Julie Hynes, Sr. Community Health AnalystLane County Public Health
SAPP 407 | University of Oregon | Feb. 2014
GAMBLING
OVERVIEW• History & trends
• Defining the issue: problem gambling
• Gambling & the brain
• Addiction & mental health connections
• Addressing the issue
POTENTIAL
DEFINITION:
______ something of valuein the _________________
something of greater value.
hopes of obtainingRISKING
Source: American Psychiatric Association ‐ DSM‐5 (2013).
Howquicklythings
are changing
Source: insidefacebook.com
Source: WSJ.com 2/11/14
GAMING & GAMBLING: PARALLELS
Stimulate dopamine
Play for similar reasons (escape, relax, stimulate, etc.)
Potential for addiction?
Anything can be a bet…
(especially
online!)
Sources: linemakers.sportingnews.com, bovada.lv
What are the 2 states that DON’T have
legalized gambling?
AVAILABILITY OF LEGAL GAMBLING IN U.S., 2014
Horsetrack
1931
Video poker began
1992
Nine tribal casinos opened
1994 - 2004
Lottery approved
1984
Image sources: Oregon Lottery, Hynes
Image sources: Oregon Lottery, Hynes
$7 out
of every
$10lottery dollars
ELECTRONIC GAMBLING:“Video Poker/Slots/Line Games”
Source: Oregon Health Authority (2012; ibid)
Photo source: Daniel Berman.
Photo: Hynes
Photo: Daniel Berman
1 in 1751 in 175,000
1 in 175 million1 in 175 billion
1 in 175 Million(174,233,510)
Odds of getting struck by lightning: 1 in 280,000
Let’s say there is 1 RED popcorn kernel in this bag of
10,000 pieces of popcorn
….you’d have a better chance of reaching in and grabbing the one red kernel of popcorn in this bag than you would of winning $100 on a powerball ticket
So…if your lucky numbers have “almost” come up in the
last 5 drawings, are your chances better, worse, or the
same?
Sports betsLottery ticketsVideo & onlineBingo & raffles
Video lottery
& online gambling
Electronic Gambling
89% Cards6%
Other5%
Gambling Treatment ClientsGamblers' Preferences
0.1%11.2%
1.2%2.7%
Research shows about what percentage of Oregon adults have a gambling problem?
2.7% of Oregon adults
(1 in 37 people)
have a gambling problem.
Behind every story…
there’s a story…
PATHOLOGICAL:Persistent and recurrent maladaptive gambling behavior...results in the LOSS OF CONTROL over
gambling. (DSM‐IV)
Definitions
Newlanguage
GAMBLING
DOESN’T START BY BEING A
PROBLEM.
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“GAMBLING DISORDER”
5.6% college age (18‐24)
2½ % 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.
The new DSM-5 (May 2013) definespathological gambling as a
“behavioral addiction,” the first of its kind.
SIMILAR BEHAVIORAL CONDITIONS, like internet and
Binge eating, aren’t yet in the category of
“behavioral addiction.”
(It is thought They might be soon.)
IS IT AN “ADDICTION”
1. Solidly established, problematic pattern of a pleasurable & reinforcing behavior
2. Physiological/psychological components of behavior pattern that create dependence
3. Interaction of these components in an individual which makes person resistant to change
Definition of addiction from Diclemente, 2003
IS SOMEONE YOU KNOW…
• Gambling to escape problems• "Chasing" losses with more gambling• Lying to family and others about the
extent of gambling• Committing crimes to finance gambling• Jeopardizing or losing relationships,
jobs, education because of gambling• Relying on others to bail him or her
out relieve a desperate financial situation caused by gambling
EXAMPLESREAL LIFE‐ in the news
http://www.oregonlive.com/portland/index.ssf/2013/06/former_postal_service_worker_s.html
Register‐Guard, 5/13/11
But really, the consequences are usually much more than crime and
being in the news…
THE STORIES GO ON.
…each problem gambler affects anaverage of 6‐12 others.
>70%are current
tobacco users
32%have current
alcohol problems
10%actually attempt
suicide
Source: Oregon Health Authority, 2012
48%experience
suicidal ideation
Have current drug problems
Hey man we r here @ starbucks on 13th c u soon
…
It’s been 2 more hrs. U coming or what?
running late sorry
on my way
Never mind. We finished the project. AGAIN. Sorry but the group is done w/your excuses.
Jordan SAPP10:49PM
5:11PM
PROCESS of
ADDICTION.
Typical Phases of
Problem Gambling
Source: Custer, R. & Rosenthal, M.
WINNING
LOSING
DESPERATION
HOPELESSNESS
Winning PHASE
Losing PHASEI’ll get my
money back in no time.
