Problem Gambling Treatment; the future arrives!


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Problem Gambling Treatment; the future arrives!
Presented by Dr Sean Sullivan, ABACUS Counselling Training and Supervision Ltd at the 2012 Cutting Edge Conference, Wellington, New Zealand.

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  • LaPlante & Shaffer, in press, American Journal of Orthopsychiatry
  • Problem Gambling Treatment; the future arrives!

    1. 1. Problem GamblingTreatment; the future arrives! Sean Sullivan PhD ABACUS Counselling, Training and Supervision Ltd
    2. 2. Current challenges for all addictions • Alcohol abuse and resistance to legislate • Smoking – risking international sanctions and penalties because of ‘free trade’ conflicts with public health • Legal ‘party’ drugs – some initiatives but uncertain outcomes regarding proof of harm and levels for e.g. synthetic cannabis • Internet addiction – what is ‘normal’ use? Longer use becoming the norm • Gambling – some controls but technology challenges, social acceptance, and attractive taxation source – uncertain growth in problems
    3. 3. PG differences to AOD• A relatively ‘pure’ behavioural addiction (no external drug influence) – often perception the addiction due more to choice• The reinforcer is a general reinforcer (e.g. money, praise) – it is resistant to satiation• Solution to problems arising from the behaviour may include continuation in the behaviour (has a built in solution i.e. a win!)• Money is a powerful reinforcer that most people want (drugs perhaps less so) – gives choice, respect, safety, peace of mind, hope……….• PG may be less likely to seek help
    4. 4. The old days• Gambling semi-controlled under Gaming & Lotteries Act 1977• Lotto introduced 1987• Gambling machines existed, but not recognised under the Act – became ‘legal’ in 1988• No casinos pre 1994– Committee of Enquiry into casinos 1988-1989• First casino opens 1994, by 2003, a total of 6 casinos open
    5. 5. Into the new era• 2003 Gambling Act – no NZ Internet gambling except Lottery & racing/sports• Online betting – Racing Board monopoly on racing and sports betting or Lotto• Internet gambling – allowed if based overseas• Technology and accessibility the challenge – can be accessed 24 hrs a day
    6. 6. Global online gambling growth Ferguson 2012
    7. 7. Mobile gambling growth• UK – 20% wagers are via online mobile devices• Now in NZ: In play betting can prompt gambling– ‘next try/yellow card?’• Estimated world-wide growth of gambling via mobile devices will increase from the $20B in 2011 to $100B in 2017 Juniper Research (May 2012)
    8. 8. An important income resource for governments• Because gambling is a substantial source of duty/tax, a large employer, and is part-owned by the state (Lotto), conflict of interest may be perceived when gambling expansion/reduction• NZ Gambling Act – no ‘for profit’ gambling permitted other than casinos• Monopoly on Internet gambling in NZ given to Lottery Commission and Racing Board• In Australia, 11% (average) of all State income is raised from gambling
    9. 9. But is problem gambling reducing? Some suggest problem gamblers ‘adapt’ & reduce their harm
    10. 10. The case for PG reducing‘While far from certain, problem gamblingprevalence rates appear to have fallensomewhat. It is unclear how much this reflectsnatural adaptation or the impact of governmentpolicy, though both are likely to havecontributed’ Productivity Commission 2009
    11. 11. But…..The Productivity Commission also comments: ‘Given (the wide influences on PG) reductions are unlikely to continue without environmental changes’
    12. 12. From exposure to adaptation contagion disease model applies? LaPlante & Shaffer, 2008
    13. 13. The adaptation model• The assumption that people adapt to novel forms of gambling, much like a contagion disease model reacts to an epidemic, may not apply to an addiction• If people adapted to gambling machines, one would expect at least this to occur within a decade. Between 1988 – 2008 in NZ, no such adaptation occurred demonstrated by reduced gambling machine spending (for same number of machines)
    14. 14. What would we expect if adaptation true?Less spent on gambling But assumes due to gambling reducing: • The larger proportion (non-problem gamblers) may be more likely to reduce discretionary spending especially in a recession • Problem gamblers increase their problems/gambling when under stress (DSM) • Reduction in amount spent may mask increased problem gambling spending – especially if those financially disadvantaged increase and this group are known to be at higher risk for PG (e.g. during a recession)
    15. 15. Less spending not necessarily reduced PGs hypothetical example 120 100 Total $ spent 80 Problem gamblers 60 Non-problem 40 gamblers 20 0 2010 2011
    16. 16. Is gambling participation reducing? Perhaps…• Abbott et al (1991) – 90% gambled in last 6 months• Abbott et al (2000) – 87% gambled in last 6 months• NZ Health Survey 2006/7 – 65% gambled in last 12 months• Spending in NZ on gambling has remained relatively constant at $2B from 2004-2008• Is spending per capita increasing (if participation is reducing) or people’s perception of their gambling, or not, flawed?
