This presentation is on trauma and problematic gambling presented by Joanne Ketch, LPC, LMFAO, DC and SAP. Joanne Ketch is an LPC, LMS, LCD and a SAP, or Rdsap. Jane is a multi credentialed clinician serving professionals, medical staff, first responders and military, and Katy, Texas. This is an encore career for Joanne, and since graduating with her master’s in Twenty Eleven, she has role held roles such as program manager for IOP, program manager for a large bereavement support satellite program held roles in Emergency Crisis Mental Health, been the assistant principal school counselor of a private school and been a care advocate for Optum Behavioral Health. Joanne has been published in Up Journey, NBC News, Care, Dash, MindsPlane, The Good Trade, Birdie Recovery, Intune and Psych Central. Currently doing and owns and operates a private practice in Katy, Texas, where her roles include psychotherapy, support services, consultation and discharge support for residential treatment centers, supervision for MFT and LPC. Joanne is a candidate for a doctorate of professional counseling degree with a specialty in addictive and compulsive behavior.
All right, miss Joanne. You’re up. We’re really excited about this topic. Ok. So let me just start with, I do not pretend to be at all an expert on this. I actually chose the topic in my most recent semester for my doctorate because I did not feel I knew enough about it, and I feel like it is an under under, researched, under, presented and under understood if that is a phrase topic area, the gambling in general, the compulsive behavior with gambling and the co-occurring presentation of trauma and gambling. So this is a cursory presentation, not superficial, but definitely first level presentation of the information that I gathered in that research. Ok. So throughout this presentation, I will probably use the term gambling disorder and problematic gambling interchangeably, they are not necessarily clinically interchangeable. It is, as we all know, with substance use disorder. It is a continuum and instead of making throughout, you know, the the fine distinctions. We’re just going to discuss it as a whole.
How Past Trauma Can Lead to Problematic Gambling
Problematic gambling shares the same concerns as things that are actually diagnosable as gambling disorder. And so the criteria is taken directly from the DSM on that. And I left the other part the trauma generalized rather than restricting it to PTSD or some other presentations. Because as we have learned in the last couple of decades, the impact of trauma on people’s lives, bodies, souls, communities, families and all of that is is pretty pervasive. And I did not want to have such a narrow focus.
So some more information on gambling criteria. Ok. And so the research is clear, we will see it over and over again throughout this presentation that gambling disorder or problematic gambling and PTSD and or trauma are frequently comorbid and either one, of course, is a source of distress. Here are some estimates and I promise ongoing. I won’t be reading the PowerPoint directly to you. That is one of my pet peeves, so I won’t be doing that. I will be summarizing, but I’ll let you read as I talk about the bullet points on them. The estimates, as I did my research, ranged in terms of what they thought people experienced in the general population as problematic gambling. But that was one of the ranges that I found. Most of this information came from Western, specifically the United States. There are some other data out there that was just too cumbersome to incorporate as an example for the firefighters. We will see in a later slide. The reason that is important is because there are ways in which firefighters and other first responder personnel are restricted. In the unhealthy coping skills because they get tested and they have other restrictions. So gambling becomes one of the ways that they can affect. Uh, mood changes in ways that that are off the radar. And so the fourth bullet point on this one, I think is is. In my opinion, alarming, considering the amount of information that we are actually exposed to as clinicians in terms of assessment, intervention and support.
Some other interesting demographics of what does inform the population of persons who who are impacted by problematic gambling less for females. And you can see from a sociological standpoint why that might be education level and in other ethnic and sociological factors. The last one, there was no significant differences found for age, marital status, income or employment. The co-occurring statistics regarding. Problematic gambling and trauma. And when I when I did my paper on this, I called it code co-occurring because the inclusion of other issues with these were alarming and off the charts. So as you can imagine, the atmosphere of some of the gambling settings supports the misuse, overuse abuse type of use. Of some substances and. But the presence of actual diagnosable disorders was also significant. And some more statistics, of course, the second bullet point refers to an earlier DSM. You might note that the author that Najavits she is the author of Seeking Safety, which is the, I would say, premier curriculum used to treat trauma and substance use disorder if you are not familiar. She did do significant research into gambling and trauma as well, which I was pleased to find when I started doing this research because I very much respect her work. So 15 percent of the people who met. Criteria for a gambling disorder also met at some point a PTSD diagnosis and do have additional comorbidities was also very significant.
