Identification and treatment strategies for youth with gambling problems

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Identification and treatment strategies for youth
with gambling problems

• Jeffrey L. Derevensky, Ph.D.
• McGill University

International Centre for Youth Gambling Problems
and High-Risk Behaviors www.youthgambling.com Del
aware, 2007
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Our current state of knowledge

• Gambling is more popular amongst males than
  females
• Adolescent pathological gamblers are greater
  risk-takers
• Gambling has become a family activity
• Adolescents with gambling problems have poor
  general coping skills
• Adolescent problem gamblers report beginning
  gambling at earlier ages, approximately 10 years
  of age
• Rapid movement from social gambler to problem
  gambler

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• Adolescent problem gamblers have lower self-
  esteem compared with other adolescents
• Adolescent problem gamblers have higher rates of
  depression
• Adolescent problem gamblers dissociate more
  frequently when gambling
• Adolescents with gambling problems, ages 14-17,
  are at heightened risk for suicide ideation and
  suicide attempts
• Old friends are often replaced by gambling
  associates
• Remain at increased risk for the development of
  an addiction or multiple addictions
• Score higher on excitability, extroversion,
  impulsive and anxiety lower on conformity and
  self-discipline measures

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• More major life events and early childhood
  traumas
• Gambling venues are relatively easily accessible
  Old friends are often replaced by gambling
  associates
• Increased delinquency and crime, disruption of
  familial relationships and decreased academic
  performance
• More self-reported learning and behavioral
  problems

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Similarities between youth and adult problem
gamblers

• Pervasiveness of the problem
• Similar reasons for reporting gambling
• Lying, stealing, cheating
• Illusion of control (Irrational cognitions and
  thinking)
• Preoccupation with thoughts of gambling
• High suicide ideation and attempts
• Chasing behavior
• Gambling as a means of escape/dissociation
• Depression/Anxiety
• Missing of work and/or school
• Loss of friends and changes in social support

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• Videotape

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Profile of the adolescent problem gambler

• Predominantly male
• Significant anxiety
• Familial problems and poor peer relationships
• Preoccupation with gambling- reported inability
  to stop despite repeated efforts
• VLT, sports betting, cards
• Serious financial difficulties
• Failure in school and/or at work
• Lying to family and friends

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Profile - continued

• Friends usually have similar gambling problems
• Stealing from family, friends, stores, bank
  fraud, etc.
• Depression or feeling dead inside
• Gambling to escape and to feel better
• General lack of effective coping abilities and
  problem solving skills
• Confused and conflicted about whether they really
  want to stop gambling
• Need for arousal or strong sensations

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Why do I gamble?

• Gambling was there for me when no one else was.
  Gambling made me know I was special and even
  powerful. The days flew byI was in a different
  world. Nothing else was important to me (male,
  age 14).
• Of course I stole money from my family. Its
  nothing personal, I needed the money (male, age
  18).
• If you really think of it, it was easy to come up
  with reasons why I should keep playing. If I was
  winning..well that was reason enough. If I was
  losing, well that is OK because Id be winning
  soon. But its more about the chase than the
  actual dollars. The chase allows you to forget
  about everything else (male, age 14).

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• Everything that was good about gambling is now
  bad. It is my whole life and Im tired. Im tired
  of lying and stealingfor something I cant seem
  to control, but dont want to do. What has
  happened to me? I need help (male, age 14).
• My problems are like a tree. The root is my
  gambling with one branch being a thief, another a
  liar, another being out of school and work. If
  you cut a branch off you havent gotten to the
  root of my problemgambling (male, age 19).

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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

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Identification and Classification
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Nomenclature Hodge-Podge (Winters, 2001)
Problem Severity Continuum
Compulsive gambling
At-Risk gambling
Problem gambling
Social gambling
No gambling
Pathological gambling
Habitual gambling
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Is Youth Problem Gambling A Primary Disorder?
Alcohol Dependence
ADHD
Conduct Disorder
Problem Gambling
Other Disorder
Depression
Drug Dependence
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Clinical Description of Pathological Gambling

• Continuous involvement in and preoccupation with
  gambling (and an inability to stop) despite
  resulting adverse consequences

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Diagnostic Statistical Manual-IV Adapted for
Juveniles (DSM-IV-J)

• DSM-IV-J (Fisher, 1992) DSM-IV-MR-J (Fisher,
  2000) developed for children and adolescents.
• Consists of 12 items, 9 categories and responses
  are given in "yes" or "no" format- new scale has
  multiple responses.
• Modeled very closely on the adult version (DSM-IV
  criteria for pathological gambling), with several
  significant adaptations.
• Other scales include the SOGRS-RA, GA-20.