My big win is just around the
corner!
Desperation PHASE
Hopelessness PHASE
Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf
THOUGHTS, FEELINGS, ANTICIPATION,
FANTASY(Gambler’s Mind, “Gambling Time/
Gambling Money”)
PLANNING(Removing obstacles
to gambling)
GAMBLING(“Winning & Losing”)
Serotonin AdrenalineDopamine
CRASHGuilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine
REALITY(Self with Others)“Real Time, Real Money”
WHAT CAN TRIGGER ACTION?Lots of things, but these are some key triggers. People at risk should especially avoid gambling when:
H
A
L
T
ungry
ngry
onely
ired
These comparisons are of course generalizations and do not by any means reflect all male and female gamblers.
Comparison by Start gambling at older age than men
Get addicted faster
Games of choice: video slots
More likely to be “escape” gamblers
Start gambling younger
Tend to like games of strategy & “action” (poker, sports bets)
Less likely to seek help
$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 in gambling treatment, 2012:
Comparison of “Action” and “Escape” Pathological
Gamblers
Excitement, competition
Early onset of gambling
Relief, escape from stress
Later onset of gambling
“Skilled” forms of gambling (sports/poker, etc)
More likely to present narcissistic or antisocial traits
“Luck” forms of gambling (lottery, slots, bingo)
More likely to presentdepressive/dysthymic traits
Action Escape
Source: Center for Substance Abuse Treatment, 2005.
CAUSES? (RISK FACTORS)
• Trauma --stemming from abuse or neglect
• Mental health issues
• Substance use• Parental
attitudes & behavior
• Competitive family
• Community norms/laws
• Early initiation
• Friends favorable toward gambling
18
25
21
16
At what age is the
brain considered
fully developed?
The PREFRONTAL CORTEX is the LAST PART to develop.
The brain is still
developinguntil
Depression/mood disorders
Narcissistic personality disorderPTSD
ImpulsivityADHD Substance abuse Alcohol abuse
Sources Ledgerwood & Petry (2006). Kausch et al. (2006). Biddle et al. (2005). Oregon Health Authority (2010). The WAGER (2002, February 12); Specker, et al., (1995); Kim & Grant (2001)
For more info: see article “The Almost Winning Addiction” in the readings.
It’s really about the action, not the money!
“ALMOST WINNING” causes dopamine to be activated the same as ACTUALLY winning.
Problem gamblers are more likely to see their near misses as “NEAR WINS”
People play LONGER when machines give them NEAR MISSES.
Neurotransmitter
Serotonin
Norepinephrine
Opioids
Dopamine
Role in Relation to
Gambling
Behavior Initiation/Cessation
Arousal, Excitement
Pleasure, Urges
Reward, Reinforcement
Dopamine: most studied neurotransmitter in problem gambling
Serotonin -- risk taking
Gambling - β-endorphin
PGs - NE levels
PGs - dopamine response
Neurotransmitter “PGs” = problem gamblers | Neurotransmitters are brain chemicals that transmit nerve impulses. Dopamine is known as the brain’s “reward system.”
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.
Sources: Tonneato, T. (1999). Cognitive psychopathology of problem gambling. Subst Use Misuse. Sep;34(11):1Anecdotal reports from problem gamblers in treatment and recovery.
Image source: Anheuser‐Busch
COGNITIVE Distortions
Lucky #’sFavorite shirt“My” machine
Superstition
Rituals/habits that are believed
to affect the outcome.
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 EvaluationAttributing wins to one’s special skill or luck, while losses are blamed on external circumstances.
Image source: Anheuser‐Busch
COGNITIVE Distortions
Forgetting about losses, only remembering wins.
Selective Memory
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
THIS
…those are other ways our
minds trick us. We are wired to
see patterns in things.
Reflect: cognitive distortion
Have you ever experienced a
cognitive distortion? What was the
experience like?
VULNERABLE POPULATIONS
• Older adults• College students• Ethnic minorities• Incarcerated
persons• Military & veterans• Women
• Substance abuse history
• Mental health history
• Youth
The “Addiction” Connection
Differences?Similarities?
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
Effects of Problem Gambling on Children
• Prone to abuse and/or neglect• Child endangerment may increase• Higher levels of tobacco, alcohol, drug use, and overeating than peers
• Higher risk of pathological gambling • Suffer effects from lack of financial stability
“The earlier people begin gambling, the more likely
they are to experience problems from gambling.”
- National Academy of Sciences
Not Your Uncle’s Gambling
Youth gambling still under-studied & under the radar
Research on:
•Amygdala active •Fight or flight,
emotion•Decision-making
altered•More vulnerable to risk‐
taking & impulsive behaviors
Source: Ramoski, S., Nystrom, R. (2007).
