Background Overall participation in gambling activities by older - - PDF document

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Problem Gam bling Am ong Older Adults: Prevalence, Etiology, and Treatm ent

Lia Nower, JD, PhD, Professor and Director, Center for Gambling Studies, Rutgers University, School of Social Work Center for Gambling Studies

Background

• Overall participation in gambling activities by
• lder adults is increasing.
• 1975: 35% of adults 65 and over gambled in

lifetime (Kallick et al., 1976)

• 2001: 81% of adults 51 to 60 gambled past

year (Welte et al., 2001)

– 12.6% gambled frequently – 3.3% problem/ pathological gamblers

• 69% of those 61 and older gambled past year

– 10.2% gambled frequently – 1.2% problem/ pathological gamblers Center for Gambling Studies

Old Adults in Prim ary Care

• Nearly 70% of 843 adults over 65 in

primary care setting gambled past year.

• About 11% stated they either wagered

more than they could afford or more than $100 on a single bet (Levens et al, 2005)

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Hotline Callers

• Of the 1,018 phone calls used in the

logistic regression analyses, 168 (16.5% )

• Older adults were more likely to have

lower incomes, longer durations of gambling, fewer problem types of gambling, and problems with casino slot machine gambling. (Potenza et al, 2006)

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Risk Factors

Higher rates of PG found am ong older adults:

• Earlier ages of onset, psychiatric comorbidity

(anxiety, substance use), poor health (Zai, 2006; Zaranek &

Chaplewski, 2005; Zaranak & Lichtenberg, 2008; Pilver et al, 2013)

• Frequent buses to casinos (Bazargan, Bazargan, & Akanda, 2000)
• Senior centers and bingo halls (Erickson et al, 2005)
• Ethnic minorities and veterans (Levens, et al., 2005)

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Motivations

• Easy access and availability
• More disposable income and time
• Loneliness and need for socialization
• Inducements (meals, busses, events)
• Improve cognitive functioning

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One Study

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Method

• De-identified data-set of 1,601 gamblers

applying for self-exclusion in Missouri from Jan 01-Mar. 03

• Completed application at one of 11

casinos or three Missouri Gaming Commission offices

• Groupings: younger (18-35), middle ages

(36-55), older (56+ )

Sam ple

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Measures

• Demographic characteristics: age at

application, household income, race employment, educational, marital status.

• Gambling behavior: years spent

gambling, age of onset, forms of gambling.

• Reasons for self-exclusion.

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Dem ographic Results

• Age: Range 21 to 79 years
• Women: 49.8%

Men: 50.2%

• Women overrepresented among middle

aged and older adults

• Younger adults: 30.6% (n= 804)
• Middle-aged adults: 59.3% (n= 950)
• Older adults: 10.1% (n= 161)

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Dem ographic Results

• Older adults more likely than younger

adults to be married and less likely to be single.

• Older adults more likely than both

younger and middle-aged adults to be widowed and less likely to be separated

• r divorced.

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Gam bling Behaviors

• Onset: Younger (20s), middle-aged (30s), older

(40s)

• Women reported later age of onset than men;

among older adults, women initiated mean age 48.7 vs 37.7 for men.

• Total years spent gambling increased with age:

Older adults gambled average of 17 years before self-excluding – more than twice the time for younger adults (7 years)

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Gam bling Activities at Onset

• Older adults first gambled on slots

(72.2% ), lottery(32.3% ), video poker(24.2% ), and black jack(20.5% ) as did middle adults.

• Younger adults gambled on an average of

four games: black jack (59.45), slots (65.9% ), video poker (33.9% ) and lottery (46.7% ).

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Past-Year Gam bling Activities

• Older adults gambled on average of three

games (slots= 80.1% , lottery= 39.8% , video poker 35.4% ) as did middle adults (slots= 80.4% , lottery 47.7% , video poker= 42.2% )

• Younger adults gambled on an average of

four games: black jack (59.45% ), slots (65.9% ), video poker (33.9% ) and lottery (46.7% ).

