal with gambling triggers; and helpful resources. Sessions 3 and 4 offer clients support around gambling while they are in a residential treatment program for their substance use and/or mental health concerns. Once they leave residential treatment, however, clients should be encouraged to continue to get support around their gambling. Over 55 specialized problem gambling treatment services are available, free of charge, throughout Ontario. Clients should be strongly encouraged to follow up with their local treatment provider once they return home. To find out where services are available in specific regions, contact the Ontario Problem Gambling Helpline at Screening for Problem Gambling Because of the correlation between mental health problems and problem gambling, as well as between substance use problems and problem gambling, screening for problem gambling among mental health and/or substance use clients is very important. The Problem Gambling Severity Index (pgsi), which is included in this guide (Appendix A), is a simple and easy-to-use gambling screening tool. Participants can complete it: prior to the delivery of this program: you may choose to screen all clients when they are initially admitted to your program; or during Session 1: you may choose to screen clients after you present the Continuum of Gambling Behaviour (slide 19). Anyone who scores 3 or higher should be encouraged to attend Sessions 3 and 4. Program Evaluation This program was pilot tested and was evaluated using a pretest and a post-test. Results from the evaluations were: pretest mean of 60% post-test mean of 76%. The pretest/post-test is available in this guide (Appendix B), so that you can measure clients learning as a result of participation in this program. Also included is a Facilitator s Evaluation form. Your feedback is important to us. Please take a few moments to complete the form (Appendix I).

10 4 Problem Gambling: Education and Treatment in a Residential Setting Acknowledgments Project leader: colleen tessier, senior project co-ordinator, Problem Gambling Project, camh Written by: chantal dubois, problem gambling therapist and trainer, Problem Gambling Project, camh, and dr. shari mckee, psychologist, Georgianwood Concurrent Disorders Program, Mental Health Centre Penetanguishene We would like to thank the following people for their contributions to the content: gary hoskins, problem gambling therapist and trainer, Problem Gambling Project, camh rena tennant, student, Georgianwood Concurrent Disorders Program, Mental Health Centre Penetanguishene We would also like to thank the following people for their support with this project: dr. daniela lobo, psychiatrist, camh stephen meredith, senior project coordinator, Problem Gambling Project, camh lisa pont, problem gambling therapist and trainer, Problem Gambling Project, camh janine robinson, problem gambling therapist and trainer, Problem Gambling Project, camh

11 Problem Gambling: Education and Treatment in a Residential Setting 5 Session-by-Session Guide

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13 Problem Gambling: Education and Treatment in a Residential Setting 7 Session 1 Depending on the number of participants and the amount of group discussion, this session will take between 60 and 90 minutes. For this session you will need: laptop computer and lcd projector Session 1 PowerPoint presentation participant handouts: - Problem Gambling Severity Index (Appendix A) - Problematic vs. Non-Problematic Gambling (Appendix C) - Session 1 PowerPoint presentation Slide 2 Gambling and Problem Gambling This first session focuses on introductory information including: how gambling and problem gambling are defined; what activities are considered gambling; prevalence rates of gambling and problem gambling; the risk factors for developing a gambling problem; the impact of problem gambling; how gambling and substance use are connected; how gambling and mental health are connected; and a comparison of problematic and non-problematic gambling.

14 8 Problem Gambling: Education and Treatment in a Residential Setting Slide 3 Why Is It Important to Talk about Gambling and Problem Gambling? People tend to be unaware of the risks associated with gambling. Unlike other high-risk activities, such as drinking and other drug use, smoking, impaired driving or unprotected sex, people are not always aware of the potential risks associated with gambling. As we will see throughout these sessions, gambling can lead to a variety of negative consequences such as financial troubles, relationship problems and physical and mental health issues, just to name a few. Gambling can be a potential trigger for substance use and/or mental health relapse. Because gambling can lead to a variety of issues such as financial loss, it may also trigger mental health problems like anxiety and depression. In addition, some individuals may turn to substances as a way of coping with negative feelings brought on by gambling. There is a link between mental health and substance use problems and problem gambling. Research shows that rates of mental health and substance use problems are higher among those experiencing problems related to gambling. In addition, rates of problem gambling are higher among those experiencing problems related to their substance use or mental health. There are some common biological factors shared by substance and gambling dependence. We all learn through reward and punishment, but for some people the reward system of the brain works a bit differently. These individuals are able to take more risks and are less sensitive to reward. As a result, it is believed that they are at increased risk for addictions (Chambers et al., 2003). Slide 4 Gambling Definition Gambling is defined as risking something of value on an event that is determined mostly by chance. A person is gambling if: he or she puts up something of value, such as money or property Although for the most part money is used for wagering, things such as jewelry, electronics and clothing can also be used. the outcome has an element of chance beyond the person s control We will focus on chance and how gambling games work in Session 2.

