by Tony Toneatto
Although valid assessment has played a central role in treatment planning for other addictive disorders, it has not received much attention in the area of gambling treatment, and few validated questionnaires of key gambling variables are available. Most treating professionals have relied on informal or site-specific “home-grown” methods, often extrapolated from successful strategies for substance abuse.
The purpose of this section is to discuss the components of an assessment strategy for problem gambling — the human and time resources available in a specific clinical setting at which a client has sought treatment, the skills and needs of the treating professional and the needs of the client. Since no standard assessment process exists yet, each treatment site or treatment professional must individualize the process with the resources available.
The major elements of problem gambling assessment to be discussed include defining problem gambling, describing the characteristics of the gambling behaviour, assessing the consequences of problem gambling, describing the context within which gambling behaviour occurs, assessing substance use and psychiatric history and treatment-relevant assessment.
Screening for Gambling-Related Problems
If an individual seeks treatment for problem gambling it is usually a reliable sign that the gambling behaviour has become problematic. However, in many cases, the individual may not be aware of the presence of a (potential) gambling problem and may have it identified by others. Descriptions and elaborations of the two instruments primarily used to assess problem gambling, the SOGS and DSM-IV, as well as the NODS, the SOGS-RA and the GA Twenty Questions, can be found in Definitions and Prevalence of gambling and Problem Gambling. Recently, the Diagnostic Interview for Gambling Severity (Winters, Specker & Stinchfield, 1997) has been developed that includes 21 items related to the DSM-IV criteria. There is evidence for good reliability and validity for this instrument but it has not yet been used as a screening instrument to identify people affected by problem gambling within the general population.
Most treatment settings will likely adapt the intake procedures that they use for their other clientele to individuals who are screened with a gambling problem. This should be encouraged as it will allow other information necessary to make the correct treatment decisions to be assessed. In the case of people affected by problem gambling, it may be important to conduct a preliminary telephone assessment when the individual contacts the treatment centre to ascertain the nature of the gambling problem, to evaluate the presence of concurrent psychosocial crises (e.g., suicidality, psychiatric crisis, homelessness, violence potential, immediate financial crisis), and to decide if the treatment centre can effectively address the clinical needs of the client. For example, unless the treatment centre is equipped with a psychiatric crisis unit, a suicidal problem gambler who is looking for treatment will likely need to be referred to a psychiatric unit. The telephone intake should be followed by face-to-face contact as soon as possible to avoid dissipating the client’s motivation.
At the initial face-to-face assessment, additional issues relevant to people affected by problem gambling need to be considered, especially their tendency, possibly more than other clinical populations, to not return for a follow-up appointment. This leads to at least three specialized aspects of the intake process for people affected by problem gambling. First, the intake process should strongly emphasize engagement and every effort made to help the client feel comfortable, in control of the treatment process (e.g., treatment goals should not be imposed), and hopeful about change. Ambivalence about change should be acknowledged and normalized. Second, useful, take-home clinical tools should be provided with the client should he or she decide not to return. These may take the form of clinical materials and readings, pamphlets, self-monitoring booklets, etc. Third, several, if possible, contact numbers should be obtained from the client to make follow-up as effective as possible. This may include offering telephone contacts as a form of treatment should the client not return for additional treatment. Thus, the intake process will include all the elements that would apply for any individual seeking help, along with the above additions that respond to the treatment-interfering ambivalence and anxiety the problem gambler may have about change.
Describing the Gambling Behaviour
Types of gambling activity
Once there is sufficient reason to believe that there is a gambling problem (whether identified subjectively or as indicated on the clinical measures discussed above), a description of the gambling is necessary. Key questions should determine the gambling behaviours that the client engages in, including the behaviours that have created the most problems for the client and for which he or she is seeking treatment. It is also useful to assess gambling activities that the client does not perceive to be a problem: informal or non-traditional types of gambling such as real-estate speculation, culture specific gambling behaviours, and casual betting between friends.
The frequency of gambling and the quantity of money that the client wins or loses each time he or she gambles should also be assessed. This is equivalent to the quantity-frequency assessment that is conducted with alcohol or drug use. Frequency is usually measured in times per day, week or month that the gambling activity occurs. Frequency information may be made more useful by inquiring about both the duration of each gambling episode and the time devoted to preparing to gamble. Lottery tickets are an example of a behaviour that may be frequent (e.g., daily), very brief (e.g., only seconds to purchase a ticket) but where the individual may spend hours trying to identify winning numbers. Racetrack bettors who pore over racing forms is another example of gambling-related activity that should be measured. Any or all of these three dimensions of the gambling behaviour can be problematic (i.e., gambling too often, for too long and spending too much time in preparation).
