CLIENT EVALUATIONSCREENING, INTAKE, ASSESSMENT, AND DIAGNOSTIC CRITERIA

1

SCREENING TOOL

Determines the possibility that a condition is present

Determines the need for further evaluation

2

WHO SHOULD SCREEN FOR GAMBLING DISORDER?

Addiction service providers

Mental health service providers

Physicians (e.g., primary care and emergency medicine)

Gerontologists

Pediatricians

Educators/School Counselors

Youth community leaders

Employee Assistance Plan service providers

Veterans groups

3In short….EVERYONE!

GOALS OF SCREENING AND ASSESSMENT

Open

Open the conversation

Increase

Increase curiosity

Begin

Begin to move from pre-contemplation

Give

Give permission to talk about gambling

Begin

Begin to make connections between gambling and other major life areas

4

I can save time on theseGambling questions…That’s not why she is hereanyway

You’ve never liedAbout gambling or Wanted to spend moreMoney on it, have you?

Phew! Nobody

Cares about gambling

here!

No, that’s not a problem

PG SCREENING – WHAT OFTEN HAPPENS…

5

WHY SCREEN FOR GAMBLING DISORDER?

Evidence of high-risk of gambling problems among individuals diagnosed with substance use and mental health disorders.

Gambling Disorder may lead to financial, emotional, social, occupational, and physical harms.

As many as 10% of primary care patients report lifetime gambling disorder.

People with gambling-related problems are more likely to smoke, consume excessive amounts of caffeine, have more emergency department visits, and be obese.

Many cases of Gambling Disorder goes undetected, because of limited assessment for this problem.

Early intervention and treatment work!

6

WHY ADDRESS GAMBLING PROBLEMS IN SUD AND MH PROGRAMS?

Individuals with substance use and mental health disorders are at higher risk for having a gambling problem

Gambling (even at moderate levels) may have an adverse impact on health and treatment outcome

Unaddressed gambling and gambling problems are likely to add to treatment costs and service utilization

7

WHY ADDRESS GAMBLING PROBLEMS IN SUD AND MH PROGRAMS?

Gambling may become a sequential addiction for individuals recovering from a substance use disorder

Gambling can be a relapse risk factor

Gambling and problem gambling may exacerbate psychiatric symptoms

Relationship violence and child abuse are related to problem gambling and severely aggravated if substance use is involved.

8

HOW FREQUENTLY SHOULD YOUR CLINICIAN SCREEN YOU FOR GAMBLING?

9Could be done at: Prelim/Asmt/Intake, groups, individual sessios

Chart1

NEVER

EVERY 3 MONTHS

TWICE A YEAR

EVER YEAR

Column1

0.077

0.615

0.231

0.071

Sheet1

Column1

NEVER7.7%

EVERY 3 MONTHS61.5%

TWICE A YEAR23.1%

EVER YEAR7.1%

SCREENING BEST PRACTICES

Include brief screen on prelim/intake (and don’t expect much)

Ask questions about types of gambling activities.

Repeat screen after relationship and trust established (at treatment plan updates?)

Conduct screen in conjunction with psychoeducation on impact of gambling on recovery/problem gambling

Use a variety of screenings on same client, at different times

Screenings tend to highlight only those with more severe gambling problems, keep in mind that even those without a diagnosable gambling disorder can have many gambling-related problems that you can help them with.

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Do you gamble much? Buying a few

lottery tickets isn’t

really gambling.

No not at all

NEED FOR CLARITY AND DEFINITION IN ASKING QUESTIONS

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SCREENING -- IDEALLY

How often do you gamble? For example, buy lottery tickets, go to the casino, play cards with friends, etc.?

I don’t really gamble, but I do buy lottery tickets a few times a week and my friends and I go to the casino to celebrate our birthdays.

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TIP:1) Ask “When

was the last time you gambled?”

2) Give examples of what constitutes as gambling

SCREENING TOOLS

Brief Screens

Brief Biosocial Gambling Screen

Lie-Bet Screen

NODS-CLiP

NODS-PERC

Screening Instruments

GA 20 Questions

NORC Diagnostic Screen for Gambling Problems –Self Administered (NODS-SA): a self-assessment version of the NODS. Designed to assist individuals in evaluating whether to modify or seek help for their gambling behavior. Based on APA DSM-IV criteria.

Problem Gambling Severity Index

South Oaks Gambling Screen (SOGS)

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LIE/BET TEST JOHNSON, HAMER, NORA ET AL., 1997

2 Questions

Have you ever had to lie to people important to you about how much you gambled?

Have you ever felt the need to bet more and more money?

If you get a “yes” on either question, further assessment is needed.