    17. 17. Hard to measure means uncertainty • But gambling losses over time is a blunt tool • Productivity Commission (Australia) estimates 40% total losses on gambling machines and 20% from moderate problem/at risk gamblers • May mask the possibility that ‘controlled’ or non- problem gamblers do reduce their gambling during a recession while problem gamblers may increase their gambling as stress increases (a recognised influence)
    18. 18. Losses constant during recession (excluding Internet gambling)Gambling losses p/a ($M) 2500 2000 1500 1000 500 0 07 02 03 04 05 06 08 09 10 11 20 20 20 20 20 20 20 20 20 20 EGM loss ($M) All gambling loss ($M)
    19. 19. Adaptation – do PGs adapt? The Victorian Gambling Study 2011• N=5003• Surveyed in 2008 and again 2009 (repeat) using a gambling screen that identified levels of PG: – NT=not a gambler – NPG= a gambler but not a problem gambler – LR=low risk for problem gambling – MR=moderate risk for problem gambling – PG=problem gambler• Findings: – 5.6% of gamblers increased their risk for PG – 4.3% decreased their risk – PGs were, with Non-PGs, the most stable categories
    20. 20. The Victorian Gambling Study 2011 (excluding Internet gambling)Transitions between PGSI groups Wave One to Wave Two (n=5003)
    21. 21. But assumption in surveys is that responders are telling the truth
    22. 22. If data is suspect, can we rely onprevalence rates or ‘adaptation’? • As only 29% of problem gamblers reported in the 1999 Australian Productivity Commission report stated they would tell the truth about their gambling, surveys specifically on gambling probably strongly under-estimate, and may vary over time
    23. 23. A.C. Nielsen NSW Survey 2007
    24. 24. Some considerations• Productivity Commission also states: ‘the share of spending accounted for by PGs appears to be very high – with no apparent downward trend’• Higher risks with those with little disposable income – many within this population spending all their non- disposable income may not result in increases in total gambling losses
    25. 25. The future?• Problem gambling in its most severe form is both chronic and persistent• Many factors suggest increased, rather than reduced, gambling problems in the future – New generation gambling machines, – ‘improvement’ in internet gambling sites, – greater competition between modes of gambling (e.g. Lotto more often, larger prizes), and – greater accessibility due to electronic advances
    26. 26. But gambling technology improves too so difficult to compare years The total amount lost per poker machine (in Australia) has risen fivefold from $19,600 in 1992-93 to $101,100 in 2008-09. The Age, July 2012
    27. 27. A hidden, difficult to measure, but resilient addiction • Prevalence measures used vary (and no gold standard) • Problem gambling is ‘persistent and recurrent’ and almost all prevalence studies for PG are snapshots rather than longitudinal assessments • Stigma high, visual symptoms low or ambiguous, may mean under-identified
    28. 28. PG prevalence in NZ: stable? 14000 12000 10000clients 8000 6000 4000 2000 0 11 0 /7 6 8 9 /1 5/ 7/ 8/ 06 0 09 0 0 0 /2 20 20 20 20 20 10 20 F to F intensive F to F all clients Gambling Helpline
    29. 29. PGs are reluctant help-seekers 2011/2012 7000 6000 5000New clients 4000 3000 2000 1000 0 Brief intervention Received both Full intervention
    30. 30. Internet gambling The future risk?
    31. 31. Internet gambling• Online gambling sites typically see revenues of $300 per paying user per month• Asia-Pacific online gambling expected to grow from $(US)34.4B to $(US)79.3B in the next few years PriceWaterhouseCooper
    32. 32. Exposure to technology – Internet Gambling• Although internet gambling has been available for at least a decade, few problem gamblers present to services with this problem mode• 2011 Gambling Helpline n=21 clients with Internet gambling problems;• NZ face to face doesn’t code by Internet until mid 2012
    33. 33. Reasons for low Internet PG presentation• Internet gambling not conducted in a public venue – little harm minimisation controls enforced, less overview (hidden)• Most clients present under some pressure – PG identified by gambling venue and excluded – access to services a requirement for re-admission to venue – Others note the excessive gambling and motivate PG to access treatment• Remember: few PGs seek help and may be influenced by hope of winning their way out of financial problems
    34. 34. Reasons for low Internet PGIn past gambling may have been hampered by: – Low Internet speed and/or insufficient computer power (slow, low level graphics) – Uncertainty around honesty or reliability of process – Fear of complexity of the InternetNow: – High speed and computer power widely available – Familiarity with Internet (especially youth) – New ‘gaming’ without money widely accessible and introduces new Internet gamblers to the process – Cross-over opportunities between gaming & gambling
    35. 35. Monthly online gambling by 18-22yr olds Annenberg Survey: U Pennsylvania 2010 18 16 14% aged 18-22 yrs 12 10 Males 8 Females 6 4 2 0 2008 2010
    36. 36. Internet gambling here• Health Sponsorship Council 2011: 8.7% of New Zealanders had gambled online in last 12 months (2% overseas sites balance Lotto-Racing-Sports NZ sites) Press Release“Proposals to increase internet speed and capacity, patterns of online gambling in overseas jurisdictions and increasing use of online payment methods all combine to suggest that NZ might be approaching a tipping point”“How do you stop people, in the privacy of their own home, accessing gaming sites?” Assoc Minister of Health 11th August 2012
