How did you get that bruise? A new focus on violence and gambling.

How did you get that bruise?
A new focus on violence and gambling
Sean Sullivan PhD
ABACUS

What is intimate partner violence?
Intimate
partner
violence
Controlling
behaviour
Isolating partner,
monitoring,
restricting access
Physical violence
Hitting, kicking,
beating
Sexual violence
Emotional
violence
Insults,
humiliation,
threats

Some research-based factors for IPV
Intimate
Partner
Violence
Alcohol &
drug use
Personality
disorders
Economic
stress
Low self
esteem
Insecurity
Depression
Anger
control

Increased Risk in PG
NZHS; Kessler 2008;Zimmerman 2006;Korman 2008;Cunningham-Williams 2007;Petry 2005
Disorder General Population PG
Alcohol (abuse/dependence) 13.5% 73%
Drug (not alcohol:
abuse/dependence)
6% 38%
Depression (any affective) 8.3% 49.6%
Anxiety 14.6% 41.3%
Anti-Social PD 3% 23%
Paranoid PD 0.5-2.5% 25%
Psychological distress K10 5-7% 21-23%
General health (NZHS) 5-7% 21-23%
Smoking nicotine 16-17% 58-76%

Impression of violence
• Anecdotally, many PG Practitioners may
consider their gambling clients to typically be
quiet, withdrawn, isolated, and unlikely to be
violent
• Anecdotally, they may consider family
members of PGs to be more likely to be
violent than gamblers, but also more likely to
leave the relationship

Many of the individual risk factors
apply e.g. Stress
• Stress, a factor of IPV, is high with both family
and problem gamblers
• Suicide rate is high - 17.3% of those admitted
to hospital after an attempt (Penfold et al
2006)
• Victorian coroners report (2013) analysed 128
gambling related suicides between 2000-2012
– 2 of these were partners of PGs

In NZ
NZ Health Survey 2012
• Problem gamblers had increased likelihood
of stress
• Compared with non-problem gamblers of
whom 4.6% were at risk, this increased to
28.2% of moderate risk and problem
gamblers (6 times the risk) for anxiety or
depression disorders

Alcohol abuse high with PGs
Massachusetts Council PG
Gambling
Problem
73%
alcohol
disorder
38% drug
use
disorder
60%
nicotine
dependent

Personality disorders & violence
Fountoulakis et al 2008
• Personality disorders associated with violence
include
– Borderline PD
– Antisocial PD
– Narcissistic PD
– Paranoid PD
All of these PDs are elevated in PGs!

Prevalence of Personality Disorders
PD General prevalence Prevalence in PG
Steel & Blaszczynski 1998
Paranoid PD 0.5-2.5%* 40%
Schizoid PD ‘uncommon’ 21%
Schizotypal PD Approx 3% 38%
Antisocial PD 3% males; 1% females 29%
Borderline PD 2% 70%
Histrionic PD 2-3% 66%
Narcissistic PD Less than 1% 57%
Avoidant PD 0.5-1% 37%
Dependent PD Common in MH clinics 49%
Obsessive-
Compulsive PD
1% 32%

Family violence and affected family gender
Suomi, Jackson et al 2013
32% of females were
victims of violence
25% were both
victims and
violent
10% of
females
were violent
N=115 PG’s from a
PG treatment service,
52.5% reported
family violence in last
year; gambling
generally preceded
family violence
Problem gamblers
were violent with:
Current partners 30%
Parents 29%
Ex-partners 19.5%
Children 7%
Extended family 5%
Siblings 5%
20% of males were
both victims and
violent
11% of
males were
violent
7% of males
were victims
of violence

Problem gamblers at-risk
Echeburua et al 2013
• Pathological gamblers more anxious and
impulsive, poor self esteem
• Greater history of Axis 1 disorders (anxiety,
depression especially)
• Males especially alcohol problems too
• 68.6% of female gamblers compared with
9.8% non-problem gamblers reported being
victims of intimate partner violence

Recent research
Dowling et al (Dec 2014) Problem Gambling and IPV
• 14 studies reviewed
• Significant relationship between PG and being a
victim of IPV
• 38.1% of PGs report being victims of IPV and
36.5% being perpetrators of IPV
• Factors in perpetration of IPV are clinical anger
problems, impulsivity, AOD, younger age and
under-employment
• Highlights needs screening for IPV and associated
AOD, MH, and provide interventions to manage
this cluster of comorbid problems