The quantity of money that the individual loses as a result of gambling should also be assessed. There are many ways to assess financial loss that take into account amounts wagered and amounts lost. This can be measured per each episode of gambling (usually a rough average), over a period of time (e.g., past year), or since the gambling problem began. This information can also be assessed to determine whether losses have been intensifying, the total accumulation of losses, and the ratio of loss to disposable income available. Since most people affected by problem gambling may not keep reliable records, the value of this assessment lies in helping the client engage in treatment. However, it is important to assess the client’s current financial status (some of which will be directly related to gambling behaviour) because the services of other professionals may need to be involved to help the client deal with poor money management, debt, creditors, etc. The finance chapter (Section 5.2) by Nick Rupcich provides an excellent overview of the potential financial issues facing the problem gambler.
Counsellors must also assess the possibility of tolerance and withdrawal. Tolerance refers to the decrease in excitement or reward value that occurs if the amount of money risked or the frequency of gambling is not increased. Withdrawal refers to a psychobiological reaction that occurs when gambling does not take place when it is desired or expected to. Typical withdrawal reactions include irritability, anxiety and general agitation. It is more difficult to specify the cause of tolerance and withdrawal in the case of problem gambling than in substance dependencies, but it may involve adaptation responses on a perceptual level.
Assessing Gambling Consequences
Most individuals seeking treatment will report multiple undesirable consequences linked to their gambling. These must be assessed in order to provide the life context in which to understand the client’s help-seeking and also to provide a measure of the impact of gambling on his or her life and the potential actions that may be needed to help this individual once the gambling problem has been addressed. The categories of consequences tend to be similar across addictions and include financial distress, strained interpersonal relationships, emotional consequences (e.g., guilt, depression), legal consequences (e.g., charged with theft, cheque fraud) and health effects (e.g., insomnia, muscle tension, headaches). Discussing these effects also has a motivational significance because they provide a survey of important values that have been threatened by the gambling behaviour. Instruments such as the sogs or dsm-iv diagnoses distil these negative consequences into a measure of severity, but they can’t provide detailed descriptions of such consequences. It is also important to assess the client’s perception of positive consequences such as avoidance of a stressful family situation and desirable social interaction. See the case study in Solution-Focused Brief Therapy for further discussion of client-perceived positive consequences.
Where feasible, it may be helpful to include significant others in this assessment to obtain a complete survey of the difficulties that problem gambling has produced. In addition, it may help the treating professional identify treatment needs of significant others, especially spouses and children, who may require clinical attention.
Context of Gambling Behaviour
In addition to describing the gambling behaviour and its effects on clients’ lives, it is also therapeutically meaningful to understand the context within which the gambling behaviour occurs. This context can have environmental, cognitive, affective and interpersonal aspects. By specifying the unique context of gambling for each individual an individualized treatment and relapse prevention plan can be formulated.
Specific environmental variables related to gambling include proximity to or presence in situations where gambling is occurring (e.g., casinos, lottery kiosks, racetracks), exposure to advertisements or other promotions that can act as stimuli to gambling, or availability of or access to money or credit necessary to gamble. Many of these, and other types of high-risk situations, can be assessed with the Inventory of Gambling Situations (igs; Littman-Sharp & Stirpe, 1999). The igs provides a unique advantage to the therapist in assessing situations that the client may not have considered but which are highly relevant to treatment. Simply asking about the environmental context of gambling may not yield a complete overview of the triggers to gambling behaviour.
Beliefs the gambler has about the probability of winning, assumptions about his or her ability to control or predict gambling outcomes, attributional processes that are applied to explain wins or losses, beliefs about luck and skill, and metacognitive beliefs about the gambler’s ability to gamble successfully are examples of the cognitive context that can influence gambling behaviour. Many of these beliefs are assessed by the Gambling Cognition Questionnaire (Toneatto, 1999). Since clients may have insufficient insight early in treatment into the kinds of cognitive processes associated with their gambling behaviour, assessing such distortions using formal tests is highly recommended in order to obtain a clinically useful perspective of the client’s gambling-related mental processes.
For many people affected by problem gambling, gambling is more likely to occur in specific emotional situations. In this sense, gambling acts as a mood regulator and mimics the effect that psychoactive substances can have on negative emotional states. This type of gambling is often termed “escape” gambling and is seen to be a symptom of difficulty coping with emotions. Common emotional contexts for gambling include depression, anxiety, tension, loneliness and boredom. Many of these high-risk emotional triggers are assessed by the Inventory of Gambling Situations (Littman-Sharp & Stirpe, 1999).
The interpersonal context of gambling can include the social variables that are more likely to lead to gambling (e.g., friends or family who gamble; group norms that validate gambling behaviour, peer pressure) and interpersonal interactions that make gambling a more likely response (e.g., conflict with others). Cultural expectations may also be a potent context for gambling for some individuals that should be evaluated (see Issues and Populations ). Again, many of these high-risk emotional triggers are assessed by the Inventory of Gambling Situations (Littman-Sharp & Stirpe, 1999). If the family or other significant others are to be included in treatment (based on their mutual consent), then including these individuals in the assessment process may be highly fruitful as this will highlight the social context of the gambling behaviour, identify interpersonal triggers to gambling, and highlight strengths and weaknesses of these relationships that can be useful in treatment planning.
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