No need to lose hope in complex gambling cases

The notion that a high number of co-occurring problems makes a patient destined for poorer recovery outcomes tends to invade the clinician's thinking in problem gambling treatment, much as it does in treatment of substance addictions. Yet a Detroit-based academician who also treats problem gamblers in an outpatient setting says research actually shows that gamblers with issues such as poor impulse control and antisocial behavior make progress in treatment at the same rate as patients who do not face these complicating factors.

“We're always trained to believe that it is more challenging to treat those who have more challenging problems,” says David Ledgerwood, associate professor in Wayne State University's Department of Psychiatry and Behavioral Neurosciences. “This leads to frustration among clinicians that they can't make more headway.”

Ledgerwood, who in March delivered a talk on predictors of gambling treatment success at the California Office of Problem Gambling's annual training summit, says he seeks to deliver a more optimistic message in his speaking engagements. He also emphasized in his March address the point that “we can't approach all problem gamblers in the same way.”

He adds, “Some are more impulsive, some less. The level of depression varies. We need to tailor intervention efforts to what we see clinically.”

Useful predictors

Variables such as the presence of a strong social support network and socioeconomic resources tend to be associated with more positive outcomes in the gambling population, says Ledgerwood, who also serves as president of the Michigan Association on Problem Gambling. Issues such as impulse control problems and depression will tend to prolong the amount of time someone will need to be in treatment, he says.

Ledgerwood suspects other factors create challenges as well, especially trauma, although he says the role of trauma in gambling disorders has not been sufficiently addressed in research. It is known that about 20 to 30% of problem gamblers meet diagnostic criteria for post-traumatic stress disorder (PTSD), he says, and the majority of problem gamblers have had some experience of trauma in their lifetime. How trauma fits into the gambling equation largely remains to be examined, he says.

In general, Ledgerwood adds, “The problem gambling literature tends to be 10 to 15 years behind the substance use literature. We should probably look toward the substance use literature for [relevant] factors.”

Level-of-care options

Ledgerwood is working on an academic paper that will summarize survey research he conducted with Michigan problem gamblers and their clinicians. As is the case in most states, Michigan has only outpatient problem gambling services available within its borders. “There are only about 9 or 10 residential or intensive outpatient programs specifically for gambling nationally,” says Ledgerwood, who also offers outpatient counseling in Detroit (he directs the problem gambling clinic at the Wayne State University Physician Group).

The research survey asked patients and their clinicians about their perceptions of the potential value of more intensive services. “There was pretty good correspondence between clinicians and clients about what levels of care clients would match to,” says Ledgerwood. Around 4 in 10 clients said they probably or definitely would enter residential treatment if it were available for gambling disorders, and just over half said they would do the same for IOP treatment.

The research employed American Society of Addiction Medicine (ASAM) criteria to evaluate problem severity, and Ledgerwood points out that individuals with more problems tended to rate their need for more intensive services more highly.

Ledgerwood says he uses Motivational Interviewing and cognitive-behavioral therapy to a great degree in his work with problem gamblers, but also explores interpersonal dynamics to a significant extent. “We often find the presence of conflicts with one's spouse and family members, which can serve as triggers for gambling,” he says. He adds that problem gambling often serves as a maladaptive way of coping with another problem, such as bereavement or depression.

Ledgerwood believes that while the professional community's engagement on treating problem gambling may have started to plateau at one point, he senses that it became re-energized as gambling disorders were formally acknowledged alongside substance use disorders in the DSM-5.

“It's now becoming fairly widely accepted that we could have addiction that is not substance-related,” Ledgerwood says. Gambling, then, is in turn sparking clinical interest in other process addictions related to sex, shopping and technology, he believes.