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Problem gamblers.
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DSM-IV-J gambling screen (Fisher, 1992)
Do you often find yourself thinking about
gambling activities at odd times of the day
and/or planning the next time you will play?
(81.6) Do you lie to your family or friends or
hide how much you gamble? (78.9) After
spending money on gambling activities do you play
again another day to try and win your money back?
(More than half the time?) (73.7) In the
past year have you spent your school dinner
money, or money for bus fares, on gambling
activities? (68.4)
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In the past year have you taken money from
someone you live with, without their knowing, to
gamble? (57.9) Do you ever gamble as a way of
escaping problems? (50.0) Do you find you need
to spend more and more money on gambling
activities? (36.8) In the past year, have you
stolen money from outside the family, or
shoplifted, to gamble? (28.9) Do you become
restless, tense, fed up, or bad tempered when
trying to cut down or stop gambling? (26.3)
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In the past year, have you gone to someone for
help with a serious money worry caused by
participation in gambling? (21.1) Have you
fallen out with members of your family, or close
friends, because of your gambling behavior?
(10.5) In the past year, have you missed
school to participate in gambling experiences? (5
times or more) (7.9) ?4 or more to meet the
criteria for PPG Percentages of endorsements
from study of adolescents by Derevensky Gupta
(2000).
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Do all gamblers present with the same profile?
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The Pathways Model
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Pathways Model proposes that...

• All problem gamblers are not alike.
• There are three (or more) distinct pathways to
  problem gambling.
• Gamblers in each pathway differ by the presence
  or absence of psycho-social and biological
  factors and behavioral manifestations.
• Gamblers in different pathways require different
  treatment strategies.

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Pathways Model (Blaszczynski Nower, 2002)

• Behaviourally conditioned
• Reinforcement cognitive distortions ? bad
  decisions
• Emotionally vulnerable
• Relieve/modulate pre-morbid aversive affective
  states become behaviourally conditioned
• Biologically-based impulsive
• Impulsivity, multiple maladaptive behaviours
  behaviourally conditioned

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• Treatment approaches.

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Psychosocial Treatments

• Behavior Therapy
• Individual stimulus control (e.g., Echeburua et
  al., 1996) PGs are taught ways to avoid high
  risk situations for gambling.
• Cue exposure and response prevention (e.g., Brent
  Nicki, 1997) PGs are exposed to
  gambling-related cues, then prevented from acting
  on gambling urges.
• Systematic desensitization (e.g., McConaghy et
  al., 1991) After induction of relaxation, PGs
  imagine scenes in which they are exposed to
  increasing approximations to their preferred
  gambling venue.

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Psychosocial Treatments

• Cognitive Behavior Therapy
• Restructuring of gambling-specific cognitive
  distortions (e.g., Ladouceur Walker, 1996)
• The concept of randomness
• Understanding erroneous beliefs (the illusion of
  control, the gamblers fallacy)
• Awareness of inaccurate perceptions
• Cognitive correction of erroneous perceptions

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Psychosocial Treatments

• Cognitive Behavior Therapy (2)
• Restructuring of gambling-specific cognitive
  distortions, problem-solving training, social
  skills training, relapse prevention training
  (e.g., Sylvain, Ladouceur, Boisvert, 1997)
• Relapse prevention training (e.g., Hodgins
  el-Guebaly, 2000)

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Psychosocial Treatments

• Cognitive-Behavioral Treatments to induce
  Controlled Gambling Ladouceur and his colleagues
  have also undertaken a series of
  cognitive-behavioral treatment studies in recent
  years that have led them to conclude that using
  abstinence as the unique proposed treatment goal
  may not be a panacea for all pathological
  gamblers.

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Psychosocial Treatments

• Motivational Enhancement (e.g., Hodgins, Currie,
  el-Guebaly, 2001) Designed to provide PGs
  feedback on likely consequences of their
  pathological gambling, in an effort to increase
  their motivation to reduce or eliminate their
  pathological gambling behavior.

