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Gambling harm awareness training for GPs - September session

Hi, everyone, welcome to this evening’s webinar.  I will just get Jenny James, our host, online and we will be off and running.
Okay.  Thanks very much Karen, and welcome everybody to this evening’s webinar, which is on gambling harm awareness training for general practitioners.  My name is Dr Jenny James and I am delighted to be your host for this evening. A little bit about my background, I currently work with the Southwest Sydney Drug Health Services in a project that aims to support GPs who are providing care for people with drug and alcohol problems.  I am a GP with a longstanding interest in drug health and mental health and well-being, and this topic is of great interest to me tonight as a GP because we know that many people gamble, gambling expenditure per capita is very high in Australia and there are many devastating effects that directly affect the health of our patients, but there are excellent treatments available, which we are going to hear about tonight, and GPs can play a really key role in screening, assessment and assisting their patients to access help for this problem.  So, to start tonight’s webinar I would like to acknowledge the traditional custodians of all the different lands from where each of us are joining in this webinar this evening and I wish to pay my respects to the elders past, present and emerging, and a very warm welcome to any Aboriginal and Torres Strait Islander participants in this evening’s webinar.  Now I am just going to run through a few housekeeping practicalities.  So, this webinar is being recorded and it will be made available to you in the coming week.  So, to interact with us this evening, and we really encourage you to ask questions and make comments, you will need to use the Zoom control panel.  If you can’t see the panel which is currently displayed on the screen, just hover your cursor over the bottom section of the shared presentation screen and the panel will appear.  The control panel allows you to select your preferred audio settings, like which _____ and interact with the presenters.  We have put all the attendees on mute tonight to ensure learning is not disrupted by any background noise, and as this is a webinar we are unable to see you as participants, so please interact with us using the Q&A box that you will see at the bottom of your screens.  Please do not enter any personal information outside of your main question and remember that other attendees will be able to see what it is you are writing.  And, if someone else has asked a question that you would like answered too, you can give it a thumps up and questions that have got more likes move to the top of the list to being asked.  We have got a dedicated Q&A session after _____ presentations, but please ask questions throughout, we will see how we go and we will try and answer them as we go.  Okay, so, this webinar is proudly funded by the New South Wales Government.  Tonight’s presentation is applicable to GPs all around the country.  There is a particular focus on the New South Wales perspective in regard to state-specific information, but just remember to always check your local and state government legislation for services that are available.  Okay.  So, we are very fortunate tonight to have two absolutely wonderful presenters with extensive experience working in this area.  We have Dr Kate Fennessy and Ms Sofia Tran.  Dr Kate Fennessy works as a senior clinical psychologist at St Vincent’s Hospital and is the manager and clinical lead of GambleAware - South Eastern Sydney.  Kate has worked in public health settings for the last eight years with a core value of equitable access to quality psychological treatment and Sofia Tran is a clinical psychologist and supervisor at the Gambling Treatment and Research Clinic at the University of Sydney.  Sofia has in-depth experience providing individual and group treatment to problem gamblers, counselling services to family members of gamblers and delivering presentations and workshops to health professionals and community organisations about problem gambling.  She has also been involved in the development of an innovative cognitive-based treatment program for problem gambling.  So, just before I hand over to our presenters to get us going, here’s tonight’s learning outcomes which you can see.  So, explain gambling harm and public health issues, be able to identify comorbid conditions and gambling problems, learn about utilisation of a range of tools for screening and for gambling in the GP consultations, demonstrate strategies providing psychoeducation to patients for reducing gambling harm and explain strategies for appropriately referring to gambling support services.  Now, for RACGP members, your CPD points will be uploaded into your CPD account within the next 30 days.  So, it’s now my pleasure to hand over to Kate, who is going to get us underway tonight.
