A training with Michele Tantriella-Modell (Emergence) and Julie Hynes (PreventionLane at Lane County Public Health). November 30, 2018

1. Michele Tantriella-Modell & Julie Hynes
November 30, 2018
PROBLEM GAMBLING
In Today’s World: Trends, Implications & Services

2. The complete slide
deck & print-friendly
handouts are posted at:
www.preventionlane.org/
gambling-training
8:37 AM

3. Training Agenda
• Introductions & Expectations
• Overview, Definitions & Trends
• Defining Disordered Gambling
• Co-occurring Issues
• Screening & Intervention
• Problem Gambling Services
• Wrap-up
(Note to Michele- I will bring a
coloring book)

4. There may be content here that
could present as a trigger to some.
Please take care of yourself
and give yourself a break if needed.
HEADS UP

5. Cover tech & new
issues in gambling,
DSM-5 criteria for
disordered gambling.
PG services – focus on
treatment & screening.
9:09
AM
Understand substance abuse
& mental health connections.

6. How about you--
YOUR expectations for today?

7. TRENDS & DEFNITIONS
PART 1.

8. Image sources: Oregon Lottery, Hynes

9. $.73out of
every
Lottery dollar
ELECTRONIC GAMBLING:
“Video Poker/Slots/Line Games”
Photo source: Daniel Berman.

10. Photo: Hynes

11. Photo: Daniel Berman

12. Lottery machine at Sea-Tac Airport , 3/18
- GAMIFICATION
- BLURRINESS

13. We don’t think of these
things as gambling.
Therefore, we don’t
think our young
people are gambling.

14. DEFINITION: GAMBLING
__________ something of value
in the ______________________
something of greater value.
hopes of obtaining
Risking
Source: American Psychiatric Association - DSM-5 (2013).

15. • Circle “yes” for the activities which you believe are gambling.
• Now, put an “S” next to the activities that are mostly skill-based,
and an “L” next to the activities that seem mostly luck-based
[Handout/Activity]
GAMBLING OR NOT?

16. BLURRING LINES?
1. PRIZE:
2. CHANCE:
3. CONSIDERATION:
Anything of value the sponsor awards in a promotion.
(Example: real money or a virtual reward to help
advancing in a game.)
A process beyond the participant's direct control
determines the outcome. (Example: an instant-win
game at a fast food restaurant.)
Requires money or significant effort.
(Example: inviting Facebook friends
in order to gain new “lives.”)

17. FREEMIUM.

18. “FREEMIUM.”
FREE* APPS…
* (WITH “IN-APP
PURCHASES.”)

19. REAL MONEY FOR PRETEND MONEY / PRIZES

20. REAL MONEY FOR
PRETEND
MONEY / PRIZES

21. Of 100 most popular Facebook games,
more than half (54%) include gambling
content (22% are slot-based)
Giroux, 2016

22. OOH!
WAYS TO LEVEL
UP FASTER!
TYPICAL FREEMIUM SCENARIO:
Source: Custer, R. & Rosenthal, M.
&@*$#!
IT’S GETTING
HARDER.
WOOHOO!
COOL FREE
GAME!

23. THE SITES MIGHT CHANGE,
BUT FANTASY SPORTS
IS NOT GOING ANYWHERE.
“DFS”

24. US SPORTS BETTING
25-year federal ban on legal sports bets for all
practical purposes except the State of…
$150B illegal market in U.S.

25. Source: https://www.washingtonpost.com/politics/courts_law/states-are-free-to-authorize-sports-betting-supreme-court-
rules/2018/05/14/31a46d16-2af1-11e8-b0b0-f706877db618_story.html?utm_term=.2b221aa0603c
“PASPA” Repeal=
2018 Big Deal

26. Sources: http://www.espn.com/chalk/story/_/id/23716636/delaware-generates-322135-bets-day-1-full-scale-betting-tuesday
https://www.nytimes.com/2018/06/11/nyregion/sports-betting-legalized-nj.html

27. • 2
Online Sports Betting:
Still illegal across state lines
Wire Act of 1961!