Again, I realize these are redundant, but I thought that was important to note from several different sources and and researchers that it kept getting noted and noted. Ok, so people who experience trauma are more likely to have gambling problems, even if they don’t have PTSD. As I said in the intro, that’s why I didn’t want to limit it to PTSD. I wanted to talk about trauma generalized and a important statistic that we will get to a little bit is suicide, suicidal ideation. Suicide attempts are significant in this dual diagnosis population as well. We have the increased arousal, the hyper awareness. Here we are being introduced a little bit with how gambling functions in a person with problematic gambling, dealing with emotional problems, depressed and anxious feelings. That, of course, interacts with making all of the problems and symptoms worse. And then they turn to gambling to manage the negative affect and experience again, trying to alleviate the distress, create a elevation in mood. Generalized coping was repeatedly shown to it became a obviously unhealthy coping skill. Persons developing a gambling disorder or problematic gambling began to, as with substance use disorders, use that more and more to the exclusion of less unhealthy coping skills. There are some. Gambling specific cognitive patterns that were identified, and we will talk about those a little bit later. Some of those are gambling expectancies where. Many problematic gamblers go into gambling situations with an exaggerated expectation of reward of impact, and so they they go into the gambling interaction with the expectation that they are going to experience a win that is going to make them feel a certain way in all of that expectation is exaggerated.
It is. It is overblown. It is. It is not. It’s disproportionate to the actual situation. Some of the neurobiology behind behind the people who are developing into a trauma and gambling co-occurring issue in terms of the neurobiology is that there’s an anti reward neuro adaptation. Research has found that with substance use disorder to the the idea of experiencing salience experiencing. Enough experiencing satisfaction can be elusive in the actual bodies of some people. And some research regarding gambling and trauma has revealed that is present in this population as well. The incentives sensitization is what is that experience of not being able to feel accurately the reward situation and the relief that comes is never what they expect going into the gambling situation, which then increases the distress and the anxiety creating a need to. Make the symptoms, alleviate the new exacerbated symptoms. So relapse and we will talk about treatment and treatment effectiveness in a minute. But one study showed that in animals, that priming dose could immediately boom with just one interaction. Create Ignite, be a catalyst for the neuro circuitry of of using air quote, using again participating in in the activity. And as with. Other compulsive behavior or substance use disorders that that we understand stress remains a a kind of constant trigger unless it is, it is managed in a way that that begins to heal the neurobiology that creates the need to seek relief and it becomes the cross.
Sensory sensitization and the bi directional becomes a particular challenge because you have to manage the stress that creates the mood and you have to manage the mood in the other direction that creates the stress, and you have to disrupt that pattern in order to treat. Both the trauma and the compulsive problematic gambling where it comes from is similar to to my current understanding of substance use disorder. It does seem to to to have a heritable or familial pattern. Studies have shown that it is. It shows up in in families. Speculation, of course, is that there’s there’s some neurobiology that creates the predisposition. Of course, we know trauma already creates the predisposition for people to it creates the predisposition in a person’s brain to seek relief. And so that makes sense as well. The next couple of slides also talk about the family, the family component, just from different researchers. And twin studies, of course, we all know are really important in. And when we’re determining whether there is a heritable factor. Ok. The co-occurring issues, of course, are also often often. Uh, genetically predetermined or at least the propensity towards them. So we have that also going on, and if somebody is predisposed to seeking symptom relief because of anxiety, depression, bipolar or other distressing diagnosable condition, seeking relief through problematic gambling is going to be more likely.
And some statistics that support the heritable component of where the this comes from. Um. So some other specific diagnosis that may be intertwined with the likelihood of developing problematic gambling. Here we have an introduction of obviously intimate partner violence is not a diagnosis, but it is a complex context in which there are many components that involve trauma and so that we will see it in a subsequent slide is definitely statistically informing of. Persons that have trauma, gambling disorder and the impact on families, communities and. And others, so in the general population, I just wanted to put this in there, recreational what the equivalent of normal drinking or the equivalent of social interaction with with with recreational behavior or substances. Recreational gambling can be associated with better health functioning and have a positive impact on life satisfaction. How we define recreational gambling is probably somewhat debatable, but I did want to put it in a slide to say that just like with with alcohol and debatably other other behaviors or substances, there is interaction that is that is quantified as. A non pathological that is acceptable, that is not that is not problematic. So there are some characteristics that they’ve identified as associated with persons who have. A propensity to develop a gambling disorder in addition to the trauma background, and that would be impulsivity, the existence of a substance use or a substance misuse, substance use disorder, other psychiatric disorders, the impulsivity keeps showing up in several several studies.