15 Problem Gambling: Education and Treatment in a Residential Setting 9 once the bet is made, it is irreversible. Irreversibility is an important part of the definition of gambling because if a bet were reversible, there would be no negative consequences. Some people generalize the definition of gambling and say, for example, that getting married is a gamble. But would getting married meet our definition? It is true that people risk something of value when they get married and the outcome is uncertain. But is this decision irreversible? No. If after getting married a person decides that he or she is not satisfied with the outcome, the situation is reversible. Slide 5 Types of Gambling Activities Note to facilitator: If time allows, you could ask the group to brainstorm the various types of gambling activities. For additional information on gambling games available in Ontario, visit the OLG website at It s important to stress that gambling is more than just casino games. In the same way that some people view different substances as more or less dangerous or serious, people may say the same of gambling. They may say things such as, I don t go to the casino, I just play bingo. The reality is that, despite the fact that some gambling activities appear to cause more problems for people, all gambling has some degree of risk associated with it. Lottery, scratch, pull-tab and raffle tickets Lotteries are the most popular form of gambling among adults in Ontario. There are over 10,700 lottery retailers in Ontario. Bingo Bingo has changed a lot over the past few decades. New technology now allows bingo halls to link to each other. This means games are played at the same time, resulting in jackpots that are substantially larger. In addition, some locations now offer electronic terminals with touch screens that assist players in playing several bingo cards at once. Sports betting The Ontario Lottery and Gaming Corporation (olg) offers individuals the opportunity to bet on certain sports (hockey, football, baseball, soccer, college football and basketball) through Pro-line. In addition, some people may place bets with bookies or simply participate in sports pools with friends or co-workers. Slot machines Slot machines are the most problematic gambling activity for Ontario adults. In fact, 60% of people experiencing gambling problems in Ontario have problems with the slots (Williams & Wood, 2004). In Ontario, slot machines are found in casinos as well

16 10 Problem Gambling: Education and Treatment in a Residential Setting as in racetrack venues. In other Canadian provinces, video lottery terminals (VLTs) are also available. Suggested reading: For more information on slot machines and VLTs, read How Do Slot Machines and Other Electronic Gambling Machines Actually Work? by Nigel Turner and Roger Horbay, available at: Card and table games Table games include things such as craps and roulette, while card games include games such as poker and blackjack. In Ontario, card and table games can be played at casinos. Some people also engage in private games at home or in social clubs. Horse betting Betting on horse races has a long history in Canada. Before casinos and lotteries were introduced, horse racing was the only legal gambling activity available in Canada. These days, horse racing has expanded far beyond placing bets at a local track. Technology now gives people the opportunity to place bets on horse races happening anywhere in the world. Internet gambling Online betting opportunities are endless. For example, a Google search for online gambling sites produces tens of thousands of results. People can bet on casino games, sports activities or bingo. People can also gamble on activities such as who will be the next person voted off on Survivor, which movie will win best picture at the Oscars and whether a pregnant actress will have a boy or a girl. Stock market speculation This activity involves purchasing stock with the sole purpose of selling it to someone else at a higher price. This is different from investing in that the speculator takes higher risks in the hopes of making a profit, while an investor looks at the value that logically may accrue over time. Betting on other games People can also engage in less formal gambling activities such as betting on a game of golf, a new baby s date of birth or the winner of a reality television program. Slide 6 Problem Gambling Definition Gambling is a problem when it disrupts or damages your: work, school or other activities; mental or physical health; finances;

