4. Summit 10th Anniversary
• First Summit, 2-day general session format
• Conference format, including workshops
• Networking opportunities
• First treatment award, Dr. Richard Rosenthal
• Prevention program primary focus
• GA and 22 California certified counselors
• CPGTSP to CalGETS
9. Evolution of CalGETS
• Freedom from Problem Gambling, self-help workbooks
in 21 languages uploaded to OPG website 10/2009
• Problem Gambling Telephone Interventions,
Intensive Outpatient and Residential (LA) 6/2010
• Data Management System online 2/2011
10. Evolution of CalGETS
• Outpatient services launched 03/2011
• First 50 authorized providers (March – April 2011)
Burgina, Lyubov
Hua, Jennie
Keith, Andrea
Schmidt, Regina
Slone, Monica
11. Evolution of CalGets
• Compliance Monitoring Reviews began in 12/2011
• 2nd residential treatment facility (SF) opened 10/2012
• 2nd Intensive Outpatient (SD) opened 07/2014
• Group services included in Outpatient 07/2015
• Helpline enhancements: text, chat, motivational text
• Program enhancements: forms, training
13. Where are we today?
• 700+ trained
• 14,500 clients served
• Largest, most comprehensive treatment program in the US!
• Positive evaluation, met program goals
15. Acknowledgements and Partners
• California Department of Public
Health
• Office of Problem Gambling
• CCPG
• Morneau Shepell
• Beit T’Shuvah
• Health Right 360
• CalGETS Providers
• UPAC
• NICOS
• FNL/BOOF
• Gaming Industry
• Dept. of Justice
• Gambler’s Anonymous
• Clients
• Affected Individuals
• Media Solutions
• OPG Advisory Board
• Many more
17. Timeline
• 1957: Gambler’s Anonymous
founded in Los Angeles
• 1986: CCPG Founded
• 1990: CPC Westwood Inpatient Program (Dr. Rosenthal)
• 2001: Dr. Fong and Rosenthal Meet
• 2003: Office of Problem Gambling established within the
California Alcohol and Drug Program
18. Timeline
• 2003: UCLA Gambling Studies Program Established
• 2009: CALGETS Established Under It’s First Name (CPGTSP)
• 2009: First client enrolled
Beit T’Shuvah
BDA / PGTI
• 2009: First OPG Problem Gambling Summit
• 2019: 10 Years of Services Provided
19. California Prevalence Study (2005)
• n = 7,121; 18 years and older
• Problem gambling: 2.2%
• Pathological gambling: 1.5%
~ 1,000,000 cases
~ 9,000 – 14,000 would seek treatment
• Highest Risk:
• African-Americans
• Disabled
• Unemployed
20. 10 Years of CalGETS
• Treatment Manuals
• Self-Help Workbook
• Treatment Manual for Gamblers
• Partners Manual
• Supervision Network
• Live Trainings – Phase I, II and Annual Summit
• Telephone Intervention
• Provider Education Resource Center
• Numerous Policies and Procedures
21. Gambling Treatment (Fong Office): 2009-2019
Treatment Options 2009 2019
Medications No FDA-Approved Medications No FDA-Approved Medications
Naltrexone, Lithium, SSRIs Naltrexone, N-Acetyl-Cysteine,
Focus on Co-Occurring Disorders
Psychotherapy CBT, Motivational Interviewing,
Relapse Prevention,
Psychodynamic, Behavioral
Mindfulness
Self-Care Activities
Resilience
Trauma
Group Support Gamblers Anonymous Gamblers Anonymous
CalGETS Groups
Office Visit Priorities “Go To Meetings”
“Get a Sponsor”
Increase motivation
Sleep Hygiene
Physical Activity
Self-Exclusion
Ending Culture of Loneliness
Nutritional Support
24. What We Have Learned: Intake
• Gambling disorder is severe at intake
• Treatment demand to CalGETS follows a seasonal pattern
• Lowest in December; Highest in March and April
• Seeking treatment occurs during times of crisis and desperation
• Client characteristics similar from year to year
• Gender: Predominantly Male
• Age: Mid 40s
• Gambling: Slot Machines, Casino Table Games, Lottery
• Mental Health: Depressed, Emotional Pain, Low Life Satisfaction
32. What We Have Learned: Follow-Up
• If gamblers stay in treatment, improvement is going to follow
• Type of treatment is less important as connection / alliance
• Improvement seen in urges, life satisfaction, reduction in gambling behaviors
• Those who do commit to recovery prefer to stay long-term (e.g. third block
requests!)