28. LET’S PLAY “GUESS THE SPORT!”

29. ANSWER: OVERWATCH (VIDEO GAME)
Source: http://www.espn.com/esports/story/_/id/24153101/overwatch-league-playoffs-london-spitfire-becomes-first-overwatch-
league-playoffs-finalist (July 30, 2018)

30. May 2, 2018: https://www.nytimes.com/2018/05/02/style/fortnite.html
ESPORTS:
COMPETITIVE
VIDEO
GAMING

31. TRADITIONAL SPORTS
A NEW EXPLOSION OF SPORTS.
Etc… Etc…And new games keep coming…
ESPORTS

33. GAMERS ARE THE NEW STARS
https://www.forbes.com/sites/insertcoin/2018/04/07/ninjas-new-fortnite-twitch-records-5-million-followers-250000-subs-875000-a-month/#5895314b478f
Now
9.5 million
followers

34. Source: https://www.gambling.com/news/10-reasons-why-fortnite-will-be-huge-for-esports-betting-1495000
GAMBLING ON THE GAMES

35. ESPORTS BETTING EXPECTED TO
SURPASS $6 BILLION IN 2018

36. GAMBLING IN ESPORTS.
2. Fantasy
esports
1. Betting on
professional
gaming teams
Image source: csgostash.com
3. Betting
in-game
decorations (skins”)
2017 Overwatch World Cup
Image source: pcgamer.com

37. SKINS. Entertainment. Street Cred. Possible $.
Image Source: https://csgostash.com/

38. PRIZE. CHANCE. CONSIDERATION.

39. WATCH: “Skin in the Game: Counter-Strike has spawned a wild multibillion-dollar world of online
casino gambling; it's barely regulated and open to any kid who wants in.” ESPN.com, 1/20/17

40. Esports betting = ~$2.3 billion market.
J. Hynes | 3/2/18 | www.preventionlane.org/ok
Source: http://www.bloomberg.com/features/2016-virtual-guns-counterstrike-gambling/

41. https://www.cnet.com/news/international-coalition-calls-on-video-game-industry-to-crack-down-on-loot-boxes/#

42. Sports Illustrated, 4/25/18:

43. Additional Recommended Video: “Skin in the Game: Counter-Strike has spawned a wild
multibillion-dollar world of online casino gambling; it's barely regulated and open to any kid who
wants in.” ESPN.com, 1/20/17

44. “MICROTRANSACTIONS”
REAL $,
VIRTUAL PRIZES

45. LOOT BOXES: ANOTHER FORM OF
MICROTRANSACTION
Small payment.
Could get something really cool…
but probably not.

46. LOOT BOXES: ANOTHER FORM OF
MICROTRANSACTION
Animation source: https://gfycat.com/gifs/detail/zealousglossygazelle

48. Prize.
Chance.
Consideration.

49. Source: https://www.businessinsider.com.au/
how-video-game-companies-are-using-gambling-tactics-to-make-customers-addicted-2017-9
SO MANY
CONNECTIONS…

50. SO MANY CONNECTIONS…
• Younger bettors avoid human connections
• Recommendation for in-play betting suggests
using TV timeouts to offer a two minute
window for players to place bets.
• Sports betting make up 15% of all global
gambling but accounts for 50% online
gambling and 68% mobile gambling.
Source: Information from 2018 Global Gaming Expo (October 2018).
Thanks to Erin Jones, University of Oregon Family & Human Services student intern, for this research!

51. problem

52. NOT ALL GAMBLING IS PROBLEM
GAMBLING. IT’S A CONTINUUM.
No
Gambling Experimentation
Recreational Problem Pathological
Sources: Moore (2016); Volberg, Hedberg, & Moore (2008); Shaffer & Hall (2001)
Between 2-3% adults 18+ problem gamblers (2.6%)
Teens (13-17 y.o.): 6% at risk or problem gamblers 2
College age (18-24): 5.6% 3
At-Risk
“GAMBLING DISORDER”

54. DSM-V (2013):
“Addiction &
Related Disorders”

56. PROCESS of
ADDICTION.

57. ACTION
CYCLE
Source:
http://www.oregon.gov/oha/amh/gambling/
gear-workbook.pdf
THOUGHTS, FEELINGS,
ANTICIPATION,
FANTASY
(Gambler’s Mind, “Gambling
Time/ Gambling Money”)
PLANNING
(Removing obstacles
to gambling)
GAMBLING
(“Winning & Losing”)
Serotonin
Adrenaline
Dopamine
CRASH
Guilt, Shame, Anger, Denial,
Justification, Restless, Irritable,
Depression, Panic or Numb,
Suicidal Thoughts Dopamine
REALITY
(Self with Others)
“Real Time, Real Money”