    37. 37. Growing concern“There is a huge flood of new gamblers (2%population currently addicted)…some 100,000 moreSwedes become addicted to gambling each year…women most likely to be addicted, with slot machinesand online games being the most common” Swedish National Institute of Public Health August 2012
    38. 38. But this could only be the beginning – growth areas for gambling are online a) Mobile gambling b) Social gambling sites
    39. 39. Growth in online gambling – Australia • “Betting on Australia’s two largest football codes is set to double over the next 5 years driven by strong growth in online gambling on sports” Deloites • “Mobile gambling is the biggest shift in online gambling, greater than offline to online. Tabcorp says 20% of their online revenue is through mobile…Sportsbet revenue is up 241% in the last year and 40% use their mobile to place bets” Dr Sally Gainsbury, Centre for Gambling Education Research, Southern Cross University
    40. 40. Growth in online gambling• Paddy Power is launching social media gambling and mobile casino products following a record year (up 47% in Australia, 79% Eire, online up 36%)• New online forms of online gambling payment solutions enable confidential bank to casino transfers (UseMyFunds) in addition to many other such as Visa and Mastercard
    41. 41. Social gaming sites targeted• “Convergence of casino gaming and social media will be ‘the next big thing’ in our industry” Chairman MGM Resorts• Will ellipse all land-based casinos in USA• 800 million users (20 times Las Vegas tourists)
    42. 42. Earning Power of Zynga Poker• In July 2012, Zynga announced that it will be providing real-money gaming outside of United States in 2013• In July 2012 Zyngas games had over 306 million monthly active users• Listed on the American Stock Exchange Zynga has quarterly revenue earnings in excess of US$300 million and is experiencing annual growth of 19 percent annually• The mobile version of the game is available in 18 languages
    43. 43. 7 of top 20 Facebook earners Gambling Apps“Play and challenge your friends to fun and addicting games...” Ranking $ Game Players 1 Zynga Texas HoldEm Poker 33 million 4 DoubleDown Casino 4.8 million 7 Slotmania 6.2 million 11 Games by GSN 4.3 million 13 Zynga Slingo 12 million 17 Best Casino 1.6 million 19 Zynga Bingo 5.5 million
    44. 44. Zynga – Buy Chips – 50% off !
    45. 45. Zynga “this game requires 800,000 chips to join”
    46. 46. Zynga – Buy Chips – Prepaid Cards
    47. 47. Online Pokerthe player has $390, the Queen of Spades and the 10 of Hearts, they call the game to start with $4
    48. 48. So what are we going to do?
    49. 49. Lets not be reactive or do nothingBut we can do something:• May be hard to control access to the InternetBut can:• Increase education of gambling risk (very little public education currently)• Can increase research into risk areas• Can provide interventions online• Can consider novel online approaches to therapy
    50. 50. Using technology in treatment• Stage 1: phone counselling, manuals for self-directed programmes• Stage 2: text counselling, email counselling• Stage 3: counselling with Skype & others, smart phones/tablets, - mobile counselling• Stage 4: virtual world/avatar programmes, more self- directed on-line programmes, stepped programmes, increased mobile counselling
    51. 51. PGs may prefer self-directed help• N=106 affected by PG and/or PTSD (commonly coexists with treatment seeking PGs -12.5%-29%) were recruited from the community and asked their treatment preferences• Treatment preferences for (only) PG identified that the preferred therapy was self-help, while (only) PTSD preferred psychotherapies – coexisting also preferred psychotherapies G
    52. 52. Internet may be both problem & solution!Internet-based treatment may better meet theneeds of some PG clients because: • May increase uptake & retention • Enquiries can be less stressful • CBT & MI easily adapted • Cost effective • Accessibility, especially when geographical/time restraints Gainsbury & Blaszczynski (2011a)
    53. 53. Some support for this• Small numbers of PGs seek formal treatment• Review of 24 randomised Internet health/mental health programmes identified these have equal to or greater effectiveness than face-to-face therapy• Some therapist interaction in online programmes indicated some greater effectiveness but mixed• Younger PGs may relate better to online therapy• Concluded: online PG programmes an alternative rather than a replacement for face to face therapy and an adjunct for those waiting for or exiting treatment Gainsbury & Blaszyznski (2011b)
    54. 54. Proteus effect: Patricia & Baji
    55. 55. The future• More than any other addiction (with the possible exception of pornography addiction), problem gambling is, and will be even moreso in the future, be impacted by technology• Even if there is an underlying common substrate for addictions, and only objects may differ (such as alcohol, other drugs, pornography, compulsive buying, and problem gambling), treatment is often driven by these differences• Adaptation, if alive and well, may provide an answer in the long term but still require a focus on minimising harm during the short-term duration of problem gambling