ABACUS Counselling, Training & Supervision

In February 2013 the Australian Medical Association released a position paper on its concern about problem gambling in Australia. This included concerns about interactive gambling, effects of gambling on young people, its support for a public health approach, its views on the roles of the Commonwealth and State/territory governments, and the roles of the gambling industry and medical practitioners.

The paper identified six recommendations for their practitioners. These were:

The need for raised awareness of medical practitioners for the physical and mental impact on individuals and their families of problem gambling, and of symptoms that may appear to be unrelated to problem gambling.
When taking a systematic lifestyle risk assessment, gambling should form part
When gambling problems are suspected, a psychosocial assessment should be undertaken
Treatment for problem gamblers and their family should include a shared care approach with community agencies such as specialist problem gambling services, community mental health, relationship counselling, alcohol and other drug services, financial advisory services, and legal services
Kits that include screening and assessment questionnaires should be available to all medical practitioners, especially GPs, to identify, manage and refer gambling affected patients
Medical courses should include problem gambling as a health issue and medical practitioners should be encouraged to participate in ongoing training for problem gambling.

The Australian Medical Association raised concerns about interactive gambling (internet, mobile phones, digital TV), referring particularly to increased youth risk; that technical innovation, marketing, and sport gambling increase, as well as the link between online advertising, social media/networking sites. The susceptibility of young people to interactive gambling as well as the online links to gambling sites, are referred to. Recommendations for State and Commonwealth are also concerned around targeting of children and adolescents, use of simulated gambling activities, and the establishment of educational programmes for school-aged children.

Comment:

The medical sector provides a substantial opportunity to identify problem gambling issues amongst gambling individuals and their whanau.
Screening resources currently exist that have been developed specifically for medical providers (and extended to others) in NZ, and have been validated for NZ populations (e.g. CHAT, COGS and Eight Screens).
It is estimated that around 80% of the public access their GP annually, although problem gamblers are more likely to access their GP for other health issues. The screening of those affected by problem gambling provides an opportunity to access the estimated over 90% of problem gamblers and their families who do not seek help for their health-affected gambling issues, and at an earlier stage for those that do, through pro-active systematic screening.
The AMA proposals are based upon the concern that ‘an estimated 2.5% of Australians experience moderate to severe problems caused by gambling. For every person with a gambling problem, it is estimated that an additional 5 to 10 people are adversely affected by their gambling’. These figures are considerably above the NZ estimates (NZ Health Survey 2006/7 of 1.7%; 2011/12 of 1.3%), but such estimates have been considered to under-estimate problem gambling prevalence rates because of a range of factors, including high stigmatism and concealment issues. Accessibility to gambling is high for both NZ and Australia compared with most countries, and prevalence rates of problem gambling may be elevated for both countries, while cultures and accessibility to medical help, may have sufficient similarities to consider the relevance of this AMA gambling release.
Although there have been several publications of articles on problem gambling in NZ medical journals, best-practice initiatives for medical professionals on gambling have been few, e.g. Sustance use and addiction in Māori, Bpac 2010
The AMA paper calls for Australian health professionals to systematically screen for gambling problems (when conducting a lifestyle assessment or when symptoms indicate the possibility of problem gambling). in NZ, there is available a validated brief lifestyle and mental health screen (the CHAT) that addresses a range of mental health, addiction, and lifestyle issues (9 in total), that align with the CEP (addiction and coexisting mental health problems). The CHAT further tests for issues commonly present with addictions both within the mental health and social sphere, which can impact upon the course of the addiction and the wellbeing of the person.
The call for GPs to work with other services mirrors the NZ CEP and Facilitation strategies.
Overall, this new Australian initiative with GPs and other medical professionals to screen for gambling problems amongst patients, is a substantial step towards systemic screening of all patients for problem gambling (and associated problems), which may have a substantial impact upon problem gambling aetiology in NZ (early intervention, as well as accessing the high percentage of those affected who don’t seek help). The goal of further integrating GPs into addiction intervention may receive support from this influential source, the AMA.

