Problem Gambling Treatment; the future arrives! Presented by Dr Sean Sullivan, ABACUS Counselling Training and Supervision Ltd at the 2012 Cutting Edge Conference, Wellington, New Zealand.

1. Problem Gambling
Treatment; the future arrives!
Sean Sullivan PhD
ABACUS Counselling, Training and Supervision Ltd

2. Current challenges for all addictions
• Alcohol abuse and resistance to legislate
• Smoking – risking international sanctions and penalties
because of ‘free trade’ conflicts with public health
• Legal ‘party’ drugs – some initiatives but uncertain
outcomes regarding proof of harm and levels for e.g.
synthetic cannabis
• Internet addiction – what is ‘normal’ use? Longer use
becoming the norm
• Gambling – some controls but technology challenges,
social acceptance, and attractive taxation source –
uncertain growth in problems

3. PG differences to AOD
• A relatively ‘pure’ behavioural addiction (no external
drug influence) – often perception the addiction due
more to choice
• The reinforcer is a general reinforcer (e.g. money,
praise) – it is resistant to satiation
• Solution to problems arising from the behaviour may
include continuation in the behaviour (has a built in
solution i.e. a win!)
• Money is a powerful reinforcer that most people want
(drugs perhaps less so) – gives choice, respect,
safety, peace of mind, hope……….
• PG may be less likely to seek help

4. The old days
• Gambling semi-controlled under Gaming & Lotteries
Act 1977
• Lotto introduced 1987
• Gambling machines existed, but not recognised
under the Act – became ‘legal’ in 1988
• No casinos pre 1994– Committee of Enquiry into
casinos 1988-1989
• First casino opens 1994, by 2003, a total of 6
casinos open

5. Into the new era
• 2003 Gambling Act – no NZ Internet gambling
except Lottery & racing/sports
• Online betting – Racing Board monopoly on racing
and sports betting or Lotto
• Internet gambling – allowed if based overseas
• Technology and accessibility the challenge – can be
accessed 24 hrs a day

6. Global online gambling growth Ferguson 2012

7. Mobile gambling growth
• UK – 20% wagers are via online
mobile devices
• Now in NZ: In play betting can
prompt gambling– ‘next
try/yellow card?’
• Estimated world-wide growth of
gambling via mobile devices will
increase from the $20B in 2011
to $100B in 2017
Juniper Research (May 2012)

8. An important income resource for
governments
• Because gambling is a substantial
source of duty/tax, a large employer,
and is part-owned by the state (Lotto),
conflict of interest may be perceived
when gambling expansion/reduction
• NZ Gambling Act – no ‘for profit’
gambling permitted other than casinos
• Monopoly on Internet gambling in NZ
given to Lottery Commission and
Racing Board
• In Australia, 11% (average) of all State
income is raised from gambling

9. But is problem gambling reducing?
Some suggest problem gamblers ‘adapt’ &
reduce their harm

10. The case for PG reducing
‘While far from certain, problem gambling
prevalence rates appear to have fallen
somewhat. It is unclear how much this reflects
natural adaptation or the impact of government
policy, though both are likely to have
contributed’
Productivity Commission 2009

11. But…..
The Productivity Commission also comments:
‘Given (the wide influences on PG)
reductions are unlikely to continue
without environmental changes’

12. From exposure to adaptation
contagion disease model applies?
LaPlante & Shaffer, 2008

13. The adaptation model
• The assumption that people adapt to novel forms of
gambling, much like a contagion disease model
reacts to an epidemic, may not apply to an addiction
• If people adapted to gambling machines, one would
expect at least this to occur within a decade.
Between 1988 – 2008 in NZ, no such adaptation
occurred demonstrated by reduced gambling
machine spending (for same number of machines)

14. What would we expect if
adaptation true?
Less spent on gambling
But assumes due to gambling reducing:
• The larger proportion (non-problem gamblers) may
be more likely to reduce discretionary spending
especially in a recession
• Problem gamblers increase their
problems/gambling when under stress (DSM)
• Reduction in amount spent may mask increased
problem gambling spending – especially if those
financially disadvantaged increase and this group
are known to be at higher risk for PG (e.g. during a
recession)

15. Less spending not necessarily
reduced PGs hypothetical example
120
100
Total $ spent
80 Problem
gamblers
60
Non-problem
40 gamblers
20
0
2010 2011

16. Is gambling participation reducing?
Perhaps…
• Abbott et al (1991) – 90% gambled in last 6 months
• Abbott et al (2000) – 87% gambled in last 6 months
• NZ Health Survey 2006/7 – 65% gambled in last 12
months
• Spending in NZ on gambling has remained relatively
constant at $2B from 2004-2008
• Is spending per capita increasing (if participation is
reducing) or people’s perception of their gambling, or
not, flawed?

