How to Become a (State Certified) Problem Gambling Counselor - Susan Campion, MS, LADC,, ICGC-II - final ...

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    How to Become a
     (State Certified)
    Problem Gambling
        Counselor

          Susan Campion, MS, LADC,, ICGC-II

Presenters:
   Susan Campion, MS, LADC, ICGC-II
    MN State Certified Gambling Counselor
     M Health Fairview Recovery Services
    Scampio1@fairview.org 612-273-4429

         Trevor Urman, HSPR 2,
        DHS, Behavioral Health Division
   trevor.urman@state.mn.us 651-431-2231

My Background:
• Fairview Recovery Services: Run the Outpatient
  Problem Gambling Program
• Board of the Minnesota Advisory Committee on
  Problem Gambling – Advise DHS on PG and $’s
• Past:
   – Northstar: training, outreach, and speakers network
   – Trained and worked at PTAB Vanguard Inpatient 2008
   – PG outpatient groups and individual counseling
   – Before that 25+ years in social services working with
     youth and families

Disclaimers:
• I am giving information to the best of my abilities
• I do not work for any of the certifying bodies
• I am primarily concerned that problem gamblers are being
  treated by counselors who are working within their scope of
  practice.
• I will say things that people, including gambling counselors,
  may feel differently about. I am sharing my experience, and
  you are free to ask questions, follow up with research or I
  will connect you with the other counselors in the area.
• You are free to email me: scampio1@fairview.org or call
  me: 612-273-4429.

Gambling
“Gambling is an activity in which something of value is
risked on the outcome of an event when the probability
of winning or losing is less than certain.” (Korn & Shaffer 1999)
       • Variants:
           • Problem Gambling
           • Gambling Disorder – DSM 312.31
           • Pathological Gambler
           • Person with a gambling problem

What we are going to cover:
• How did this topic come up?
• Who decides what you (LADCs) should know in order to
  treat problem gamblers?
• What “they” think you should know and how to find it?
• What gambling counselors think you should know?
   – Some of the differences
• Resources

ØPlease email me for a copy of this PowerPoint for a full list
 of all this information: scampio1@fairview.org

Questions:
• Quick introduction of who you are, background,
  and something you want to learn from the session?
• Who is screening for Problem Gambling at intake?

• Who is treating problem gamblers at their
  treatment programs?

• What do you see as the main differences?

Board of Behavior Health (BBHT)
 (licensing board for LADCs)

• Q. If a LADC has had no additional training on Problem
  Gambling, does having a LADC give them the credentials
  to assess and treat problem gambling?
   – To: Kari Rechtzigel
        • Executive Director
        • MN Board of Behavioral Health and Therapy

BBHT cont.
• A. “Problem gambling/gambling addiction is not
  specifically mentioned in chapter 148F, so there is
  no definitive statutory language regarding whether
  treating persons with gambling addictions falls
  within the scope of practice for LADCs. The law
  doesn’t say they can and it doesn’t say they
  can’t. With respect to scope of practice for LADCs
  and regulations related to conduct, I recommend
  that you review the following sections of chapter
  148F.”
   – Quoted with permission from email with Kari Rechtzigel, May 20, 2016

BBHT cont. (rabbit hole…)
• 148F.01 – Definitions (subdivisions 9, 10, and 18 in
  particular)
• 148F.12 – Conduct
• 148F.125 – Competent Provision of Services (this
  section is probably the most helpful)
• 148F.14 – Informed Consent
• 148F.165 – Client Welfare

148F.125 COMPETENT PROVISION OF SERVICES.

• Subdivision 1.Limits on practice.
• Alcohol and drug counselors shall limit their practice to
  the client populations and services for which they have
  competence or for which they are developing
  competence.
• Subd. 2.Developing competence.
• When an alcohol and drug counselor is developing
  competence in a service, method, procedure, or to treat
  a specific client population, the alcohol and drug
  counselor shall obtain professional education, training,
  continuing education, consultation, supervision, or
  experience, or a combination thereof, necessary to
  demonstrate competence.

148F.125 COMPETENT PROVISION OF SERVICES.

• Subd. 3.Experimental, emerging, or innovative services.
• Subd. 4.Limitations.
• Alcohol and drug counselors shall recognize the
  limitations to the scope of practice of alcohol and drug
  counseling. When the needs of clients appear to be
  outside their scope of practice, providers shall inform
  the clients that there may be other professional,
  technical, community, and administrative resources
  available to them. Providers shall assist with identifying
  resources when it is in the best interests of clients to be
  provided with alternative or complementary services.
• Subd. 5.Burden of proof.- is on the clinician

What did you learn in school?
• Problem gambling during your LADC Program?

