20 Lessons Learned in 20 Years of Prevention of Problem Gambling

Originally presented at a past NCPG annual conference by Jim Wuelfing and Susan McLaughlin and updated by Susan.

20 Lessons Learned in 20 Years of Prevention of Problem Gambling

Updated from a presentation introduced at a past National Council on Problem Gambling Annual Conference by Jim Wuelfing, The New England Center, and Susan McLaughlin, Connecticut DMHAS Problem Gambling Services

The following 20 Lessons are talking points for further conversation, and solely the opinions and experiences of the authors. Jim and I have each been in prevention since the 1970’s and the field of gambling since the mid-1990’s, over 90 years of combined experience in PG (Yikes!).  More information on what is referenced here can be found on www.ct.gov/dmhas/pgs and http://gamblingawarenessct.org.  Enjoy the discussion! Susan

  1. How we start the conversation is critical to the “buy in”.

When we begin with “let’s talk about problem gambling”, the door usually shuts.  After all, “there is no problem gambling here”.  The principal may have just broken up a fight over a dice game, the coach may be ignoring card play for money on the bus ride, and the family may be wringing their hands over someone’s inability to pay bills due to frequent casino trips, but the relation to gambling remains unexplored.  Gambling is the “hidden” addiction, mostly due to the normative and pervasive role gambling plays in our lives.

We have learned to start the conversation with listening: tell us an early time in your childhood when you first learned about or recognized gambling.  What was the activity?  Who were you with?  How did it make you feel?  Or ask: Have you ever won anything? Or use the current moment: what are the gambling opportunities open to you in your community? How are people impacted by these activities? How do you define gambling?

Our role is to “take the problem out of gambling”.  Let’s talk about “gambling awareness”.  Oh?  Tell me more…

  1. We are not as alone as we used to be!

In the mid 1990’s, there were less than a handful of prevention people in the U.S. trying to figure out how to prevent gambling problems.  Most prevention efforts were focused on captive audiences, like G.A. members talking at a school health class.  Prevention itself was an emerging field, and the only models we had to guide us were those developed in response to HIV-AIDS and substance abuse.

Connecticut DMHAS Problem Gambling Services hired the first state problem gambling prevention consultant and in 2001 created the first full time prevention position dedicated to problem gambling.  Now, with the National Council on Problem Gambling and close to 40 state affiliate Councils on problem gambling, prevention is considered essential alongside treatment and research.  The recovery movement has also gained inclusion. The NCPG Prevention Committee has published “A Common Understanding of Prevention of Problem Gambling” white paper and has a wide and robust national network of preventionists in the problem gambling field (posted on the NCPG Prevention Committee site, www.ncpgprevention.org).

Connecticut continues to build upon the prevention infrastructure to include gambling awareness (more on this later). We need to continue to build our network by partnering with mental health and substance use professionals, veteran and senior organizations, EAPs, primary care, departments of education, corrections, local civic groups and others.

  1. We introduce gambling as a “co-occurring behavior”.

Gambling often occurs with other behaviors, such as tobacco smoking, alcohol and other drug use. Depression, anxiety, and sleep disorders can all co-occur with gambling. Unaddressed gambling can prolong or worsen these conditions. The research demonstrates that gambling is rarely addressed in substance use or mental health treatment and can lead to relapse.  Prison data indicate unaddressed gambling problems lead to recidivision and parole violations.

  1. Empowerment model works best.

Prevention used to be about giving people all the facts and assuming they would make the “right” decisions.  With the advent of Dr. Gil Botvin, et al, we learned there are much more positive outcomes when people are informed by the facts and also develop and utilize decision making, stress management and other healthy life skills. Addressing “risk factors” has been folded into increasing protective factors and developmental assets.  This enables and allows the individual to practice their own best medicine.

Empowerment is a prevention strategy, and it takes time and focus.  Prevention is in the “process” as much or more than in the “product”.  We must be willing to take the time and effort to build relationships and trust the process. And to remember that these life skills are interchangeable and generalizable: the skills can apply to gambling or other risk behaviors and serve the individual across the lifespan.

  1. We expand ATOD to ATODG.

To change long established state and national paradigms is a heavy lift, and we have to start somewhere.  We add the “G” of gambling to the Alcohol, Tobacco and other Drug acronym to address the role gambling plays in ATOD behaviors and bring parity to the conversation.

Serious gambling problems—“pathological” —have been included in the DSM since 1980, and “gambling disorder” is in the recent DSMV.  Disordered gambling is the only behavioral disorder included in the addictions section of the DSM-V.  The continuum of gambling behaviors closely aligns with that of alcohol use: abstinence, occasional use, social use, “problem” behaviors, more serious behaviors and consequences, and inability to stop.