Thank you Jenny for that introduction and good evening everybody.  You can see in your screen there is a little introductory poll asking whether or not you have treated or referred patients with gambling problems before to your knowledge.  I suppose this is one of the key points for this presentation, is that sometimes this problem goes by undisclosed, so we are very curious about this and now let me just share my screen as you are entering your responses in to that poll.  (Pause).  Okay, so we can see the poll results there, thank you for that.  About 50-50, which is pretty typical for people identifying within general practice gambling problems. I thought I would just kick off today with an example I suppose of a case that we might see presenting with gambling disorder in our clinical practice.  Andre, age 54, first started playing pokies in his 20s, so pokies sometimes is referred to as electronic gaming machines, and I am hoping that you are familiar with those, they are on every street corner in New South Wales pretty much, and he was in the pub having a beer with mates when he first commenced gambling.  Over time he started betting online; horses, sports, games, whatever he could find.  He loved the adrenaline rush, nothing else mattered when he was gambling.  On presentation, Andre said he estimates that he has lost AUD 500,000 over those 20 years, lost jobs and friendships, mortgaged the family home, which was repossessed, and his marriage broke up, and he currently has no contact with his ex-wife and two teenage sons.  Andre recently borrowed AUD 20,000 from his parents, has maxed out his credit cards and he is currently unemployed, and one of the things that we are curious about when people present is, the function of gambling for that person, what it does give them, and that can inform our treatment course.  So, Andre said I love the thrill of the chase, I was always chasing the next win, just one more, just one more, but I lost it all.   So, I suppose Andre is an example of what we want to prevent by having these types of sessions, he has obviously had a long course of his disorder with several different types of gambling harm, so, he is an example that we may return to later on.  There is just another poll here.  Wanting to take your temperature about how confident you feel if you did see somebody in your rooms who is gambling, and that’s really problematically gambling.  How confident would you feel that you could help them?  So, I will give you a moment just to enter in your response if you don’t mind.  (Pause).  So, just before we see those results there, we may as well star at the beginning, which is what is gambling really?  I know, before entering into this area of clinical practice, I didn’t really have much personal or clinical experience in gambling.  So, the results of how confident you feel, you do feel pretty confident - about 50% of you feel confident that you could help them, which is great news, and about 41% of you said disagree or strongly disagree.  So, I am really glad that we have got the full range tonight.  So, gambling, a good working clinical definition I find is risking something of value for the chance to win something of greater value.  It is important to note that a lot of people gamble throughout their lives without any real ill effect or not much ill effect at all, it seems to be a normal part of human behaviour just as substance use is or alcohol use is, and there is concrete evidence that gambling in a lot of recorded cultures contributing to things like, for example, raising revenue to build the Great Wall of China apparently.  And we know that in Australia gambling has been a really widely accepted part of our culture as we go through the decades with different forms of technology with increasingly embracing sports betting.  That has changed, but certainly it does seem to be part of our broader culture and that is pretty unique I think to Australia.  And a lot of patients presenting will have had gambling as part of their life lifelong and it is part of their family story as well, so that is important sometimes to acknowledge that gambling has given them some things and contributes to their lives in that way.  So, different types of gambling, very broadly we could say that gambling falls into two main groups, there is wagering, in which people are betting on the outcome of a real world event, so that could be sports, racing, dogs, trots, it might be two fly’s crawling up a wall, it might be sports betting, it might be what are Meghan and Archie’s next child going to be named, whatever the real world event is.  And the second group would-be gaming, so that would include the pokie machines and you can see the individual pokies up the top there, but also Lotto and Keno as well as casino table games, card games and tile games, so that would be blackjack, roulette, ____ those types of games.  There are also emerging forms of gambling that we are becoming increasingly aware of clinically, which seem to be sort of accelerated during these COVID times, and they include gaming related gambling, a few different forms of that, but also bitcoin, trading or rapid day trading, they are not traditionally thought of as being gambling, but people end up with large amounts of debt and it can look like a gambling disorder, so we treat it as a gambling disorder as well.  So, in terms of epidemiologically what we are looking at within New South Wales, problem gamblers make up around about 1% of the population, and that number is pretty stable, actually globally and over time that people with gambling disorder are at about 1% of the population.  