  – May depend on when and where you were trained
  – The reason this is important because those who work
    with problem gamblers see gambling addiction as
    different than the other addictions, and therefore,
    needing different assessment, treatment, and aftercare.

Training for Problem Gambling to
be within your “Scope of Practice”
• Minnesota Problem Gambling Service Provider
  (DHS) - must take NATI training
• National Council on Problem Gambling (NCPG)
  • Northstar Alliance on Problem Gambling (MN)
• Wisconsin Council on Problem Gambling
• Others online and in person

Getting the Training
• State Approved Problem Gambling Counselor:
    • Email: dhs.problemgamblingprogram@state.mn.us
    • North American Training Institute
        • Studies in gambling addiction 60 hours
• Other Trainings (will not count towards state approval)
    • Wisconsin Council on Problem Gambling
       • Face to face training
    •   New York Council on Problem Gambling
         • 60 hour core curriculum training online

State of Minnesota Problem
Gambling Service Provider (including
LADC’s)
 • Individuals and Recovery Programs:
       • Request for Proposals for Qualified Grantee(s) to Provide
         Problem Gambling Treatment Services
       • Training Qualifications:
               • Gambling Addiction Certificate, 60 hours of online training in
                 the subject of counseling the pathological gambler.
               • Currently through UMD North American Training Institute
                 (NATI) for $1295 (possible scholarships if you are in a
                 treatment shortage area)

DHS Contact Information:
• Email:
   • dhs.problemgamblingprogram@state.mn.us
• Grants:
   • https://mn.gov/dhs/people-we-serve/people-with-
     disabilities/services/home-
     community/resources/grants-and-rfps.jsp
• Treatment providers list:
   • https://mn.gov/dhs/people-we-
     serve/adults/services/gambling-problems/programs-
     services/treatment-providers-gambling.jsp

State of Minnesota Problem
Gambling Advisory Committee
• Next sessions:
   • Thursday November 14, 2019 9:30am - Noon, Club
     Recovery, Edina
   • Thursday January 9, 2020, 9:30am - 2:30pm,
     M Health Fairview Riverside, Minneapolis
   • Thursday March 12, 2020, 9:30am - 2:30pm,
     M Health Fairview Riverside, Minneapolis

   • Email DHS to get on the email list - Bi-Monthly, 2nd Thurs

Continuing Education
• Online Trainings
• National and State Conferences

                                   Northstar Problem
                                   Gambling Alliance
                                   State Conference
                                   info@northstarproblemgambling.org

Wisconsin Council on Problem
Gambling
(not a certification in MN, but a cost effective education)
- best list of what should be covered in “scope of practice”

    • WCPG's Gambling Disorder Training Program
    • Phase 1
        • History and prevalence of gambling and problem gambling
        • Types of gamblers
        • Definitions of gambling
        • Screening and assessment
        • Co-morbid and co-occurring disorders
        • Family counseling
        • Group and individual counseling strategies and treatment approaches to
          problem gambling

WCPG's Gambling Disorder
Training Program
• Phase 2*
  •   Self-help programs and natural recovery
  •   Motivational enhancement and the use of harm reduction
  •   Financial issues and asset protection plans
  •   Neurotransmitters and communication in the brain
  •   Psychopharmacology: Research, cautions, and treatment
  •   Gambling and legal issues
  •   Workplace warning signs
  •   Mind, Body, and Spirit: Practical advances in gambling treatment

  *Must provide proof of Phase 1 completion.

WCPG's Gambling Disorder
Training Program
• Phase 3*
   • Multicultural issues and problem gambling (Hispanics, African
     Americans, and Asians)
   • Women and problem gambling
   • Special Populations: Adolescents
   • Special Populations: Older Adults
   • Special Populations: Women

  *Must provide proof of Phase 1 and Phase 2 completion.

WCPG's Gambling Disorder
 Training Program
• Phase 4*
  •   Problem gambling and relapse
  •   Ethical
  •   Professional code
  •   National certification and standards/National Certification Exam

  *Must provide proof of Phase 1-3 completion.

Wisconsin Council on Problem
Gambling Disorder Training Program
• After Phase 1 & Phase 2 thirty-hour training
    • Assess, screen and evaluate for gambling problems
    • Refer clients for appropriate levels of care and
    • Begin the treatment planning process, etc.
• Following completion of the 60 hour training
    • Work with family and significant others & special populations
    • Present salient patient education topics to clients and families
    • Prepare court reports, assist with complete asset protection plans
    • Use an array of clinical strategies focusing on impulse control and
       self-regulation interventions in the treatment of gambling
       problems, etc.

