Trauma Informed Care and Gambling [Part One]

1. Trauma Informed Care
&
Gambling
Part 1: research, assessment and screening
Abacus Counselling, Training and Supervision Ltd

2. What is Trauma?

3. In groups answer the following
• What is your understanding of the concept ‘trauma’?
• Is someone who has already experienced trauma more likely
to be affected by addiction?
• Is trauma more likely to arise after someone is affected by
addiction?
• Where does the level of risk for trauma fit with gambling
harm? More, similar, or less than other addictions?
Discussion

4. “An abstract concept referring to the enduring adverse
impact of extremely stressful events. It is multiple and
chronic exposure to developmentally adverse
interpersonal events such as chronic maltreatment,
neglect, abandonment/loss, physical/sexual assault,
emotional abuse, and witnessing violence or even
death.”
(Isaac, 2015)
‘Trauma’

5. Trauma:
“Experiences that overwhelm an individual’s capacity to cope.
Reactions to trauma vary from person to person, from minor
disruptions in an individual’s life, to debilitating responses.”
TIP Guide, 2013
“Trauma results from an event, series of events, or set of
circumstances that is experienced by an individual as
physically or emotionally harmful or threatening and that has
lasting adverse effects on the individual’s functioning and
physical, social, emotional, or spiritual well-being.”
SAMHSA, 2012
What is Trauma?

6. Caused Naturally By People: accidents By People: intentional
Earthquakes Car accidents Domestic violence
Hurricane Airplane crash Sexual assault/abuse
Fires/Explosion Sinking ship Physical abuse/neglect
Tsunami Accidental shooting Terrorism
Volcanic eruption Building collapse Homicide/suicide
Flooding Radiation leak Home invasion
Landslide/slip Chemical spill/spray School/office bullying
Trauma Examples

7. • Following the Christchurch earthquakes, gambling spending
appeared to increase as did levels of gambling harm.
• Where does the ‘natural’ trauma influence impact and for how
long?
• Discuss how natural and accidents caused by others may
influence interpersonal trauma.
Discuss

8. Recent research
Roberts et al 2016 in Addiction
• ‘Growing evidence to show that gambling harm is a specific risk
factor for family and intimate partner violence.’
• Gamblers experiencing harm 2-3x more likely to be in physical
fight in last 5 years.
• Gamblers experiencing harm with AOD use at higher risk for
violence, but even when this factor allowed for, there was
elevated violence.
• Concluded that Minimising Gambling Harm services should
screen for alcohol, violence and IPV, and tailor treatment
accordingly.

9. • 370 gamblers and 84 affected others accessing Minimising
Gambling Harm services took part in a survey on gambling and
family/whanau violence and abuse (n=454).
• Half of participants were victims of physical, psychological,
emotional, verbal or sexual abuse (past 12 months)
• 44% committed the violence or abuse.
• Verbal most common: (37% ‘screamed/cursed’/41% victims;
34% ‘insulted/talked down to’/40% victims)
• Physical abuse: (7% caused physical harm/9% victims; 9%
threatened physical harm/12% were threatened; no-one
reported sexually abusing/4% were sexually abused).
Recent NZ research
Bellringer M et al, 2016. Problem gambling and family violence in help-seeking
populations: Co-occurrence, impact and coping (AUT)

10. More affected others reported committing and being victims of
violence and abuse (except financial abuse) than gamblers:
• 57% committed violence/abuse compared with 41% gamblers.
• 66% victims of violence/abuse compared with 47% gamblers.
• Gamblers more likely to commit financial abuse.
• 75% violence was to/from current or ex partners; 25% to children and
other family/whanau members.
• 46% affected other victims thought violence/abuse was caused by
gamblers’ gambling compared with 21% gambler victims.
• 54% affected other perpetrators thought violence/abuse caused by
gamblers’ gambling compared to 33% gambler perpetrators.
Recent NZ research
Bellringer M et al, 2016. Problem gambling and family violence in help-seeking
populations: Co-occurrence, impact and coping (AUT)

11. Posttraumatic stress symptoms in pathological gambling (Green
et al 2017).
• 34% of PGs had coexisting PTSD. Concluded treatment of trauma
positive for outcomes in PG treatment.
University of Lincoln (Roberts et al 2017)- males with gambling
problems more likely to have suffered childhood traumas
(physical or witnessed) in the home. 23% males with
mild/moderate PG childhood trauma (vs 8% non-PG) with more
trauma as PG severity increased.
• “Highlights a need for gambling treatment services to include
routine screening for traumatic life events or substance abuse, so
that treatments can be better tailored.”
More research findings
on gambling harm & trauma