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Onset and Past-Year Form s by Age

Variables Younger adults ( n= 4 9 0 ) Middle Aged Adults ( n= 9 5 0 ) Older Adults ( n= 1 6 1 )

Onset Gam bling

n % n % n %

Strategic form s

120 24.5 124 13.1 21 13.0

Non-strategic form s

132 26.9 449 47.3 91 56.5

Mixed form s

238 48.6 347 36.5 47 29.2

Past-Year Gam bling Strategic gam bling only

95 19.4 54 5.7 9 5.6

Non-strategic gam bling only

121 24.7 491 51.7 95 59.0

Mixed gam bling

268 54.7 392 41.3 54 33.5

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Reasons for Self- Excluding

• Older adults more likely than other

groups to indicate they self-excluded to prevent suicide (13.7% versus 6.7% of younger and 7.7% of middle-aged adults).

• Older adults were less likely to self-

exclude because they hit rock bottom, recognized they needed help or wanted to save their marriage.

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Logistic Regression Results

• Compared to younger adults, older adults were

more likely:

– To have gambled longer before self-exclusion. – To be married and/ or retired/ unemployed. – To express a strong preference for non-strategic forms

• f gambling.

– They were nearly four times as likely to self-exclude in an effort to prevent suicide.

• Compared to middle-aged adults, older adults

were more likely:

– To have gambled longer and/ or be unemployed. – They were nearly three times as likely to self-ban to prevent suicide. Center for Gambling Studies Predictors of Older Adult Self-Excluders

Variable

Older Adults vs. Younger Adults

B SE p value Odds ratio ( 9 5 % CI )

Years gam bled 0 .1 3 0 .0 2 < 0 .0 0 0 1 1 .1 4 ( 1 .1 0 , 1 .1 8 ) Married 0 .6 9 0 .2 9 < 0 .0 2 1 .9 9 ( 1 .1 2 , 3 .5 1 ) Not in w orkforce 1 .7 3 0 .3 1 < 0 .0 0 0 1 5 .6 5 ( 3 .0 6 , 1 0 .4 5 ) Past-year, non- strategic only 2 .3 6 0 .9 7 < 0 .0 2 1 0 .5 4 ( 1 .5 7 , 3 5 .6 6 ) Prevent suicide 1 .3 4 0 .4 7 < 0 .0 0 4 3 .8 2 ( 1 .5 3 , 9 .5 4 )

Older Adults vs. Middle-Aged Adults

Years gam bled 0 .0 4 0 .0 1 < 0 .0 0 0 1 1 .0 4 ( 1 .0 2 , 1 .0 6 ) Not in w orkforce 1 .4 4 0 .2 1 < 0 .0 0 0 1 4 .2 2 ( 2 .8 0 , 6 .3 6 ) Prevent suicide 0 .9 7 0 .3 2 < 0 .0 0 3 2 .6 3 ( 1 .3 9 , 4 .9 7 )

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I m plications

• Older adults progressed from first gambling on

black jack as well as non-strategic forms to a clear preference for non-strategic forms of play (93% ), particularly slots and video poker.

• Older adults feared suicide with continued

gambling.

– This is particularly troubling in light of higher suicide rates among both pgs and older adults, who are often reticent to access care. – Highlights need for targeted prevention, intervention and treatment services. Center for Gambling Studies

DSM 5 Criteria: Gam bling Disorder 3 1 2 .3 1

• Tolerance ( increasing am ounts of m oney

to achieve desired excitem ent)

• W ithdraw al ( restless or irritable w hen

attem pting to cut dow n or stop)

• Loss of Control ( repeated, unsuccessful

efforts to control, cut back, or stop)

• Escape ( often gam bles w hen feeling

distressed)

• Chasing ( going back another day)
• Lying ( concealing extent of involvem ent)
• Lost relationships
• Bailouts

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DI SORDERED GAMBLI NG

• 1 9 8 0 -2 0 1 3 : I m pulse control disorder

characterized by the inability to cut back

• r stop gam bling.
• 1 .7 % of adults and 3 -5 % of youth m eet

clinical criteria for disorder.