2019-2020 WCPG Gambling
Disorder Training Program
15 CEU’s = $125 · 30 CEU’s = $175 · 60 CEUs = $300
(15 hours per Phase)
Green Bay                   Madison                    Milwaukee
Phase 1– Nov. 14-15,        Phase 1– Jan. 9-10, 2020   Phase 1– April 23-24,
2019                        Phase 2– Feb. 13-14,       2020
Phase 2– Dec. 5-6, 2019     2020                       Phase 2– May 7-8, 2020
Phase 3– Jan. 23-24, 2020   Phase 3– April 16-17,      Phase 3– Sept. 17-18,
Phase 4– Feb. 6-7, 2020     2020                       2020
                            Phase 4– May 14-15,        Phase 4– Oct. 22-23,
                            2020                       2020

Wisconsin Council on Problem
    Gambling Statewide
 Conference, Green Bay, WI
March 19-20, 2020 (Pre-Conference on March 18, 2020)
 Make your reservations now by calling 1-800-233-1234
to get the special conference rate of $119.00 or Below is
  your booking link that you can make and change their
              sleeping rooms reservations.

         https://www.hyatt.com/en-US/group-
              booking/GRBRG/G-WCPG

National Council on Problem
Gambling
• International Certified Gambling Counselor (ICGC-I or II)
    • Documentation of 30 hours (ICGC-I) or 60 hours (ICGC-II)
      of gambling specific training
    • Applicants are required to obtain clinical experience
      treating gamblers and/or family members (100 hours for
      ICGC-I; 2,000 hours for ICGC-II) in an approved setting with
      a minimum number of sessions with a Board Approved
      Clinical Consultant (BACC).
    • Copy of passing ICGC examination score report
       • NCPG website list board certified supervisors

https://www.igccb.org/
• International Gambling Counselor Certification
  Board (IGCCB)
• International Certified Gambling Counselor (ICGC-I
  & ICGC-II)
• ICGC counselors must demonstrate a specific
  number of hours in gambling-specific training,
  clinical experience treating gamblers, and
  successful completion of the Certification
  Examination for Gambling Counselors.

Questions about getting
training or certification?

Working with Problem
Gamblers

- Burden of proof is on the clinician to
show they are trained/skilled to work with
problem gamblers

What Every Addiction Counselor
 Should Know About Disordered
 Gambling
• Introduction for addiction counselors to learn to
  recognize the problem gambler. This will include
  disordered gambling co-occurring with CD or MH,
  screening for problem gambling, and available
  resources for client’s and their families.

Learning Objectives:
• Learn to be aware of cross addiction to problem
  gambling in the CD population
• Gain a better understanding of the specific needs of
  the problem gambler
• Learn resources in the community for problem
  gamblers, their families, and how to become a state
  certified gambling counselor

Problem Gambling

  …is gambling behavior which causes
  disruptions in any major area of life:
  psychological, spiritual, physical, social or
  vocational.

Source: National Council on Problem Gambling

Forms of Gambling
• Slot machines            • Online: sports,
• Poker & blackjack          slots, poker
• Horse races              • Baccarat
• Raffles
                           • eBay & DealDash
                             – bidding
• Lottery & scratch offs
                           • Anything that
• Pull tabs
                             puts them in
• Sports betting
                             action

Most People Have Gambled

• 92% of Minnesotans have gambled in their lifetime,
  75% in the past year
• 140,000 people, 4% of the population, in the Twin
  Cities Metro could meet the criteria for disordered or
  problem gambler

There is an
increase in
problem
gambling if a
casino is
within 50
miles from
home

Responsible Gambling
• Low Risk:
    • For fun, not profit
    • Set time & money limits
    • Not chasing losses
    • Spending money and time
      one can afford to lose
    • Not gambling when
      depressed, grieving, lonely
    • Trying to win to solve family
      financial problems

DSM-5 Diagnostic Criteria:
 Gambling Disorder 312.31
• Reclassification from DSM- IV to DSM-V:
   • From Impulse Control Disorder (with hair pulling &
     Kleptomania) to Addiction
   • Pathological Gambling to Gambling Disorder
   • Lowering of Threshold for a Diagnosis
      • From 10 to 9 Criteria
          • removed “committed illegal acts”
          • Clarified other wording

   • (Great White Paper on the NCRG website)

DSM-5 Diagnostic Criteria:
Gambling Disorder 312.31
• Persistent and recurrent problematic gambling
  behavior leading to clinically significant impairment
  or distress, as indicated by the individual exhibiting
  four (or more) of the following in a 12-month period

   (Gambling is the wagering of money or something of value on an event with an
     uncertain outcome with the primary intent of winning additional money
     and/or material goods.)