58. Typical Phases
of Problem Gambling
Information source: Custer, R. (1982); Lesieur, H. & Rosenthal, M. (1991)
WINNING
LOSING
DESPERATION
HOPELESSNESS

59. Winning PHASE
• Early “big win”
• Excitement
• Feeling on top of the
world
• Gambling is main
Image attribution: C-3PO: https://titoupaul.files.wordpress.com
Yes! I am a
winner.

60. Losing PHASE
• Large losses
• Using credit
• Borrowing money
• Arguing
• Missing school
I’ll get my
money back in
no time.
My big win is
just around the
corner!

61. Desperation PHASE
• Obsessed with next win/game
• Lying
• Depressed
I sold my arm
but still short
of cash. Maybe
I can ask han
solo for a
loan.

62. Hopelessness PHASE
• Major life consequences
• Winning no longer a goal; staying in “action” is
the goal
• Lost relationships, isolation
• Considering suicide
• Hitting “bottom”

63. connections

64. The PREFRONTAL
CORTEX is the LAST
PART to develop.
The brain
is still
developing
until

65. Source: Brain Briefings (2007, October), Society for Neuroscience, Washington, DC
Gambling & Dopamine
Dopamine not released when expecting a loss.
Flooded with dopamine when expecting a win!
It’s not about the money – it’s about the action of the game and the hope of
winning.

66. Neurotransmitter
Serotonin
Norepinephrine
Opioids
Dopamine
Role in Impulse
Control
Behavior Initiation/Cessation
Arousal, Excitement
Pleasure, Urges
Reward, Reinforcement
 Serotonin -- risk taking
Gambling -  β-endorphin
PGs -  NE levels
PGs -  dopamine response
Potential Neurotransmitter Roles
in Disordered Gambling
Dopamine: most studied neurotransmitter in problem gambling

67. Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):159

68. Image source: Anheuser-Busch
Cognitive Distortions
• Lucky #’s
• Favorite shirt
• “My” machine
Superstition
Rituals/habits that
are believed
to affect the outcome.

69. Cognitive Distortions
• Example (win): “Yeah buddy! I was just waiting on my
card. I know this game inside and out.”
• Example (loss): “I would’ve won if that idiot didn’t get
lucky and draw an ace.”
Biased Evaluation
Attributing wins to one’s
special skill or luck, while
losses are blamed on
external circumstances.

70. Image source: Anheuser-Busch
Cognitive Distortions
Forgetting about losses, only
remembering wins.
Selective Memory

71. Cognitive Distortions
Failure to see each event as
independent. Examples:
• Trying to see patterns in coin flips.
• “This slot machine is DUE to hit!”
Gambler’s Fallacy

72. Image source: http://www.drugabuse.gov/pubs/teaching/largegifs/slide-2.gif
Survival Reward Pathway

73. Trauma.
(Hodgins et al. 2010; Kraus et al. 2003; Najavits et al. 2010; Petry and Steinberg
2005; Taber et al. 1987)
Exposure to early childhood
trauma has consistently been associated
with disordered gambling.

74. GAMBLING & ACEs
Associated w/ ADHD, personality disorders
&…Disordered gambling
Poole, J.C., Kim, H.S., Dobson, K.S., & Hodgins, D.C.(2017, March). Adverse childhood experiences and disordered
gambling: Assessing the mediating role of emotion dysregulation. Journal of Gambling Studies, DOI
10.1007/s10899-017-9680-8
Adverse
Childhood
Experiences
(ACEs)
Emotional
disregulation
Self-medicating
w/substance use,
eating, gambling,
etc.
Substance use
disorders, eating
disorders,
disordered
gambling

75. 23%
are current
tobacco users
66%
have current
alcohol
problems
39%
have had a
mental health
episode of care
Source: Oregon Gambling Treatment Programs Evaluation Update,
24%
experience
suicidal ideation
Have current
drug problems

