LOOKING BEYOND HOMELESSNESS PROBLEM GAMBLING Annika Lindberg Counselling Psychologist National Problem Gambling Clin

1. LOOKING BEYOND HOMELESSNESS PROBLEM GAMBLING Annika Lindberg Counselling Psychologist National Problem Gambling Clinic Jenny Dreyer Deputy Manager, Outreach Team Connection at St Martin’s

2. What assumptions might we make about the reasons this person is homeless?

3. Content • Facts about gambling • Gambling within the homeless population • The progression of a gambling problem • CBT for problem gambling • Support for problem gamblers

4. Diagnostic criteria DSM-IV Pathological Gambling Impulsive-Control Disorder category What do we mean by Impulsive-Control Disorder? • Failure to resist impulses, drives or temptations to perform an act of potential harm • Works to relieve prior tension and arousal, or experience pleasure and gratification • May follow with feelings of regret and guilt after the act

5. Persistent and recurrent maladaptive gambling behaviour as indicated by 5 (or more) of: • Preoccupation with gambling activities • Gambling with increasingly larger amounts of money • Repeated unsuccessful attempts to stop • Restlessness or irritability in doing so • Gambling to escape from problems or lift mood • ‘Chasing’ losses – returning to try to win back money lost • Concealing extent to which they have gambled • Relying on others to help solve financial problems caused by gambling • Committing illegal acts to finance gambling • Jeopardising relationships/social/occupational opportunities & housing

6. Gambling in the UK British Gambling Prevalence Survey 2010 as measured by DSM-IV - 73% of the population gambled in the previous year (up 5% from 2007) - Estimated prevalence of 0.9% problem gamblers (up .3% from 2007) = 451,000 adult problem gamblers in UK - men twice as likely to be PG than women(APA, 1987; Cunningham-Williams et al, 1998; Welte et al, 2002) Studies indicate that the prevalence of problem gamblers amongst the homeless could be as high as ~20% (Nower, 2007; Schaffer et al 2002; Talbot, 2002)

7. The psychoeconomics of gambling from a homeless perspective • Homelessness provides a social setting in which opportunities for healthier psychosocial reinforcement are limited, allowing lesser reinforcers, e.g. Gambling and intoxicants to gain greater strength (Skinner, 1969) • People in poverty, e.g. the homeless, may perceive greater potential to change their lives from a gambling win than those who are better off • There are greater financial demands and fewer financial resources and fewer buffers • The importance of pleasurable activities

8. Gambling problems often go undetected and the homeless are no different in this respect Nondisclosure due to shame, stigma; fear of being judged by service providers - that access to housing may be withheld Lack of awareness of available help considered to be the ‘least of their [multiple] problems’ (Holdsworth, 2012)

9. Visible and ‘invisible’ support needs Comorbid substance misuse issues - 80% among homeless population; 40% among problem gamblers (Nower, 2008) Comorbid mental health issues in particular depression/anxiety are an issue associated with problematic gambling; biploar and antisocial PD - Suicidality:49% treatment-seekers had SI or attempts (Petry et al, 2002) Physical disability and health issues

10. How to spot a gambling problem The following may indicate a gambling issue, especially where other support needs do not account for the client’s presentation ‘Secretiveness’ or a reluctance to freely disclose ‘more private’ information (Holdsworth, 2012) Unexplained history of abandonment or evictions due to service charge arrears Missing hostel payments/accrue service charge arrears Large debts ‘Living on the streets’ whilst in employment (e.g. to pay off debts) Association with other known gamblers Sleeping in close proximity with betting shops Pre-occupation with money/obtaining money Persistent borrowing money from others Moodiness, irritability and/orappearing absent-minded and distracted

11. A downward spiral accompanied by ‘implausible explanations’

12. Screening and Assessment Given the high prevalence of problematic gambling in this population there is an urgent need to integrate gambling screening into assessment paperwork. Move from ‘tick box’ to exploratory questioning: In the past 12 months, how often have you bet more than you could afford to lose? Never (0), sometimes (1), most of the time (2), almost always (3)

13. Canadian Problem Gambling Index 2. How often have you needed to gamble with larger amounts of money to get the same feeling of excitement? 3. How often have you gone back another day to try to win back the money you lost? 4. How often have you borrowed money or sold anything or get money to gamble? 5. How often have you felt that you might have a problem with gambling?