Gambling Disorder Criteria:
  • Needs to gamble with increasing amounts of money in
    order to achieve the desired excitement.
  • Is restless or irritable when attempting to cut down or
    stop gambling.
  • Has made repeated unsuccessful efforts to control, cut
    back, or stop gambling.
  • Is often preoccupied with gambling (e.g., having
    persistent thoughts of reliving past gambling
    experiences, handicapping or planning the next venture,
    thinking of ways to get money with which to gamble).

Gambling Disorder Criteria: cont.
  • Often gambles when feeling distressed (e.g., helpless,
    guilty, anxious, depressed).
  • After losing money gambling, often returns another day
    to get even (“chasing” one’s losses).
  • Lies to conceal the extent of involvement with gambling.
  • Has jeopardized or lost a significant relationship, job, or
    educational or career opportunity because of gambling.
  • Relies on others to provide money to relieve desperate
    financial situations caused by gambling.

Gambling Disorder 312.31
Specify if:
• Episodic: Symptoms subsiding between periods of gambling disorder for
  at least several months.
• Persistent: Meet diagnostic criteria for multiple years.
• In early remission: Met criteria for at least 3 months but for less than 12
  months.
• In sustained remission: None of the criteria for gambling disorder have
  been met during a period of 12 months or longer.

Specify current severity:
  Mild: 4–5 criteria met.
  Moderate: 6–7 criteria met.
  Severe: 8–9 criteria met.

Screening:
• Brief Biosocial Gambling Screen (BBGS)
   • Can get free magnets at www.ncrg.org
• National Opinion Research Center DSM Screen for
  Problem Gambling (NODS)
• South Oaks Gambling Screen (SOGS)

   • Everyone can use these tools

Brief Biosocial Gambling Screen
(BBGS)

Screening Tools
•   Can do the BBGS at intake or
    if there is a concern can do
    the SOGs
•   Anyone is allowed to use
    and score these tools
•   The SOGs Forms is online

National Opinion Research Center
(NORC) DSM Screen for Problem
Gambling (NODS)
 • Series of 17 Yes or No questions asked by interviewer

 • 5 yes answers, likely diagnosis of Pathological Gambling
   (DSM-IV). Highest score is a 10.
    • Basically asking the DSM criteria questions

 • Can be found online (NCRG)

South Oaks Gambling Screen
(SOGS)
• Often used (needed for the State PG program)
• Self Administered, but can be asked by the
  interviewer
• 16 questions, but many multi answer questions
• Maximum score of 20. Five or more is probable
  pathological gambler
   • Details:
      • Type of gambling
      • How much money they gambled
      • Where they got the money to gamble

Then What?
• Possible more specific screening tool
   • (BBGS -> SOGS/NODS or DSM-V)
• Complete a full assessment
   • We use the same format as the Rule 25 with modifications
     (dimensions 1-6 for tx plan too)
   • Gambling history (games, amounts, big wins)
   • Financial (debt, bankruptcies, bailouts, IRS, unopened bills,
     theft (pending legal). (Remember $ is drug of choice)
   • Suicide risk assessment

Refer out to other Providers
• Inpatient:
   • Project Turnabout Vanguard (Granite Falls)
• IOP:
   • Fairview                                 Grant from DHS (paid for
   • CARE (Duluth)                            by the lottery) covers
   • Club Recovery (Edina)                    most of the cost of
• Individual providers:                       treatment for patient
   • 1-800-333-HOPE                           and/or concerned others
• Talk to a provider
   • Susan Campion & Craig Johnson (Club Recovery), Sheryl Anderson
     (Vanguard), & Jon Von Eshen (Pathways)

Call the Helpline
 Refer Out: 1-800-333-HOPE
     – MN Problem Gambling Helpline
     • Inpatient
     • Intensive Outpatient
     • Group, Individual Counseling
         • MN State Problem Gambling Grant
              • More insurance is covering
              • Helpline will give resources
              • 12 sessions for concerned others

The Hidden Addiction
• Unlike alcohol or drug addiction, problem gambling
  has few outward signs.

• A strong link exists between pathological gambling
  and suicide.

Source: National Council on Problem Gambling

Similarities and Unique Characteristics
between Problem Gambling &
Chemical Dependency
                  Booklet written by Sandi
                  Brustuen, the founder of the
                  Vanguard Treatment Program
                  for Problem Gamblers at
                  Project Turnabout. Call for
                  copies.

