Gambling Use Disorder Treatment Considerations

1. Leigh Falls Holman, Ph.D., LPC-S, RPTS, NCC, CSC
AMHCA Diplomate & CMHC Substance Abuse & Co-Occurring Disorders
President-Elect, International Association of Addiction and Offender
Counselors (IAAOC)

2. Level Refers to:
0 Never gambled
1 “Social” or “Recreational” gambling
Gambling does not result in significant problems
2 Wagering resulting in some gambling-related problems
At-Risk Gambling
In-Transition Gambling
Problem Gambling
3 Gambling associated with significant problems
Meet diagnostic criteria for Gambling Use Disorder

3. Phase Description
Winning •Betting is fun, exciting, social, and a way to escape
•Occasionally win large sums generally leading to betting larger
amounts and spending more time gambling.
Losing •Preoccupied with gambling
•Needs to place larger bets more frequently
•Losses increase but rationalized as a “loosing streak”
•Begin to “chase” losses, lie about extent, and experience
gambling-related difficulties.
•Begin to make and break promises to self and others to quit
gambling.
Desperation •May experience health problems & relationships may deteriorate
•Feelings of desperation & hopelessness ensue
•Losses continue to mount
•Fantasizes about winning
•May steal, write bad checks, or commit other crimes to finance
gambling
Hopeless •No longer believes there is hope or help
•Gives up
•Suicidal ideation or attempts
•Jail or prison becomes a possibility

4. Cogitive Distortion Example
Gambler’s Fallacy Belief that completely random events (coin toss)
are influenced by recent events
Illusions of Control Superstitious behaviors where gamble believes
s/he has a reliable means of manipulating the
event outcome in his/her favor
Magnification of
Gambling Skills
Exaggerated self-confidence
Recall Bias Tendency to remember and overestimate wins
while forgetting about, underestimating, or
rationalizing losses.

5.  Gamblers seek different emotional
experiences through their gambling
activity:
◦ Escape Gamblers: Gambling becomes
a trance-like escape
◦ Action Gamblers: Gambling becomes
a powerful stimulant

6.  Predisposing Factors:
 Physical, emotional, or sexual abuse
 Poor relationships
 Losses
 Values:
 Denial of gambling as a problem
 Maintain family trust is important
 Gambling Habits:
 Onset later in life
 Faster progression of compulsive behavior
 Seeking to escape from loneliness or boredom
 Begins as a social activity and entertainment
 Participates mainly in games of chance
 Fewer big-win experiences

7.  Emotional Consequences:
 Becomes emotionally dependent on gambling
 Preoccupied with gambling
 Depression
 Secretive about excess gambling
 Guilt about both financial losses and failure to meet standards of
behavior
 Guild over lost time with family
 Shame related to dishonesty
 Fears of being revealed and disgraced
 Financial Consequences:
 Loss of household money
 Credit card problems
 Use of money from family savings or accounts
 Sale of valued family possessions
 Recovery Issues:
 Denial that gambling is a problem
 Frequently doesn’t want to stop gambling
 Partner may not intervene
 Family less supportive in getting help
 Child care
 Male dominated treatment and recovery services

8.  Predisposing factors:
 Family of origin
 Personality characteristics
 Introduction to Gambling:
 Introduced by friends or family
 Begins betting at an early age
 Occasional gambling
 Experimenting with new types of gambling
 Developing a relationship with gambling
 Deviant behavior
 Precipitating or traumatic event
 Experiences a big win

9.  Winning Phase:
◦ Frequent winning
◦ Fantasizing about winning
◦ Increases amount of money bet & time spent
gambling
◦ Lies about gambling
◦ Brags about winning

10.  Losing Phase:
 Chases losses
 Loses time from work or school
 Cannot stop gambling
 Begins to accumulate debts
 Relationship with family & friends impacted
 Frequently borrows money
 Drops non-gambling activities
 Becomes irritable, restless, depressed

11.  Desperation Phase:
 Unable to pay debts
 Sells possessions or family valuables
 Increases drug/alcohol use
 Thoughts of committing crimes to finance gambling
 Loss of job or drops out of school
 Withdraws from family & friends
 Blames others
 Shame, guilt, despair
 Thoughts of or attempts at suicide
 Emotional, physical, financial breakdown.

12.  Often begins when a recreational gambler wins big.
 Predominantly male, view gambling as a skill to be
learned & as a desirable way to make a living without
the drudgery of employment
 Experience an unequaled rush of sensation; feel
powerful & special, adrenaline rush; enjoy
recognition & status
 Tend to play games requiring skill like black jack,
craps, or poker; or a handicapping sporting event
(like racing).