Other behavioral or process addictions are also documented as being predictive. So the sexual behavior shopping. And the. Co-occurring issue of intimate partner violence. Gambling disorder and and PTSD that as a as a as a trio is a I did a paper on that. It’s an alarming group of of data and in a situation. And that one study, nearly 20 percent fit that criteria. More more researchers on the co-occurring. Ok, here we have some of the suicidal ideation. It’s important to know that trauma, PTSD and gambling each stand alone have their own alarming suicidal ideation and attempt attempt statistics. Taken together, there is an exaggerated impact. Veterans, of course, have have have. They’re they’re their own trauma and data that that need to be looked at and studied problematic gambling has as as all behaviors and substances have their own specific characteristics and life impacts that that come with it. In this case, bankruptcy and other things obviously can be associated with gambling disorder. Just some more information on the suicide. And life impact. Ok, so emotional dysregulation mention of the ACEs study. And I mention that gamblers with PTSD are documented as being more prone to error, quote negative emotion in general. Um, the ability to manage emotions. The tie to the positive gambling expectancies that I talked about and negative affective states.
So again, managing the distress, managing the negative mood, states, trying to elevate the mood, trying to escape the distress. Neuroticism is an old term, I used that because that’s what was in the in the research. The autonomic arousal, which is associated with chronic chronic stress and and trauma is important because if that is untreated and we have untreated trauma, people seek to relieve that. And this kind of pulls it all together, the traits of the person more likely to develop into a gambling disorder. The impulsivity, the sensitivity to rewards, the tolerance to delayed rewards and the gambling cognitions. And just re reiterating. Here are some of the specific gambling related thought process if you’re not familiar, the gambler’s fallacy is the belief that a series of losses is bound to be followed by a win. You will hear gamblers, people with a gambling problem in particular say I’m due. It’s due to hit. It’s it’s time for a seven. The hot hand fallacy is, let’s say there’s a group of people playing Texas Hold’em, and if you’re familiar with with that, you know the the flop will come. And after people are playing for a while, somebody notices, Hey, sevens are coming. And and it’s this this idea that follows that sevens are hot, that sevens are coming more and people will start to people with some gambling. Miss Cognitions will will start to make their gambling decisions based on sevens being hot, as if as if cards have memories.
And, you know, card statistics change based on that. There’s a. A. Sorry about that typo. There are connections in the brains of problematic gamblers where they associate coincidental moments in their context with the outcome of gambling. They also tend to perceive that they have more of a power over the gambling situation than others. Now in gambling. Settings for different gambling. There is some, some more input from the gambler versus others, but in general, many people with problematic gambling have have a an exaggerated impact over over what they what they think they can. They can change. There are people who think if they’re third in line to get lottery tickets, they’re in a better space. I’m. Some more social context that that might set people up for the development of a gambling disorder. And more links between trauma. Social context and the development of a gambling disorder. And we can’t talk about trauma without mentioning aces. And so three or more we’re associated with three times as likely to report disordered gambling. And more on childhood adverse experiences. More on the gambling cognitions, the illusions of control beliefs and predictability of chance, the idea that you can stop, which of course we know is is present in other substance use disorders or process addictions. And the idea that the gambling itself will improve mood, affect or will be. And more researchers saying the same thing. Give me a chance to skim those.
Um, the selective bias jumps in in that first bullet point, kind of the losses get under under. Process not not understood accurately in context. And so more on the gambling cognitions. Praying helps me when. Notary, so as it turns out, research shows that addressing the distortion like you would in in cognitive behavioral therapy hasn’t actually been shown to be effective. Here are some of the most common metrics and assessments. For both trauma and gambling. The South Oaks gambling screen snogs is probably the most. Known. The treatment outlook currently for problematic gambling is. In pretty sad, pretty dismal. There’s not a pharmacological drug that is approved for use, although there are some that are often used in substance use disorder that are prescribed off label. Um. Treating. These symptoms becomes part of the treatment plan. That’s. Obviously, redundant motivational interviewing is probably your best starting point. And the most research centered for helping motivate change. Again, the mention of naltrexone. And using antidepressants agonists and mood stabilizers kind of off label, they are not obviously going to directly impact gambling, but might impact the symptomology that underlies the gambling. And they might help with the trauma. I did not find other than. The navigates Lisa navigates work programs that specifically address trauma and gambling. And some more on the pharmacological suggestions. And some more. The the research was ambiguous, to be honest, I did not. Come away from that part with with any.
