Identification and treatment strategies for youth with gambling problems

1. 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 Delaware, 2007

2. 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

3. 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

4. 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

5. 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

6. Videotape

7. 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

8. 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

9. 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 by…I was in a different world. Nothing else was important to me (male, age 14). • Of course I stole money from my family. It’s 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 I’d 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).

10. Everything that was good about gambling is now bad. It is my whole life and I’m tired. I’m tired of lying and stealing…for something I can’t seem to control, but don’t 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 haven’t gotten to the root of my problem…gambling (male, age 19).

11. 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

12. Identification and Classification

13. Nomenclature Hodge-Podge (Winters, 2001) Problem Severity Continuum Compulsive gambling At-Risk gambling Problem gambling Social gambling No gambling Pathological gambling Habitual gambling

14. Is Youth Problem Gambling A Primary Disorder? Alcohol Dependence ADHD Conduct Disorder Problem Gambling Other Disorder Depression Drug Dependence

15. Clinical Description of Pathological Gambling Continuous involvement in and preoccupation with gambling (and an inability to stop) despite resulting adverse consequences

16. 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.

17. Problem gamblers…….

18. 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%)

19. 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%)

20. 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).

21. Do all gamblers present with the same profile?

22. The Pathways Model

23. 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.

24. 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

25. Treatment approaches…….

26. 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.

27. 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 gambler’s fallacy”) • Awareness of inaccurate perceptions • Cognitive correction of erroneous perceptions

28. 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)

29. 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.”

30. 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.

31. 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).

32. Therapeutic Approaches for Problem Gamblers The McGill Model

33. 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.

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

35. 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

36. 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

37. 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.

38. Gambling Problems Gamble to Escape Truancy/ Delinquency Chase Losses Preference for Gambling Stealing Money Problem Gambling Lying about Gambling Family/ Peer Problems

39. Clinical practice

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

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

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

43. 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 individual’s record their gambling activities (including wins and losses, time spent, and type of activity) on a daily basis.

44. 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.

45. 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.

46. 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.

47. 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.

48. 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.

49. 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.

50. Alternative approaches?????