Developed by: Sachin J. Karnik , Ph.D., LCSW, CADC, NCGC-II, CPS Director of Prevention &

1. CULTURAL DIVERSITY IN GAMBLING AND SUBSTANCE ADDICTION: IMPLICATIONS FOR CLINICAL INTERVENTIONS AND PREVENTION PROGRAMMING Developed by: Sachin J. Karnik, Ph.D., LCSW, CADC, NCGC-II, CPS Director of Prevention & Clinical Services Delaware Council on Gambling Problems, Inc. E-Mail: sachin.karnik@dcgp.org

2. CONTACT INFORMATION SACHIN J. KARNIK, Ph.D. LCSW, LCDP, CADC, NCGC-II, CPS Director of Prevention & Clinical Services 100 West 10th Street, Suite 303 Wilmington, DE 19801 Phone: 302-655-3261 E-Mail: sachin.karnik@dcgp.org

3. OBJECTIVES • This workshop examines the nature of problems gambling in a multi-cultural context, where perspectives about gambling as related to ethnic diversity will be examined. Specifically, clinical connections will be presented, in the context of diversity, with regards to accurate diagnosis, culturally bound syndromes, and various co-occurring disorders as well as cross-addiction issues. Effective treatment approaches will be presented and small group exercises will be conducted to build practical understanding of the application of culturally sensitive practice with regards to prevention programming and treatment approaches. Also, neuro-psychological basis of cultural conditioning will be presented in the context of identification, assessment, and effective treatment of addictive disorders with an emphasis on gambling disorder. From a clinical standpoint, DSM V differential diagnostic processes as related to cultural background and the unraveling accurate etiology will be presented. Finally, implications of cultural conditioning processes in the development of prevention programs will also be examined. This workshop attempts to bridge together fragmented areas in the addictions and promote greater understanding of how culture shapes reality.

4. (PART 1) WHAT IS ADDICTION?

5. ADDICTION – TO BIND A PERSON • “Addiction; from the Latin verb ‘addicere,’ to give or bind a person to one thing or another. • Generally used in the drug field to refer to chronic, compulsive, or uncontrollable drug use, to the extent that a person (referred to as an ‘addict’) cannot or will not stop the use of some drugs. It usually implies a strong (Psychological) Dependence and (Physical) Dependence resulting in a Withdrawal Syndrome when use of the drug is stopped. • Many definitions place primary stress on psychological factors, such as loss of self-control and overpowering desires; i.e., addiction is any state in which one craves the use of a drug and uses it frequently. Others use the term as a synonym for physiological dependence; still others see it as a combination (of the two).” • GAMBLING ADDICTION • Reference: Koob, George F.; Arends, Michael A.; Le Moal, Michel. Drugs, Addiction, and the Brain (Kindle Locations 370-375). Elsevier Science. Kindle Edition.

7. MOLECULAR & CELLULAR BASIS OF ADDICTION • Addiction is a complex phenomenon with important psychological and social causes and consequences. However, at its core, it involves a biological process: • the effects of repeated exposure to a biological agent (drug) on a biological substrate (brain) over time. • Ultimately, adaptations that drug exposure elicits in individual neurons alter the functioning of those neurons, which in turn alters the functioning of the neural circuits in which those neurons operate. • This leads eventually to the complex behaviors (for example, dependence, tolerance, sensitization, and craving) that characterize an addicted state.

8. NEUROTRASMISSION • Drugs of abuse alter the way people think, feel, and behave by disrupting neurotransmission, the process of communication between brain cells. Over the past few decades, studies have established that drug dependence and addiction are features of an organic brain disease caused by drugs' cumulative impacts on neurotransmission.

9. NEUROTRANSMITTERS • A person reads. The words on the page enter the brain through the eyes and are transformed into information that is relayed, from cell to cell, to regions that process visual input and attach meaning and memory. When inside cells, the information takes the form of an electrical signal. To cross the tiny intercellular gap that separates one cell from the next, the information takes the form of a chemical signal. • The specialized chemicals that carry the signals across the intercellular gaps, or synapses, are called neurotransmitters.

10. NEUROTRANSMISSION • The ebb and flow of neurotransmitters—neurotransmission—is thus an essential feature of the brain's response to experience and the environment. To grasp the basic idea of neurotransmission, compare the brain to a computer. A computer consists of basic units (semiconductors) that are organized into circuits; it processes information by relaying electric current from unit to unit; the amount of current and its route through the circuitry determine the final output. The brain's corresponding basic units are the neurons—100 billion of them; the brain relays information from neuron to neuron using electricity and neurotransmitters; the volume of these signals and their routes through the organ determine what we perceive, think, feel, and do.