We have seen probably in the last decade reduced participation in gambling, so if people are asked have you posted bet or have you gambled in any form in the last year, that number which is now 42.9% used to be a lot higher.  So, what we are seeing is a strange thing where there is reduced participation, but the people who are participating are often at increased harm.  So, the harms are still existing and that 1% is very stable.  There are a few indicators as to people who might be a little bit more at risk of developing a gambling disorder or experiencing gambling harm, and across the board that usually includes people who are a little bit younger, males, and people who are single, and people who are experiencing gambling harm are usually people who have more limited resources.  So, living in a lower socio-economic area, or perhaps more likely to draw their income from welfare payments or unemployed.  What we do know about gambling disorder though is that it doesn’t actually discriminate, it is across the socio-economic spectrum, cross-culture and across age range, and clinically what we see is that the largest group presenting for assistance, formal treatment with gambling disorder are young males, so men in their 20s and 30s or younger, and then the second largest group are women who are middle-aged or older, and there are probably lots of reasons, age and stage reasons why that is the case.  In terms of Australian gambling statistics the most recent that we have is the financial year 2018-19.  I just wanted to include some aspects of the scope of the losses that we are talking about, because Australia has far and away the largest number of pokie machines per capita in the world, and far and away the largest amount of dollars lost per capita as well.  So, expenditure in that year across Australia was AUD 25,000,000,000, that’s losses out of people's pockets.  Around about half of that was in gaming machines, pokie machines, and a quarter of the total was just in gaming machines just in New South Wales.  So, we just wanted you to have some sense that this is something that is definitely in our backyard.  I know that you are joining us from across Australia and possibly further afield, but certainly this is something that you will see in your rooms if you haven’t already.  It probably equates to around AUD 1,500 per person on this call in that year and because we know that that is probably not the case the lion's share of that amount is actually from problem gambling losses.  And expenditure on gaming machines is actually increasing across Australia, but increasing at a much higher rate in New South Wales, even though as I said before the participation generally is going down.  So, there are also some interesting facts about the fact that people who are from a culturally and linguistically diverse background have the lower participation in general across these gambling forms, but again being from culturally and linguistically diverse background you may be at higher risk of developing a gambling disorder.  So, if we are thinking about the gambling disorder, that 1%, I suppose we are really classifying that people have an addiction, which means that we are thinking that people have a craving for the object of that addiction, and in gambling terms that’s is usually couched in terms of being preoccupied, so you are thinking about gambling, you are thinking about wins, losses, strategy and also how to solved some of the problems that are caused by gambling problematically.  Just as with other addictions, you are also thinking about the loss of control over gambling, so having a number of unsuccessful attempts to control or cut back or stop your gambling, and also betting more money than intended to or staying for longer than you intended to stay, and continuing to take the decision to gamble despite adverse consequences.  There are also pharmacological criterion in the DSM criteria, things like tolerance, so having to bet increasing amounts of money to get the desired excitement, and withdrawal, there is a withdrawal syndrome if you have been gambling heavily and you stop, where it is a dopaminergic withdrawal where people will become irritable or restless for a period of time as well.  So, just on that third point, the adverse consequences related to gambling, that’s one of the key learnings I suppose from this evening, that we want to help you to identify what might be part of the adverse consequences of gambling.  So, I am wondering if you could write your thoughts on that in the Q&A module.  What are some negative thoughts that you have seen clinically relating to gambling or what do you imagine might be negatively related to gambling there.  (Pause).  I might just go ahead and give you the answer because I can’t see the Q&A module.  ____ financial loss, financial and relationship issues, crime, losing jobs, very good.  Yes.  So you have certainly identified across the spectrum that financial loss is one of the key problems with gambling problematically and obviously when we are evaluating clients in assessment we are thinking about the proportion of their income that they are gambling.  If you are Kerry Packer, then perhaps it is less harmful than if you are somebody on the DSP for example.  And we know that your financial functioning and your financial health is actually a key indicator about your mental health and your well-being.  So, that financial loss leads to a lot of these other problems, but you have also identified, yes, relationship breakdown, low mood, anxiety and something that sets gambling a part as well is criminal activity.  