Statewide Gambling Therapy Service South Australia Flinders Centre for Gambling Research www.sagamblingtherapy.com.au Malcolm Battersby Peter Harvey
Funding • Office of Problem Gambling, Department of Families and Social Inclusion • Casino, SA Clubs and Aust Hotels Association via Office of Problem Gambling • Flinders University • Acknowledgements: • Jane Oakes, Ben Riley, Sharon Harris, Dave Smith, Amii Larsen,
A woman has been jailed for at least two years for stealing more than $800,000 from her employers to feed her gambling habit http://www.abc.net.au/news/2012-07-13/l
Gaming machines take over peoples’ minds “The damn machines take your mind over, your body and soul over, and that’s probably the reason why people commit suicide, because it just takes control. But it’s – what would you call it, it’s being delirious. ” Larry (PA)
The urge and the "Zone" – loss of critical thinking “It’s the urge. Once you start it’s almost like you’re in the "Zone" and you ignore all random thoughts in your head that say ‘stop, get out, you’re just going to lose it’’. ‘I also can become hyper- focused where you’re so focused on one machine you can’t leave it ” Simon (SGTS)
"Zone" unable to meet basic demands altered awareness “ You just didn’t get a drink. You just didn’t go to the toilet you didn’t get anything to eat . You had absolutely nothing all the hours that you were there’”. Janet (PA)
Statewide Gambling Therapy Service • Flinders Therapy Service for Problem Gamblers established in 1996 • Expanded in 2007 to become Statewide Gambling Therapy Services • Inpatient / outpatient • Consumer Consultants • The SGTS is run through the Southern Adelaide Health Service (FMC) and Flinders University funded by SA government with contributions from the industry • Comprehensive assessment and treatment using mental health and Cognitive Behaviour Therapy (CBT) urge reduction program for people with gambling problems • Training opportunities for students (social work, mental health sciences, psychology)
Well documented that ease of access increases problems…
EGMS most addictive form of gambling…Why? • availability & access • attraction of sights, sounds • increasing speed and betting rates • near misses • dopamine pathways / reward system operates like a substance addiction
312.31 Gambling Disorder (DSM V ) Non substance related disorder - not better accounted for by a manic episode At least 4 of the following criteria • Preoccupation • Tolerance • Loss of control • Withdrawal • Escape negative affect • Chase losses • Lying • Risk significant relationship or job • Relies on bailout
Theory: the development of problem gambling • Initially : Classical conditioning – pairing excitement (arousal) induced by the reward of gambling with neutral stimuli • external eg the machine colours, sounds, the venue, money , • internal : positive mood, low mood, anger, boredom create a gambling urge These stimuli then become triggers to gambling arousal without gambling occurring
External Triggers: Classical Conditioning
Gambling triggers - internal
Conditioning • Then ; Operant conditioning of gambling behaviour • Positive - intermittent variable ratio reinforcement ie increase in gambling behaviour mediated by arousal Unpredictable reward timing and amount Eg near miss Classical and operant conditioning lead to development and increase of the urge As the arousal becomes heightened it becomes aversive ie an ‘urge’ http://www.youtube.com/watch?v=I_ctJqjlrHA
Variable Ratio Reinforcement
Operant Conditioning – reward learning • Money: actual or fantasy • Cheap / free drinks and food • Excitement, social interaction
Conditioning Finally: Negative reinforcement via tension relief ‘a behaviour is reinforced or strengthened by avoiding or removing a negative outcome or stimulus’. ie the act of gambling reduces the urge temporarily but has the effect of increasing the strength of the urge the next time the person comes across a gambling trigger or cue
Why Cue Exposure? • If for most problem gamblers an urge or arousal exists and conditioning provides a reasonable explanation of the development of the urge then we should use a de-conditioning approach to extinguish the urge • Gaming machines are designed using a range of reinforcement schedules and provide the ideal experimental paradigm to test a treatment which aims to reverse the psychological process which created the behaviour (as compared to anxiety disorders which are not ‘created’ )
Why cue exposure? •Problem Gambling in fact provides one of the rare occurrences in mental disorders where a theoretical model of causation can directly support the selection of an intervention •Large evidence base for use of exposure in anxiety disorders where arousal or anxiety is linked to triggers for all 6 anxiety disorders and brief (2-12 sessions) even single session exposure (phobias) can lead to major improvements or even ‘cure’ of anxiety disorders
Exposure and response prevention • Obsessive compulsive disorder provides the closest paradigm to problem gambling • Once the anxiety/urge has been overcome the avoidances, distractions and modifiers become unnecessary (Oakes et al, 2008,2010,2011)
Function
Sometimes solutions create more of the problem…
DIG!
DIG!
Costs of Avoidance • Loss of independence • Frustration • Social isolation/loneliness • Restricted lifestyle • Conflict over money
Graded Cue-exposure with Response Prevention
Habituation
Screening Assessment • Cognitive behavioural Assessment • Mental state • Risk assessment • Suitability (exclude acute psychosis, suicide plans, recreational drug use, benzodiazepine use, alcohol ) The problem is predictable and observable. • Treatment Rationale
STATEWIDE GAMBLING THERAPY SERVICE Gambling Screening Assessment Assessing Therapist PATIENT LABEL Full Name, *Signature *Screening Date Patient Profile * Age, *Marital Status *Occupation, *Suburb lived in What Is the problem at the moment? Where Does the client gamble or not? When Does the client gamble or not? Why/Triggers Does the client gamble? With Whom Does the client gamble and when gambling, does the client socialise?
Specific Autonomic Behaviour Cognitive Incident What happens physically How does the client Thoughts/Imager when having an urge to place bets, any y of gambling, gamble eg; sweating and superstitious self talk palpitations? habits, take a erroneous break, smoke or beliefs? drink? Before During After
Money Hotels Bills Sadness Anger Happiness Gambling relieves the urge Excitement Anxiety Restlessness Rushing temporarily Uncontrollable urge (Battersby et al., 2008) I shouldn’t go Only $20 I might win! My lucky day!
Gambling episodes within pattern of problem gambling Gambling reduces urge: reinforces gambling; trigger maintains urge- eliciting power. No reappraisal.
n o i t a u t i b Exposure - Habituation a H Time Don't avoid URGE 8 7 6 5 4 3 2 1 0
Principles of Exposure Graded : tackle the easiest trigger first • Prolonged : Remain with the trigger until your urge has reduced • by at least 50% - you must feel the urge go away Repeated : repeat or practice the task at least 5 times per week • preferably daily • Focussed : don’t distract yourself, allow the gambling thoughts to stay and don’t replace with correcting thoughts
Graded Cue-exposure with Response Prevention A typical hierarchy for EGM problem Client achieves extinction • Gradually increase amounts of $ until goal reached • Sitting at EGM with small amount of $ • Outside venue with small amount of $ • Inside venue at lounge area (no $) • Outside venue (no $) • Simulator/DVD • Music • Picture Start
Imaginal exposure (guided imagery) • 30-45 mins in session • A step by step account in the here and now fully immersed in all the sensory facets of the gambling scenario • Use the 4 principles of exposure to guide the content and duration of the imagery task • Complete the scenario up to the point of gambling but not the act of gambling • Audio tape or video the client description of the session • Replay at home for homework using the 4 exposure principles
Therapy session plan 1. CBT Assessment and rationale, baseline measures, money management 2. Full psychiatric and psychosocial history, 1. Family involvement 2. Review rationale 3. Review money management 4. Exposure tasks agreed, use urge monitoring record and treatment diary 3. Homework reviewed, cash management reviewed, new exposure tasks in hierachy 1. Urge surfing for spontaneous urges
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