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Pharmacological Treatments

• SSRIs (to reduce comorbid depression and OCD and
  decrease urges to gamble) Especially
  fluvoxamine, but also including clomipramine,
  paroxetine, citalopram, and fluoxetine
• Lithium carbonate A mood stabilizer that can
  help PGs with a bipolar spectrum diagnosis
• Opioid antagonist Naltrexone (to reduce
  urge-related symptoms and decrease problematic
  behaviors).

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Therapeutic Approaches for Problem Gamblers
The McGill Model
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Intake assessment

• Semi-structured interview (general information),
  including DSM-IV criteria
• Allow them to ask questions about procedures and
  expectations
• Completion of forms- personal information,
  questionnaire pertaining to their gambling
  behavior, frequency and severity of problem,
  family history, academic/work history, medical
  history, and identification of co-existing
  addictions.

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• Risk-taking measures (SSS and AISS)
• Personality assessment (HSPQ- selected subscales)
• Depression, suicide ideation, suicide attempts,
  and hopelessness assessment (RADS, BHS)

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The Stages of Change

• Stage 1 Precontemplation
• gambling is not viewed as a problem
• Stage 2 Contemplation
• beginning to think about gambling as an
  activity to change
• Stage 3 Preparation
• decision to change gambling behavior

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• Stage 4 Action
• the gambler takes steps to stop gambling
• Stage 5 Maintenance
• long-term success requires continued work to
  sustain initial changes
• Stage 6 Termination
• gambling no longer represents a temptation or
  problem

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When you treat an individual with a gambling
problem, you must take into account their entire
person. Not just the fact that they gamble
uncontrollably.
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Gambling Problems
Gamble to Escape
Truancy/ Delinquency
Chase Losses
Preference for Gambling
Stealing Money
Problem Gambling
Lying about Gambling
Family/ Peer Problems
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Clinical practice
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Clinical implications

• Gambling is a form of maladaptive coping
• Identification of underlying stressors
• Assessment for depression and anxiety
• Assessment for substance abuse

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Treatment

• Emphasis on the importance of honesty and mutual
  respect.
• Provide a non-judgmental environment.
• Allowing them to feel understoodthat their
  beliefs, perceptions and behaviors are common
  among young problem gamblers.
• Discussion of reasons underlying the need to
  gamble.

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Treatment

• Emphasize the importance of honesty and mutual
  respect.
• Provide a non-judgmental environment.
• Allowing them to feel understoodthat their
  beliefs, perceptions and behaviors are common
  among young problem gamblers.

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• 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.
• Encourage a decrease in gambling participation
  (time and money).
• Have individuals record their gambling
  activities (including wins and losses, time
  spent, and type of activity) on a daily basis.

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Essential therapeutic goals

• Acceptance of gambling as a problem.
• Identifying and clarifying the irrationality of
  their though processes when gambling (beginning
  of cognitive restructuring).
• Building social support systems for the
  adolescent. This can include involving parents,
  siblings, and close friends in the treatment
  process. As well, we make ourselves available for
  social support, by providing a pager number.

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• Reconstruct a healthy peer environment. This
  includes having them stop socializing with
  friends who gamble. In order to accomplish this,
  they may have to contact childhood friends, and
  friends that were present before the gambling
  onset. Techniques to develop to make and maintain
  new friends are discussed.
• Restructure their free time so that they remain
  busy engaging in activities other than gambling.
  These include participating in sports, exercise
  programs, hobbies, returning to school, and/or
  obtaining and maintaining a job.

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Therapeutic tools

• Incorporate an eclectic and flexible approach.
• Use significant individuals (i.e., parents,
  siblings, friends) in the adolescents
  environment as a support network.
• Work in conjunction with a psychiatrist or
  general physician.

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• Encourage them to experience other age
  appropriate activities. This is particularly
  difficult as they are often depressed and
  anxious, and have difficulty deriving pleasure
  from non gambling-related activities (e.g.,
  movies, restaurants, dating, etc.).
• In general, most adolescents receiving treatment
  report that in comparison to their gambling,
  nothing approximates the pleasure and enjoyment
  received when gambling (independent of the
  financial outcome).
• Provide a reality check. Adolescents have a
  distorted perception of the amount of money and
• time they spend gambling.

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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.

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• 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.

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• Alternative approaches?????

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