“When might I use this screening?” – Great to use within another assessment, such as an SUD assessment, or when conducting a verbal screening upon first meeting a client.

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BRIEF BIOSOCIAL GAMBLING SCREEN (BBGS) GEBAUER, LABRIE & SHAFFER, 2010

3 Questions

1. During the past 12 months, have you become restless, irritable, or anxious when trying to stop/cut down on gambling? Yes No

2. During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled? Yes No

3. During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get help with living expenses from family, friends, or welfare? Yes No

A “yes” response to any single item indicates potential gambling-related problems and the need for additional evaluation.

“When might I use this screening?” – Great to add to other preliminary or intake paperwork. Can be filled out by the client. Great for use by professionals working in a non-behavioral health setting.

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NODS CLIPTOCE-GERSTEIN, GERSTEIN & VOLBERG, 2009

3 Questions

Loss of Control: Have you ever tried to stop, cut down, or control your gambling?

Lying: Have you ever lied to family members, friends or others about how much you gamble or how much money you lost on gambling?

Preoccupation: Have there been periods lasting 2 weeks or longer when you spent a lot of time thinking about your gambling experiences, or planning out future gambling ventures or bets?

Answering “yes” to one or more questions is indicative of a potential gambling problem.

“When might I use this screening?” – Great to add to other preliminary or intake paperwork. Can be filled out by the client. Great for use by professionals working in a non-behavioral health setting.

16

THE NODS-PERC VOLBERG, MUNCK & PETRY, 2008

An answer of “yes” to one or more questions indicates the need for further assessment.

4 Questions

17“When might I use this screening?” – Great to add to other preliminary or intake paperwork. Can be filled out by the client. Great for use by professionals working in a non-behavioral health setting. Great that is asks about how gambling has affected their relationships.

GA 20 QUESTIONS

18

All newcomers in GA are asked to respond to the 20 questions at their first meeting

GA 20 Questions is not a validated screening tool

Specific to gamblers

Compulsive gamblers answer yes to at least 7 of the 20 questions

May be used in conjunction with SOGS

“When might I use this screening?” – Help people prepare for something they might expect if they go to a GA meeting. Great for use in group sessions. There are also versions for “those living with a gambler”, “those who grew up with a gambler” and for teens. (See the Gam-Anon website.)

NORC

17 Questions

0 = not consistent with problematic levels of gambling

1 or 2 = consistent with mild but subclinical risk for gambling problems

3 or 4 = consistent with moderate but subclinical gambling problems

5 or higher = consistent with a likely diagnosis of pathological gambling, consistent with the diagnostic criteria of the DSM-IV

Highest score possible is 10.

19“When might I use this screening?” – Great for use in an intake or individual session, or use as a follow-up to a brief screening.

PROBLEM GAMBLING SEVERITY INDEX (PGSI)

9 Questions

Thinking about the last 12 months…1.Have you bet more than you could really afford to lose?Never = 0 Sometimes = 1 Most of the time = 2 Almost always = 3

0: Non-problem gambling

1-2: Low level of problems with few or no identified negative consequences.

3-7: Moderate level of problems leading to some negative consequences8+: Problem gambling with negative consequences and a possible loss of control

20“When might I use this screening?” – Great for use in an intake or individual session, or use as a follow-up to a brief screening.

THE SOUTH OAKS GAMBLING SCREEN SOGS

37 Questions

SOGS - the 1st validated screen for compulsive gambling

Developed by Dr. Blume & Dr. Lesieur at South Oaks Gambling Treatment Program

SOGS is copywritten to protect the items, but can be used by clinicians

Max score of 20 (some questions not counted in scoring)

Score of 5+ indicates need for assessment

21“When might I use this screening?” – Great for use prior to completing a full diagnostic assessment as a supplement to the gambling assessment.

So how do I move the client from screening to assessment?

22

Counselor

I can see from your responses on your screening (or assessment) that you were being really honest and open. That shows how motivated you are to work on your recovery.

Some of your responses about gambling suggest that gambling may have a negative effect on your recoveryand I’d like to give you some feedback and information that we can talk about. How does that sound to you?

PROVIDING FEEDBACK AND ENHANCING MOTIVATIONPROVIDE AFFIRMATION

23

TIP:3) Tell the client what the screening indicated and make a recommendation/referral for further assessment

PROVIDING FEEDBACK AND ENHANCING MOTIVATIONCounselor – “That’s great. I appreciate

your willingness to talk about an area that you haven’t thought about before and look at how it might effect your

recovery.”

Client – “OK I guess. I never really thought much about my gambling. My drinking has always been the problem that seems to get me into trouble.”

24

How else might you follow-up with a client who’s gambling screening score indicates that they need a further gambling assessment?