17. Hard to measure means uncertainty
• But gambling losses over time is a blunt tool
• Productivity Commission (Australia) estimates 40%
total losses on gambling machines and 20% from
moderate problem/at risk gamblers
• May mask the possibility that ‘controlled’ or non-
problem gamblers do reduce their gambling during a
recession while problem gamblers may increase
their gambling as stress increases (a recognised
influence)

18. Losses constant during recession
(excluding Internet gambling)
Gambling losses p/a ($M)
2500
2000
1500
1000
500
0
07
02
03
04
05
06
08
09
10
11
20
20
20
20
20
20
20
20
20
20
EGM loss ($M) All gambling loss ($M)

19. Adaptation – do PGs adapt?
The Victorian Gambling Study 2011
• N=5003
• Surveyed in 2008 and again 2009 (repeat) using a
gambling screen that identified levels of PG:
– NT=not a gambler
– NPG= a gambler but not a problem gambler
– LR=low risk for problem gambling
– MR=moderate risk for problem gambling
– PG=problem gambler
• Findings:
– 5.6% of gamblers increased their risk for PG
– 4.3% decreased their risk
– PGs were, with Non-PGs, the most stable categories

20. The Victorian Gambling Study 2011
(excluding Internet gambling)
Transitions between PGSI groups Wave One to Wave Two (n=5003)

21. But assumption in surveys is that
responders are telling the truth

22. If data is suspect, can we rely on
prevalence rates or ‘adaptation’?
• As only 29% of problem gamblers reported in
the 1999 Australian Productivity Commission
report stated they would tell the truth about their
gambling, surveys specifically on gambling
probably strongly under-estimate, and may vary
over time

23. A.C. Nielsen NSW Survey 2007

24. Some considerations
• Productivity Commission also states:
‘the share of spending accounted for by PGs appears to be
very high – with no apparent downward trend’
• Higher risks with those with little disposable income –
many within this population spending all their non-
disposable income may not result in increases in total
gambling losses

25. The future?
• Problem gambling in its most severe form is both chronic
and persistent
• Many factors suggest increased, rather than reduced,
gambling problems in the future
– New generation gambling machines,
– ‘improvement’ in internet gambling sites,
– greater competition between modes of gambling (e.g.
Lotto more often, larger prizes), and
– greater accessibility due to electronic advances

26. But gambling technology improves
too so difficult to compare years
The total amount lost per poker machine (in
Australia) has risen fivefold from $19,600 in
1992-93 to $101,100 in 2008-09.
The Age, July 2012

27. A hidden, difficult to measure, but
resilient addiction
• Prevalence measures used vary (and no gold
standard)
• Problem gambling is ‘persistent and recurrent’
and almost all prevalence studies for PG are
snapshots rather than longitudinal assessments
• Stigma high, visual symptoms low or ambiguous,
may mean under-identified

28. PG prevalence in NZ: stable?
14000
12000
10000
clients
8000
6000
4000
2000
0
11
0
/7
6
8
9
/1
5/
7/
8/
06
0
09
0
0
0
/2
20
20
20
20
20
10
20
F to F intensive F to F all clients Gambling Helpline

29. PGs are reluctant help-seekers
2011/2012
7000
6000
5000
New clients
4000
3000
2000
1000
0
Brief intervention Received both Full intervention

30. Internet gambling
The future risk?

31. Internet gambling
• Online gambling sites typically see revenues of
$300 per paying user per month
• Asia-Pacific online gambling expected to grow
from $(US)34.4B to $(US)79.3B in the next few
years
PriceWaterhouseCooper

32. Exposure to technology
– Internet Gambling
• Although internet gambling has been available for at
least a decade, few problem gamblers present to
services with this problem mode
• 2011 Gambling Helpline n=21 clients with Internet
gambling problems;
• NZ face to face doesn’t code by Internet until mid
2012

33. Reasons for low Internet PG
presentation
• Internet gambling not conducted in a public venue – little
harm minimisation controls enforced, less overview
(hidden)
• Most clients present under some pressure
– PG identified by gambling venue and excluded – access to
services a requirement for re-admission to venue
– Others note the excessive gambling and motivate PG to access
treatment
• Remember: few PGs seek help and may be influenced
by hope of winning their way out of financial problems

34. Reasons for low Internet PG
In past gambling may have been hampered by:
– Low Internet speed and/or insufficient computer power (slow,
low level graphics)
– Uncertainty around honesty or reliability of process
– Fear of complexity of the Internet
Now:
– High speed and computer power widely available
– Familiarity with Internet (especially youth)
– New ‘gaming’ without money widely accessible and introduces
new Internet gamblers to the process
– Cross-over opportunities between gaming & gambling

35. Monthly online gambling by
18-22yr olds Annenberg Survey: U Pennsylvania 2010
18
16
14
% aged 18-22 yrs
12
10 Males
8 Females
6
4
2
0
2008 2010

36. Internet gambling here
• Health Sponsorship Council 2011: 8.7% of New
Zealanders had gambled online in last 12 months
(2% overseas sites balance Lotto-Racing-Sports NZ
sites)
Press Release
“Proposals to increase internet speed and capacity, patterns of
online gambling in overseas jurisdictions and increasing use of
online payment methods all combine to suggest that NZ might
be approaching a tipping point”
“How do you stop people, in the privacy of their own home,
accessing gaming sites?”
Assoc Minister of Health 11th August 2012