While a “behavior” and not a substance, gambling’s impact on brain and body chemistry is similar to substances.  Our job is to connect the dots between gambling as a legitimate disorder and inclusion in state and national health standards and practices. ATODG.

  1. Find creative ways to open doors.

We have made tremendous impact by “just showing up”.  Join local and state level advisory groups and quality improvement teams, and offer gambling awareness as a part of the conversation. Join prevention networks.  Train members of a traditionally underserved population for peer reach out, as PGS has done with the Asian American Pacific Islander (AAPI) community through the Ambassador Program.

Any conversations on suicide, domestic violence, corrections, workplace fraud, financial literacy, high school and college sports, coaching, recovery programs, womens’ and youth issues are opportunities to introduce gambling and the impact on that particular population.   You can offer a lunch and learn to the group, or video/presentation and panel relevant to the matter at hand.

Working with youth offers unique opportunities to expand the impact by utilizing the prevention strategy of “multiple strategies across multiple populations”.  Train youth to take the material discussed back to their peers, or have them interview their parents on how they feel about gambling activities. Have the youth present what they have learned, or PSA’s or media they have created, at a school board or town council meeting.  By sharing, they increase their capacity to understand and advocate for this issue as well as engage a new group of learners.

When resources allow, offer awareness and educational materials to allies and potential partners for free, and guide them to local and on line resources.  This field is notoriously generous with resources and much of what is shared is at no cost. Incentivize initiatives like infusing gambling into their ongoing substance use and mental health work.

  1. Science of brain development is our biggest ally.

Well said.  The developing teen brain is a perfect match for the “low effort, big reward” offered through gambling. Impulsivity, low perception of risk/harm and the lack of developed executive function create that perfect storm.

Educate parents on healthy use of technology for children as they begin to video game on their devices (one recommended resource, “The Simple Parenting Guide to Technology”, by Joshua Wayne, or check out Cam Adair’s work on http://camerondare.com). The emerging dynamic of gambling within the gaming world, “e-sports”, is impacting our experience of sports and leisure.  Stay abreast of the research and share it with your networks.  Monitor how high schools and colleges embrace gaming as a way to include “marginalized” students. Remember, this is not about demonizing the technology; this is about creating informed decisions and behavior.

  1. Stop complaining about the lack of data.

Yes, there is a paucity of current data, largely due to the fact that gambling is the one disease or disorder that receives no federal funds.  Often gambling research is funded by the gambling (“gaming”) industry and therefore suspect. *Often “prevention” research is built on youth treatment populations and therefore not generalizable.

Just start collecting data on each and every project/intervention, no matter the size and scope of the intervention.  Prevention resources may not able to support complex longitudinal interventions where change in behavior is tracked, but we can always track logistics (where, what, how many participants, etc.) ask process questions and create a body of “promising” outcomes. We use group discussion and recording as well as on-line tools. These data can then be included in outreach and reports, and leveraged in grant applications to obtain more resources to support evidence-based work.

With youth groups, we not only poll the youth following the project using a simple, brief on-line tool, we have the adult allies complete a brief interview on their opinion of the impact of the intervention on their youth.

Here is a three prompt tool that consistently yields valuable results:

As a result of participating in this (program/presentation/event):

  1. What is something you affirmed for yourself (meaning, you were pretty sure about before this event, but now you know is true)?
  2. What is something you learned (you did not know before)?
  3. What is something you will now do differently?/What is something you can do with what you learned here today?/How will this information impact your work/family/relationships?

This is just one example; the point is to collect the best data you can.  Create partnerships with public health and research experts and develop data helpful to you that can be built on.

*A word on industry funding.  Many state lotteries and casinos, as well as tribal casinos, allocate funds from their gambling revenues to support state sponsored gambling treatment, helpline marketing, and related activities.  These funds are essential to the work of the PG field, and are much appreciated.  These allocations continue to represent a small percentage of gambling revenues, a portion of which come from people who have gambling problems. https://www.apgsa.org/wp-content/uploads/2018/01/2016_Survey_of_PGS_USA.pdf

  1. Our approach is not anti-gambling.

We can trace gambling back throughout human history.   Gambling adds excitement and reward and often supports worthy causes. Like any other risk activity, it can have adverse consequences.

Government and tribal casinos, state lottery portfolios, off-track and sports betting—legal and otherwise—are embedded in our landscape.  Card and dice games, dares, gambling with friends and family are part of our culture.  E-sports is an unprecedented phenomenon. States have become more and more dependent on gambling revenues to balance their budgets.

