2. C Steve Chiasson Steve Chiasson BA. CPGC

3. Presentation Objectives To identify unique aspects and critical factors in the treatment of problem gambling To provide a comprehensive approach to stabilizing problem gambling and preparing clients for change To present an approach to treatment that is based on the integration of experiential knowledge and empirical evidence

4. Problem Gambling in Perspective Findings estimate that 332,000-449,000 Ontario adults have moderate to severe gambling problems Only 2% are in the formalized treatment system Clients receiving treatment commonly report numerous failed attempts to control or stop gambling, resulting in feeling perplexed, hopeless and resigned

5. Problem Gambling in Perspective Actively gambling clients commonly report: Experiencing profoundly altered states both physically and mentally Doing things they would have never believed that they were capable of doing Not grasping the magnitude of the negative consequences to their behaviours associated with gambling

6. Clinical Experience Clinical experience includes working with over 2,100 clients over 15 years Extensive problem gambling group work, currently providing four therapy groups each week ( 52 clients in group services) Additional group: Mindfulness Meditation Practice

7. Main Clinical Framework Biopsychosocial perspective Learned behaviour model Collaborative approach Based in principles of Motivational Enhancement (instilling hope and increasing self-efficacy) Externalization of the problem Normalize their experience - they are not alone

8. Theoretical Comparisons of P.G Two General Perspectives First Perspective Theories that assert the variations in gambling behavior result from variations in the characteristics or make-up of the individual Biological or genetic differences account for problem gambling Black and white distinction, the individual is either a compulsive/pathological gambler or not

9. Theoretical comparisons cont’d Second Perspective Theories that attribute excessive/problem gambling to psychological determinants and habitual processes such as Behavioral, Cognitive and Need-State models Some form of psychological mechanism accounts for disordered gambling Emphasize the developmental and habitual nature of gambling rather than pathology

10. Theoretical comparisons cont’d Avoids labels such as compulsive or addiction and instead makes reference to impaired control or disorder gambling Central to these theories is the idea that every person who gambles has the potential to become a problem gambler Non-problematic gamblers may experience many of the same processes, but to a lesser degree

11. Provincial Standard for Problem Gambling Treatment Cognitive - Behavioural Therapy Goals of CBT To identify and raise awareness of cognitive distortions regarding gambling Challenge the distorted thinking, i.e. the evidence that forms beliefs, thinking and expectations

12. Cognitive – Behavioural Model cont’d Cognitive restructuring, i.e. correcting erroneous perceptions, beliefs and expectations regarding gambling Initiating behavioural change

13. Behavioural Cognitive Therapy Emphasis on the implementation of behavioural strategies to initiate change and to stabilize gambling behaviour. At this stage clients’ cognitive problem solving skills are typically not reliable/effective when applied to gambling and can in fact be a risk factor. Rather than a focus on critical thinking skills and correcting cognitive distortions BCT emphasizes behavioural strategies.

14. Behavioural Cognitive Therapy cont’d Cognitive strategies become more of a focus after the problem gambling behaviour has stabilized. CBT approach strategies are the core strategies for maintaining change. Central to this approach is a focus on risk management. Identifying and addressing risk behaviours and risk cognitions.

15. Self Changers: What Worked? N=314 David Hodgins University of Calgary Action% of people New Activities/Change in focus68% Stimulus Control/Avoidance48% Treatment37% Cognitive34% Budgeting31% Willpower/Decision-making/self- control 23% Social Support10% Others – confession, no money, non- gambling external factors, self-reward, spiritual, addressing other addictions <5%

16. Message to Preparation and Early Action Stage Clients.... Behave one’s way out of problem gambling rather than taking the typical approach to problem solving i.e. to thinking their way out of problem Disordered thinking and the effects of behavioural conditioning can be extremely overpowering. Clinical experience indicates that behavioural strategies are clearly more effective than cognitive strategies in terms of stabilizing problem gambling behaviour

17. Revisiting Preparation Stage? As was referred to earlier many clients experience unsuccessful action Clients typically “rush” into action without being properly prepared or “equipped” for the task at hand Preparation Action