• 3 % of adults and 6 -8 % youth have

serious gam bling problem s that lead to adverse consequences: legal, fam ilial, psycho-social.

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PHASES OF DI SORDERED GAMBLI NG

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• Big w in or series of sm aller w ins
• Praise and recognition
• I ncreasing desire to gam ble m ore

to “chase” the w in

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W inning Phase: play for excitem ent,

w in fuels m ore frequent play

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Phases of Disordered Gam bling: Losing Phase

• I ncreased gam bling activity leads

to losses

• Chasing losses to recoup m oney
• I ncreased gam bling generating

m ore losses

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Losing Phase: I ncrease frequency

• f bets to w in back lost funds

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Phases of Disordered Gam bling: Desperation Phase

• Lying
• Borrow ing from friends, fam ily
• Crim inal activity ( stealing,

em bezzling, w riting bad checks)

• Bankruptcy, unem ploym ent,

hom elessness

• I ncreasing w ithdraw al, preoccupation

and m oodiness

• Depression, hopeless and thoughts of

suicide

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Desperation Phase: engaging in crim inal

• r other desperate acts to obtain m oney to gam ble

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The Pathw ays Model

Blaszczynski, A. & Nower, L. (2002). A Pathways Model of problem and pathological gambling. Addiction, 97, 487-500. Center for Gambling Studies

Pathw ays Model proposes that...

All problem gamblers not alike:

• Three (or more) distinct pathways to problem

gambling

• Gamblers in each pathway differ by presence or

absence of psycho-social, biological factors & behavioral manifestations

• Gamblers in different pathways require different

treatment strategies for success

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Pathw ay 1 Problem Gam blers Ecological factors

Availability Accessibility Acceptability

Classical & Operant Conditioning

• Arousal/excitement

Subjective excitement Physiological arousal

• Erroneous Cognitions

Irrational Beliefs Illusions of control Biased evaluations

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Pathw ay 1 Problem Gam blers

Ecological factors

Availability, Accessibility Acceptability

Classical & Operant Conditioning

• Arousal/excitement
• Cognitive schemas

Classical & Operant Conditioning

• Arousal/excitement
• Cognitive schemas

Increasing involvement establishes habitual pattern of gambling behaviour. Occasional Frequent Regular/heavy

Chasing Losses & Problems

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Clinical Characteristics: Pathw ay 1 Problem Gam blers Dem ographics:

• Gamble to achieve a sense of “belonging,” to combat

loneliness, to generate excitement, or to escape dysphoric mood states

• Shorter period of excessive gambling
• Problems less severe
• Stable childhood & family history

Psychopathology

• Absence of psychopathology
• Depression/ anxiety: secondary to problem gambling
• Substance abuse minimal: onset after gambling problems

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I dentifying Pathw ay 1 Gam blers

• Screen for depression, anxiety, personality
• factors. Fail to identify significant pathology

unrelated to gambling problems.

• Perform psychosocial assessment. Fail to identify

significant pathology in family as well as issues of abuse, grief, loss.

• Assess social support and stress-coping
• strategies. Identify healthy social or

environmental support, active stress-coping.

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Treating Gam blers in Pathw ay 1

• Cognitive-behavioral therapy and education to

dispel illogical “magical” thinking.

• Focus on realistic appraisal of loss progression

and breaking through denial.

• Involve supportive members of family and social

system in treatment.

• Teach adaptive stress-coping styles and healthy

activities providing excitement and mental stimulation.

• Conduct lethality assessment.

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Pathw ay 2 Problem Gam blers Ecological factors Conditioning

• Arousal/excitement
• Cognitive schemas

Vulnerability factors

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Pathw ay 2 Problem Gam blers Vulnerability factors

• Childhood disturbance
• Personality

Risk-taking, Seek sensation, escape Boredom proneness

• Arousal levels

Hyper-arousal/anxious Hypo-arousal/depressed

• Poor coping/problem solving skills

Life stresses Family discord Substance abuse

Ecological factors Conditioning

• Arousal/excitement
• Cognitive schemas

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Pathw ay 2 Problem Gam blers

