G.Bellio, 2008

Development of Therapeutic Programs for Pathological Gamblers in an

Addiction Treatment Service, Castelfranco Veneto, Italy.

Graziano Bellio* & Amelia Fiorin*** psychiatrist, ** psychologist

Addiction Treatment Service, Castelfranco Veneto (TV)

Veneto Region

Local Social-Health Unit (ULSS) n. 8

ASOLO (TV)

G.Bellio, 2008

VENICE

CASTELFRANCO VENETO

G.Bellio, 2008

Castelfranco Veneto, Giorgione’s hometown

G.Bellio, 2008

National gambling revenue per year

2528

35

42

05

1015202530354045

2004 2005 2006 2007

Italiangamblingrevenue(billions €)

Source: AAMS, 2008

G.Bellio, 2008

The ‘addiction model’ of Pathological Gambling has encouraged several Italian

Addiction Treatment Services to work with gamblers

G.Bellio, 2008

Philosophical background

“As interest in pathological gambling grows, adaptation of effective treatments from the field of substance abuse may advance the study of treatment for pathological gambling.”

(Petry, 2002)

G.Bellio, 2008

1. No single treatment isappropriate for allindividuals. Matchingtreatment settings, interventions, and services to eachindividual’s particularproblems and needs iscritical to his or herultimate success in returning to productivefunctioning in the family, workplace, and society.

G.Bellio, 2008

Treatment Strategies

• THERAPEUTIC GOALS:• Gambling reduction or abstinence• Improved financial managing skills• Treatment of alcohol and drug

abuse• Treatment of psychiatric

comorbidity

G.Bellio, 2008

Treatment Strategies

• In severe cases the therapist must often pursue intermediate/partial goals

• If allowed, the family must be involved as soon as possible as an important resource

• Some gamblers can benefit from brief and limited therapeutic programs essentially based on psychoeducation, monitoring and behavioral interventions

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Treatment Steps

1. Intake and resistance overcome2. Diagnosis and assessment3. Treatment

• Individual• Familial• Group

4. Discharge and follow up

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Assessment

• Most relevant factors to define the therapeutic program:

• Symptom severity• Impulsivity• Psychiatric comorbidity• Family’s resources

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Clinical phenomena Rating scalesGambling behaviors, severity of symptoms, urges to gamble

SOGS *, DSM criteria *,G-SAS

Erroneous thoughts, cognitive biases

GRCS *

Quality of life Q-LES-Q

Psychopathology SCL-90R *, Zung, ASRS…

Impulsivity BIS *Multidimensional assessment PG interview * (not

standardized)

Rating Scales - Interview

* mandatory

G.Bellio, 2008

Gambler’s Typologies (Blaszczynski)

EMOTIONALLY DISTURBED GAMBLER

PSICHOPATHOLOGYEMOTIONAL DISTURBANCES

IN CHILDHOOD OR ADOLESCENCE

Mild - Severe prognosis

“NORMAL” GAMBLER

RISKY OR PATHOLOGICAL GAMBLING BEHAVIOR

WITHOUT COMPLICATIONS

Good prognosis

IMPULSIVE / ANTISOCIAL GAMBLER

TEMPERAMENTAL IMPULSIVITY

ADHD OR ANTISOCIAL PERSONALITY

Severe prognosis

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• Blaszczynski’s classification is useful to build the therapeutic program for pathological gamblers:

• Prognosis• Intensity of care• Pharmacotherapy

Gambler’s Typologies (Blaszczynski)

G.Bellio, 2008

Transversal (aspecific)Treatments

(i.e., motivational counselling, relapse prevention)

Common psychobiologicaland behavioral factors

(i.e., loss of control, craving, familial problems)

Specific Treatments(i.e., methadone maintenance, financial coaching)

Specific factors related tothe dependence object

(i.e., alcohol, other drugs, gambling, shopping)

Addictions

Methodological background

G.Bellio, 2008

Supportive psychotherapy

• Supportive psychotherapy is a diadictreatment that uses direct measures to ameliorate symptoms and maintain, restore, or improve self-esteem, ego functions, and adaptive skills (Winston et al.,2004).