18. Stages of Change Prochaska, DiClemente & Norcross

19. Preparation Stage Client has made decision to take steps to stop a problem behaviour(s) i.e. through abstinence or control Clinician's role is to guide client in developing an effective change plan and helping to prepare client to move forward. This includes: Increasing awareness regarding the nature of the problem

20. Preparation Stage cont’d Helping client make a realistic assessment of the difficulties they may encounter and plan for each of these contingencies e.g. what obstacles do you foresee? Clinician draws on knowledge and experience, gently suggesting strategies that have worked with other clients While respecting the clients choices, the clinician provides feedback and can gently warn against change plan strategies that seem inappropriate or ineffective Collaboratively determine ways to evaluate plan and revise plan if necessary Prochaska, DiClemente & Norcross

21. List Challenges: Universal Factors Challenges to Stabilizing Problem Gambling

22. Nature of Habits Habits occur with respect to thoughts and behaviour Often start off in an innocent manner Habits often develop due to lack of awareness Acquired through repetition Done automatically Difficult to break

23. Nature of Habits cont’d The experience of changing a habit is typically associated with discomfort and/or distress. The acquisition of a “bad” habit is influenced by personal risk factors.

24. Gambling Habit Strength Low habit strength vs. high habit strength Once a gambling habit is established, cognitive factors have little effect on betting A gambling habit can be modeled as a stochastic process without any reference to any cognitive process William Jolly 2004

26. Operant Conditioning Gambling is based on variable ratio reinforcement schedule The variable ratio schedule produces both the highest rate of responding and the greatest resistance to extinction (for example, the behaviour of gambling at slot machines) Considered to be the most powerful method of keeping someone engaged in a behaviour

27. GAMBLING DISTRESS GAMBLINGTIME OF DAY GAMBLING

28. Classical and Operant Conditioning Wins delivered at variable ratios that are resistant to the effects of extinction, produce states of excitement described as equivalent to a “drug-induced high”. Repeated pairings classically condition this arousal to stimuli associated with the gambling environment. Through second order conditioning, gambling cues elicit an urge to gambling which results in a habitual pattern of gambling (Dickerson, 1979; Sharpe & Tarrier, 1973).

29. Neurochemical Factors Neurochemical dysregulation Dopamine and Serotonin

30. Dissociation

31. The Anticipation of Outcome

32. Coping with and Reducing Distress Associated With Changing Talk about it Exercise Deep relaxation (Prochaska) Building coping skills Dialectic Behavioural Therapy

33. Mindfulness Meditation Reduce rumination Less reactive to thoughts/urges Present moment focus. Developing this skill competes against the skill of dissociation

34. Carrying out the Plan Action Stage Carrying Out the Plan

35. Stages of Change Prochaska, DiClemente & Norcross

36. Action Stage Processes Self–liberation Reinforcement management Helping relationships Counter-conditioning Stimulus control

37. Important to Prepare Clients for a Longer Period of Action Positive relapse Disordered thinking (feeling that they can control gambling) Cue exposure e.g. availability Challenges related to managing money Promotion/advertising

38. Addressing the Context of Problem Gambling Address not only the target behaviour (PG), but also the context in which it (PG) has been occurring e.g. the scaffolding that supports it/holds it in place. Problem Gambling

39. Creating Incompatibility With Problem Gambling Creating incompatibility through changes in behaviours, beliefs, attitudes and ways of being that have been associated with the gambling behaviour

40. Action Stage Strategies (Behavioural Strategies) S ubstitute in new ways of thinking and behaviours O pen up - Talk about the change e.g. distress A void and counter high risk situations R eward yourself

41. Key Message to Client Expect that it will be difficult to stop themselves from having thoughts about gambling as these thoughts are often automatic in nature. The key is how the thought is managed. Learning to manage thoughts about gambling through the effective use of behavioural and cognitive strategies.

42. Next Steps Once the gambling behaviour is stabilized, faulty or distorted cognitions can be examined in depth and challenged. There is an increase in focus on critical thinking skills. Behavioural strategies are maintained and/or modified when clinically appropriate.