Similarities Between Pathological
Gambling and Chemical Dependency
 •Preoccupation with taking and/or seeking substances or
 gambling and/or obtaining money to gamble.

 •Consuming more of the substance and/or taking it for a longer
 period of time than intended or gambling larger amounts of
 money and/or over a longer period than intended (increased
 tolerance)

 •Has repeated unsuccessful efforts to control, cut back, or stop
 gambling.

Similarities Between Pathological
Gambling and Chemical Dependency
(cont.)
   • Repeated efforts to cut down and/or control substance use
     or cut down and/or stop gambling.

   • Given up social, occupational, and/or recreational activity to
     seek and/or take substance or given up activities to gamble.

   • Continuation of substance use despite social, occupational,
     legal problem and/or physical disorder that is exacerbated
     by continued use of substance or gambles despite inability
     to pay mounting debts.

Similarities Between Pathological
Gambling and Chemical Dependency
(cont.)
    • Has jeopardized or lost significant relationship, job,
      educational, or career opportunity due to use or gambling.

    • A great deal of time is spent in activities necessary to
      obtain the substance, use the substance, or recover from
      the substance.
        • In gambling, this is part of the action. Their days are
          filled with planning the gamble, how to get money to
          gamble, how they are going find the time to gamble,
          the lies they will need to tell (before and after), the
          pressure to find the money they need after they lost all
          the money.

Unique Characteristics of
Pathological Gambling
 Secrecy – problem gambling is difficult to detect
 Swiftness – gambling for fun to problem gambling can
 happen in 6 months
 Shame – only blame themselves
 Controlling – of others, treatment process, think they
 can control the outcome of the game
 Introversion – gambling may seem social but in reality it
 is very isolating (may come across as outgoing, social)

Unique Characteristics of
Pathological Gambling (cont.)
 Intellectualizing – often well-educated, hard workers (until their
   not). Mind in action (meditation eases this)

 Socioeconomic status – many professionals, business owners, high
   achievers (access to large sums of money)

 Deceit – seem compliant, sees lying to the counselor as a gamble

Unique Characteristics of
Pathological Gambling (cont.)
Restlessness – complain of boredom, have a hard time keeping still
 (meditation is good for this too)

Financial and Legal Problems – often facing foreclosure, divorce, or
  felony charges from embezzlement

   • Taken From: Pathological Gambling & Chemical Dependency:
     Similarities and Unique Characteristics. Project Turnabout
     Vanguard Gambling Program
           • 1-800-862-1453 for copies

High Risk of Suicide:

• 46% of problem gamblers reported thoughts of
  suicide and 3% reported attempted suicide within 6
  months of intake.

• Suicide rates are higher in compulsive gamblers
  over any other addiction

Learning to See Gambling
Addiction in a Co-Occurring
Population

Co-morbidity among
Pathological Gamblers:
•   Alcohol use disorder (45% – 73%)
•   Drug use disorder (23% - 38%)
•   Major Depression (9% - 37%)
•   Dysthymia (4% - 20%)
•   Mania (3% - 23%)
•   Generalized Anxiety (8% - 11%)
•   Panic Disorder (3% - 23%)
•   Phobia (10% - 24%)
•   Obsessive-compulsive disorder (4% - 17%)

Learning to See Gambling
Addiction in a Co-Occurring
Population
Learner Outcomes:
• Upon completion of the program, the participant will
  be able to:
      1. Understand the similarities and differences between substance
      use disorders and problem gambling.
      2. Discuss the relationship between gambling addiction and mental
      health disorders for clients with co-occurring illness.
      3. Identify effective screening tools and when to implement their
      use in clinical settings.

Lifetime Co-morbidity

“Although nearly half (49%) of those with lifetime
pathological gambling received treatment for mental
health or substance abuse problems, none reported
treatment for gambling problems.” Kessler et al., 2008 (National
Comorbidity Survey Replication)

Types of Gamblers

• Action: Grandiose, can’t settle
   • Poker, blackjack, table games, sports gamblers
        • Brags about wins, buys gifts, drinks, big spender with wins, people know
          their names

• Escape:        Get into flow (like driving down the road, and you don’t
 remember driving the last few minutes)
   • Slots, scratch offs, online, sports gamblers
        • Recent empty nester, job loss, grieving, caretaker, people pleaser, “I take
          care of everyone else so I deserve this”