76. Spotlight ON
MENTAL HEALTH CONNECTIONS
• Depression/mood disorders1
– Depression – in one study, 76% of PGS had depression
– Bipolar disorder – correlations with BPD & PG
• PTSD (studies of military veterans)
– PTSD among problem gamblers estimated between 12.5 – 29% 2,3
• ADHD4 20-25% of problem gamblers
• Alcohol & other substance abuse disorders
Sources 1. Ledgerwood & Petry (2006). 2. Kausch et al. (2006). 3. Biddle et al. (2005). 4. Waluk, Youssef & Dowling (2015)

77. The “Addiction” Connection
• Loss of control
• Denial
• Depression/mood swings
• Progressive
• Tolerance
• Use as an escape
• Preoccupation
• Similar “highs”
• Self-help groups
• Family involvement
• Use of rituals
Differences?Similarities?
 Defining “use” (gambling)
 Behavior not attributable to chemical
ingestion
 No biological test
 More intense sense of shame and guilt
(anecdotal)
 Unpredictable outcome
 Fantasies of success /quitting is giving up
hope
 Easier to hide

79. Some Key Risk Factors
Other
addiction
issues
Starting
early in life
Friends / family
favorable
Community
laws &
norms
Mental
health issues

80. Vulnerable Populations
People with
other
addictions
issues
People with
other mental
health issues
Military/
Veterans
Young
people
Incarcerated
persons
People of
color
Older adults
WomenPeople of
lower SES
People with
history of
trauma
Men
LGBTQA+

81. Adolescent Behavior &
Brain Development
• Preference: excitement
and  effort activities
• Prefer novelty
• Poor planning & judgment
• Minimal consideration of
negative consequences
• More risky, impulsive
Source: Grant, J (2008, October). The Adolescent Brain & Impulsive Behaviors. Healthy Brain Development: Key Impacts &

82. Age 65+
• Rate of problem gambling lower (1.2%) 1
• BUT living close to gambling facility  risk
– six times more likely to be problem gamblers
•  risk factors 2
• Gambling = most frequently
identified social activity 2
• Challenges in problem acceptance
Sources: 1. Moore (2001, ibid). 2. McNeilly & Burke (2000). Late life gambling: The attitudes and behaviors of older
adults. Journal of Gambling Studies, 16, 393-415.

83. People of Color
• Higher proportion of
problem gamblers
(except Asians)
• Spend 2.5x more on
gambling in a typical
month
Source: Moore, Jadlos, & Carlson, 2000

84. Incarcerated Persons
• One in three offenders meet criteria for
PG 1
– Highest rate in any population
• Gambling common in prison culture
• Resources limited to investigate crime &
gambling 2
Sources: 1. Williams, Roysten & Hagen. (2005). Gambling and Problem Gambling Within Forensic Populations, A Review
of the Literature 2. Myers, H. (2006). Organized crime in Oregon.

85. Military & Veterans
• All four branches operate slot
machines overseas
• Service members at higher risk
– Male, younger, racial/ethnic minorities
– Marine corps highest rate of PG
Source: Department of Defense (2002). Survey of Health Related Behaviors Among Military Personnel Washington, DC:
Author. Report information available at http://www.tricare.mil/main/news/dodsurvey.htm

86. Typical Issues: (problem gamblers in Oregon treatment)
>23%
are current tobacco
users
66%
have current
alcohol
problems
39%
Have had a
mental health
episode of care
Source: Oregon Gambling Treatment Programs Evaluation Update, 2016
24%
experience
suicidal ideation
Have current
drug problems

87. addressing
the issue

88. THE BARRIERS OUR
PROFESSION ARE REAL.
Tobacco
Substance Abuse
Problem Gambling

89. Prevention

91. FAMILY COMMUNITY
Barnes et al.,1999; Hayatbakhsh et al., 2006; Johansson et
al., 2009; King & Delfabbro, 2016; Raylu & Oei, 2002;
Scholes-Balog et al., 2014; Shead et al., 2010; Volberg,
2008; Winters et al., 2002
SCHOOL INDIVIDUAL/PEER
- Family conflict
- Family history antisocial
behavior
- Parental gambling
- Academic failure &
poor school performance
- Low school commitment
- Male
- Early initiation
- Early big wins
- Rebelliousness
- Delinquency
- Impulsivity
- Competitiveness
- Interaction w/
antisocial peers
- Friends’
use/pressure
- ATOD use
- Psychological
distress, mental
health issues
ADDRESS RISK FACTORS BY DOMAIN
- Exposure to gambling
- Availability & accessibility
- Media portrayal

92. i.e.,
• Prevention efforts that address RISK FACTORS
common to other problem behaviors;
• Prevention efforts that address PROTECTIVE
FACTORS (e.g., prosocial behaviors)
Examples: Alcohol & drug curricula, Life Skills programs,
parenting programs, etc.
RESEARCHERS RECOMMEND OVERALL
PREVENTION INITIATIVES AS MOST EFFECTIVE.