17 Problem Gambling: Education and Treatment in a Residential Setting 11 reputation; relationships with family or friends. Note to facilitator: It is important to note that problem gambling is not just about losing money it can affect a person s entire life. Another important issue to consider is language. The term that we use here is problem gambling. It is important for you to be familiar with the different terms used in the field, and why we chose this one in particular. The three most common terms used to describe over-involvement in gambling are compulsive gambling, pathological gambling and problem gambling. Compulsive gambling is a term familiar to the general public and used by Gamblers Anonymous. The term is not entirely accurate because gambling is not a compulsive disorder. It is classified as an impulsecontrol disorder in the DSM-IV; however, there is disagreement in the field about whether gambling belongs in this category. Pathological gambling is the diagnostic term used in the DSM-IV. Pathological gambling is defined as a maladaptive practice characterized by persistent and repetitive playing that is present when clients meet five or more of the following criteria: - they are preoccupied with gambling; - they need to gamble with increasing amounts of money to attain the desired state of excitement; - they have repeatedly and unsuccessfully attempted to control, cut back or stop gambling; - they are restless or irritable when attempting to cut down or stop gambling; - they gamble as a way of escaping from problems or relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety or depression); - after losing money gambling, they often return another day to get even; - they lie to family, a therapist or others to conceal the extent of their gambling; - they have committed illegal acts such as forgery, fraud, theft or embezzlement to finance gambling; - they have jeopardized or lost a significant relationship, job or educational or career opportunity because of gambling; or - they rely on others to provide money to relieve a desperate financial situation caused by gambling. Note: A person who meets five or more of the above criteria is not considered to be a pathological gambler if his or her actions can be explained by a manic episode. Problem gambling is the term that is most commonly used throughout Canada. It is descriptive and is compatible with the notion that this problem can be very significant or very minor. People do not have to lose everything in their lives before getting help for problem gambling. Therefore, the term is broader and more inclusive. It is often used to describe gambling behaviour that involves some type of harmful consequence. Problem gambling includes, but is not limited to, compulsive and pathological gambling. It is the most effective term because it does not label or stigmatize the person with the problem in the way pathological or compulsive can.

18 12 Problem Gambling: Education and Treatment in a Residential Setting Why does it matter what we call it? The behaviour gambling problematically is the issue on which to focus. People have the problem, but they are not the problem. For example, calling someone a problem gambler can reduce him or her to one thing: a problem. Describing the situation rather than labelling the person for example, someone experiencing a gambling problem or someone affected by problem gambling reduces blame and stigma. Slide 7 Gambling Prevalence Rates 63.3% of Ontario adults have gambled in the past year. (Wiebe et al., 2006) Lottery tickets, raffle tickets and scratch tickets are the most common gambling activities engaged in by Ontario adults. (Wiebe et al., 2006) Slide 8 Problem Gambling Prevalence Rates 3.4% of Ontario adults have moderate to severe gambling problems. Although the research indicates that 63% of adults in Ontario gamble, 3.4% experience moderate to severe problems with gambling. That is equal to approximately 332,000 people (Wiebe et al., 2006). Another 5.8% are at risk of developing a gambling problem. (Wiebe et al., 2006) Slot machines are the most problematic gambling activity engaged in by Ontario adults. Slot machines are the most problematic gambling activity because they provide intermittent reinforcement a type of reinforcement that is very powerful because it is not continuous. Not only are slot machines the gambling activity with which adults in Ontario have the most difficulty, they are also the gambling activity that derives the most revenue from those who experience problems. 60% of the revenue derived from those experiencing gambling problems comes from slot machines (Williams & Wood, 2004).

19 Problem Gambling: Education and Treatment in a Residential Setting 13 Slide 9 Problem Gambling Prevalence Rates (continued) Men experience double the rates of gambling problems experienced by women. In Ontario, males are twice as likely as females to have a gambling problem (4.6% vs. 1.4%) (Wiebe et al., 2006). Young adults aged 18 to 24 years have the highest rates of gambling problems. In Ontario, 6.7% of 18- to 24-year-olds experience moderate to severe gambling problems, compared to: 4% for ages 25 to 34; 3.2% for ages 35 to 49; 2% for ages 50 to 59; and 2.2% for those aged 60 years and over. (Wiebe et al., 2006) Slide 10 Some Risk Factors An early big win A big win early on can lead to false expectations about future wins. It is important to keep in mind that what is considered big, in terms of a win, is subjective and may vary from person to person. For example, while some people may see $100 as a big win, others might not consider this amount to be very significant. Not understanding the odds of winning As we will see in Session 2, people often have false beliefs about how gambling games work. These false beliefs (for example, believing that there is a system that will increase one s chance of winning) put people at increased risk of developing a gambling problem. A history of alcohol and/or other drug problems As we will see in more detail in just a few moments, there is a link between substance use problems and gambling problems. A history of mental health problems, particularly depression, anxiety or trauma As we will also see, there is a link between mental health issues and problem gambling. In addition, research shows that rates of adult and childhood trauma are high among those experiencing gambling problems, and that problem gambling rates are higher among those who have experienced trauma (Boughton & Brewster, 2002; Ledgerwood & Petry, 2006; Biddle et al., 2005).