Literature:

The clustering of psychiatric disorders in high-risk gambling populations. Authors: Abdollahnejad M, Delfabbro P, Denson L (2013) Journal of Gambling Studies (in press)

Findings:

Participants were 140 regular gamblers recruited from the general public in Australia
A number of assessment instruments were completed (both self-report and semi-structured) for mental disorders and two gambling screens (NORC & PGSI)
Psychiatric disorders were more prevalent in those diagnosed as pathological disorders as compared with other gamblers
Mood and anxiety disorders particularly, were significantly higher with pathological gambling participants and almost two-thirds of these were identified with either a mood or anxiety disorder plus a further disorder (in addition to the pathological gambling)
This was evident for both male and female pathological gamblers
The authors noted that this finding highlighted the high rates of comorbidity of pathologically gamblers in the community, and especially the co-presence of anxiety and mood disorders o The authors noted that this also highlighted the ‘significant challenges facing treatment services in the treatment of PG, and the extent to which this (problem gambling) should be treated as the primary disorder’

Comment:

Although previous research has highlighted the high presence of co-existing disorders with problem gambling (e.g. Kessler et al, 2008), this is a very recent study of a community population in Australia (possibly more generalisable to NZ) for a disorder that is subject to constantly varying environment and gambling modes
The reference to treatment services and the question of which to treat as the primary disorder is addressed in NZ through the roll- out of its CEP programme in treatment of addictions and coexisting problems, where all problems are treated with equal focus
However, this research does emphasise the importance of assessing problem gambling clients for a range of other mental health problems, and particularly, mood or depressive disorders and anxiety disorders
Training of practitioners who work with problem gamblers, whether PG specialists or other health professionals, should be resourced to identify both mood and anxiety problems, and when problem gambling is identified, further steps should be taken to address these mood/anxiety problems which have been found in this study to be present in the majority of pathological gamblers
Review of the full text may provide even further factors of significance to NZ when available.

Literature:

An empirical evaluation of proposed changes for gambling diagnosis in DSM-5 Petry N, Blanco C, Stinchfield R, Volberg R (2013) Addiction (in press)

Findings:

With the recent release of DSM-5 there have been changes to the criteria for the disorder for problem gambling. The criteria relating to committing of illegal acts to finance gambling has been dropped from the previous list of ten criteria, leaving nine, and the threshold of (any) five of the ten criteria being positive confirming the diagnosis has now reduced to four out of the remaining nine criteria.
Data from five problem gambling sources were analysed comprising a random USA survey (n=2417), gamblers in venues (n=450), brief intervention studies (n=375), problem gambling (PG) treatment clients (n=149, and randomised general intervention studies (n=319)
The NODS gambling screen based upon DSM-IV criteria was used for analysis to compare both prevalence rates and classification rates of problem gambling under both the ten previous and nine remaining DSM criteria.
The authors found that the reduction in criteria required to diagnose problem gambling as well as the elimination of the ‘illegal’ criterion did not affect the findings. The new lesser criteria DSM-5 resulted in ‘equal or slightly better classification in all comparisons and across all samples’
They concluded that the ‘illegal’ criteria was unnecessary for diagnosis of pathological gambling and that the reduced cut-off from five criteria to four resulted in a more consistent diagnosis for DSM-IV

Comment:

This research was conducted by prominent researchers and addresses important changes to the criteria for problem gambling following the release this year of DSM-5, the most commonly used diagnostic manual in USA (and NZ). The other manual, the WHO ICD-10, is more commonly used in Europe. o Pathological Gambling has been moved from ‘Impulse Disorders not elsewhere classified’ to ‘Substance-related and addictive disorders’ and is renamed ‘Gambling Disorder’)
The reduction of criteria as well as reducing the threshold from five to four criteria may have significance for validity of problem gambling screens, comparison of past research with new research (when the measure used has changed), as well as the target or focus of this research, the statistical effects of this change
Review of the full text when available, will enable a further assessment of whether all the DSM-5 changes were considered outside of the statistical analysis. For example, DSM-5 changes to criteria include adding the qualifier ‘often’ to the DSM-IV criteria ‘Is preoccupied with gambling’, such that it is not always present ( for example, a PG may consider that there are sometimes occasions when they think of other things, and therefore are not (always) preoccupied with gambling and answer ‘no’). Another change is, instead of ‘Gambles as a way to escape from problems’, it becomes ‘Gambles when feeling distressed’; and ‘chasing one’s losses’ refers to often long-term , not short-term, chasing. Finally, all criteria must occur within a 12-month period, whereas in DSM-IV, there was no time requirement. These changes may possibly alter how a PG may respond to these criteria, and so change the comparison outcome. This may be clarified in review of the full text.

Literature:

Examination of proposed DSM-5 changes to Pathological Gambling in a helpline sample Authors: Weinstock J, Rash C, Burton S, Moran S, Biller W, O’Neil K, Kruedelbach N (2013) J Clinical Psychology (In press)

Findings:

In a similar study to the above paper to assess the impact of removal of the ‘illegal’ criterion from the DSM diagnosis criteria for DSM-5, the researchers compared DSM-IV criteria responses by gambling helpline counsellors (n=2750) in the USA.
Callers completed a semi-structured interview as well as the DSM-IV criteria. Of the callers, 81.2% met the criteria for Pathological Gambling
Keeping the threshold at five criteria, but removing the ‘illegal’ criterion affected (reduced to non-pathological) the gambling status of only 2% of callers, while reducing the criteria to four, then three, then two, increased prevalence rates from 9% to 17%.
The researchers commented that they noted that even sub-clinical gamblers were experiencing ‘significant adverse consequences’ from information other than from the screen itself.