Problem & Compulsive Gambling
Prevalence Rates are Higher for:
• Casino employees        • Prison populations
• Women                   • Early exposure to
  • Swiftness
• Uncoupled                 gambling
• Parents were gamblers   • Those with mental
• Seniors
                            health and
                            substance abuse
                            problems

Warning Signs of Problem Gambling
• Increasing money and time spent gambling
• Gambling for longer periods of time or spending more money
  than originally planned
• Bragging about wins, but not talking about losses
• Not spending money on basic needs, bills, medical
• Social isolation, leaving events early, not keeping plans
• Needing financial bailouts due to gambling losses
• Lying about how money or time is spent, excuses

What Clinicians need to know
about Gambling Disorders
• Do you ask your clients if they gamble?
• When they say no, do you think about the fact that
  75% of people have gambled within the last year?
• Could they possibly be hiding something?

Opinion on Gambling
• How clinicians view gambling will determine the
  nature of their assessment and treatment plan:
      •   Moral weakness?
      •   Psychosocial?
      •   Biological?
      •   Behavioral?
      •   Impulse control?

Problem Gambling with Mood
Disorders
• Feel more alienated from others, more social disconnection
• Hopeless and pessimistic; less responsive to pleasant activities
• Have harder time controlling impulses, especially when
  depressed/stressed
• More likely to have current anxiety disorder
• Have an increased suicide risk

Substance Use Prevalence
• 1/3 of individuals in substance use treatment identified as
  problem gamblers (71% lifetime SUD)
• OSAM Survey
    • 27.6% gambled more when using alcohol or other drugs
    • 16.7% used more alcohol or drugs when gambling
    • 15.6% gambled to buy alcohol or drugs

Substance Abuse Programs
• Have brochures in your waiting room on problem gambling
       - Call or email Northstar Problem Gambling Alliance
           • Elder, Military, Women, Collage…
• Screen for problem gambling at intake
• Include information on problem gambling in treatment
   • Listen for signs of problem gambling or increases in gambling
   • Inform the clients of cross addiction
   • Continue education on problem gambling
• Refer out to problem gambling counselors, IOP, or Inpatient
   • Helpline 1-800-333-HOPE

“A Big Win will Fix Everything”

Treatment Challenges
• Money management, money is drug of choice, having money
  and not having money are triggers
• Hidden addiction, lies, often family does not know
• Swiftness, women can go 0-100 in a few months
• Patients: employed, middle income, mortgage, huge debt
  because they had access to credit
• Felony theft, from work, business, family, can be in the
  $100,000’s+
• Shame, continuing to lie to counselor

Consequences
• 18% to 28% of males and 8% of females in Gamblers
  Anonymous have declared bankruptcy
• Between 69% and 76% of pathological gamblers have missed
  time from work due to gambling
• Between 21% and 36% of gamblers in treatment have lost a job
  due to gambling
• 46% of problem gamblers reported thoughts of suicide and
  3% reported attempted suicide within 6 months of intake

Impacts Domestic Violence
• 25% of spouses of pathological gamblers have been abused
• 50% higher chance of domestic violence if partner is both a
  problem gambler and a problem drinker
• Gamblers, both men and women, are vulnerable to domestic
  violence, physical and emotional abuse
• Spouses who withhold money from spouse sometimes
  unknowingly endanger themselves

Integration
• Screen
• Keep checking, look for repeated problems that could be
  caused by a gambling problem
• Support client if they are gambling or if they show signs of
  being a problem gambler
• Refer out if not in your scope of practice or if client needs more
  intensive services, IOP, or inpatient
• Include problem gambling resources in aftercare

Be Part of the Solution

Screening Tools

  •   Can do the BBGS at intake or
      if there is a concern can do
      the SOGs
  •   Anyone is allowed to use
      and score these tools
  •   The SOGs Forms is on
      Demand 614885 or online

During Assessments
• Unexplained money problems vs. income
• Large amount owed to the IRS (hand pays)
• Frequent trips to Vegas, fantasy football, phone games, where
  they spend their free time, isolation
• Magical thinking - “if only…one big win”
• Meth and scratch offs (scratchies) & casino living
• Ask about medications

During CD Assessments:
• Unexplained money problems vs. income
• Large amount owed to the IRS (hand pays)
• Frequent trips to Vegas, fantasy football, phone games
• “Magical thinking” - “if only…”
• Meth and scratch offs (scratchies)
• Meds: Abilify (Aripiprazole), Requip (ropinirole) Zelapar
  (selegiline hydrochloride), Comtan (entacapone) Mirapex
  (pramipexole), more get added, some become antidotal before
  FDA steps in.
• Restless leg - sign of being in action
• Add 3 question screen - BBGS

