May 15, 2015. ACCBO / NASW

1. DISORDERED GAMBLINGin 2015: Trends, Implications & Services

2. Training Agenda
• Introductions & Expectations
• Overview, Definitions & Trends
• Defining Disordered Gambling
• Co-occurring Issues
• Screening & Intervention
• Problem Gambling Services
• Wrap-up

4. Introductions &
Expectations

7. DEFINITION:
______ something of value
in the _________________
something of greater value.
hopes of obtaining
RISKING
Source: American Psychiatric Association - DSM-5 (2013).

8. A long
history

9. 1931
Video poker began
1992
Nine tribal casinos opened
1994 - 2004
?
Lottery approved
1984

10. Gambling in Oregon
 Lottery
 Scratch-its
 Megabucks
 Powerball
 Keno
 Video lottery
 Bingo/charitable
gaming
 Casino gaming
 “Social gaming” (e.g.,
card houses)
 Sports bets
 Horse racing
 Internet
 Office pools
 Poker/card nights
 Bets among friends
 Stock market (??)

11. Local “Social Gaming”

12. Image sources: Oregon Lottery, Hynes

13. Image sources: Oregon Lottery, Hynes

14. 2,400
retailers
in Oregon
ELECTRONIC GAMBLING:
“Video Poker/Slots/Line Games”
Source: Oregon Lottery

15. $8.60
out of
every $10
spent on
lottery
Video Lottery:
Video Poker / Video Slots / “Line Games”
Source: The Oregonian
Photo source: Daniel Berman.

16. Going Mobile: Real Gambling…
16

17. …to Free* Apps…
17

18. And this is where lines
in 2015 start to blur…..
Gaming
or
Gambling?
18

21. 21

22. Fantasy Sport$
22

23. 23

24. 24
24

25. 25
25

26. 26

27. 27

28. Key
“A’s”
of the
Trends

29. AVAILABILITY.

30. Amygdala
active
Risk-taking
& impulsivity
Source: Ramoski, S., Nystrom, R. (2007). Image source: simpsons.wikia.org
age…

31. Acceptability.

32. Advertising.

33. Pop-up on my kid’s game, Feb 2015
33

34. 2012 Oregon Student Wellness Survey, Lane County (“ESD”) and Oregon;
available at http://oregon.pridesurveys.com/esds.php?year=2012
Awareness (low).

35. Oregon parent/youth focus groups revealed:
• All parents’ focus group said their kids didn’t
gamble
• All of their kids, in their own focus groups,
said they did gamble
• Neither sees gambling as risky
ATTITUDES.

36. More Gamblers ► More Problem
Gamblers
Prevalence of
gambling
problems
is a function of the
overall level of
gambling
participation

37. “Last Week Tonight with John Oliver” –
11/9/14
https://www.youtube.com/watch?v=9PK-netuhHA

38. disordered

39. PATHOLOGICAL:
Persistent and recurrent
maladaptive gambling
behavior...results in the LOSS
OF CONTROL over
gambling. (DSM-IV)
Historical
Definitions

40. New language

41. It’s a“Continuum”
No
Gambling Experimentation
Recreational Problem Pathological
Sources: 1. Moore (2006). 2. Volberg, Hedberg, & Moore (2008). 3. Shaffer & Hall (2001). 4. Northwest Survey & Data Services
(2007). 5. Moore (2001).
At-Risk
“GAMBLINGDISORDER”

44. Electronic Gambling
Electronic
Gambling
89% Cards
4%
Other
7%
OregonGamblingTreatment
Gamblers'Preferences
Source: Oregon Health Authority.

45. The new DSM-5 (May 2013) defines
pathological gambling as a
“behavioral addiction,”
the first of its kind.

46. Typical Phases of
Problem Gambling
Source: Custer, R. & Rosenthal, M.
WINNING
LOSING
DESPERATION
HOPELESSNESS

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

48. $32k
85%
90%
24%
$27k
$!
IS THE AVERAGE HOUSEHOLD INCOME.
Range is from $0 to over $1million/year.
ARE WHITE. 4.4% Hispanic/Latino., 3.4% Asian. People
of color are under-represented in treatment.
prefer ELECTRONIC GAMBLING.
Video (slots/poker/line games).
Cards 4.1%; scratch-its 1.3%; sports 0.9%;
HAVE COMMITTED CRIMES TO FINANCE THEIR
GAMBLING. Most crimes are “white collar” (forgery,
check fraud, embezzlement.)
IS THE AVERAGE INDIVIDUAL GAMBLING
DEBT.
Oregonians ingambling treatment, 2012:

49. 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

51. Effects on Children
• Higher abuse & neglect
• Higher levels of tobacco,
alcohol & drug use, overeating
& gambling among their
children
Sources: 1. National opinion research center (1999). 2. Darbyshire, oster, & carrig (2001). 3. Gupta & derevensky (1997);
jacobs (2000); wallisch & liu (1996). 4 volberg et al. (2008; ibid).