More research rolling out
• AUT finishing a large study in family violence
research – possibly mid-year release

A NZ systematic CEP screen: The CHAT
• Developed in NZ originally for primary health
• Now starting to be widely used
• Covers 9 topics with 16 (main) questions around
addictions and health lifestyle issues
• Is brief, validated for Asian, Māori, Pacific, and
each set of two (or one) questions are in turn
validated and published in research journals
• Screens for depression

Lifestyle Assessment form (CHAT)
(Case Finding and Help Assessment Tool)
What we do and how we feel can sometimes affect our health. To help us assist you to reach and maintain a healthy
and enjoyable lifestyle, please answer the following questions to the best of your ability
How many cigarettes do you smoke on an average day?
none less than 1 a day 1-10 11-20 21-30 31 or more
Do you ever feel the need to cut down or stop your smoking? (tick no if you don’t smoke)
no  yes
if yes, do you want help with this? no yes but not today yes
Do you ever feel the need to cut down on your drinking alcohol? (if you don’t drink alcohol, just tick no)
no yes
In the last year, have you ever drunk more alcohol than you meant to?
no yes
if yes to either or both of these questions, do you want help with this? no yes but not today yes
Do you ever feel the need to cut down on your non-prescription or recreational drug use?
(if you do not use other drugs, just tick no)
no yes
In the last year, have you ever used non-prescription or recreational drugs more than you
meant to?
no yes
Do you ever feel unhappy or worried after a session of gambling? (if you do not gamble, just tick no)
no yes
Does gambling sometimes cause you problems?
no yes

During the past month have you often been bothered by feeling down, depressed or
hopeless?
no yes
During the past month have you often been bothered by having little interest or pleasure in
doing things?
no yes
if yes to either or both of these questions, do you want help with this? no yes but not today
yes
During the past month have you been worrying a lot about everyday problems?
no yes if yes, do you want help with this? no yes but not today yes
What aspects of your life are causing you significant stress at the moment?
none relationship work home life money health study other (specify)__________________
Is there anyone in your life whom you are afraid or who hurts you in any way?
no yes
Is there anyone in your life who controls you and prevents you doing what you want?
no yes
if yes to either or both of these questions, do you want help with this? no yes but not today
yes
Is controlling your anger sometimes a problem for you?
no yes if yes, do you want help with this? no yes but not today yes
As a rule, do you do more than 30 minutes of moderate or vigorous exercise (such as walking
or a sport) on 5 days of the week?
yes no if no, do you want help with this? no yes but not today yes
© Department of General Practice & Primary Health Care The University of Auckland

• Screening works best when client engaged
with treatment (trust, hope, motivated)
• Low self esteem may be present in both
victims and perpetrators
• Identify goals, using strategies that avoid
barriers of low self esteem (e.g. magic
question in Solution Focused Therapy)
• Work within readiness to change paradigm,
and use Motivational strategies to progress
Interventions

Why not just leave?
Reasons for
not leaving
IPV
relationship
Fear of
retaliation
Lack of
alternative $
Concern for
children
Lack of social
support –
friends or
family
Stigma of
losing
custody of
children
Love and
hope for
change

So, interventions?
• Be aware of the high risk of IPV in PG
• Symptoms aren’t always overt, but neither are
PGs
• That clients may be victims, perpetrators, and
both victims and perpetrators
• Screen, but also ask about perpetration (not in
CHAT) once engaged with client
• Disclosure choice if imminent harm to self and
others – less choice (duty of care) if children at
risk and report to CYFS

• Engage so as to elicit disclosure of victimisation
or perpetration of IPV
• Providing information around commonality of IPV
issues and their barriers to their goals (reduce
PG, improve relationships, meet family
responsibilities, avoid consequences, etc)
• Address underlying issues (depression, anxiety
which may lead to anger and then IPV)
• Anger management strategies
• Work with clients within their PD constraints

Summary
• Gambling treatment services to ensure policies in
place include violence issues
• Engagement, providing context for these sensitive
questions, and that perhaps that research has
found it’s prevalence is higher than thought
• Explaining why addressing violence issues are
relevant to gambling problems
• Providing appropriate interventions in an
integrated approach
End

How did you get that bruise? A new focus on violence and gambling.

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How did you get that bruise? A new focus on violence and gambling.