12. • Individual trauma from rape, sexual assault, physical attack,
aggravated robbery (can also emotionally affect close others); shame
can distort perception of responsibility for women feeling unduly
responsible – isolated/victimized.
• Group trauma: ‘first responders’ (secondary trauma); military
(war/‘peace-keeping’); communities, cultures (historic and
generational); refugees/asylum-seekers (many survive multiple losses,
witness acts of war, violence, deaths, torture, rape, starvation).
Trauma increases risk for substance use for refugees after war-related
experiences (Kozaric-Kovacic; Ljubin &Grappe, 2000) – CEP (trauma-
related disorders/AOD).
• Terrorism (unique sub-type of human-caused disaster). Goal is to
maximise uncertainty, anxiety, fear in communities.
Trauma from Intentional Acts by others

13. • Occur between people who know each other and often continue
to reoccur – physical/sexual abuse, sexual assault, domestic
violence, elder abuse/neglect.
• Intimate partner violence (IVP) – pattern of actual or threatened
physical, sexual, emotional abuse: current and former spouses,
boyfriend/girlfriends (IVP - 20% of non-fatal violence against
women; 3.6% against men).
• Children who witness or hear actual assaults/threats; assaulted
partner’s distress or pleas for help; exposure to aftermath:
injuries, property damage; promises it won’t happen again and
ongoing cycle.
Interpersonal Traumas

14. • Any event or trauma that occurs within a developmental stage and
influences later development or adjustment or physical/mental health
(eg life-threatening illness).
• ACE: Child experiencing physical, sexual, emotional abuse; AOD or
gambling-dependent parent; family member in jail, mentally ill or
suicidal; spousal abuse; separation/divorce/absent parent during
childhood.
• ACEs negatively affect well-being into adulthood, increase vulnerability
to physical, mental and substance use disorders and enhance risk for
repeated trauma exposure across the lifespan. Child abuse is highly
associated with depression, suicidal thoughts, PTSD, dissociative
symptoms; alcohol use (2-4 x greater than with no ACEs).
Dube, Anda, Felitti, Edwards & Croft, 2002
Developmental Trauma and
Adverse Childhood Experiences (ACE)

15. Mental Health Services that incorporate:
• An appreciation for the high prevalence of traumatic experiences
in persons who receive mental health services.
• A thorough understanding of the profound neurological,
biological, psychological and social effects of trauma and
violence on the individual.
Jennings, 2004
What is Trauma-informed Care (TIC)

16. • Opportunities for client choice, collaboration and connection.
• Promote self-efficacy, dignity and personal control.
• Equalise power imbalances in relationships.
• Allow for expression of feelings without judgment.
• Provide treatment choices; establish safe connections in
community.
Implementing TIC in Services

17. • Emphasis on safety (physical, emotional, cultural) for clients –
treatment practices/environment and strengths-based
language (non-stigmatising).
• Consumer input into policies and protocols .
• Staff safety – prevent vicarious trauma and burnout – provide
supervision; EAP; support self-cares.
Implementing TIC in Services

18. Pairs:
How well do you feel your workplace is currently set up to
support you in implementing trauma-informed care for your
clients? 10 min.
Exercise

19. • Trauma screening tool: Abacus Trauma Likelihood Assessment Screen
(‘ATLAS’) – ‘free use’ tool.
• Screen can be used conversationally as a guide for indicating trauma,
or can be filled out by clients directly - the scoring section can be cut
and pasted onto a separate sheet for this use, if desired.
• Positive scores indicate the need for more detailed and specific
assessment, however, will be a good indication of needing trauma-
informed care.
• Screen is not researched and independently validated, but is made up
of validated instruments: DSM 5 and the CHAT screen (Case finding
and Help Assessment Tool).
Screening for Trauma

20. William (29), is divorced with two children whom he rarely sees. He
has been referred to you by his lawyer pending his sentencing for theft
to support his gambling. He is distracted, clearly anxious as you expect,
and says he has no excuses and needs to be punished as he hates what
he has become. He started gambling on sports in his late teens which
distracted him from his ‘horrible’ abusive father, and sad, alcoholic
mother. As a sole child, he couldn’t wait to leave home but didn’t want
to abandon his mother. His gambling allowed him to have hope and
also forget feeling trapped. He breaks down crying.
In pairs, role playing William and his counsellor, apply the Atlas
screen either verbally or self-completed.
Exercise: William