11. THE BRAIN: A LIVING ORGAN • Of course, the brain, a living organ, is much more complex and capable than any machine. Brain cells respond with greater versatility to more types of input than any semiconductor; they also can change, grow, and reconfigure their own circuits.

12. WHAT IS CULTURE? • Culture is the conceptual system developed by a community or society to structure the way people view the world. It involves a particular set of beliefs, norms, and values that influence ideas about relationships, how people live their lives, and the way people organize their world.

13. SPOKEN AND UNSPOKEN RULES • Culture is not a definable entity to which people belong or do not belong. Within a nation, race, or community, people belong to multiple cultural groups and negotiate multiple cultural expectations on a daily basis. These expectations, or cultural norms, are the spoken or unspoken rules or standards for a given group that indicate whether a certain social event or behavior is appropriate or inappropriate.

14. CULTURE AND GROUPS • The word “culture” is sometimes applied to groups formed on the basis of age, socioeconomic status, disability, sexual orientation, recovery status, common interest, or proximity. Counselors and administrators should understand that each client embraces his or her culture(s) in a unique way and that there is considerable diversity within and across races, ethnicities, and culture heritages. Other cultures and subcultures often exist within larger cultures.

18. CULTURAL BOUND SYNDROMES • DSM-IV-TR • The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes: • Name Geographical localization/populations • Running amok Malaysia, Indonesia, Philippines, Brunei, Singapore • Ataque de nervios Hispanic people as well as in the Philippines where it is known as "Nervous Breakdown" • Boufféedélirante West Africa and Haiti • Brain fag syndrome West African students • Dhat syndrome India • Falling-out, • blacking out Southern United States and Caribbean • Ghost sickness Native American • Hwabyeong Korean

19. CULTURAL BOUND SYNDROMES • Koro Chinese and Malaysian populations in southeast Asia; Assam; occasionally in West • Latah Malaysia and Indonesia • Locura Latinos in the United States and Latin America • Mal de pelea Puerto Rico • Nervios Latin America, Latinos in the United States • Evil eye Mediterranean; Hispanic populations and Ethiopia • Piblokto Arctic and subarctic Eskimo populations • Zou huorumo (Qigong psychotic reaction) Chinese • Rootwork Southern United States, Caribbean nations • Sanguedormido Portuguese populations in Cape Verde • Shenjingshuairuo Chinese • Shenkui, shen-kʼuei Chinese • Shinbyeong Korean • Spell African American, White populations in the southern United States and Ethiopia • Susto Latinos in the United States; Mexico, Central America and South America • Taijinkyofusho Japanese • Zār Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies

20. ELEVEN CRITERIA IN DSM V FOR DIAGNOSIS OF ANY SUBSTANCE USE DISORDER&LINKAGE WITH GAMBLING DISORDER CRITERIA

21. SUBSTANCE INGESTION & IMAGINATION • 1 - The individual may take the substance in larger amounts or over a longer period than was originally intended. (DSM – V) • (Ingestion, Quantity, and Time - Chemical Addiction) • 1 - Needs to gamble with increasing amounts of money in order to achieve the desired excitement. (DSM-V) • (Fascination/Imagination/Conception, Quantity, and Time – Gambling Addiction)

22. CONTROL ILLICIT DRUG USE • 2 - The individual may express a persistent desire to cut down or regulate substance use and may report multiple unsuccessful efforts to decrease or discontinue use. • Is restless or irritable when attempting to cut down or stop gambling. (DSM V) • Attempt to “regulate” gambling activity by addicted gamblers: • Desire to gambling within limits • Decision to walk away after loss limit reached is changed

23. USE-ABUSE-RECOVERY FROM EFFECTS • 3 - The individual may spend a great deal of time obtaining the substance, using the substance, or recovering from its effects. • Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). (DSM V) • Obtaining money (non-ingestion) • Energy is being used in gambling without ingestion…

24. CRAVING • 4- Craving is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. DSM V: After losing money gambling, often returns another day to get even (“chasing” one’s losses). (Craving in problem gambling with winning, losing, temporarily stopping, etc.) DSM V does NOT discuss craving in the s/s of gambling disorder explicitly. • Intense desire/urge to place bets • Euphoric Recall, selective recall, etc.