Engage parents, schools and stakeholders by having non-judgmental conversations about the normative, pervasive and cultural aspects of gambling.  Explore how states benefit from legalized gambling. Explain that our mission is to create informed consumers and good decision makers and share the Three Important Messages (next).

  1. Deliver our “Three Important Messages”.

Simple, straightforward.  Each message stands alone as well as offers the opportunity for more in-depth conversation.

  1. Gambling is not a risk-free activity.
  2. Know how to keep the problem out of gambling.
  3. There is help available for people with gambling problems and persons affected.

(Refer back to #1, “How we start the conversation”)

  1. Capacity building should always be in the forefront.

A preventionists’ job is to support the individual/community to take care of themselves, to “build capacity”.  Communities need a process to include each person, each voice, and to address individual and collective needs.  Think of that proverb “when you teach a man to fish”: he can now take care of himself rather than wait for the “expert” to solve his hunger.

  1. “Nothing about us without us.”

Prevention is about a process more than about service delivery—the process is our service delivery.  Prevention is “the active process of creating conditions and fostering personal attributes that promote the well-being of people”.

We do this by incorporating Maslow’s hierarchy of needs and specific learning theory.  Dialogue Education offers a “learner centered” experience.  Belonging, Mastery, Independence and Generosity make up the esteemed “Circle of Courage” model (Reclaiming Youth at Risk, Brendtro, Brokenleg and Brocken). We strive to create these conditions as the foundation to learning and positive engagement and change.

Are we treating people as objects (“I know what’s best for you and you don’t”), recipients (“I know it’s good for you to be involved but I still know best”) or resources (I can’t know how to help you without your input and direction”)? Be careful to design your process in a way that ensures everyone has a voice, and that it is heard and included.

  1. Go for infusion into existing prevention programs and make them replicate-able and sustainable.

Stand-alone gambling awareness is a tough sell—no time or priority. Its co-occurring nature is a natural for inclusion in programs addressing substance use and mental health, financial planning, sports management, health and wellness, suicide prevention, recovery planning and domestic violence and intimate partner violence. How can you infuse gambling awareness into existing prevention programs? If you are at a loss as to “how”, structure a focus group and listen to the stories.  You will have all you need to begin. (Refer back to #6, “Find creative ways to open doors”.)

Engaging and training the trainers and facilitators of these programs is critical, as well as making the connections with the funders and overseers so that the program does not depend on the specific person in charge.  The organization/agency needs to hold an investment in this work.

One program model is the Congregational/Community Assistance Program, a multi-hour/session program which involves a network of trainers, funding and incentives for program oversight and delivery, and an annual event which brings together program recipients for advanced learning, sharing, networking, and celebrating their successes.

On the “macro” level, Connecticut has retooled its’ prevention infrastructure into five Regional Behavioral Health Action Organizations (RBHAOs) and includes mental health along with substance use.  Gambling is now infused into the overall mission, funding and deliverables.

  1. Awareness tables at events: useful or useless?

We have all been there. Yawn.  No one comes to the table.  Or they pass by saying “Yeah, I have a gambling problem, I never win…” It is always a tradeoff.  We network with the other staff at their tables.  We may get one or more people who want to share their personal story. How do we know if we are increasing calls to our helpline?  If they take our stuff, do they use it?  Is it helpful?

At PGS we started to combine data gathering with giveaways.  If you fill out this brief survey —we have been using the nine item Problem Gambling Severity Index (PGSI) — you will receive a t-shirt.  Through our “shirts for surveys” efforts we have collected a strong data base that we can parse to the type of event: recovery, college, or mental health, for example, and demonstrate above average scores on the Index, which in turn, helps us advocate for increased services for specific populations.

We agree in theory that if a table at an event inspired one person to seek help, it is worth it.  Expanding how we think about these events to include some form of data collection helps our larger mission as well.

  1. Incorporate the peer-to-peer and youth-to-adult voices.

Training young people to deliver information to same age and younger youth, as well as to parents and other adult allies, accomplishes important goals.  Not only do the youth become knowledgeable about the issue, but learning and prevention theories concur that demonstrating skill or knowledge helps build a myriad of developmental assets.

PGS has supported a range of youth peer leadership initiatives throughout the years, including the community-based Caribe youth project in Bridgeport, the school wide GAMES program (Gambling Awareness in Monroe through Education our Students), and select regional youth groups participating in the annual PAWS (Peers are Wonderful Supports) conference.

Yes, it takes time and attention to provide training in public speaking skills, practice fielding questions, and discuss appropriate attire and demeanor.  Aligning with the prevention theory to include additional populations and strategies strengthens the message and supports the youth with life-long skills.