14. CPGI cont… 6. How often have people criticized your betting, or told you that you had a gambling problem, regardless of where or not you thought it was true? 7. How often have you felt guilty about the way you gamble or what happens when you gamble? 8. How often has your gambling caused you any health problems, including stress of anxiety? 9. How often has you gambling caused any financial problems for you or your household? A score of 8+ is categorised as a Problem Gambler

15. Types of Gamblers

16. Types of gamblers Pathways Model (Blaszczynski and Nower, 2002) 1. Behaviourally conditioned May be chance entry, no significant co-morbidity Low end of PG continuum, prey to conditioning effects 2. Emotionally vulnerable Negative family backgrounds, life events, developmental Low self-esteem and emotional escape though gambling 3. Anti-social/Impulsive Wider range of behavioural problems, negative emotions interpersonal difficulties, poly-drug, criminality

17. How does the homeless problem gambler differ from our ‘typical’ problem gambler? • Disadvantaged in multiple ways: many homeless people have history of broken families and being in care = less social support and fewer resources, as well as often having multiple support needs • Negative self identity • Poorer coping skills – often longer standing problems with gambling • ‘Nothing to do, nowhere to go’: More time on their hands – more time to gamble and fewer distractions • Less money- more stress from accumulated financial stressors

18. Progression of a problem • In order to understand the progression of a gambling problem, 4 phases have been identified. Please note that these phases are not established in research however are popular among clinicians and patients since they make it possible for gamblers to identify in the descriptions. The winning phase: • Gambling is enjoyable and social. • Gambling is a great way of relieving stress or other negative emotions. • The gambler feels great and powerful, and often begins to form irrational beliefs about how likely they are to win, or how much control they have over the game in which they are gambling. • Still very few negative consequences of gambling.

19. The losing phase: • ceased preoccupation with gambling. • Bets increase in size, losses are rationalized e.g. ‘I can afford to lose this amount’. • Losses become larger and/or more frequent. • The desperation phase: • Increased psychiatric symptoms e.g. insomnia, anxiety, depression and/or mood swings, anger outbursts and avoidance. People in this phase can sometimes be mistaken for bipolar disorder patients. • Gambling becomes increasingly erratic and disorganized. • Eating habits become poorer. • Social life decreases and the gambler becomes more isolated. • Gamblers at this stage often start resorting to criminal behaviour to fund their habits, having exhausted all other options. • The gambler might start to identify their gambling as a problem, and will increasingly start identifying themselves as gamblers.

20. The hopelessness phase: Sense of hopelessness, the gambler may have made substantial losses e.g. close relationships, large amounts of money, house, car, job etc. Homelessness and malnutrition. Still chasing losses. Increasingly depressed mood, often accompanied with suicidal thoughts, ideation and even attempts. *Gamblers usually seek help during the 3rd and 4th phase. The time it takes for a gambler to progress can vary greatly depending on the type of gambling the individual engages in and several other factors*

21. Gamblers seen at CNWL • number of referrals to date since 2009 approximately 1500 • Increasing numbers of referrals all the time • Significantly higher problem gambling incidence within the homeless population!

22. Treatment and the clinic • Assessment • Group vs individualtreatment • Support for familymembers • Helpwithmoney management • Aftercare

23. Psychological treatments: CBT Gooding and Tarrier 2009 - Systematic review and meta-analysis of CB interventions 25 studies overall - immediate & follow-up 1078 had pre and immediate post scores 0-3 month overall effect size 0.72; 6month 0.56 Abstinence 0-3mnth = 1.87; more effective with males No difference in individual / group CBT outcomes ‘robust short term effects which do endure’ ‘cautious optimism’

24. CBT models Robert Ladouceur Earlier RCTs in Canada, strong cognitive correction element 2001 RCT- up to 20 sessions (avg.11); 2007 self-help workbook Nancy Petry Cognitive-behavioural programme, 8 session manualised Contingency management element, 2006 RCT Tian Oei Cognitive-behavioural programme with therapist manual 2010 RCT 6 x 2hourly sessions; Manual = 10 session with electives

25. Models comparison

26. What is in CBT for problem gambling psycho-education cognitive restructuring modification of gambling cognitive errors analysis of triggers and risk situations acquisition of coping skills assertiveness training Problem solving training Social skills training Communication training Imaginal desensitisation In-vivo exposure to gambling situations and response prevention Stimulus control Self-reinforcement Aversion therapy Relaxation Alternative or pleasurable activity planning Motivational interviewing (MI).