20 14 Problem Gambling: Education and Treatment in a Residential Setting A family history of problem gambling Research shows higher rates of problem gambling when a first-degree relative also has or had a gambling problem (Lobo & Kennedy, 2006). Loneliness, boredom or lack of leisure activities Gambling can easily alleviate feelings of loneliness or boredom. Also, since it is easily accessible and available and is promoted as fun and exciting, it is easy to see why someone may turn to this activity. Slide 11 Some Risk Factors (continued) A habit of using gambling to cope with negative feelings or events The dissociative nature of gambling the escape that it sometimes provides may be very appealing to someone who is unable to cope with negative feelings. A tendency for impulsive behaviour As we will see in a few moments, those who struggle with impulse control have higher rates of problem gambling. Financial problems Some people who struggle financially may falsely believe that gambling is a solution to their financial problems. Note: The more factors that apply, the more likely a person is to develop a gambling problem. Note to facilitator: The reasons for developing a gambling problem are both wide-ranging and complex. According to the pathways model, developed by Alex Blaszczynski (1998), people experiencing gambling problems can be categorized into one of the following three groups or pathways : Non-psychopathological or normal: For this group, problem gambling is linked to environment and learning. Problem gambling may stem from an early win or false beliefs about being able to win. These people do not necessarily have pre-existing psychological problems; they simply misunderstand the games, lose money and/or chase losses. (Chasing losses refers to continuing to gamble to try to win back money already lost, which almost always results in more losses.) According to Blaszczynski, with early intervention, these people may be able to control their gambling. Emotionally vulnerable: For this group, gambling problems are due to difficulty in managing stress or crisis in their life. They use gambling as a way of avoiding underlying issues and current stresses. These people can even be vulnerable during times of good stress, such as the birth of a child. Blaszczynski believes that abstinence, as well as learning anxiety reduction techniques, is the best option for these people.

21 Problem Gambling: Education and Treatment in a Residential Setting 15 Biologically influenced or impulsive: This group comprises individuals who tend to have an impulse disorder, such as attention-deficit/hyperactivity disorder (ADHD). For this small percentage of people, gambling can trigger other binge behaviours. According to Blaszczynski, these people should receive counselling to deal with impulse control. People in this pathway will require intervention by a psychologist or psychiatrist. The pathways model demonstrates that people develop gambling problems for different reasons. The model might not, however, account for all the factors that lead people into gambling problems. Slide 12 Impact of Problem Gambling Significant financial loss The most common negative impact of problem gambling is financial loss. Savings, property or belongings may be lost and excessive spending on gambling may also mean that bills are not paid, utilities are cut off and money for necessities such as groceries is in short supply. Higher rates of relationship and family breakdown Because gambling can be hidden for a long time, many families are shocked when the full impact of the gambling is discovered. While some families are able to recover, not all are able to survive gambling problems. Higher rates of emotional and health problems The stress of problem gambling can cause health issues such as anxiety, depression or other stress-related issues such as poor sleep, ulcers, bowel problems, headaches and muscle pains. Work-related difficulties Once gambling problems begin, preoccupation with gambling or gambling-related debt may lead to neglected work responsibilities or increased absenteeism. Legal problems Some individuals may turn to theft, fraud or embezzlement to finance their gambling or to deal with gambling-related debt. Higher rates of suicide Suicide attempts are more frequent among those who are experiencing problems related to gambling, compared with the general population. In addition, suicide attempts are more common among people experiencing problems related to gambling than among those experiencing problems with any other types of addictions (National Council of Welfare, 1996). As a result, it is important to screen those who are struggling with this issue for suicidality.

