Tony Toneatto
In addition to measuring gambling-related variables, a comprehensive assessment should also measure several other factors that may influence gambling behaviour. Two important variables believed to interact with problem gambling, substance use/abuse and psychiatric history, will be discussed.
Substance use/abuse
Alcohol or drug abuse may predate or develop concurrently with the gambling problem. Furthermore, substance misuse may become a substitute for problem gambling and vice versa, one becoming an escape from the other. Substitution responses are found among both men and women. It is important to evaluate the severity of substance misuse in order to determine whether treatment for this issue is required. If the substance abuse is directly functionally related to the gambling behaviour (e.g., drug use only occurring after a gambling episode), addressing the gambling problem may ameliorate the drug consumption. However, if substance abuse does not change as a result of gambling reduction, precedes gambling episodes, or appears to be independent of the gambling problem, then the substance abuse may be needed to be treated separately. The Alcohol Use Disorder Identification Test (audit; Saunders, 1993), the Alcohol Dependence Scale (Skinner & Allan, 1982) or the Drug Abuse Screening Test (dast; Skinner, 1982) are rapid ways of assessing the severity of alcohol or drug use, respectively.
Psychiatric symptoms
If the emotional consequences associated with gambling are judged to be severe, it is necessary to assess if psychiatric symptoms existed before problem gambling behaviour and it may be useful to assess these separately. Since anxiety and depression are the most likely symptoms to manifest in treatment- seeking people affected by problem gambling, it is important to evaluate whether these symptoms require referral to a psychiatrist. This will be necessary if the symptoms do not improve as a result of reductions in gambling, have become associated with alcohol or drug abuse, have led to suicidality, or are sufficiently intense to make engagement into treatment for gambling difficult. Rapidly assessing the severity of anxiety and depression symptoms can be accomplished using the self-administered Beck Anxiety Inventory (Beck, 1961) and the Beck Depression Inventory (Beck & Steer, 1987), respectively. The Hamilton scales for Depression or Anxiety are clinician-administered and should only be used by counsellors who feel comfortable that they can observe the clinical criteria of depression and anxiety. The Symptom Checklist-90 (Derogatis, 1977) is a rapid way to screen for these and other types of psychiatric symptoms if it is suspected that there may be psychotic symptoms, hostility or somatic concerns. High scores on these measures indicate a referral to a psychologist or psychiatrist may be necessary.
In addition, suspicion that the gambler may be suffering from a major mental illness (e.g., schizophrenia, bipolar disorder, delusional disorder) should also elicit a referral to a psychiatrist. A history of psychiatric treatment, a family psychiatric history, and a childhood diagnosis of attentional, hyperactivity or conduct disorders should be assessed since additional treatment may be indicated and also provide some information about the function of the gambling behaviour in the individual’s overall life context. (Refer to , “ Special Treatment Issues: Concurrent Disorders ,” for a detailed examination of psychiatric disorders and problem gambling.) While practitioners who are neither physicians nor psychologists are not permitted to diagnose psychiatric disorders, assessing psychiatric symptomatology should be a routine component of any counsellor’s assessment approach. Unless the counsellor is unfamiliar with psychopathology (in which case a close relationship with other professionals to consult with should be developed), the assessment of anxiety and depression will aid in the proper treatment plan for the client. Clients who report an extensive psychiatric history (including medication management), psychiatric hospitalizations, or previous psychotic episodes need to have the appropriate mental health professionals involved early and as an integral component of the treatment team, since the gambling behaviour may represent only one aspect of a much more complicated clinical profile.
Treatment-Related Assessment
Two treatment-related variables will be discussed — goal assessment and motivational assessment — since these will have an impact on the nature and course of treatment. These issues are often raised in the assessment and treatment of chemical addictions as well.
Goal assessment
As is the case with substance abuse, individuals will differ in the goal they work toward in treatment. While it is probably advisable for all clients to refrain completely from all gambling initially to allow a period of relief from the gambling-related consequences, not all clients will agree. In addition, many individuals may wish to gamble at a reduced level even following a period of not gambling. Furthermore, the client may intend to gamble on games that he or she does not believe he or she has a problem with (e.g., a racetrack problem gambler who continues to play the weekly lotteries). Thus, it is important to be aware of the intention to gamble at a reduced level and whether or not other forms of gambling will continue, since they will affect the specific interventions that will be implemented.
Motivational assessment
It is likely that most gamblers will be seeking treatment with some degree of ambivalence. To evaluate the strength of the client’s motivation, being aware of the negative consequences of gambling or the benefits of not gambling are not sufficient. While they may be acutely aware of gambling-related problems and the benefit of stopping, clients may continue to value the positive aspects of gambling (e.g., excitement, potential of winning money) and the disadvantages of not gambling (e.g., boredom, loneliness). At the present time there are no validated measures of motivational status among people affected by problem gambling although Toneatto (in preparation) is currently validating a potential assessment measure. Nevertheless, there are multiple meaningful indicators of motivational conflict that can help raise clinicians’ awareness of the potential of motivational threats to treatment engagement and progress. These include minimizing the effects of the gambling behaviour on the client or their significant others, plans to resume gambling, beliefs that systems of winning exist, social contexts that encourage gambling (e.g., friends, entertainment), desire to delay making changes to their gambling behaviour, and feelings that a non-gambling lifestyle is devoid of satisfaction, contentment or meaning. This type of client is likely quite ambivalent about stopping gambling, which may express itself in the form of relapses, inconsistent attendance, minimal behaviour change, or premature dropout from treatment. (See “Motivational Interviewing,” in The Therapeutic Framework ).
Individuals interested in using the instruments mentioned in this chapter that are not included in the Appendix A of this manual, should contact the authors to receive information on how to use the instrument and interpret the results.
References
Beck, A.T.,Ward, C.H. Mendelson, M., Mock, J. & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571.
Beck, A.T., Epstein, N., Brown, G. & Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897.
Derevensky. J. & Gupta, R. (1997). Prevalence estimates of adolescent gambling: A comparison of the SOGS-RA, DSM-IV-J, and the GA 20 Questions. Paper presented at the 10th International Conference on Gambling and Risk-Taking, Montreal.
Derogatis, L.R. (1077). scl-90: Administration, Scoring and Procedures Manual-I for the Revised Version and other Instruments of the Psychopathology Rating Scale Series. Baltimore: Clinical Psychometrics Research Unit, Johns Hopkins University School of Medicine.
Report to the National Gambling Impact Study Commission. (1999). Chicago: National Opinion Research Center.
Shaffer, H.J., Hall, M.N. & Vander Bilt, J. (1997). Estimating Prevalence of Disordered Gambling Behaviour in the United States and Canada: A Metaanalysis. Harvard Medical School Division on Addictions: Boston.
Toneatto, T. (in press). Reliability and validity of the Gamblers Anonymous Twenty Questions. Journal of Gambling Studies.
Toneatto, T. (1999). Gambling Cognition Questionnaire. Paper presented at the 107th annual meeting of the American Psychiatric Association, Boston.
Ursua, M.P. & Uribelarrea, L.L. (1998). 20 questions of Gamblers Anonymous: A psychometric study with population of Spain. Journal of Gambling Studies,14, 3-15.
Winters, K.C., Stinchfield, R. & Fulkerson, J. (1993). Patterns and characteristics of adolescent gambling. Journal of Gambling Studies, 9 (4), 371.
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