Vulnerability factors

• Childhood disturbance
• Personality
• Optimal levels of arousal
• Poor coping/problem solving

skills

Ecological factors Conditioning

• Arousal/excitement
• Cognitive schemas

Pathological gambling: Emotional escape Excitement

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Clinical Characteristics: Pathw ay 2 Problem Gam blers

Demographics:

• Dysfunctional/traumatic childhood, family
• Situational stresses
• Poor coping skills

Psychopathology:

• Moderate psychopathology: neuroticism,

depression

• Gambling & substance abuse = emotional escape

from aversive states of anxiety and/or depression

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I dentifying Pathw ay 2 Gam blers

• Screen for depression, anxiety, personality
• factors. Identify moderate pathology unrelated to

gambling problems.

• Perform psychosocial assessment. Identify

family pathology, issues of neglect, abuse, grief, loss.

• Assess social support and stress-coping
• strategies. Identify lack of social or

environmental support, maladaptive coping strategies.

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Treating Gam blers in Pathw ay 2

• Cognitive-behavioral therapy.
• Confront denial.
• Address issues of comorbidity (addiction, mental

health).

• Use supportive therapy to heal losses and

address family issues.

• Teach adaptive stress-coping styles and

problem-solving strategies.

• Refer for psych eval. if appropriate.
• Conduct lethality assessment.

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Pathw ay 3 Problem Gam blers

Ecological Factors Vulnerability factors Conditioning

• Arousal/excitement
• Cognitive schemas

Differential reward/punishment system

Associated behaviours Criminality, substance abuse, impaired relationships Problem Gambling

Biological Correlates

Biochemical

• Serotonergic
• Noradrenergic
• Dopamine

Cortical

• EEG differentials

Neuropsychological

• Impulsivity

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Clinical Characteristics: Pathw ay 3 Problem Gam blers

Demographics:

• Age: early onset problem gambling
• Early history of family instability, abuse

and/ or neglect

• High levels of impulsivity, anti-social

behavior Psychopathology

• Elevated levels of psychopathology
• Substance abuse
• ADHD symptoms prominent
• Broad spectrum of criminal behaviors

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I dentifying Pathw ay 3 Gam blers

• Screen for depression, anxiety, personality
• factors. Identify severe pathology

(personality, impulsivity, sensation- seeking, criminality).

• Perform psychosocial assessment. Identify

severe family pathology, issues of neglect, abuse, grief, loss.

• Assess social support and stress-coping
• strategies. Identify lack of healthy social or

environmental support, maladaptive coping strategies.

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Treating Gam blers in Pathw ay 3

• Cognitive-behavioral therapy.
• Confront denial.
• Address issues of comorbidity (addiction,

mental health).

• Address fulfilment of narcissistic desires,

issues of meaning.

• Teach adaptive stress-coping styles and

problem-solving strategies.

• Refer for psych eval and med management.
• Conduct lethality assessment.

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I ntegrated Model of Pathological Gam bling

Biological correlates

Coping styles Differential reward/punishment system Pathological gambling patterns established

Phenomenology:

• Affective disturbance,

criminality, substance abuse, impaired relationships

Environment

Exposure Early wins Arousal/excitement Cognitive schemas Vulnerability factors

Blaszczynski, A. & Nower, L. (2002). A pathways model

• f problem and pathological gambling. Addiction, 97,

487-499.

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Cognitive Techniques for Treatm ent Resistant Gam blers

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Main Reasons Gam blers Resist Treatm ent:

• Denial
• Gambling for Income or

Debt Relief

• Irrational Thinking

– Biased Evaluation – “Gambler’s Fallacy” – Illusion of Control

• Misunderstanding probability

and “near miss”

• Gambling to feel important or

invisible – arousal – depression/self‐esteem

• Gambling to Provide Meaning

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Types of Resistance

• Active:

Client is involuntary and refuses to participate in words or actions.

• Passive:

Client says s/ he wants help but fails to complete assignments or progress toward abstinence.

• Combination: Client verbally suggests cognitive

breakthroughs and completes assignments but continues to gamble.