“Peer” can include all ages and stages of life.  People in recovery (with “lived experience”) are invaluable supports to their peers. Both DMHAS and the Ct Community for Addiction Recovery (CCAR) offer training for peers, and there is a robust network of people who include gambling in their peer work. There is an authenticity inherent with youth and peers of all ages, and the audiences are receptive to their experience and message.  A real “win/win”.

  1. Harm reduction is a prevention message.

The NCPG Prevention Committee’s “Common Understanding” document (refer to #2, “We are not as alone as we used to be”) demonstrates the inclusion of “secondary” and “tertiary” prevention—working with at-risk and involved populations, respectively.  Prevention theory and strategies are relevant to each level on the continuum of care. It is about meeting people “where they are” and providing the decision making, stress reduction and life skills necessary to a life of health and well-being.

In fact, in prevention we prefer to look at the “continuum” as a circle rather than a straight line; as people move through their treatment and recovery and begin to set plans and goals for a recovery life style, how can they keep the problem out of gambling? And we employ those same tools we utilize in “primary” prevention, such as skill building and asset development, to minimize harm. Mindfulness practices and other skill building programs have been built into problem gambling treatment and recovery programs and have been widely well received.

  1. “Financial Literacy” is an open door.

One approach is to offer that gambling is entertainment and should be considered and budgeted for as such.  The NCAA, in an effort to keep players clear from the pitfalls of gambling,  first started talked with its players about how to budget and invest in the 1990’s.  Major banks followed suit by offering on-line curricula to high schools to assist graduating seniors prepare for college loans and credit.  Middle and high schools now offer community resource fairs where they are exposed to the responsibilities of living on their own: car loans, phone plans, rent and the like. How does entertainment—and what constitutes “entertainment”— fit into your monthly budget?

Planning a trip to the casino or figuring out how much income can be safely spent on weekly lottery play are budgeting decisions.  Through the Ambassador Program, PGS recently modified the long standing “Gambling and Financial Well-Being” curriculum as a way to engage the AAPI population.  The curriculum had been developed and delivered to elders, women, and people in recovery with positive results (posted under Resources on http://gamblingawarenessct.org).

  1. Include “problem gamblers” as a part of our focus.

As previously stated, this field is not only about universal, or primary, prevention.  We meet people at all ages and stages of life, and employ the prevention theories and strategies across the lifespan and continuum of care.  At-risk and involved populations have become so embedded in recent years that we do not need to single them out for advocacy as we once did!

  1. Embrace the Public Health Approach and the Continuum of Care.

Another long term goal coming to realization. Now that people agree to this in theory, it is time to allocate federal funding to support longitudinal research and comprehensive prevention programs where we can deliver the seven prevention strategies across multiple client, consumer and community groups.

The reason we have been so successful in the U.S. in reducing highway fatalities and tobacco smoking is the utilization of multiple prevention strategies over multiple populations.  Law enforcement, state government, schools, community organizations, and media were enlisted to engage and train stakeholders, do research, create media campaigns, mandate ages restrictions, increase perception of harm and shift community norms.  These efforts included and impacted youth, parents, police, community members, coaches, teachers and the like.  Smoking rates and impaired driving were dramatically reduced.  It is this kind of effort and commitment that will make an impact in problem gambling.

One modest effort is the innovative model DiGIn (Disordered Gambling Integration) which was developed by Dr. Lori Rugle at PGS and subsequently replicated throughout the country.  Simply put, in a substance use or mental health facility, gambling becomes integrated into the culture as a legitimate issue of concern.  Staff are trained in problem gambling basics, and gambling questions are included in admission screening.

The goal of DiGIn is not solely to identify problem gamblers, although that may happen, it is to include gambling as a legitimate topic within the treatment program, such as in anger management group, in case studies, in waiting room literature, and overall in agency culture (let’s have a conversation about all the scratch tickets in the trash, for example).  It is about noticing and addressing the ways gambling is apparent. As has been demonstrated in the literature, unaddressed gambling in SA/MH treatment is a potential risk for relapse.

  1. Prevention and recovery have much in common.

This is another novel concept that has gained legitimacy in recent years.  Both about wellness; and in the continuum of prevention, intervention, treatment and recovery, the two most closely related just might be prevention and recovery.

In conclusion…
It has taken a generation to move the emerging field of prevention of problem gambling to this place. It will take continued effort to bring it to parity with ATOD.  Federal funding and increasing commitments of funding and consumer protections from the gambling industry are vital and fundamental to the health and well-being of our citizens across the lifespan. We hope these “20 Lessons Learned” will inspire further conversations and positive outcomes moving forward.

Susan D. McLaughlin, MPA, CPS, Primary Prevention Services Coordinator, Connecticut DMHAS Problem Gambling Services