22 16 Problem Gambling: Education and Treatment in a Residential Setting Slide 13 Concurrent Substance Use and Gambling Problems There are higher rates of alcohol, other drug and nicotine dependence among those who are experiencing gambling problems. In both treatment and general population samples, research shows higher rates of alcohol, other drug and nicotine dependence among those who are experiencing gambling problems (Kennedy et al., 2008; Petry et al., 2005; Welte et al., 2001; Crockford & el-guebaly, 1998; Smart & Ferris, 1994; Bland, et al., 1993; Cunningham-Williams et al., 1998; Toneatto et al., 2002; Feigelman et al., 1998). There are also higher rates of problem gambling among individuals with substance use problems. In addition, research shows higher rates of problem gambling among individuals with substance use problems (Daghestani et al., 1996; Giacopassi et al., 1998; Lejoyeux et al., 1999; Crockford & el-guebaly, 1998; Lesieur et al., 1986; Stinchfield et al., 2005). Slide 14 Possible Links between Gambling and Substance Use Problems Gambling is falsely viewed as a safer alternative. Because gambling is promoted as a fun activity, and because people are not as aware of its potential risks, people who make changes to their substance use sometimes engage in gambling, believing it is safer than drinking or using other drugs. Gambling is falsely viewed as a way to finance substance use. Someone needing money for drugs, for example, may turn to gambling, believing that this is an easy way to make money. Using substances can lead to poor judgment in gambling activities. Gambling while under the influence is particularly risky, as it may lead to poor decision making. Substances may be used to cope with negative consequences of gambling. Someone struggling with, for example, significant financial losses because of gambling may turn to alcohol or other drugs to cope with negative feelings. There are some common biological factors shared by substance and gambling dependence. As already mentioned, we all learn through reward and punishment, and for some people the reward system of the brain works a bit differently. These individuals are able to take more risks and are less sensitive to reward. As a result, it is believed that they are at increased risk for addictions (Chambers et al., 2003).

23 Problem Gambling: Education and Treatment in a Residential Setting 17 Note to facilitator: These are some possible connections between gambling and substance use. You may want to ask participants if they can think of additional connections. Slide 15 Mood Disorders and Problem Gambling Mood disorders are very common among those who are experiencing gambling problems. Mood disorders such as major depressive disorder and dysthymic disorder, as well as manic and hypomanic episodes, are common among those who experience gambling problems (Petry et al., 2005). Also, according to a study conducted by Kennedy et al. (2008), there is more than twice the Canadian average rate of problem gambling in people seeking help for major depressive disorder. Further, this study found that more than 70% of people experiencing gambling problems reported that their mood disorder came before their gambling problem. In addition, according to a Canadian study by McIntyre et al. (2007), individuals who have been diagnosed with bipolar disorder have double the rates of problem gambling experienced by the general population. In some cases mood disorders can lead to the development of a gambling problem; in other cases, gambling problems can lead to a mood disorder. In some cases, the mood disorder is a contributing factor to the development of the gambling problem, while in other cases, it is the result of the gambling problem. For example, someone who struggles with depression may turn to gambling because it helps to alleviate depressive symptoms. Or, because of financial losses due to gambling, a person may start experiencing mood-related problems. In some cases, the mood and gambling problems may be cyclical the mood disorder leads to a gambling problem which in turn leads to more mood issues, and so on. Being aware of the connection between gambling and mood problems is important as it will have an impact on treatment for both of these issues. Slide 16 Anxiety Disorders and Problem Gambling Anxiety disorders are very common among those who are experiencing gambling problems. Anxiety disorders such as panic disorder (with or without agoraphobia), social phobia, specific phobias, generalized anxiety and obsessive-compulsive disorder are common