25. SOCIAL IMPAIRMENT • Recurrent substance use may result in a failure to fulfill major role obligations at work, school, or home (Criterion 5). • The individual may continue substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (Criterion 6). • Important social, occupational, or recreational activities may be given up or reduced because of substance use (Criterion 7). • The individual may withdraw from family activities and hobbies in order to use the substance. • Problem Gambling: • Lies to conceal the extent of involvement with gambling. • Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.

26. RISKY USE • This may take the form of recurrent substance use in situations in which it is physically hazardous (Criterion 8). • The individual may continue substance use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (Criterion 9). • The key issue in evaluating this criterion is not the existence of the problem, but rather the individual’s failure to abstain from using the substance despite the difficulty it is causing. • Risk in Problem Gambling

27. TOLERANCE • Tolerance (Criterion 10) is signaled by requiring a markedly increased dose of the substance to achieve the desired effect or a markedly reduced effect when the usual dose is consumed. • Tolerance is NOT discussed in the DSM V criteria for gambling disorder. • Tolerance effect in gambling….

28. WITHDRAWAL • Withdrawal (Criterion 11) is a syndrome that occurs when blood or tissue concentrations of a substance decline in an individual who had maintained prolonged heavy use of the substance. • Withdrawal in problem gambling…

29. DIVERSITY OF HUMAN DYNAMICS • An understanding of race, ethnicity, and culture (including one’s own) is necessary to appreciate the diversity of human dynamics and to treat clients effectively. • Incorporating cultural competence into treatment improves therapeutic decision-making and offers alternative ways to define and plan a treatment program firmly directed toward progress and recovery.

30. PREVENTION SCIENCE • Prevention Scienceis the application of a scientific methodology that seeks to prevent or moderate major human dysfunctions before they occur. Reference for this slide: Coie, J. D., Watt, N. F., West, S. G., Hawkins, J. D., Asarnow, J. R., Markman, H. J., Ramey, S. L., ... Long, B. (January 01, 1993). The science of prevention. A conceptual framework and some directions for a national research program. The American Psychologist, 48, 10, 1013-22.

31. PRECURSORS OF DYSFUNCTION • Regardless of the type of issue on hand, the factors that lead to the problem must be identified and addressed. Prevention research is thus focused primarily on the systematic study of these potential precursors of dysfunction, also known as risk factors; as well as components or circumstances that reduces the probability of problem development in the presence of risk, also known as protective factors.

32. PREVENTION INTERVENTIONS • Preventive interventions aim to counteract risk factors and reinforce protective factors in order to disrupt processes or situations that give rise to human or social dysfunction. • Prevention is an active process that creates and rewards conditions that lead to healthy behaviors and lifestyles. Prevention efforts target different individuals and groups with different programs, depending on their needs.

33. ORIGIN OF THE WORD “PREVENT” • Prevent comes from the Latin word praevenire. Venire means to come. Prae means before. “To come before.” • To prevent is to act in anticipation of; to act ahead of; to precede. So, prevention is the act of anticipating by action – the act of coming before.

34. PREVENTION – AN ACTIVE PROCESS • Prevention is an active process of creating conditions and personal attributes that promote the well-being of people. • Prevention Efforts: Identifying the factors which cause a condition and then reducing or eliminating them.”

35. AGENT – HOST – ENVIRONMENT(Public Health Model) • Agent is the drug or disease • Host is the body in which it resides (with its particular susceptibilities, knowledge, and attitudes) • Environment is the context in which it occurs (for example, peer pressure). To successfully prevent problem gambling (gambling disorder), it is necessary to affect all three elements.

36. PREVENTION ACCORDING TO SAMHSA • As defined by SAMHSA, “A proactive process that empowers individuals and systems to meet the challenges of life events and transitions by creating and reinforcing conditions that promote healthy behaviors and lifestyles.” (CSAP promotes six strategies to implement comprehensive prevention.)