So, sometimes people will return in desperation to do things that they didn’t wish to do to try and solve the problem caused by gambling.  You might also have health problems, and I think the most common comorbidity with gambling is having cardiovascular problems, emotional or psychological distress, issues concentrating at work or maintaining a job or maintaining your studies and relationship difficulties, loss of trust there and lying about the extent of your gambling is a key problem then. So, that brings us to a case study and our case studies this evening were put together by a GP colleague.  So, we have got here case study 1, John, age 45, who you have seen as a GP over the years.  He has hypertension and you are treating that with Ramipril 5mg.  He has identified past risky alcohol use and he is complaining of insomnia and fatigue and he said on presentation, Marie wanted me to attend today, really I am okay, just not sleeping so well.  If you can give me a sleeping tablet I can take for a few days, that should solve it.  So, I know that we are in a gambling webinar, but would you consider screening somebody like John for gambling in your ordinary practice?  I would like to know yes, no, not sure or depends how busy I am, which I think is an important thing to acknowledge how many demands on your time there is as a GP screening for everything.  However, I think it is very important and I am really privileged to be able to speak to you today as GPs, because as Jenny said earlier in her opening remarks, GPs are really in a position to identify gambling problems when they are quite severe, but also people who are at lower risk of harm who are pre-contemplative.  You have said as the poll results, you probably would screen him for gambling 37%, and 20% said not sure, and 25% said it depends on how busy I am, which I think is very fair to say.  So, I only really get to speak to people clinically who have already experienced severe harms, they are presenting usually in crisis, and we know that our public dialogue and discourse around gambling is that people don’t necessarily know that it’s a treatable mental health condition, they may not be aware of the reach and the adverse consequences of their own gambling in their lives, they are probably not aware that they are able to speak to you about it, so I think it is a really key position, but you have to be able to raise that awareness, provide some psychoeducation support, any efforts that they do not have to change and connect them to gambling support services.  We do know that for this condition, I guess similarly to other addictions, but gambling disorder does have some specific aspects to it which increase the level of stigma and shame experienced by patients.  It can be very very difficult to talk about these things.  I had a patient I think last year, who really said to me, you know it’s almost _____ these days to have a problem with alcohol or ____ problem with heroin, but I have got a problem with pokies, how can I tell my wife about this, how can I tell my business partners about this, and I certainly I wouldn’t want anyone else to find out, including the bank, you know, if I ever want a mortgage and things like that.  So, you will see that internalised stigma and we as health professionals I suppose are looking from that medical model perspective where we are wanting to say, this is a treatable mental health condition and you as somebody who is suffering from this have every right and are very deserving to access equitable healthcare and excellent care for that and that is a treatable thing.  However, the patients may need some convincing of that, somebody like John, for example, might be pre-contemplative and may not be aware or really wishing to disclose it all about this problem, but I suppose I don’t need to tell you about having sensitive conversations because you probably do that all day, and approaching this and opening this dialogue is no different to asking you about any other problems our patients face.  So, as with anything, a warm rapport, a therapeutic alliance, an open and non-judgemental approach of course will always help.  So, I am curious as to your thoughts about how you would approach somebody like John for example, how would you couch this question or how would you open the conversation with somebody like him?  If you wouldn’t mind again popping your thoughts in the Q&A module.  You would use PGSI, excellent, I do, and we will get to some screeners soon, but that is an example of one of the screeners that is used to identify gambling problems in a generalist population, so excellent work.
Just whilst people are putting some comments in, all that information about asking, it is so important isn’t it, so we also talk about substance use disorders, about the five As.  There might be some GPs listening who are drawing all the parallels between the frameworks used with assessment and asking issues around substance use and comparing that to gambling, so those five As, which the first A is just asking a question and then assessing and advising, assisting arranging.  So, if you see a patient who is drinking, you know, unsafe levels of alcohol, we ask them about them, we assess things like their stage of change, we advise them with brief advice about how to assist with referrals, and we just see these patterns coming up in terms of assessment and advice around gambling as well, so it is just a good framework just for GPs to remember the similarities.