24 18 Problem Gambling: Education and Treatment in a Residential Setting among those who are experiencing gambling problems (Petry et al., 2005; Crockford & el-guebaly, 1998). In fact, according to a study conducted by Kennedy et al. (2008), people with gambling problems reported higher rates of anxiety disorders than the Canadian average. In some cases anxiety disorders can lead to the development of a gambling problem; in other cases, the gambling problem can lead to an anxiety disorder. Similar to mood disorders, in some cases the anxiety disorder is a contributing factor to the development of the gambling problem, while in other cases, it is the result of the gambling problem. For example, people who are having difficulty dealing with anxiety may turn to gambling because the sometimes dissociative nature of gambling helps to alleviate their anxiety symptoms. Or, some people may struggle with anxiety resulting from the many lies they have told to conceal their gambling problem. In some cases, the anxiety and gambling problems may be cyclical the anxiety disorder leads to a gambling problem which in turn leads to more anxiety, and so on. Being aware of the connection between gambling and anxiety problems is important as it will have an impact on treatment for both of these issues. Slide 17 Impulsivity and Problem Gambling Impulsivity in general is common among those experiencing gambling problems. Research shows that impulsivity as a trait as well as disorders that include aspects of impulsivity, such as attention-deficit/hyperactivity disorder, antisocial personality disorder and substance-related disorders are common among those experiencing gambling problems (Rodriguez-Jimenez et al., 2006; Petry et al., 2005; Crockford & el-guebaly, 1998). Pathological gambling is classified as an impulse-control disorder in the DSM-IV. The person s lack of impulse control can make self-restraint difficult. Slide 18 Psychosis and Problem Gambling Rates of pathological gambling are higher among individuals who have been diagnosed with schizophrenia than in the general population. There is not a lot of research on gambling and psychotic disorders. The research that exists, however, suggests that rates of pathological gambling (this term is discussed ina moment) are higher among individuals who have been diagnosed with schizophrenia than in those who have not been diagnosed (Borras & Huguelet, 2007).

25 Problem Gambling: Education and Treatment in a Residential Setting 19 Psychosis is not as common among those experiencing gambling problems as are mood and anxiety disorders or impulsivity. Although psychosis is not as common as other mental health disorders among those experiencing gambling problems, it remains an issue for some. For some, psychotic symptoms such as auditory hallucinations may be a contributing factor to gambling. For example, a person may hear voices telling him or her to gamble. In addition, for those who already struggle with psychosis, the stress of problem gambling may be a trigger for psychotic symptoms. Slide 19 Continuum of Gambling Behaviour Note to facilitator: Explain the continuum to the group. Be sure to clarify that a person can be at more than one place on the continuum. For example, you may place yourself at occasional gambling for your bingo play and regular gambling for your lottery use. Once you ve described the continuum, ask participants where they fit on the continuum in terms of their own gambling behaviours. Depending on people s comfort level, this activity can either be done as a group or individually. For those who fall into the No Gambling, Occasional Gambling and Regular Gambling categories of the continuum, prevention and education is recommended. This is the purpose of Sessions 1 and 2. For those who fall into the Problem Gambling and Pathological Gambling categories of the continuum, changes related to their gambling behaviour are recommended. This can mean either reducing or quitting some or all gambling activities. These clients should also participate in Sessions 3 and 4, where gambling problems are addressed in more detail. At this time, if you have not already done so, have participants complete the Problem Gambling Severity Index screening tool (Appendix A). Anyone who scores a 3 or higher should be encouraged to attend Sessions 3 and 4. No gambling With no gambling, there is no risk of developing a problem. Occasional gambling A person who gambles occasionally is someone who may, for example, go to the casino for an evening of entertainment once in a while. Gambling is not this person s main leisure activity. Regular gambling A person who gambles regularly may dedicate considerable time to gambling but not to the point where it is damaging to other areas of his or her life. This person may, for example, buy weekly lottery tickets or go to weekly bingo.

26 20 Problem Gambling: Education and Treatment in a Residential Setting Problem gambling As already defined, problem gambling is a pattern of gambling that disrupts or damages one s health, finances, reputation, relationships or vocational/academic pursuits. The problems can range from mild to severe. Pathological gambling For a small but significant number of people, gambling seriously harms all aspects of their lives. People with gambling problems this severe are unable to control the urge to gamble, despite the harm it causes. Slide 20 Problematic vs. Non-Problematic Gambling Note to facilitator: Give participants a copy of the Problematic vs. Non-Problematic Gambling handout (Appendix C) and review it with them. If time allows, prior to distributing the handout, you can also do a brainstorm with the group to come up with examples of problematic and non-problematic gambling. Financial limits Non-problematic: Individuals who gamble non-problematically only lose money that they can afford to lose. Money is budgeted for this activity in the same way that money is budgeted for other social activities. When the funds are spent, the gambling stops. Problematic: Individuals who gamble problematically lose more money than they can afford to lose and often make the situation worse by trying to win back what they have lost. Time limits Non-problematic: Individuals who gamble non-problematically control the amount of time they spend gambling. Problematic: Individuals who gamble problematically often lose track of time and spend more time gambling than they intend. Entertainment Non-problematic: Individuals who gamble non-problematically enjoy gambling as a form of social or recreational activity in which they engage periodically. Gambling meets personal social needs such as getting out of the house and seeing other people. Problematic: Individuals who gamble problematically are more likely to see gambling as a form of income or a game of skill that they can conquer.