Feeling of of comfort on what can be done from the pharmacological standpoint, CBT, some research showed that it can help. Not necessarily with the gambling cognitions, but certainly with the ways in which CBT can help. It can help. It can help people, but again, not with the gambling cognitions themselves. And there’s just some way a certain study was laid out. Um, should be no surprise that there were there’s a lot of drop out. That’s true of many. The treatment settings for four use disorders. There are a lot of technological treatments being developed and used for gambling disorder. There’s a lot of promise to that because it reduces it reduces barriers. It has a lot of flexibility, anonymity and confidentiality. And so those are being researched and pursued, which is hopeful. Virtual reality and video games. Are some of the avenues being researched right now, which looked promising? Some of them take the form of desensitization and an exposure. I don’t have any conclusions on those yet, but the the research was interesting. Smartphones and apps are being are being developed virtual reality, so again, the tech side of things. The second bullet point indicates, you know, combining types of treatment, which which is usually the most helpful is to treat from various various avenues. And some results from telephone support. And then some of the social context that makes. Recovery challenging for. Gambling disorder. Peer support. As with other 12 step. Settings, it is notoriously difficult to get accurate research in in 12 step recovery.
And with all of these, it was nearly impossible to find information on research that couples trauma treatment and the gambling disorder treatment. Social connectedness, though we all know is is very much an important part of almost any distress that we want to help our clients alleviate. Gamblers Anonymous is one of the least accessible and more difficult to find, and the dropout rate is very high. There are self-help interventions, there’s there’s GA has some themselves, there are some books and some. Some other interventions and workbooks and things like that, if people want to work on things themselves. And again, it’s hard to identify the effectiveness of that. GA, of course, is is a total abstinence based. And mindfulness, I worry sometimes in my practice that mindfulness is is suggested and used so often in in the in our collective vernacular that that people are starting to dismiss it as as as trendy or superficial that I think I worry that. People will. Reject the usefulness of it or the developing a practice of it. Because it does have the practice of mindfulness, both as a specific intervention, a specific meditative technique and a way of going through life does have pretty documented. Help. And for the very things that we’ve discussed this, I’ve discussed this whole time. And so more on mindfulness. This combining mindfulness and CBT. And fewer fewer symptoms. And just some more studies on mindfulness. Stress management being primary as as it is with with the intervention of any use disorder or behavioral disorder.
Ok, so I want to take you through a case study on this one, because I think this case study depicts some of the very things that that we’ve been talking about. And so Robert was born in 1931, obviously the worst of the depression. His father died before he was two. And although Robert’s mom was a was a widow. I’m understanding that a single mother in the 30s and 40s still came with stigma and judgment. Robert grew up poor. Psychologically, themes such as grief, abandonment, attachment, trauma weren’t part of the vernacular, so that was never addressed. It was never intervened on. A Robert was a natural athlete that helped that became a coping skill. He was actually given a a full ride scholarship that he was unable to utilize because his family did not have the money to give the support material for books and transportation and clothes. He worked briefly before he was drafted for the Korean War, where he served stateside and always felt guilty about with that kind of a almost a survival guilt. And then when he was done with his service, he went back to that same utility company. He met a nursing student. They married while he served in New Mexico, and they had three daughters. His mother died when he was in his early 20s, so his dad died when he was less than two.
His mother died when he was in his early 20s and he developed this idea that he was going to die young because his important people died young. His it’s not in here. But his sister actually had an illness that took away her hearing when when she was a minor. So he was a minor. So he had multiple traumas, big traumas, little traumas. He grew up in a system of sports and activities, and I understand that his mother dated briefly and one person and broke up because of the way that person interacted with the boys he and his brother. There was some hint, but never explained that there was some abuse there, and that was the reason for the breakup. So there was. Unrecognized trauma. Robert, developed with behaviors that were observed today, would be observed as as diagnosable anxiety processed, any kind of illness as catastrophic would go from a headache to a brain tumor began smoking cigarets before cigarets were revealed to be what they were quit in his 40s, but continued for quite some time. He always had somatic concerns, he he quite frequently took things for his stomach. If you were to look at his symptoms, he would have scored 19 on the. On the on the generalized anxiety and some obsessive compulsive behaviors with family members, he would have conversations in his mind and about upcoming interactions and would present them as if he had actually already had those conversations had a strong work ethic.