21. • Memories of traumatic events are mostly unintegrated – (flashbacks)
– thinking about threat slows reaction time so the frontal lobe ‘shuts
down’ with threats to survival – so a coherent narrative of events may
not be created.
• These fragmented, sometimes unconscious memories can be
stimulated by even subtle reminders of past trauma, thus the
Amygdala (body’s alarm for danger) is stimulated, setting off survival
responses even if no actual danger is present (e.g. resemblance to an
abuser; survivor of an earthquake reacting to the rumble of a train
going by – ready to run outside).
• Same process can be initiated by cues/triggers or stimuli for survivors
of interpersonal trauma or ACE.
Neurobiology of Trauma

22. Cortex
Hippocampus
Stimulus
Sensory Thalamus Amygdala
Response
(Very fast)
Social,
environmental
intervention
Neuroregulatory
interventions
Psychotherapy
Psychopharmacology
(slower)
Biology of Trauma

23. https://www.youtube.com/watch?v=BF5SzIN63w8
Anticipation as powerful as winning and 100x as much time spent anticipation.
Inside the brain of a gambling addict: BBC News

24. Distinguishes between two types of trauma:
a) Big “T” trauma – associated with fear-based events e.g.
overwhelming experiences that can’t be integrated.
b) Little “t” trauma resulting from maladaptive caregiving
(causing emotional distress but may not overwhelming).
• Connecting current problems to early relationships can be
difficult when there may be continuing feelings of emotional
dependency.
• If caregiver relationships were lacking/abused, future intimate
relationships are challenging; self esteem, trust, and
confidence are affected.
Trauma-informed Psychotherapy

25. Discuss briefly the following two quotes with your partner;
feed back, and discuss in the main group:
“The inheritance of mental health and of ill health through
family micro-culture is no less important, and may well be far
more important, than is genetic inheritance.”
Bowlby, 1973
“Traumatic stress incubates in isolation and feeds on shame.”
Kerr, 2015
Discussion

26. • Research: ‘Investigation association between shame &
gambling harm (handout).
Schlagintweit et al 2017
• Important to address shame (rather than guilt) as unbearable
shame from past or from gambling may drive excessive
gambling.
Shame & gambling

27. • A primary goal of parents/caregivers is teaching how to bond
with others and regulate emotions.
• Having capacity to regulate emotions is vital for forming
relationships (note emotional regulation disorder/BPD).
• Emotions are the basis for intimacy and understanding one’s
own needs and desires.
Attachment Theory
Bowlby; Ainsworth

28. Mothers who provided secure attachments:
• Reflected sensitivity to emotional needs.
• Accepted, rather than rejected infant’s emotional needs.
• Cooperated with the infant rather than control/dominate.
• Appeared emotionally available rather than ‘remote’.
• Adapted to infant’s natural rhythms/emotional needs.
Forming secure attachments
(Caregiver/infant bonding)

29. • Discuss how parental gambling may result in attachment
issues with children and youth.
• How important is it to identify risk to gambling harm clients’
children?
• Is this information, if provided to clients about risk to their
children, likely to increase guilt and shame and interfere
with their recovery, or provide positive insight?
Discussion

30. • Caregiver frequently appears frightened (e.g. violence).
• Caregiver is emotionally unavailable (e.g. depressed).
• Caregiver is frightening (e.g. when caregiver is abusive).
• Household is chaotic, keeping caregiver from emotionally
attending to the infant (ref: Ainsworth).
• Adverse Childhood Experiences study (US; 17,000 participants,
1995/7) – “2/3 of U.S. households have conditions that can
damage the infant/caregiver bond.”
Challenges to Secure Attachment

31. Jillian (34), mother of 3 children (aged 4, 6, and 9), has sought help
following referral to you by her GP who has prescribed
antidepressants. Her husband gambles all their money and they
constantly have to move to avoid creditors and landlords seeking rent
arrears. She says she loves her husband, he never abuses her, but she
can’t get him to understand how much she now hates her life. She
can’t leave because her children need a father (hers ran away when
she was a child) but she wonders whether the children, who are now
always fighting and crying, her increasing inability to comfort them,
may be causing him to gamble and it’s her fault. She asks you for
advice.
In pairs role-playing Jillian and her counsellor, take turns to address
her question.
Exercise

32. • Group round: how well you think your service implements or
could implement Trauma-Informed care, using ideas from the
workshop.
• Two things you will take away from the workshop that could
help you in your work with clients.
• Closing of workshop.
Finishing