• Tracking gamblers after one year is crucial but a difficult task
• BUT, many burning questions remain (Dr. Rosenthal will address)
35. What Have We Learned: Treatment Settings
• Problem Gambling Telephone Intervention
• Asian Languages
• English and Spanish
• Outpatient
• Intensive Outpatient Programs
• UPAC
• Beit T’Shuvah (Right Action Program)
• Residential Treatment Programs
• Beit T’Shuvah (Right Action Program)
• Health Right 360
36. What Have We Learned: Treatment Setting
• Problem Gambling Telephone Intervention
• Works but growing demand for chats, text, virtual assistants
• Designed to transition to live but some PREFER telephone format
• Intensive Outpatient Programs
• Outpatient to IOP vs. RTP to IOP
• No consensus on length of time in treatment
• Residential Treatment Programs
• Clients prefer at least a 90 day stay – how much of a difference does that
make?
• How do you keep up with treatment costs?
39. What Have We Learned in 10 Years?
• Nearly every year, amounts to 25% of incoming clients
• Majority of AIs are spouses / romantic partners
• Treatment works but retention is not as high as with the gamblers
• Gambling patterns of AIs are relatively unexplored
• Health and mental health impacts on AIs not as well understood
• Gambling disorder can be a family condition, so how do we best treat
the entire family?
• What level of treatment demand can we expect and how do we
increase it?
41. What Have We Learned in 10 Years?
• CALGETS trains, supervises and collaborate with the LARGEST
gambling disorder workforce in the nation
• MFTs, every year remain the predominant licensed therapist
• Authorizing MDs has not happened
• Embedding gambling disorder into training curriculums at an earlier
stage in the career is important but how?
• The diversity, curiosity and unique skillset of providers is the greatest
strength of CalGETS Treatment
44. What Have we Learned in 10 Years?
• Treatment demand rises with more media, advertising and publicity
• Client satisfaction for 10 years has been consistently high
• Vast majority of clients are grateful for no-cost services and the quality of care
that they receive
• Other states ebb and flow in training, quality of care, provider skill
and administrative security / oversight
• California’s strong partnership and stakeholders and relationships built
through the years
• Shared Governance
45. Summary of CalGETS Evolution
• CalGETS has evolved from an idea in 2002 (“state-funded treatment”)
to a >300 person, no-cost-treatment program in 2019!
• Treatment throughout CalGETS is constantly evolving and adapting
• Emphasis being placed on total mind and body health and wellness
• Recovery, not simply sobriety
• Treatment needs and requests from clients are evolving
• Texting, instant access , instant feedback requested
• More co-occurring disorders being uncovered
• Types and Forms of gambling are constantly changing
• From brick and mortar to mobile and virtually constant
46. What Will CalGETS Look Like in 2029?
• Telehealth, online and virtual treatment options
• Boundless therapy
• Greater ability to monitor / track progress or signs / symptoms
• Use of Brain Stimulation Therapies
• Stigma Reduction that will increase Treatment Demand
• A New DMS?
• Governor Canale?
• #CalGETS20 #$20millionbudget
49. Background
• UGSP official beginning – 2003
• Annenberg Foundation – 2004
• Think Tank on DSM-V – 2008
Minor adjustments to criteria
But where to put it (classification)
Problem gambling
Continuum or are PGs qualitatively different
Loss of control
50. I. What is it?
• Impulse control disorder, behavioral addiction, obsessive-compulsive
spectrum disorder, impulsive-compulsive continuum, volitional
disorder, disorder of cravings or desire, manifestation of underlying
disorder, co-occurring disorders, mood disorder, etc.
• The most important of the burning questions, also perhaps the one
most satisfactorily answered.
• It’s an addiction!
51. A definition of addiction
Addiction is a pattern of behavior in which the relationship with a
substance or activity is excessive (harmful consequences) and
progressive. What is progressive is: (1) the time and importance
attached to it, (2) the individual’s inability to regulate or control their
involvement with it (they have difficulty setting or sticking to pre-
determined limits, and difficulty stopping or not starting, (3) the harm
it causes both for themselves and others, and (4) their worsening
feelings, primarily of shame, guilt, helplessness, and/or depression.
52. DSM-5 criteria for Gambling Disorder
1. Needs to gamble with increasing amounts of money in order to
achieve the desired level of excitement (tolerance)
2. Restless or irritable when attempting to cut down or stop gambling
(withdrawal)
3. Repeated unsuccessful efforts to control, cut back or stop gambling
(impaired control)
4. Preoccupation with gambling (reliving past experiences,
handicapping or planning next venture, schemes for getting money)
5. Gambles when feeling distressed (helpless, guilty, anxious,
depressed)
53. DSM-5 criteria for Gambling Disorder
6. After losing money gambling, often returns another day (chasing)
7. Lies to conceal the extent of one’s involvement with gambling
8. Has jeopardized or lost a significant relationship, job, or educational
or career opportunity because of gambling
9. Relies on others to provide money to relieve desperate financial
decisions caused by gambling (bailout).