25

ASSESSMENT TOOL

Determines diagnosis and severity

Determines level of care

Determines other needed assessment/referrals

Sets up the treatment plan

26

“Those procedures by which a program

evaluates an individual’s strengths,

weaknesses, problems and needs,

and determines priorities

so that a treatment plan can be developed.”

(ASAM PPC-2R, p. 359)

DSM-5 DIAGNOSTIC CRITERIA FOR PATHOLOGICAL GAMBLING IN GAMBLING DISORDER

1. Preoccupation

2. Tolerance

3. Failure to Control

4. Withdrawal Symptoms

5. Escape Problems

6. Chasing Losses

7. Lies/Conceals

8. Jeopardize job, relationships, education

9. Relies on others for money

Need 4 of 9 criteria for DM-5 diagnosis

27

4-5 = Mild6-7 = Moderate8-9 = Severe

Specifiers:• Persistent• Episodic• In Early Remission• In Sustained Remission

THE ASAM CRITERIA – NEW CONTENT

Chapter 9 – “Emerging Understandings of Addiction”

Gambling Disorder

Tobacco Use Disorder

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GAMBLING PATIENT PLACEMENT CRITERIA --GPPC®

www.thegppc.com/wp-content/uploads/image/GPPC.png29

SIX DIMENSIONS OF GPPC AND ASAM

GPPC

DI: Frequency/Intensity/Duration of the Disorder

D2: Biomedical Conditions / Complications

D3: Cognitive/Behavioral/Emotional Conditions

D4: Readiness to Change

D5: Relapse or Continued Problem History/Potential

D6: Current Recovery/Living Environment

Adapted from ASAM PPC-2R (2001)

ASAM

DI: Withdrawal Potential

D2: Biomedical Conditions and Complications

D3: Emotional/Behavioral Cognitive Conditions

D4: Readiness to Change

D5: Relapse, Continued Use, or Continued Problem

D6: Recovery/Living Environment

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ASSESSMENT OUTLINE: DIMENSION 1

Potential Withdrawal symptoms from gambling (ASAM): Restlessness, Irritability, trouble sleeping, anxiety, panic attacks, headache, stomach ache

Frequency/Intensity/Duration (GPPC): When did you first start gambling and what kind?

When did you notice the gambling started to increase? What do you think caused that?

How often have you been gambling in the past year/30-90 days?

How much do you spend on average per time/week/month?

What’s the most you have ever lost? What’s the most you have ever won? What did you do with the winnings?

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ASSESSMENT OUTLINE: DIMENSION 2

Impact of gambling on:

Sleep

Nutrition

Physical Activity

Stress-related health issues

Medication compliance

32

ASSESSMENT OUTLINE: DIMENSION 3

How has gambling impacted your emotions and mental health? Any guilt or shame about your gambling or what happens when you gamble?

How has gambling impacted thoughts of suicide or other quick escapes?

What has the ripple effect been on your emotions, sleep, relationships, and productivity?

Don’t forget the basics: psychological diagnosis, medications, suicide/homicide/self-harm, trauma history, violent history, learning disabilities, TBI’s.

33

ASSESSMENT OUTLINE: DIMENSION 4

What do you enjoy most out of gambling?

What role do you see gambling playing in your future?

Do you intend to return to gambling again in the future and under what kind of conditions?

Is anyone else pressuring you to stop gambling?

If you continue to gamble, where would that lead in 5-10 years?

What consequences do you hope to avoid by NOT gambling or reducing your gambling?

To whom do you owe money?

Is anyone calling you to collect on money you owe them?

Have you committed any crimes to get money to gamble? Have you borrowed without someone’s knowledge or not paid them back?

Don’t forget the basics: legal history

34

ASSESSMENT OUTLINE: DIMENSION 5

Collect gambling hx if not already done so in D1

What are your triggers or cravings to gamble? (note: most common and high-risk triggers are a lack of money, or too much money)

Are you concerned about any other behaviors being done in an addictive manner?

How does money move through your household? How do you pay for things? (debit, credit, cash, check, etc.)

35

ASSESSMENT OUTLINE: DIMENSION 6

Factors limiting treatment options Competitiveness Cultural Identity issues (family, generational, neighborhood, ethnicity, etc.) Have you lied about or hidden your gambling from anyone? Spiritual History Involvement with formal religious groups/practices/beliefs Relationship with higher power or philosophy Value System, Meaning in Life, Feelings of Connection

Don’t forget the basics: living situation, work/school/volunteering, support system, relationships, hobbies

36

MENU OF OPTIONS

Problem Gambling Specific Treatment

Abstinence

Limited Gambling/Harm Reduction

Gambler’s Anonymous or GamAnon

Brief Interventions

37

TIP:4) Offer alternatives

to/in conjunction with traditional

treatment

They did their assessment and are ready to start treatment….sort of

38

THE NOT-SO-OBVIOUS PURPOSE OF INTAKE

“Selling” your services Why should I engage in gambling treatment?