Treatment Planning:
 • Often see Guilt and Shame (high suicide risk)
 • Family involvement
     • Hidden, possibly family didn’t know about gambling, or debt,
       or facing legal issues
     • Still have many lies about money spent, amount of gambling,
       or have not come clean that 401K is gone
 • Owe money to Family, IRS, unpaid bills
     • Haven’t opened bills in months
     • Family Means Credit Counseling
     • How are they getting by?
     • Often enter tx when all access to money is gone

Treatment Planning
• Often see guilt and shame (high suicide risk)
• Family involvement
   • Hidden, possibly family didn’t know about gambling, or debt, facing legal issues,
     foreclosure, and/or bankruptcy
   • Still have many lies about money spent, amount of gambling, or have not come
     clean that the 401K is gone
• Owe money to family, IRS, unpaid bills
   •   Haven’t opened bills in months
   •   FamilyMeans a nonprofit credit counseling agency
   •   How are they getting by?
   •   Often enter treatment when all access to money is gone

Treatment Planning cont.
• Isolation, often don’t/won’t attend GA or other supports
   • How can they fill up their time with pro-social activities?
   • May try to work extra to make money, transfer of addiction
• Give up/reduce access to money - money is drug of choice
   • This could possibly be done in steps
   • Also consider money from future “windfalls”: inheritance, insurance payouts,
     bonus checks, these are all huge triggers (this is their stash for future gambling)
• Self-ban from casinos & card rooms (with help)
   • Remove themselves from mailing lists

Treatment planning cont.
• Isolation, often don’t/won’t attend GA or other supports
    • How can they fill up their time with pro-social activities?
      (may try to work extra to make money)
• Give up access to money - Money is drug of choice
    • This could possibly take baby steps
    • Also consider money from future “windfalls”: inheritance,
      insurance payouts, bonus checks, these are all huge
      triggers (this is their stash)
• Self-ban from Casinos & Card Rooms (with help)
    • Remove themselves from mailing lists

Treatment & Counseling
• Cross or transfer addiction: often to food or shopping
• Talking about gambling in group often triggers euphoric recall
  and will trigger gambling
• May continue to play free or paid online games
   • Fantasy football, CandyCrush, Facebook games, casino, or poker games
• Not about the money
   • Staying in action, money has no value, can’t leave until it is gone
• Naltrexone can be used to decrease both alcohol and gambling
  urges

Treatment & Counseling: cont.
 • Cross or transfer Addiction: often to food or shopping
 • Talking about gambling in group often triggers euphoric recall and
   will trigger gambling – they will remember the highs of the wins
   and not the lows of the losses
 • Free or paid online Games
     • Fantasy football, Candy Crush, Facebook games
 • Casino or Poker games on their phone
 • Naltrexone used for Alcohol and Gambling Addiction
 • Not about the money – staying in action, money has no value,
   can’t leave until it is gone

Assignments
• Relationship with money        • Setting Goals in Recovery
• Communication                  • Working with family
• Relationships – (re)building   • Rebuilding trust with
  connections                      everyone in their lives
• Shame – TOSCA - 3S             • Introduction to Gamblers
                                   Anonymous and
• Concerned others group           FamilyMeans
• Strengthening their virtues    • Leisure & balance
  (Virtues Project)
                                 • Humility
• Spirituality & grief
                                 • Assertiveness
• Thinking errors

Support – Limit Access
• Exclusion from gaming facilities – must go in person to each
  casino
   • Do this only if they can go with a strong trusted other, they will try to gamble
     “one last time”
• Stop mailings
   • Casinos will randomly call and ask if they want to be put back on their list or
     offer incentives
• Cut up ALL rewards cards
• Block gambling on cell phones
   • Can find online programs, or may need a non-internet phone if it includes
     shopping, ebay, or other sites

Support – Limit Consequences
• Trusted person to help with finances
• Limit access to family money, even paychecks can disappear in
  an hour
• Limit amount of cash they have available on them
• Protect assets
   • retirement, mortgage, windfalls, insurance payments, bonus checks…
• Protect future assets
   • inheritance, life insurances
       • Grief will trigger gambling and they will go through all the money quickly

Support - Therapeutic
• Brief Interventions, CBT, DBT, …
• Reduce isolation
• Meditation/mindfulness
• Reduce need for control, increase self esteem, reduce shame, reveal
  lies
• Increase motivation for abstinence
• Constant screening for increased gambling
• Watch for cross addiction – will go to food, shopping, working,
  exercise, eating, alcohol, CandyCrush, ebay…
• Constant suicide assessments