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Denial

• Client denies:

– To continue gambling – To avoid confronting hopelessness – To avoid loss of an activity that provides excitement and escape

• Counselor should:

– Request financial documentation – Explore monitored and controlled gambling – Request client keep cognitive rating of gambling situations log

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Financial Planning

• Detail all expected income and expenses

– List income, living expenses, transportation expenses, food, childcare, education, medical miscellaneous

• Detail all amounts owed to family, friends, loan

sharks, bookies, etc. – Resist gambler’s attempts to differentiate among debtors

• Establish a budget

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Controlled Gam bling?

• Controlled Gambling = limits on the

amount and time spent gambling

• Appropriate first step for gamblers in

denial

• Require specific amount and time per

week allowed

• Agree that success or failure determines

feasibility

• Solicit an outside monitor (spouse,

friend)

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Gam bling for I ncom e

• Client believes

gam bling:

– Is an easy way to make money – Is an income- generator rather than a form of entertainment – Will provide status and power lacking in client’s life

• Counselor should:

– Refer to financial record for objective view of “income” earned – Equate gambling with other forms of entertainment – Address issues of power and control in client’s life

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Gam bling for Debt Relief

• Client believes

gam bling:

– Will solve ever- increasing money problems – Will make gambler a “hero” rather than a failure with family – Will provide quick fix for consequences of impulsivity and poor planning

• Counselor should:

– Keep list of actual wins/ losses and challenge client’s perception based on actual percentages – Require client to formulate weekly debt repayment plan – Require client to establish a weekly savings plan

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ADDRESSING IRRATIONAL THINKING

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Biased Evaluation

• Client tends to:

– Explain away losses and attribute winnings to skill, luck or a working system – Believe his/ her system is rational,

• bjective and

predictable

• Counselor

should:

– Identify the system and

• bjective ways to

test it – Point out subjective determinants, relying on uncontrollable factors

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Gam bler’s Fallacy

• Client believes:

– “The more I lose the better chance I have

• f winning”

– Random events are somehow un- random – Past experience should guide future successes

• Counselor should:

– Explain the reality of “randomness” – Discuss irrational superstitions – Educate client on the actualities of how machines work and the realities of probability and odds

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I llusion of Control

• Client believes:

– He or she somehow has a “magical power” to control the gambling

• utcome
• Counselor should:

– Educate on the notion

• f randomness: all

events are independent and, therefore, uncontrollable – Address issues of loss and control in client’s life (list of losses)

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PROBABI LI TY AND NEAR MI SS

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Educate the Client

• Learn probabilities/ odds for various

games

• Understand the workings of machines and

why a “near miss” is really just a miss.

• Demonstrate the “unconnectedness” of

random events.

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GAMBLI NG TO FEEL I MPORTANT

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• Client m ay:

– Equate winning with being a “winner” – Gamble for arousal

• Counselor should:

– Address feelings of unimportance – Foster esteem-building – Address dysfunctional core beliefs – Teach progressive relaxation, imaginal desensitization WIN

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Gambling to Feel Invisible

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• Client seeks:

– Escape from pain, loss, boredom – Dissociative experience

• Counselor should:

– Conduct lethality assessment – Refer for psych eval. & med management, med check-up – Teach active, problem- focused stress coping skills

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GAMBLI NG FOR MEANI NG

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Logotherapy

• Client:

– Seeks to supplement meaning in life through gambling – Lacks healthy priorities.

• Counselor should:

– Assign Man’s Search for Meaning (Frankl) – Identify personal meaning – Explore issues of spirituality and transcendence that contradict the gambler’s desire to “play God”

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Conclusion

There is m uch m ore w ork to be done:

• To identify older adult problem gam blers in

gam ing settings and to develop targeted intervention strategies.

• To investigate the risk and resiliency

factors that aid in prevention, intervention and treatm ent efforts.

• To develop educational program s in senior

centers to address erroneous gam bling- related cognitions and other factors that lead to problem gam bling.

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email: lnower@rutgers.edu http://gambling.rutgers.edu http://www.lianower.com @KnowDice