Comment:

This paper tests aspects of the above statistical analysis with apparent additional variability with this helpline population than the Petry et al paper above. Although the difference at a five criteria cut-off without the ‘illegal’ criterion was very low in the reduced prevalence finding for the callers, (presumably because either few answered yes to the ‘illegal’ criterion, or those that did scored more than six and when the criterion was removed, remained positive), the change in prevalence rates at an increased 9% seems relatively substantial.
This difference then, does suggest that changes may be substantial in prevalence rates in surveys using the new criteria, and raises the possibility that screens may need to be re-validated, and care taken in before/after DSM-% comparisons. However, further research would have to be considered first, as well as study of the full paper when released, to reach this conclusion
Perhaps more importantly at this stage, the finding that even sub-clinical callers were significantly affected, raises the question as to whether screens are identifying moderate-severe PG, or even whether screens that identify severe PG are sensitive enough (i.e. whether they are identifying false negatives).

Literature:

Characteristics and predictors of problem gambling on the Internet Authors: McCormack A, Shorter G, Griffiths M (2013) International J of Mental Health and Addiction (In press)

Findings:

The researchers enlisted respondents (n=1119) from posts on 32 international gambling websites to ascertain whether they could identify links between internet gambling and problem gambling.
Information was sought on gambling activities, frequency of their gambling, reasons for gambling online and demographic issues.
Compared to non-problem gamblers, online problem gamblers were more likely to be male, be smokers, drink alcohol while gambling online, have a disability, gamble for more than 4 hours a session, regularly use two or more gambling activities, gamble after a near miss and gamble alone.
Characteristics of offline and online gambling were considered to be similar, with the conclusion drawn that online gambling is a risk generally for those with (offline) gambling problems.

Comment:

Although little in differences were identified between online and offline characteristics of problem gamblers, the characteristics of problem gamblers were confirmed for both environments
The higher likelihood of smoking, drinking, longer sessions and having other disabilities indicates the possible need to address a wide range of issues in therapy o NZ approaches of CEP (addressing coexisting issues) are supported when this strategy is matched to the potential needs of both online and offline problem gamblers.

Literature:

Characteristics of gamblers using a national online counselling service for problem gambling Authors: Rodda S Lubman D (2013) J of Gambling Studies (In press)

Findings:

The authors describe the development and roll-out of a national chat and email service for problem gambling.
The advantages of the service were its immediacy, its ease of access, its alignment with other health service strategies, and potential to attract age groups who may have previously not sought help
In the 2-year period ending September 2011, over 85,000 visits to the online service were recorded. In addition, 1722 people entered into real-time chats with its counsellors, and 299 entered into the email support programme. Approximately 70% were accessing first-time treatment (chat 68%, email 78%), with chat clients more likely to be female, under 40 years of age and email clients also more likely to be female, but over 40 yrs. Young males also were highly likely to access the email support service.
Conclusions were drawn that these email and chat initiatives were likely to attract first-time help seekers with gambling problems and it was an important alternative for those affected by problem gambling.
The authors acknowledge that further research is required to identify what outcomes of the service will eventuate.

Comment:

This Australian initiative describes an alternative to a telephone-only service for PG clients that appears to provide a further electronic initiative.
The email option appears to be most popular, especially for younger males and women over 40. Gamblers may prefer the additional anonymity of emails, the reduced pressure for instant responses (although the service was real-time and delays may be relatively small), as well as the immediacy over telephone contact, the reduced pressure of email over live conversations, and the option to delay response at their choice.
It would appear that the approximately 2000 clients that accessed the services over the two years did so on many occasions, (although a lesser number may have contacted many times – the full text tables may clarify when the paper is published) – online may engender more contacts, and possibly more efficient counsellor participation. It is possible that a counsellor could respond to more than one email ‘conversation’ at a time, should the demand require, and so ensure that accessibility remains high (telephone conversations are discrete events)
The chat option appears to find favour with a female younger cohort, suggesting a range of online options are seen as desirable and may further extend to Skype, smartphones and suchlike programmes (groups as well).
New clients appeared not to be focused upon youth who might prefer an online option, but rather, on a range of new clients (especially female), who may have reasons to prefer online over telephone.
Although these options have been offered in NZ, the uptake appears to be lower and the full text when available, may offer strategies that may optimise this immediate and highly accessible series of options to new cohorts that otherwise would be unlikely to access PG services.