• Cognitive-behavioral interventions can be delivered within the framework of supportive (integrated) psychotherapy

G.Bellio, 2008

Cognitive – behavioral interventions

– Individual Therapy• Craving management• Organization of the financial plan • Financial coaching• Debts management• Changing erroneous thoughts• Relapse prevention (trigger management)• Free time management• Problem solving

– Group Therapy• Relapse prevention

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G.Bellio, 2008

Mild craving Severe craving R = relapse

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Family interventions

• Interventions WITH the family• Financial coaching• Family psychoeducation

• Interventions THROUGH the family• Financial managing• Conflict managing• Relapse managing• Supportive interventions for the spouse• Motivation enhancement of the gambler

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SA - SOGS 12Woman 59 y.o., married to an

alcoholist; 3 married daughters;

Games: lotto and scratch cards; late

onset of PG; gambling as

opportunity forsocial involvement

Depression;

Chronic conflict andunexpressed

aggression towardher husband;

G.Bellio, 2008

Treatment program

• SA – Emotionally vulnerable gambler (Blaszczynski)• Pharmacotherapy of depression

– Partially effective

• Craving managing– Partially effective

• (Externally) Financial managing and coaching– Effective

• Family psychoeducation– Effective

G.Bellio, 2008

BF - SOGS 13Male, 49 y.o.,

homeless since few years; the only son, when his parents died he spent all possessions and

lost all his properties in

gambling;

Games: slot machines and

videopoker; earlyonset of PG; he has

had no occupationalexperience

G.Bellio, 2008

Treatment program

• BF - Impulsive, antisocial gambler (Blaszczynski)• Social interventions on primary needs

– Effective, with some problems• Pharmacotherapy of depression

– Effective• Financial managing and coaching

– Not feasible• Interventions on cognitive biases

– Not effective• Family psychoeducation

– Not feasible

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CC - SOGS 7Male, 51 y.o.,

married, 2 sons;

Games: slot-machines and

videopoker; late onset of PG;

no debts;

Low level of familial conflicts

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Treatment program

• CC – “Normal” gambler (Blaszczynski)• Family psychoeducation

– Very effective

• Financial managing and coaching– Very effective

G.Bellio, 2008

Thanks to dr. Capitanucci for the encouragement

G.Bellio, 2008

Addiction Treatment Center Castelfranco V.to

Pathological GamblingProgram

Clinical Population:demographic and

clinical data

G.Bellio, 2008

The Addiction Treatment Service of Castelfranco Veneto delivers

services in the field of Pathological Gambling since 2001

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New outpatients per year

46

1416

14

20

11

0

5

10

15

20

25

before2002

2002 2003 2004 2005 2006 2007 *

* Limited: up to August 2007

G.Bellio, 2008

Gamblers Treated (per sex)

0.98(0.47)

0.74(0.46)

SCL 90 R (GSI)(+ Std Dev)

10.79(4.30)

11.44(3.39)

SOGS(+ Std Dev)

58(39 – 69)

44.16(24 – 69)

Mean Age(min - max)

FM

G.Bellio, 2008

Pathological GamblersJanuary 2001 – August 2007

851768TOTAL

1028Individual/familial consultation

11110Early Drop-Out

641450Treated

TOTALFM

G.Bellio, 2008

Age

0

5

10

15

20

25

15-24 25-34 35-44 45-54 55-64 > 64

Early DOsConsultationsTreated

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Education level

7

31

25

1 0

7

2 2 1

63

00

5

10

15

20

25

30

35

treated Early DO Consultation

fifth gradeeighth gradeHigh schoolother / not known

G.Bellio, 2008

Occupation

4

47

13

27

2 16 3

05

101520253035404550

treated Early DO consultation

unemployedemployedother / not Known

G.Bellio, 2008

Development of Therapeutic Programs for Pathological Gamblers in an Addiction Treatment Service, Castelfranco Veneto, Italy.Castelfranco Veneto, Giorgione’s hometownNational gambling revenue per yearPhilosophical backgroundTreatment StrategiesTreatment StrategiesTreatment StepsAssessmentRating Scales - InterviewGambler’s Typologies (Blaszczynski) Gambler’s Typologies (Blaszczynski) Methodological backgroundSupportive psychotherapy�Cognitive – behavioral interventionsFamily interventionsTreatment programTreatment programTreatment programAddiction Treatment Center Castelfranco V.to�Pathological Gambling ProgramNew outpatients per year