53. Some Key Risk Factors
Other
addiction
issues
Starting early
in life
Friends / family
favorable
Community
laws &
norms
Mental health
issues
53

54. People with
other
addictions
issues
People with
other mental
health issues
Military/
Veterans
Young people
Incarcerated
persons
People of
color
Older adults
Women
People of
lower SES
People with
history of
trauma
Men
Vulnerable Populations
54

55. >70%
are current
tobacco users
24%
have current
alcohol problems
5%
actually attempt
suicide
Source: Oregon Health Authority, 2013
27%
experience
suicidal ideation
Use illicit drugs

56. 5.6% college age (18-24)
2.7 % all adults (18+)
4% teens (13-17)
This is the first
generation of
widely available
electronic
gambling.
We really don’t
know the effects
yet.
1.2 % older adults (65+)

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

58. 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.

59. 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

60. 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.

61. 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
• Alcohol & gambling
connected
• Further article of interest:
http://www.cnn.com/2007/US/05/22/military.
gambling/index.html
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

62. Co-Occurrence with Mental Health &
Addictions
Thought processes & distortions
Neurobiology & addiction connections
Similarities & differences

63. Mental Health & Addictions Connections
• Depression/mood disorders 1
– 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
• ADHD
• Alcohol & other substance abuse disorders
Sources 1. Ledgerwood & Petry (2006). 2. Kausch et al. (2006). 3. Biddle et al. (2005). 4. Oregon DHS (2009).

64. brain

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

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. 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.

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

69. Dopamine levels and behavioral pattern resulting from learned audiovisual cue (Figure from Self, 2003)
Source: Biology, Addiction & Gambling (http://www.basisonline.org/backissues/2003/vol8pdf/wager838.pdf)
"Monetary reward in a gambling-like experiment
produces brain activation very similar to that observed
in a cocaine addict receiving an infusion of cocaine.”
-Hans Breiter, MD, co-director of the Motivation & Emotion Neuroscience Center,
Massachusetts General Hospital

70. Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):159
Anecdotal reports from problem gamblers in treatment and recovery.

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

72. 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.

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

74. 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

75. Have you ever
experienced a
cognitive distortion?
What was the
experience like?
Reflect: cognitive distortions.

77. Creating conditions in families,
schools, and communities that
promote the wellbeing
of people
Emotional and behavioral health
Physical health

79. Addressing the “A’s”

80. 1. Awareness Building: Focusing on Brain
Development & Technology
2. Education: Making Evidence-Based
Connections with Other Problem
Behaviors
3. Policy: Systems level,
implementing “Big P” & “little p”

82. Current special emphasis:
• Brain development.
• Technology.

83. • Supporting evidence-based programs.
• Curriculum integration.
• Training integration.

86. Identification & Treatment

87. Intervention
Helpline
emergence
24/7:
1.877.MY.LIMIT
Referred to provider for
assessment
Family members come in;
later bring gambler in

88. Treatment Options in Oregon
• Minimal intervention: GEAR
(Gambling Education and Reduction)
• Outpatient treatment (46)
• Crisis respite (1)
• Residential treatment (1)

89. Assessment Tools
• “Valid and Reliable”
– DSM-V
– South Oaks Gambling Screen (SOGS)
• Frequently Used
– Gamblers Anonymous 20 Questions (GA-20)

90. Screening: The “Lie-Bet”
• Two questions to rule out pathological gambling
behavior
– 1) Have you ever felt the need to bet more and more
money?
– 2) Have you ever had to lie to people important to
you about how much you gambled?
• One or both “yes” answers indicate further
assessment needed
– Further evaluation can be made by calling
1-877-MY-LIMIT (877-695-4648)

91. 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)

92. Treatment is Free IN OREGON.
24 hrs: 1-877-My-limit
Online: www.opgr.org

93. 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

94. System Evaluation Results
• Treatment is working
– 50% successful completion rate
– 64% of clients reported either no gambling or
reduced gambling at 6-months post-treatment
• 97.3% of the completers at six-month follow-
up and 93.9% of those at 12-month follow-up
indicated strong endorsement regarding
recommending the program to others
1. Oregon Health Authority, T.L. Moore (2014)

95. 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

96. Revisiting Our
Expectations,
Q&A
Anything lingering?

97. Evaluations

98. Thank You!!
JulieHynes
Prevention Specialist
Lane County Public Health
Prevention Program
541.682.3928
Julie.Hynes@co.lane.or.us
preventionlane.org
MicheleTantriella-Modell
Program Director
Emergence Meridian Gambling
Treatment Program
541.741.7107
mtmodell@4emergence.com
4emergence.com