93. WHAT
CAN WE
DO IN
OREGON
?
Px education
& awareness
Track policy,
work w/
stakeholders
ID & referral
to treatment
PREVENTION

95. Treatment & Recovery

96. DSM Criteria Revisited
1. Preoccupation with
gambling
2. Increases amount of
money gambled
3. Unsuccessfully tries to
quit
4. Restless or irritable
when trying to cut
down/stop
5. Gambles as an escape
6. “Chases” losses
7. Lies to others to conceal
gambling
8. Has jeopardized
relationships
9. Relies on others to bail
him/her out
Gambling Disorder = Four or more of above, AND:
The gambling behavior is not better accounted for
by a Manic Episode.
Mild (4-5) / Moderate (6-7) /Severe (8-9)

97. Intervention
Helpline
emergence
24/7: 1.877.MY.LIMIT
Referred to provider for
assessment
Family members come in;
later bring gambler in
This is an actual helpline counselor. Everyone
who answers the phone is a Certified
Gambling Addictions Counselor (CGAC).

98. Treatment Options in Oregon
•Minimal intervention: GEAR
(Gambling Education and Reduction)
•Outpatient treatment
•Crisis respite (1)
•Residential treatment (1)

99. IT OFTEN TAKES
YEARSFOR
SOMEONE TO
1) admit they have a problem
2) seek help, and then
3) continue in recovery

100. Larger version of this
chart: click here
Source: Written by Robert L. Custer, M.D; image source: Council on Compulsive Gambling of New Jersey, Inc..

101. Treatment is free.The Oregon legislature requires that 1% OF
LOTTERY PROFITS go to a Problem Gambling
Treatment Fund.

102. Emergence Gambling
Treatment Program
Treatment is gender-specific
Multimodal treatment
- Individual sessions - Family therapy
- Group sessions - Recreational counseling
- Didactic lectures - Audiovisual education
Suggest to explore 12-step program

103. THE “average” person
IN OREGON PROBLEM
GAMBLING TREATMENT
55% male
White
48years old
Employed
Problem started at 37
Mostly gambles at video lottery terminals (in delis, bars, restaurants, taverns)
Owes $23K in gambling debt
Started gambling at 24

105. IN TREATMENT, 2016:
Outpatient (81%) Residential (5%)
Respite (1%) Home-based (4%)
Prison-based education & treatment (10%)
friends
& family
134
gamblers1,081
Source: Oregon Gambling Treatment Programs Evaluation Update, 2016

106. gambler.
IT’S NOT ALL JUST
ABOUT THE
NEED HELP TOO!

107. Learning.
Education about problem gambling as an addiction. What to
watch out for. Gaining tools for financial/legal/other issues.
Dealing with trust issues. Being allowed to vent rage and betrayal.
Healing from more “unfolding truths.”
No more secrets. No more bailouts!
Getting continued support. Renew sense of hope &
empowerment. Determining future of relationship.
Healing.
Growing.

108. Where we need your help:
SCREENING (Brief Biosocial
Gambling Screen - BBGS)

109. Wrapping it All Up
• The lines of gaming and gambling have blurred, and it’s
become much more popular
• This popularity doesn’t come without cost
• Gambling problems often mimic other disorders in
manifestation, consequences, & co-occurrence
• Problem gambling services are free, confidential, available
and effective
• Important to assess for issue & make your clients aware of
services

110. COMMENTS?
QUESTIONS?

111. Evaluations

112. Thank You!!
Julie Hynes
Prevention Specialist
Lane County Public Health
Prevention Program
541.682.3928
Julie.Hynes@co.lane.or.us
Michele Tantriella-Modell
Program Director
Emergence Meridian Gambling
Treatment Program
541.741.7107
mtmodell@4emergence.com