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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)
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G.Bellio, 2008
VENICE
CASTELFRANCO VENETO
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G.Bellio, 2008
Castelfranco Veneto, Giorgione’s hometown
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G.Bellio, 2008
National gambling revenue per year
2528
35
42
05
1015202530354045
2004 2005 2006 2007
Italiangamblingrevenue(billions €)
Source: AAMS, 2008
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G.Bellio, 2008
The ‘addiction model’ of Pathological Gambling has encouraged several Italian
Addiction Treatment Services to work with gamblers
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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)
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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.
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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
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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
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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)
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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
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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
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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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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;
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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
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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
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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
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Thanks to dr. Capitanucci for the encouragement
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Addiction Treatment Center Castelfranco V.to
Pathological GamblingProgram
Clinical Population:demographic and
clinical data
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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
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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
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Pathological GamblersJanuary 2001 – August 2007
851768TOTAL
1028Individual/familial consultation
11110Early Drop-Out
641450Treated
TOTALFM
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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
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Occupation
4
47
13
27
2 16 3
05
101520253035404550
treated Early DO consultation
unemployedemployedother / not Known
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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