Certainly and I can see that people have their own unique style as well as that framework, sometimes it is more direct that you will just say, look, do you gamble, do you have a problem with gambling, do you like going to the casino, for example.  Or maybe probing a little bit more about some of the presenting issues as well that he is presenting with.  So, I have put together some thoughts, but I think the five As model is a good one Jenny to keep in mind for GPs.  You might want to ask this within a general lifestyle assessment.  When talking about stressors and this is a really relevant thing within this COVID age that we are living through, that people might turn to new ways of coping or their ways of coping might be escalated to problematic levels as a way of coping with stressors.  You might want to talk about a more formal mental health assessment and ask directly.  And, if clients are presenting as John is with, I don’t actually know if it is poor self-care, but these are some indicators that may point to a gambling problem, so certainly the financial distress or pressure, poor self-care, you know, sometimes there is unstable housing or sleep difficulty or you know, not looking after yourself in terms of the food that you are eating, intimate partner conflict is quite common unfortunately in this presentation and dopamine agonist medication.  Gambling can be a very rare adverse effect for some Parkinsonian medications for example that you might just, if somebody is taking that medication, be having a look at some of the adverse effects.  So, back to John, when you ask about gambling in a way that you have chosen, he says I occasionally have a gamble, and we will return when my colleague Sofia is talking about treatment to John's case as well about how you might take the conversation further, because he has disclosed to you, but we know that a lot of people gamble and it is non-problematic, so just looking at the scope of perhaps if that is negatively affecting some of these presenting issues that he is experiencing.  Just on that I suppose, the stages of change model can be helpful with any addiction and that certainly with gambling, being responsive and gauging yourself to the perceived level of motivation for change in your patients, you don’t want to be too far ahead, if John is just getting his head around the fact that maybe gambling might be a factor, you don’t want to be rushing necessarily to strategies to start treatment, and again if he is ready in his all in action mode, you don’t want to be lagging too far behind and starting to explore his level of motivation, and I can see that some of your comments reflect that as well. So, again, I suppose with psychiatric conditions in general, people are not defined by their problems, we don’t wish to be defined by our difficulties, and so I guess in this field we are steering away from gambling addict for sure and a problem gambler as well.  It is more the person is experiencing problem gambling or defining the behaviour separate from the person. I just wanted to take you through before handing over to my colleague Sofia some screening tools.  I like this one for GPs because it really points to two DSM-5 criteria and it is psychometrically very sound even though it is very short.  So, have you ever bet, it’s called the lie/bet test, have you ever been more than you intended to? And have you lied to others to conceal the extent of your gambling?  And then they directly speak to two of the DSM-5 criteria and if you answer yes to one or more of these, you may have an issue, it’s worth exploring.  BBGS is similar based on three criteria.  Have you become restless, irritable or anxious when trying to stop, so that’s pointing to your loss of control.  Have you tried to keep your family or friends from knowing how much you gambled and the hiding of this difficulty is part of the DSM-5 criteria for gambling disorder.  And did you have such financial trouble that you had to get help with living expenses is also a key indicator.  One or more yes answers requires further evaluation.  The longest screen is one of which we have already mentioned this evening, the PGSI, is pretty widely used in Australia, has four items on behaviour and five on adverse effects of gambling, and these are both non-diagnostic screeners that are used in generalist populations to pick up the possibility of gambling problems, but they do have Likert scoring and they do have maybe experiencing a gambling problem and the results are graded so that you have kind of a scale of severity there.  The South Oaks gambling screen is used more widely globally, it is a little bit longer.  Before I hand over, I just did want to mention that this is often quite a distressed population when we are talking about that 1% of the population who are experiencing a gambling disorder.  Around about 50% who are experiencing depression or anxiety and of course they may be using gambling to modulate an underlying mood disorder, but also gambling makes you depressed and is very very stressful if you are doing it problematically, so a proper assessment and a timeline there can really pick apart that chicken and egg, you know, which came first, and that can really inform treatment.  Around about a third or a quarter, numbers differ there, have another substance use addiction and that can be alcohol use disorder or they might be vulnerable to other addictions as well, so, around 50% of people presenting for formal treatment for assistance with gambling are experiencing suicidal ideation and 17% of attempted suicide, and that is quite high and it is higher than substance use disorder or alcohol use disorder.  As I said before, cardiovascular conditions are the most common health comorbidity and you know financial relationship, employment, accommodation and legal problems are really common in this population.  So, it’s really valuable that you are looking at perhaps having conversations with people before they get to that point I suppose.  And on that note, I would like to hand over to my colleague Sofia.  We will re-join you for the question and answer portion of the presentation.