37. Growing concern
“There is a huge flood of new gamblers (2%
population currently addicted)…some 100,000 more
Swedes become addicted to gambling each year…
women most likely to be addicted, with slot machines
and online games being the most common”
Swedish National Institute of Public Health August 2012

38. But this could only be the beginning –
growth areas for gambling are online
a) Mobile gambling
b) Social gambling sites

39. Growth in online gambling – Australia
• “Betting on Australia’s two largest football codes
is set to double over the next 5 years driven by
strong growth in online gambling on sports”
Deloites
• “Mobile gambling is the biggest shift in online
gambling, greater than offline to online. Tabcorp
says 20% of their online revenue is through
mobile…Sportsbet revenue is up 241% in the last
year and 40% use their mobile to place bets”
Dr Sally Gainsbury, Centre for Gambling Education Research,
Southern Cross University

40. Growth in online gambling
• Paddy Power is launching social media gambling and
mobile casino products following a record year (up
47% in Australia, 79% Eire, online up 36%)
• New online forms of online gambling payment
solutions enable confidential bank to casino transfers
(UseMyFunds) in addition to many other such as
Visa and Mastercard

41. Social gaming sites targeted
• “Convergence of casino gaming and social
media will be ‘the next big thing’ in our
industry”
Chairman MGM Resorts
• Will ellipse all land-based casinos in USA
• 800 million users (20 times Las Vegas
tourists)

42. Earning Power of Zynga Poker
• In July 2012, Zynga announced that it will be
providing real-money gaming outside of United
States in 2013
• In July 2012 Zynga's games had over 306 million
monthly active users
• Listed on the American Stock Exchange Zynga has
quarterly revenue earnings in excess of US$300
million and is experiencing annual growth of 19
percent annually
• The mobile version of the game is available in 18
languages

43. 7 of top 20 Facebook earners Gambling Apps
“Play and challenge your friends to fun and addicting games...”
Ranking $ Game Players
1 Zynga Texas HoldEm Poker 33 million
4 DoubleDown Casino 4.8 million
7 Slotmania 6.2 million
11 Games by GSN 4.3 million
13 Zynga Slingo 12 million
17 Best Casino 1.6 million
19 Zynga Bingo 5.5 million

44. Zynga – Buy Chips – 50% off !

45. Zynga “this game requires 800,000 chips to join”

46. Zynga – Buy Chips – Prepaid Cards

47. Online Poker
the player has $390, the Queen of Spades and the 10 of Hearts,
they call the game to start with $4

48. So what are we going to do?

49. Lets not be reactive or do nothing
But we can do something:
• May be hard to control access to the Internet
But can:
• Increase education of gambling risk (very little public
education currently)
• Can increase research into risk areas
• Can provide interventions online
• Can consider novel online approaches to therapy

50. Using technology in treatment
• Stage 1: phone counselling, manuals for self-directed
programmes
• Stage 2: text counselling, email counselling
• Stage 3: counselling with Skype & others, smart
phones/tablets, - mobile counselling
• Stage 4: virtual world/avatar programmes, more self-
directed on-line programmes, stepped programmes,
increased mobile counselling

51. PGs may prefer self-directed help
• N=106 affected by PG and/or PTSD (commonly
coexists with treatment seeking PGs -12.5%-29%)
were recruited from the community and asked their
treatment preferences
• Treatment preferences for (only) PG identified that
the preferred therapy was self-help, while (only)
PTSD preferred psychotherapies – coexisting also
preferred psychotherapies
G

52. Internet may be both
problem & solution!
Internet-based treatment may better meet the
needs of some PG clients because:
• May increase uptake & retention
• Enquiries can be less stressful
• CBT & MI easily adapted
• Cost effective
• Accessibility, especially when geographical/time
restraints
Gainsbury & Blaszczynski (2011a)

53. Some support for this
• Small numbers of PGs seek formal treatment
• Review of 24 randomised Internet health/mental health
programmes identified these have equal to or greater
effectiveness than face-to-face therapy
• Some therapist interaction in online programmes
indicated some greater effectiveness but mixed
• Younger PGs may relate better to online therapy
• Concluded: online PG programmes an alternative rather
than a replacement for face to face therapy and an
adjunct for those waiting for or exiting treatment
Gainsbury & Blaszyznski (2011b)

56. Proteus effect: Patricia & Baji

57. The future
• More than any other addiction (with the possible
exception of pornography addiction), problem gambling
is, and will be even moreso in the future, be impacted by
technology
• Even if there is an underlying common substrate for
addictions, and only objects may differ (such as alcohol,
other drugs, pornography, compulsive buying, and
problem gambling), treatment is often driven by these
differences
• Adaptation, if alive and well, may provide an answer in
the long term but still require a focus on minimising harm
during the short-term duration of problem gambling