27. Support for problem gamblers Gamblers Anonymous: 0207 384 3040; www.gamblersanonymous.co.uk GamAnon (for loved ones): 0870 050 8880; www.gamanon.co.uk GamCare, nationwide counselling support & online forum: 0808 802 0133; www.gamcare.co.uk Gordon Moody Association; 01384 241 292; www.gordonmoody.org.uk CNWL National Problem Gambling Clinic; see contact details on last slide

28. Homeless Problem Gambler PilotAssessing the local need: All commissioned rough sleeping services in Westminster were invited to an awareness raising session delivered by NPGC A large client group was asked the screening question “how often have you bet more than you could afford to lose” Rates of problematic gambling within London homeless population appear significantly increased, as seen in homeless populations elsewhere

29. Identifying what kind of help clients want Ask them! Not every problem gambler scoring high on the PGSI wanted help or the type of help available 1:1 vs group therapy or ‘workshops’ (availability and costs will limit access to 1:1)

30. A joint effort Traditional and existing services may need support of a worker with knowledge and experience in working with rough sleepers Homeless clients attending the pilot workshops appeared: To have lower levels of intrinsic motivation To be more ‘contemplative’ about change Require a more flexible and encouraging approach, e.g. less strict about attendance, utilising contingency management

31. Lessons learned Awareness raising sessions are important in helping problematic gamblers to self-identify and have the confidence to seek help Clients should be more comprehensively assessed as individuals prior to beginning attendance at the workshop Risk assessments may highlight other unknown support needs, e.g. suicidality Assess for suitability for groupwork (e.g. clients with untreated comorbid SMI or substance misuse issues may not be appropriate) Allows client opportunity to share individual life experience to avoid ‘spillage’ in group sessions Allows opportunity to explain how group is conducted and expectations

32. Lessons learned, cont… Contingency Management Within addiction services, contingency management or systematically rewarding desired behaviours, e.g. attendance of workshops, is recognised as effective – vouchers vs rewards systems. Accountability Many clients with long history of rough sleeping may benefit from an increased sense of ‘accountability’ – explore ways that the group can help each other to increase attendance and participation Identify ‘gambling’ champions

33. Exercise • Howcanyour organisation screen for gambling problems? • Howcouldyour organisation support individualsidentifiedwith gambling problems?

34. References • Nower, L. (2007). Problem Gambling and Homelessness: Results from an Epidemiological Study. Retrieved from: https://apha.confex.com/apha/135am/techprogram/paper_155376.htm • Schaffer, H., Freed, C., & Healea, D. (2002). Gambling Disorders Among Persons with Substance Use Disorders Seeking Treatment at a Community Centre. Psychiatric Services, 5:9. Retrieved from: http://ps.psychiatryonline.org/article.aspx?articleid=180399 • Talbot, C. (2002). Gambling and homelessness: A Case Management Resource. Adelaide, Uniting Care. Retrieved from: http://www.austgamingcouncil.org.au/images/pdf/eLibrary/2760.pdf

35. Further reading Pathological gambling: etiology, comorbidity and treatment. Nancy Petry, 2005 A cognitive-behavioural therapy programme for problem gambling: Therapist manual Raylu and Oei, 2010 Overcoming Your Pathological Gambling Robert Ladouceur & Stella Lachance. 2007 Overcoming Compulsive Gambling Alex Blacszczynski, 1998

36. Contacts Annika Lindberg Counselling Psychologist National Problem Gambling Clinic 4th Floor, Soho Centre for Health and Care 1 Frith Street London W1D 3HZ E-mail: gambling.cnwl@nhs.net Phone: 020 7534 6699 Fax: 020 7534 6700

37. Contacts Jenny Dreyer Deputy Manager, Outreach – Building Based Services Team Connection at St Martins 12 Adelaide St London WC2N 4HW E-mail: jenny.dreyer@cstm.org.uk Phone: 020 7925 7895