27 Problem Gambling: Education and Treatment in a Residential Setting 21 Other activities Non-problematic: Individuals who gamble non-problematically enjoy gambling as one of many social activities in a balanced lifestyle. Problematic: Individuals who gamble problematically often spend a great deal of time gambling while missing family functions and skipping other activities that they used to enjoy. They often think about gambling even when they are not gambling. Relationships Non-problematic: Individuals who gamble non-problematically do not allow their gambling to disrupt their personal, social and professional relationships. Problematic: Individuals who gamble problematically find that gambling disrupts personal, social and professional relationships. Personal control Non-problematic: Individuals who gamble non-problematically have control over the amount of money they spend gambling. Problematic: Individuals who gamble problematically lose control over the amount of time and money they spend gambling.

28 22 Problem Gambling: Education and Treatment in a Residential Setting

29 Problem Gambling: Education and Treatment in a Residential Setting 23 Session 2 Depending on the number of participants and the amount of group discussion, this session will take between 60 and 90 minutes. For this session you will need: laptop computer and lcd projector Session 2 PowerPoint presentation Internet access flipchart and markers participant handouts: - Reducing the Risk (Appendix D) - Session 2 PowerPoint presentation Slide 21 Understanding Gambling This second session focuses on: how games of chance work; false beliefs and superstitions associated with gambling; and strategies for reducing the risk of developing a gambling problem.

30 24 Problem Gambling: Education and Treatment in a Residential Setting Slide 22 The Slot Machine: What Every Player Needs to Know Note to facilitator: Most people are unaware of how games of chance actually work, and false beliefs are particularly common with slot machines. The Slot Machine: What Every Player Needs to Know is a 10-minute video that was co-developed by the Ontario Problem Gambling Research Centre and OLG. This video challenges many of the myths associated with slot machines and clearly shows how they really work. To view the The Slot Machine: What Every Player Needs to Know video, go to the website. The link to the video is available at the bottom of the home page. This video is intended as a prevention tool. It is not meant to encourage anyone who has quit gambling to resume. Be sure to inform participants of this prior to showing the video. In addition, although the focus of this video is slot machines, it describes a number of important concepts that are relevant to all games of chance. After the group watches the video, ask participants what they thought: Was this new information? Did they know the odds would always be the same for each play of the slot machine? Or did they believe the odds changed based on when the machine last paid out? Were they surprised that past wins/losses have no impact on current or future wins? If they do occasionally gamble on slot machines, will this information change how they play? If so, how? Slide 23 The Coin Toss: Activity 1 Note to facilitator: Explaining important concepts about how games of chance work (for example, randomness, independent outcomes, odds) can be particularly challenging. The following coin toss activities are intended to help you demonstrate these concepts in a simple way. Some participants may question whether this activity is considered gambling. Because no one is risking anything of value, it is not. Activity 1: Flip a coin five times and write the five outcomes ( heads or tails ) on the board. Now flip the coin another five times, but before each flip ask participants what they think the outcome will be. Record each outcome. Once you ve completed all 10 coin tosses, ask participants what made them pick heads or tails. What was their reasoning? Debrief: Guessing heads or tails is just that a guess. There is no sure way to know what will come up. It is random.

31 Problem Gambling: Education and Treatment in a Residential Setting 25 People often mistakenly look for patterns, lucky streaks or what is due to come up when they gamble. All games of chance have an element of randomness that affects the outcome. There is no way to predict what the outcome will be. (We will go into more detail about randomness in a moment.) Slide 24 The Coin Toss: Activity 2 Activity 2: For this second activity, ask participants which of these three patterns is the most likely to occur and why they picked the pattern they did. Heads or tails? H H H T H H H T T T T T T T T H H H H H T T T T T T T T T T Debrief: People are likely to choose the first pattern. As mentioned for the previous activity, however, there is no pattern that is more likely to come up. People choose the first pattern because it appears to be more random; that is, it looks more like what we would expect. The second and third patterns seem too ordered to occur naturally. However, since each independent flip of the coin has a 50% chance of landing on heads or tails, all three series of 10 flips are equally likely to occur. Slide 25 Randomness Most gambling games are based on randomness, meaning they occur without reason, aim or pattern. This means: no one can predict the outcome; there is no connection between results; all outcomes are equally likely. Note to facilitator: When gambling, people often mistakenly try to assign patterns. For example, someone may believe that a slot machine is due for a win because it has lost several times in a row. But, since each spin activates a random number generator, there is no way of knowing when a machine is due to win each spin is random.