54. Summary of GD criteria
• Criteria describe harmful consequences, impaired control,
preoccupation, tolerance, withdrawal
• Additionally describes chasing (unique to gambling), lying, and bailout
• Lying mentioned for only three DSM diagnoses
• Custer introduced bailout in DSM-III, gambler feels “protected from reality”
• Four of nine needed for diagnosis
• Progression expressed by seven criteria
• GD would be synonymous with addiction
55. II. Irresistible impulse or impulse not resisted?
Multiple ways of describing loss of control
• Voluntary or involuntary
• Bad (criminal) or sick (patient)
• But usually binary (either-or) – ignores progression
For the gambler
• Inability to stop (lack of brakes)
• Inability to stay stopped (not start)
• Inability to stay within limits, not increase amt. wagered, time or
frequency of play, risk involved.
56. “The line between an irresistible
impulse and an impulse not resisted
is probably no sharper than that
between twilight and dusk.”
APA Insanity Defense Work Group, 1983, American
Journal of Psychiatry
57. III. The problem of Problem Gambling
• Paralleled substance abuse (which is not part of DSM-5)
• Created semantic problems
• If it’s subclinical, how can it be in the DSM?
• Yet want early detection and treatment.
58. The problem of problem gambling
• Viewing Problem Gambling as distinct (separate) entity
• Based on number of criteria; on a continuum
• What, if anything defines it?
• Some problems but not sufficient for PG
• More like what precedes or follows it?
• Pairing of social and problem gambling
• Pairing of problem and pathological gambling?
• Transitional? Can be read both ways
• Avoids the question of where the disorder begins
59. IV. Continuum or are PGs different from
problem and serious social gamblers?
• Is GD a separate and distinct entity or does it exist on a continuum?
• You can’t be a little pregnant. You can be a little diabetic,
hypertensive or obese.
• Where is the line? Is there a line?
• Does it change as society, culture changes? Or as we learn more?
• Is the line determined by loss of control?
• Harmful consequences?
• Do they gamble differently?
60. V. Acute or chronic?
• If it’s an addiction, which addiction model: acute like cocaine or
chronic, life-long disorder, like alcohol or heroin.
• Although more recent findings are of different varieties of alcohol use
disorder ( AUD). Most common may have a course of one year.
• Spontaneous remission holds for gamblers as well. 50% quit on their
own.
• Is it a chapter in a person’s life or a life-long problem?
61. VI. What should be the goal of treatment?
• Lack of agreement about outcome measures
Indecision in the alcohol, SUDs literature
oRecent questioning of abstinence
UGSP: decrease in gambling, cravings, depression, increase in quality of life
• Is it to stop gambling, or is that a band aid?
• Treating the most obvious, dramatic symptoms
• To placate the insurance companies and creators of the DSM?
62. What should be the goal of treatment?
• If we don’t address underlying problems, including what they’re
avoiding or escaping from, are we setting them up for failure?
• Should we focus on affect tolerance, coping mechanisms, relationship
issues, defenses?
• Need for long term outcomes.
63. What should be the goal of treatment?
• Some who appear to be treatment drop-outs are early responders.
But we don’t know what happens to them long-term.
• Do they “get it” quickly and move on, maybe by dealing with
problems more directly? Or is this a “flight into health,” and an
avoidance of therapy by someone who needs it?
• The problem of these “good beginners,” who learn the language,
know how to please.
• Again, need long-term follow-up.
64. VII. Is GD a brain disease, and why it should
matter?
• Jurisdiction (turf) – ‘treat alcohol, drugs, then after 2 years sobriety,
treat gambling’ (1989).
• until you can show us abnormality in the nucleus accumbens…
• Stigma – psychological less than physiological
• GA – need for a disease model, explanation to reduce guilt and shame
May not have to be correct
Allergy to alcohol still in AA Big Book
66. A moving target…
• At least four phases:
• Damon Runyon characters
• Middle aged men, long gambling career - 20-30 years gambling before
seeking help
• Race track, bookies, neighborhood, illegal, Las Vegas
• Women, middle aged, middle class
• Slot machines, luck-based
• College kids, younger gamblers
• Poker – private games, tournaments, gambling online, video games,
day trading
• A casino in your pocket, daily fantasy sports, eSports,
cryptocurrency, legal sports betting, prop bets
67. A moving target…
• Increasing legalization
state-run lotteries, promoting social causes
Socially acceptable
• Advancing Technology
Greater accessibility
Faster, more interactive, more efficient (at taking money)
Different learning curve (for luck and skill-based games)