“The adolescent brain is especially sensitive to the
effects of dopamine.
• Single‐parent household• Gambling on
cards/sports• Being male, older teen• Lower household
income• Competitive• Having lost more than
$50 in a single month
• Started gambling before 8th grade (early initiation)
• Parents who gamble‐‐youth twice as likely to be at‐risk gamblers & four times as likely to be problem gamblers
Source: Volberg, et al (2008; bid).
RISK FACTORS FOR YOUTH
Gambling & Oregon Teens
Six in 10 Oregon (63 percent) have gambled46 percent gambled in the past year3 percent gamble weekly or more
Six percent problem gamblers or at riskPreferred games in order:
Free Internet gambling-type gamesCards (poker)Sports bets
Games of personal skill
Source: Volberg, et al (2008; bid).
Lane County 2012 Student Wellness Survey (SWS)
2012 Gambling, Substance Use and Mental Health among Oregon Youth
0%
10%
20%
30%
40%
50%
Gambling Alcohol BingeAlcohol
Marijuana CigarettesDepression Psychdistress
Percen
tage
6th 8th
11th
Source: http://oregon.pridesurveys.com/esds.php?year=2011n=55,611 students (18,885 6th grade; 21,368 8th grade; 15,358 11th grade)
Used alcohol in the past month
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Grade 6 Grade 8 Grade 11
Percen
tage
Did not gamble
Gambled
Available at: www.preventionlane.org/sws.htm
Binge drank in the last 30 days
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Grade 6 Grade 8 Grade 11
Percen
tage
Did not gambleGambled
Available at: www.preventionlane.org/sws.htm
Smoked cigarettes in the past month
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Grade 6 Grade 8 Grade 11
Percen
tage
Did not gambleGambled
Available at: www.preventionlane.org/sws.htm
Used marijuana in the past month
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Grade 6 Grade 8 Grade 11
Percen
tage
Did not gambleGambled
Available at: www.preventionlane.org/sws.htm
Skipped school one or more days in the past month
0%5%
10%15%20%25%30%35%40%45%50%
Grade 6 Grade 8 Grade 11
Percen
tage
Did not gamble
Gambled
Available at: www.preventionlane.org/sws.htm
Percent of youth who attempted suicide in the
past year
7.2%5.0%
11.3%9.0%
0%
5%
10%
15%
20%
25%
30%
Grade 8 Grade 11
Percen
tage
Did not gamble
Gambled
Available at: www.preventionlane.org/sws.htm
Percent of youth that attempted suicide in the past year
10.1%8.0%
21.0%18.6%
0%
5%
10%
15%
20%
25%
30%
Grade 8 Grade 11
Percen
tage Did not
bet/gamble morethan wanted to
Bet/gambledmore thanwanted to
Conclusion?
Teens who gamble are smoked up, toked up, drunk emo delinquents.
Conclusion?
Teens who gamble are smoked up, toked up, drunk emo delinquents.
delinquency
sexualbehavior
depression
substanceuse
gambling
ProblemBehaviors
Conclusion: Problem Gamblingis
ONE COMPONENT of Problem Behaviors
Identification & Treatment
Online: click here
Source: Written by Robert L. Custer, M.D; retrieved from Council on Compulsive Gambling of New Jersey, Inc..
Intervention
Helpline 541.741.7107: emergence Or 24/7: 1.877.MY.LIMIT
Referred to provider for assessment
Family members come in; later bring gambler in
A Simple Screen: Lie-Bet Tool(Johnson et al., 1988)
1.Have you ever felt the need to betmore and more money?
2.Have you ever had to lie to people important to you about how much you gambled?
Valid and reliable for ruling out pathological gambling behaviorResponse to ONE or both indicates referral for longer assessmentuseful in screening to determine whether a longer tool (e.g., SOGS, DSM‐IV)
should be used in diagnostics
Assessment Tools
SOGSDSM
DSM Criteria Revisited1. Preoccupation
with gambling2. Increases amount
of money gambled3. Unsuccessfully
tries to quit4. Restless or
irritable when trying to cut down/stop
5. Gambles as an escape
6. “Chases” losses7. Lies to others to
conceal gambling8. Has jeopardized
relationships9. 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.
Treatment is Free.
24 hrs: 1877‐my‐limitOnline: 1877mylimit.org
Minimal intervention: GEAR (Gambling Education and Reduction)Outpatient treatment (44)Crisis respite (2)Residential treatment (1)
TREATMENT OPTIONS IN OREGON
EMERGENCE GAMBLING TREATMENT PROGRAM
Treatment free for gamblers and loved ones275 problem gamblers and family members treated last yearGender-specific
Multimodal treatment Individual sessions - Family therapyGroup sessions - Recreational counselingDidactic lectures - Audiovisual educ.