Perfect attendance. His brother died young. He was in his 50s, but still a relatively young man. And that just absolutely furthered Robert’s idea that he was going to die young like the rest of his family. There were lots of family members with alcohol use disorders and and other some younger nephews and nieces with. Drug abuse problems, so there were significant substance use disorder going on there. I would think that that Robert probably would have qualified for obsessive compulsive personality disorder, which is probably an underdiagnosed disorder. But Robert’s middle daughter was diagnosed with cancer in the in the eighties, when computers were starting to come into the workplace. He felt he felt intimidated and overwhelmed, and he retired pretty early in his 50s. And but back in the sixties, his wife actually hit her own bottom with her alcohol dependance, and she did get sober, sober and remain sober. But being the partner of a woman with an alcohol use disorder in the 60s would qualify as a little tea, little trauma. And he never did process or really, he was supportive, but he didn’t quite understand that she got and stayed sober, but also became depressed, and the home became to the point of almost hoarding. And that was a source of trauma for all of the family members. So the couple retired to Florida. She got involved. She was the nurse, remember, and so she got involved in first responders and her depression alleviated.
They would they would go to Vegas yearly. They attended bingo often. Now bingo was a habit from from early on. They would go to bingo when the oldest sisters were were, were very young and they remember that he was very, very twitchy before he went to bingo. So when they were in their in their 20s and 30s, Robert and his wife, they would need to go to bingo and he would be really, really anxious about that. And and he angry and irritable until he could go. So bingo was present. Going to Vegas a couple of times a year became present. He did have healthy coping skills up until probably his his 40s, maybe into his 50s. He he played softball. There was deer hunting that that included some social support and some some great interaction and even some mindfulness, although it would not have understood it to be that. So there’s the twitchy stuff and bingo. In 1980, Robert went to the racetrack in New Jersey, the Meadowlands for the first time and won $6000 and absolutely immediately began having an interaction with the racetrack where he could not not go. And he would go pretty constantly strained his. His work, strained his marriage, obviously strained money, probably his health. He put his his work on the line. He had all of the gambling cognitions that were talked about and and it was he just he just risked everything in the pursuit of that particular gambling.
He aged his his wife, died when they were in their seventies and he lost. He lost access to some of his healthier coping skills, which were movement and exercise. When they moved to Florida, he did promise his family that he would not bet on the dogs, which, to the family’s knowledge, he did fulfill, but he never had any treatment or information that lottery tickets, for example, were gambling and that continuing to go to Vegas was was was not advised. So after the death of his spouse and and the reduction in coping skills, things started to go poorly. He started to have some sleep issues. He started to go to internet cafes where there were slot machines. He had some community and fellowship there, which reinforced the behavior, and he spent time, which is pretty common for elderly, elderly gamblers. So. He would have. Classified as definitely having a a gambling disorder at various times. Then he developed the depression, which continued, he still had the anxiety issues, he had the kind of little T and Big Tree big trauma. Eventually, he stopped being able to sleep. He was. He was prescribed Ambien. And I don’t know if you guys know, but Ambien is very poorly prescribed often to the elderly, and there’s very infrequently a infrequently there is an exit plan. And so he was never exited off of it and never taught sleep hygiene. And so he stayed on Ambien for years. Eventually, one day he kept having falls and eventually he got put into a assisted living right after a fall.
He got up the next morning to go to a convenience store for a for a sandwich and a lottery ticket. Again, gambling and instead of driving away, he drove literally into the convenience store and drove into the convenience store. And that is when he was put into the assisted living. At some point, the assisted living wanted to take over his medication because they get more profit that way. They did not transfer his his Ambien over and. Um. And what happened was. He went into withdrawal from the Ambien, which is not exactly a benzodiazepine, but the withdrawal from it in a elderly, frail body caused him. To. Go into withdrawal and. Robert died as a result of that. And so the. Combination of Roberts trauma, untreated, trauma, co-occurring and the development of the gambling disorder kind of takes us through all of the hundreds of slides that we have been through and how those work together for what in many, in many ways was was years and years of unmitigated distress. Thank you to Joanne Ketch for this amazing continuing education presentation.