13.  Often describe a system they have
 Generally much more competitive personalities
 Like to be perceived as a high-roller, respected &
admired, viewed as talented and skilled
 Stimulated by overcoming the odds – even
purposely take irrational risks to provide more
stimulation that comes from digging out of a
hole

14.  Compulsive Activity
 Loss of Control
 Continued Use Despite Adverse
Consequences

15.  Stein, Hollander, & Liebowitz (1993) define
compulsive gambling as “a conflict between a
gambler’s stated intention, such as to not gamble,
or to not gamble more than X amount, and the
actual behavior, which violates the intention.”
 May experience ‘fugue-like’ states where they “find
themselves engaging in unplanned, spontaneous
gambling activity” (Chamberlain, 2004, p. 135).
 Triggers: internal & external

16.  The Chase (1984) – the more they lose the more they gamble
– chasing losses
 Double Down: double each bet they make following a loss
with the intention of winning the bet that will eliminate the
loss.
 Downward spiral of loss of more than intended and
continuing to gamble to try to win back the losses.
 Gambling binges frequently end in exhaustion, disoriented,
& an overwhelming sense of despair and depression that is
unavoidable.
 Reports of being overpowered by the impulse to gamble
 Increasing pervasiveness of gambling in a person’s life to
the point that all activities center around gambling.

17.  Mental health consequences include anxiety,
depression, substance abuse, loss of a sense of
self, loss of hope, feelings of shame &
embarrassment, fear of consequences, suicidal
ideation & attempts.
 Financial consequences, job loss
 Relationship issues: abandonment of family
members; wives of compulsive gamblers are 4
times more likely to commit suicide than the
general population (Lesieur, 1993); miss family
commitments; irritability, defensiveness, verbal
and physical violence.

18.  “The risk for self-destructive behavior is higher
[in gambling] than with any other addiction”
(Chamberlain, 2004).
 The longer they are able to hide the gambling,
the more problematic it becomes. There are no
obvious signs of intoxication, like substance
dependence.
 Gambling is non-linear in it’s consequences
(may have a win as they are going through a
downward spiral, where substance addiction
consequences generally progressively get worse.)

19.  CBT
◦ Abstinence or
◦ Harm reduction
 MI
 12 Step

20.  4 Strategies:
◦ Cognitive Restructuring
◦ Developing Problem-Solving Skills (alternative responses
to stress)
◦ Social Skills Training
◦ Relapse Prevention (identify, avoid, and/or cope with
High Risk Factors (HRFs)
 CBT Research Studies:
◦ * Many studies compare CBT intervention with wait list
or Gamblers Anonymous, which are both non-treatment.
So it’s difficult to discern whether these studies are only
indicating that treatment is better than no treatment.
◦ Tend to be short-term follow up
◦ Placebo effect is high

21.  Approach:
◦ Both directive & client-centered styles used
◦ Designed to enhance client’s motivation to initiate process
of change
◦ Identify and mobilize the client’s intrinsic values and goals
to stimulate behavioral change
 MI Research:
◦ MI was developed out of research on what worked for SUDs
clients
◦ Raylu & Casey (2010) n=102 randomized
CBT workbook plus MI better outcomes 6 months than CBT
alone or waitlist
◦ Hodgins et al. (2001) n= 102 compared CBT workbook and
workbook plus MI and wait list
6 month follow up: frequency and amount lost were lower
in MI group
2 year follow-up: 77% MI group improved

22.  Self-exclusion:
Some casinos offer a program that allows
gamblers to ban themselves from the
establishment, thereby limiting HRFs
 Funds-Management
Limit access to funds. Canceling CCs,
removing ATM cards and/or credit cards from
wallets, direct deposit paychecks

23.  GAM-ANON – established as a program for
the families and friends of problem gamblers
 Community Reinforcement and Family
Therapy (CRAFT) model adapted for gambling
◦ Use behavioral principles to reinforce non-gambling
behaviors (negative reinforcement)

24.  Opiod Antagonist
◦ Most studied and efficacious class of meds for this
population
◦ Naltrexone – block mu opiod receptors and
modulate dopaminergic transmission in
mesocorticolimbic pathway
 Glutamatergic Agents
◦ N-acetylcystein (NAC), a glutamate-modulating
agent demonstrates potential as an intervention
 Lithium and Anti-epileptics: no significant
differences
 Atypical Antipsychotics: negative outcomes
 Antidepressants : Mixed results

25.  Journal of Addiction and Offender Counseling
 Journal of Gambling Studies (Springer
publishes)
 Gamblers Anonymous
http://www.gamblersanonymous.org/ga/
 24 hour confidential National Gambling
Helpline: 1-800-522-4700

26.  American Psychiatric Association . (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Washington, D.C.: APA.
 Grant, J. E., & Odlaug, B. L. (2014). Diagnosis and treatment of gambling disorder. In Behavioral
addictions: Criteria, Evidence, and Treatment. K. P. Rosenberg & L. C. Feder (Eds.). Boston, MA: Elesvier.