Support – Pharmacological
• Opioid Antagonists: Naltrexone
• OTC: N-Acetyl Cysteine (NAC): Amino Acid
• Others: Antidepressants, SSRI’s, Mood Stabilizers, Anti-
  psychotics

   Some Medication can increase urge to gamble:
       • Restless leg: Mirapex
       • Parkinson’s: Requip, Zelapar, Comtan, Mirapex
       • Antipsychotic Drug: Abilify (Dopaminergic drugs)

Support – Outside & Aftercare
•   Gamblers Anonymous
•   Gam-Anon for affected others
•   Other culturally specific support groups
•   “Connection is the opposite of addiction”
•   Credit Counseling “FamilyMeans”
•   www.gamblersanonymous.org - Great video!
     • Store: DVD “Big Steve” $5.00
         • Filmed in the 60's, a story on how one man battled with and overcame his
            gambling addiction

Support for Gamblers
• Helpline – 24 hour support, referrals, will mail out
  informational packets 1-800-333-HOPE
• Gamblers Anonymous (GA) http://www.minnesotaga.com
• Gam-Anon http://www.gamanonmn.com/1.html
• https://minnesotarecovery.org/
• http://mnalternatives.com/AA_Alternative_Support_Groups.p
  df (non-12 Step & Secular)

Recovery Programs Can:
• Include information on problem gambling
• Screen for problem gambling at intake
• Listen for signs of problem gambling
• Inform the clients of cross addiction
• Continue education on problem gambling
• Have brochures in your waiting room on problem
  gambling - call or email Northstar
• Come to the MN Conference - Learn about
  problem gambling

Resources
• Fairview Problem Gambling Page
   • https://www.fairview.org/overarching-care/behavioral-health-
     services/gambling-addiction
• Minnesota Problem Gambling
   • Helpline 1-800-333-HOPE
• National Council on Problem Gambling
   • Helpline 800-522-4700 http://www.ncpgambling.org/
• Northstar Problem Gambling Alliance
   • 612-424-8595 www.northstarproblemgambling.org
• Resources for Professionals & Providers list
   • http://treatmentandhope.com/

Resources for Problem Gambling

§ Minnesota Problem Gambling Helpline (1-800-333-
  HOPE)
§ National Helpline (800-522-4700)
  (www.ncpgambling.org)
§ Treatment (www.nojudgment.com)
  §   Inpatient & outpatient programs
  §   Individual counselors
  §   Northstar Problem Gambling Alliance (612-424-8595)
      (www.northstarproblemgambling.org)

Resources cont.
• National Center For Responsible Gaming
   • http://www.ncrg.org/
• SAMHSA TIP 42 Problem Gambling, 2005
   • http://www.ct.gov/dmhas/lib/dmhas/pgs/cooccuringworkbook.pdf
• NCRG: What Clinicians Need to Know About Gambling
  Disorders (Booklet):
   • http://www.ncrg.org/sites/default/files/uploads/docs/monographs/ncrgmono
     graph7final.pdf

Research Used
•   American Psychiatric Association. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. Fourth ed. Washington, DC:
    American Psychiatric Association; 1994.
•   Potenza MN, Xian H, Shah K, Scherrer JF, Eisen SA. Shared genetic contributions to pathological gambling and major
    depression in men. Archives of General Psychiatry. Sep 2005;62(9):1015-1021.
•   Feldman, M.A. (2013). Increasing The Odds. (8). A Series Dedicated to Understanding Gambling Disorders. Centers of
    Excellence in Gambling Research. Retrieved November 9, 2014, from
    www.ncrg.org/sites/default/files/uploads/.../ncrgmonograph8_fnl.pdf
•   Rash, C.J., and Petry, N.M. (2014). Psychological treatments for gambling disorder. Psychological Research on Behavioral
    Management. 7: 285–295. Doi:10.2147/PRBM.S40883. PMCID: PMC4199649
•   National Council on Problem Gambling Website and past presentations
•   Northstar Problem Gambling Alliance Website and past Presentations
•   Mass Council on Problem Gambling, “integrating Problem gambling into Substance Abuse, Mental Health and Primary Care
    settings - PowerPoint

Research:
• National Center on Responsible Gaming (NCRG)
  • Great information on College Gamblers
  • Yearly Conference in Vegas, offers scholarships
• Canada, Australia,
• Massachusetts Council on Problem Gambling
  • Offers free webinars

Thank You!                 Questions?

Susan Campion
scampio1@fairview.org
612-273-4429

Trevor Urman
trevor.urman@state.mn.us
651-431-2231