Suggest to explore 12‐step program
• Only about 2% of Oregonians who need treatment enroll
• Those enrolling who lived within a 50 mile radius of a casino were significantly more likely to report casino as their primary venue
• 30% enter treatment through the statewide helpline
Source: http://www.oregon.gov/oha/amh/gambling/gear‐workbook.pdf
THOUGHTS, FEELINGS, ANTICIPATION,
FANTASY(Gambler’s Mind, “Gambling Time/
Gambling Money”)
PLANNING(Removing obstacles
to gambling)
GAMBLING(“Winning & Losing”)
Serotonin AdrenalineDopamine
CRASHGuilt, Shame, Anger, Denial, Justification, Restless, Irritable, Depression, Panic or Numb, Suicidal Thoughts Dopamine
REALITY(Self with Others)“Real Time, Real Money”
DISRUPTING THE ACTION CYCLE
• Barriers to Money• Treatment• Support Systems• Accountability• H.A.L.T. (hungry, angry, lonely, tired)
Slide credit: Janese Olalde, MEd, CGAC, CADC
FAMILY TREATMENT ISSUES
• Allow venting of rage and betrayal• Education of compulsive gambling as an illness• Family Groups• Renew sense of hope• Empowerment• Seek support – treatment • GAM‐ANON• DON’T KEEP SECRETS!
Slide credit: Janese Olalde, MEd, CGAC, CADC
Family Financial Issues
• Create own avenue to financial stability (employment or other)
• Protect financial assets• Close joint accounts• Use automatic/electronic deposits for gambler’s income
• NO BAILOUTS!
Slide credit: Janese Olalde, MEd, CGAC, CADC
Couple Issues in Therapy
Sequencing with individual work Assess possibility of domestic violence Impact on partner and children Role of money in the relationship Deal with hurt, anger, mistrust Dealing with “unfolding truths”
Slide credit: Janese Olalde, MEd, CGAC, CADC
Promotion & Prevention
Creating conditions in families, schools, and communities that
promote the wellbeing of people
Emotional and behavioral health
Physical health
Awareness & communication of the problem is relatively low.
2012 Oregon Student Wellness Survey, Lane County (“Esd”) and Oregon; available at http://oregon.pridesurveys.com/esds.php?year=2011
Targeting Parental Attitudes
Oregon parent/youth focus groups revealed:
• All parents in the groups said their kids didn’t gamble
• All kids in the groups said they did gamble• Neither sees gambling as risky
Targeting Parental Attitudes
Most parents believe:• Youth gambling is harmless • Youth who gamble are unlikely to have problems in school
• Youth gambling is not associated with alcohol or drug use
…and those beliefs are part of the problem
Crashed cars“Scared straight”
Boot campOne‐time activities
Our efforts in Oregon have
a focus on: • Public awareness• Policy• Support for in‐school prevention curriculum
• Parent education
Problem Gambling Advisory Committee
• Meets monthly• Works on policy & awareness issues
• Comprised of professionals & community members
Various Methods
ON THE RIGHT PATH
KEY CHALLENGES IN THE FIELD
• Youthful subject• Perception of harmlessness
• Stigma/shame• Industry
IS IT “SOCIAL” OR PROBLEM GAMBLING?
Social GamblerOccasional
Sticks w/ limits
Hopes to win, expects to lose
Can take it or leave it
Problem GamblerFrequent, preoccupied
Plays w/needed $, borrows
Hopes & expects to WIN
Primary source of “fun”
10 TIPS FOR RESPONSIBLE GAMBLING
1. Gamble only if it's fun.2. Think of the money you lose as the cost of
entertainment.3. Set a dollar limit and stick to it.4. Set a time limit and stick to it.5. Accept losing as part of the game.
10 TIPS FOR RESPONSIBLE GAMBLING
6. Don't borrow money to gamble.7. Don't let gambling interfere with family, friends,
or work.8. Don't gamble to win back losses.9. Don't use gambling as a way to cope with
emotional or physical pain.10. Know the warning signs of problem gambling.
SUMMARIZING THIS CONTENT
• We defined gambling & problem gambling• We looked at trends• We looked at connections with other issues• We saw the effects on the brain• We looked at how to address problem gambling
•
Under $100$100‐$1,000
$1,000-$2,500More than $2,500
Problem gambling treatment is ‘free’ in Oregon for gamblers AND loved ones.
The average problem gambler in Oregon
gambling treatment owes
$4,000 in gambling-related debts.
The average problem gambler in Oregon gambling treatment owes
$30,000 in
gambling‐related debts.
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