37. CSAP’S 6 PREVENTION STRATEGIES • Information dissemination - pushing out information to create awareness about a community issue, problem or invitation to get involved is readily accomplished via social media • Education - depending on how this is done it could be a push or a pull strategy. Social learning puts the individual in the center, making our ability to get noticed and engage people even more important than ever before • Alternatives - this strategy is often focused on alternative activities in for specific populations e.g., youth.  Social media provides an alternative enabling sharing our thoughts, ideas, experiences, products, artifacts and intentions so it becomes a kind of alternative. • Problem ID & Referral - when we see problem we have a unique opportunity to provide support helping people find what they need.  A good many social media offer a way to get or give help. • Community-based Process - coalitions and providers are often engaged in the process of helping community members engage to envision a better future and a path for getting there. Social media is a way to engage, learn, share, produce and create change. • Environmental strategies - policy strategies and social media can play a role in influencing these strategies from documenting rallies in real time to sharing day-to-day conversations about these strategies as they develop. 

38. COMMISSION ON CHRONIC ILLNESS - 1957 (The traditional definition, which has been used for a broad range of prevention efforts, draws upon a classification system first proposed by the Commission on Chronic Illness in 1957.) • Primary prevention is directed at averting a potential health problem before it starts. • Secondary prevention is directed at early detection and, as appropriate, early intervention. • Tertiary prevention is directed at minimizing disability and avoiding relapse. Therefore, prevention can be thought of as taking place along a continuum.

39. IOM – CLASSIFICATION SCHEME • An alternative classification scheme for prevention, offered by Gordon in 1983. This continuum of care concept is used by the Institute of Medicine (IOM) , part of the National Academy of Sciences, to illustrate interventions needed by those at different levels of risk for substance abuse and mental health disorders. These universal , selective , and indicated prevention categories are defined and illustrated in the next few slides. The chart shows that those who have an identified problem are in need of treatment. Treatment includes screening and care for existing problems. Once standard treatment has been provided, individuals require aftercare or maintenance as part of rehabilitation and to help them remain drug-free.

40. Prevention-Treatment-Maintenance

41. UNIVERSAL PREVENTION • Universal prevention measures address an entire population (national, local, community, school, or neighborhood) with messages and programs aimed at preventing or delaying the use of alcohol, tobacco, and other drugs (and…gambling). The mission of universal prevention is to deter the onset of substance abuse by providing all individuals with the information and skills necessary to prevent the problem. The entire population is considered at risk and able to benefit from prevention programs.

43. SELECTIVE PREVENTION • Selective prevention measures target subsets of the total population that are considered at risk for substance abuse (and problem gambling) by virtue of their membership in a particular segment of the population. Examples include children of adult alcoholics, students who are failing academically, and those who live in high drug use neighborhoods. Selective prevention targets the entire subgroup, regardless of the degree of risk of any individual within the group.

44. INDICATED PREVENTION • Indicated prevention measures are designed to prevent the onset of substance abuse in individuals who do not meet the medical criteria for addiction, but who are showing early danger signs, such as falling grades and some use of alcohol and/or marijuana. The mission of indicated prevention is to identify individuals who are exhibiting early signs of substance abuse (problem gambling) and other problem behaviors and to involve them in special programs.

45. RESTORING WELLNESS

46. WHAT IS GAMBLING DISORDER IN THE DSM V?

47. GAMBLING DISORDER • An important departure from past diagnostic manuals is that the substance-related disorders chapter of the DSM V has been expanded to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.

48. DSM V: GAMBLING DISORDERSigns/Symptoms – part 1 • Persistent and recurrent maladaptive gambling behavior as indicated by five (or more) of the following: • Preoccupation: The person is preoccupied with gambling and has frequent thoughts about gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble, etc. • Tolerance: Similar to drug tolerance, the person needs to gamble with increasing amounts of money in order to achieve the desired excitement or “rush” • Loss of Control: The person has made repeated unsuccessful efforts to control, cut back, or stop gambling

49. DSM V: GAMBLING DISORDER Signs/Symptoms – part 2 • Withdrawal: The person is restless or irritable when attempting to cut down or stop gambling • Escape: The person gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g., feelings of helplessness, guilt, anxiety, depression) • Chasing: After losing money gambling, the person often returns another day to get even (“chasing” one’s losses) • Lying: Lies to family members, therapist, or others to conceal the extent of involvement with gambling

50. DSM V: GAMBLING DISORDER Signs/Symptoms – part 2 • Illegal Activity: The person has committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling (DSM IV) • Risked Relationships: The person has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling • Bailout: Relies on others, such as friends or family, to provide money to relieve a desperate financial situation caused by gambling ** The gambling behavior is not better accounted for by a Manic Episode