32 26 Problem Gambling: Education and Treatment in a Residential Setting Another example to consider is the lottery. Whether you buy a quick pick ticket or you select the numbers yourself has no impact on the outcome. All outcomes are equally likely. (Turner & Powel, 2007) Slide 26 Independent Outcomes Most gambling games involve independent outcomes. Random events are independent from each other; in other words, gambling games have no memories. For example, a spin of the roulette wheel is in no way affected by the previous spin. Note to facilitator: What happened on previous plays has no impact on current or future play. If we consider our coin toss example again, a coin toss has no effect on the next coin toss. The coin doesn t remember what the last outcome was and is not capable of balancing the overall outcome so that it is 50/50 (Turner & Powel, 2007). Slide 27 The House Edge The house is the organization that sponsors the games. Examples include the casino, bingo hall, racetrack and lottery commission. The house edge is what the house charges the player to play the game. When people gamble on casino or lottery games, for example, they are always playing at a mathematical disadvantage, because the odds are set up in favour of the house. Even in games that involve some skill (for example, poker, sports betting) the game is set up to guarantee a profit for the house. Over time, no amount of skill can beat this house edge. Although people may win in the short term, because of this built-in advantage, over time they will likely lose more than they will win. This is what makes casinos and lotteries so profitable. (Turner & Fritz, 2007) Examples of the house edge: Blackjack: When both the player and the dealer go over 21 (technically a tie), the player loses.

33 Problem Gambling: Education and Treatment in a Residential Setting 27 Roulette: The wheel has 38 slots but only 36 have numbers and are either red or black. The two remaining slots are 0 and 00 and both green. Therefore, when the marble lands on either 0 or 00, all the players who bet on red or black lose their bets. Slide 28 Odds The odds are your chances of winning. For example, in a coin toss your chance of accurately predicting the outcome is two to one (50%). In gambling, the odds are always against the person placing the bet. The house (the casino, bingo hall, racetrack, lottery commission, etc.) is absolutely guaranteed mathematically to win over time. This is how they make their money. The longer you gamble, the more likely it is you will lose. Because the house has a mathematical advantage, the longer you gamble, the more likely it is you will lose. The house always has the edge. This is because the odds are set up in favour of the house. (Turner & Powel, 2007) Slide 29 What Are Your Chances? Say that my brother lived somewhere in Ontario but I did not know his phone number. If I were to randomly dial any Ontario residential phone number, what do you think the odds are that I would reach him? Most people would say that this is impossible! And yet so many people play Lotto 6/49 and believe they have a good chance of winning. Note to facilitator: According to Statistics Canada, in 2008, the Ontario population was approximately 12,900,000. If you consider that not every single Ontarian has a residential telephone number, you can see that the chances of reaching my brother by telephone are better than my chances of winning the Lotto 6/49 (which are approximately one in 14 million)(statistics Canada, 2009).

34 28 Problem Gambling: Education and Treatment in a Residential Setting Slide 30 Games of Chance No Skill These games are based only on chance, randomness and independent outcomes. Examples: lottery/scratch tickets roulette bingo dice games slot machines (Turner & Fritz, 2007) Slide 31 Games of Chance Some Skill These games involve some skill, but so much randomness is involved that the chances of winning are still very low. The house advantage is lower than games that require no skill, but although players may win in the short term, it is mathematically likely that over time, they will lose more than they win. Examples: card games By following a basic strategy, skilled players may have more opportunity to minimize their losses, or play for longer with the same amount of money. It is important to remember, however, that card games still have a random element (there are only so many cards and you don t know which cards will be dealt) and that players can lose many times consecutively regardless of how well they play. sports betting There is still a great deal of uncertainty in sports betting (for example, weather conditions, health of the players, etc.). For Pro-line, for example, you have to make the point spread and/or choose the three winning teams in order to win. horse betting There is also a great deal of uncertainty in horse betting (for example, health of the horse or the jockey, track conditions, etc.). In addition, the odds are based on how many bets have been placed on a certain horse. (Turner & Fritz, 2007)