What can you do that can help me?

Why do I have to sign so many forms?

What do you mean the family needs to be involved?

What exactly am I signing up for?

39

PRE-CONTEMPLATION TO CONTEMPLATION

Counselor: You did a great job of looking clearly at the things you enjoy about gambling, what you see as benefits, as well as some of the downsides or costs of gambling. What do you make of that?

Client: Yeah, I think I see what you are getting at. Gambling is fun, but it always seems to lead to drinking. I know how drinking is messing me up, but I never thought about the gambling.

40

ADDRESSING AMBIVALENCE

FOR THE SUD PATIENT

Counselor: I think it is really good that you are able to see both sides of what gambling is about for you. You do have fun gambling, but you can see that it also interferes with your goal of not drinking.

Client: Yeah, I just always thought it was something fun to do. I didn’t really look at the connection to my drinking.

41

TREATMENT OUTCOME AND CLIENT ATTRIBUTION OF THERAPIST CHARACTERISTICS

High On: Low On:

Empathy Blaming

Warmth Ignoring

Understanding Rejecting

Acceptance

Positive Regard

Collaboration

Successful repair of relationship ruptures

Genuiness

42

ENGAGING PROBLEM GAMBLING CLIENTS

Be familiar with the most common crises of the problem gambler

Financial conflicts – “I’m losing my house…”

Family conflicts – “My spouse is leaving me”

Despiration – “ I can’t go on like this anymore…”

Vocational conflicts – “I’m going to lose my job”

Legal conflicts – “I’m about to go to jail…”

Be ready with some problem solving strategies that emphasize engagement in the treatment process.

ENGAGING CLIENTS WITH GAMBLING ISSUES

What concrete help (menu of options) do you have for them that matches motivational level to address common problems?

Help to sort out and manage emotions

Structured problem solving

Budget and Pressure relief

Help family to understand, cope..

Local attorneys, etc.

What few items of basic client education can you offer to help each client better understand this is a disorder and help is available?

FAMILIES AND MOTIVATION

Discrepancy between family members’ stage of motivation and gambler’s stage of motivation

What is the family member motivated for?

45

Bonus Activity

1) Pair up

2) Role play – Screen each other

46

TIPS:

Before:1) Ask “When was the last

time you gambled?”2) Give examples of what

constitutes as gambling

After: 3) Tell the client what the screening indicated and make a recommendation/ referral for further assessment4) Offer alternatives to/in conjunction with traditional treatment

Client EvaluationScreening ToolWho Should Screen for Gambling Disorder?Goals of screening and assessmentPG Screening – What Often Happens…Why Screen for Gambling Disorder?Why address gambling problems in SUD and MH programs?Why address gambling problems in SUD and MH programs?HOW FREQUENTLY SHOULD YOUR CLINICIAN SCREEN YOU FOR GAMBLING?Screening Best PracticesNeed for Clarity and Definition in Asking QuestionsScreening -- IdeallyScreening ToolsLie/Bet Test Johnson, Hamer, Nora et al., 1997Brief Biosocial Gambling Screen (BBGS) Gebauer, LaBrie & Shaffer, 2010NODS CLiP�Toce-Gerstein, Gerstein & Volberg, 2009The NODS-PERC Volberg, Munck & Petry, 2008GA 20 QuestionsNORCProblem Gambling Severity Index (PGSI)The South Oaks Gambling Screen SOGSSlide Number 22Providing Feedback and Enhancing Motivation�Provide affirmationProviding Feedback and Enhancing MotivationSlide Number 25Assessment ToolDSM-5 Diagnostic Criteria for �Pathological Gambling in Gambling DisorderThe ASAM Criteria – New ContentGambling Patient Placement Criteria -- GPPC®Six Dimensions of GPPC and ASAMAssessment Outline: �Dimension 1 Assessment Outline: �Dimension 2Assessment Outline: �Dimension 3Assessment Outline: �Dimension 4Assessment Outline: �Dimension 5Assessment Outline: �Dimension 6Menu of Options���Slide Number 38The not-so-obvious purpose of IntakePre-contemplation �to Contemplation��Addressing Ambivalence��for the Sud patientTreatment Outcome and Client Attribution of Therapist CharacteristicsEngaging Problem Gambling ClientsEngaging Clients with Gambling IssuesFamilies and MotivationSlide Number 46