Hi everyone, thanks Kate, I am just going to share my screen now.  Here we go.  Alright.  So, I am going to start my section with a case study, so this is Sam, she is 38 years old, and Sam attends a telehealth appointment with you.  She says I am really ____, I lost my job and I don’t know how I am going to pay my bills.  You have been seeing Sam for years and you know her and her family, her father has an alcohol use disorder and her mother died of breast cancer in her early 50s.  Sam has a history of low mood and takes no medications.  So, you ask Sam, can you tell me more.  Sam starts to cry, she says I have so much financial pressure, I feel at breaking point.  It started out as a bit of fun, I would go to the pub, have a beer and play the pokies and I actually won some money.  But with COVID, I have started gambling online, I have tried limiting my use, they are leading to apathy times, but it is out of control, I need help.  So, Sam is an example of a patient that recognises that her gambling is an issue.  She knows it is causing her financial pressure, she has lost her job, and she has made some unsuccessful attempts to stop on her own by deleting the apps, and now she is seeking professional help from you and that’s fantastic.  So, one thing I wanted to point out about Sam’s story is that her story of how she started gambling is a really common story of what we hear in the clinic.  So, for her it started as something social, she had a good time and importantly she had an early win and an early positive impression with gambling, and that’s something that we see with a lot of our clients, even so by the time they come to us for treatment, the gambling is mostly causing them harm, it wasn’t always the case like that, and there was usually something positive and fun about it early on that got them started with gambling and then from there it’s just a very slippery slope and things can grow and get out of hand very quickly.  There’s just going to be a second … another poll that comes up now, so with the following statement I feel confident advising and treating my patients for gambling harm.  Do you strongly agree, agree, disagree or strongly disagree with that statement and I will just give you a moment to fill that out.  Alright.  So, it is fantastic that Sam is seeking help for her gambling and I am going to talk about what you can do as a GP to provide support for a patient like Sam and the different treatment options available.  So, in terms of the poll answers, it’s split 50-50, so about 41% of people say they agree, 48% of people say they disagree and small numbers in terms of strongly agree or strongly disagree.  Okay.  So, in terms of providing psychoeducation these are the main messages that you can convey to your patients.  So, the first thing is just to validate and normalise that gambling concerns are really common.  Secondly, to let people know that gambling can start to become a problem or a concern when a person spends more time and more money than intended, that gambling can lead to other issues in a person’s life including issues with finances, mental health, anxiety and depression symptoms for example, relationship difficulties, physical health concerns and work, and this really links onto those gambling harms that Kate spoke about earlier.  And then importantly, let clients know that there are a variety of effective confidential and _____ options available that can help them to reduce or stop their gambling.  So, these are some of the different treatment options available.  So, the first option is free and confidential gambling counselling and I will talk about this option more in the next slide, but there are a range of counselling options available.  So, this can be done face-to-face or also online such as via Zoom, and also by phone, and there are counselling support services for the person who is experiencing harm through gambling, but also counselling for their partners and family members as well.  And the counselling services provided by GambleAware, they are completely free, they are of course confidential and they are provided by counsellors and psychologists who have specific experience working in gambling.  So, for a patient like Sam, whose gambling is having significant negative impacts on her life, and she is open and motivated for change, I would definitely suggest that she seek gambling counselling. Another support option is by providing educational and self-help resources for the patient to read and work through on their own.  Towards the end of the presentation, I will show you where you can find this information on the GambleAware website, and this is a really great option for patients who are eager to find out more about gambling and to start to apply some of these strategies on their own.  It could be in addition to counselling, but this is also really useful for clients who are more in that lower risk category when it comes to their gambling or people who are ambivalent and not quite ready to engage in gambling counselling yet, this could be a really good starting point for them to do some work on their own and start to think and reflect on their own gambling.  Self-exclusion is another option that’s available and this is where a patient voluntarily bans themselves from either a venue, like a pub or club or casino, or bans themselves from online gambling websites.  And from my experience, self-exclusion can be a useful adjunct to therapy or counselling, it can be a good additional barrier to gambling, but I would personally say for most of the clients I see, that it is not a replacement, so I always recommend that a patient also engage in some counselling so that they can learn the information and tools that they need to manage the gambling themselves rather than just solely relying on an external ban or an external block, but this can be a useful adjunct for some people.  So, if a person was interested in doing a self-exclusion they can contact the GambleAware number and find out more information because the exact process depends on what they want to ban themselves from.  So, the self-exclusion can be done with one of the GambleAware counsellors or it can be done by directly contacting the venue or the online betting website themselves.  So, a question that commonly gets asked by medical practitioners is whether gambling can be treated using medication, and what the literature says is that no medication has been formally approved for the expressed treatment of gambling disorder.  The research evidence really shows that psychological therapies that are most effective for reducing gambling behaviour.
As GPs, we might very well be using medications to treat some of the comorbidities, that’s a very important point that there is no validated medication to treat problems with gambling.
Yeah, thanks for that Jenny.  In some cases, you are right medication can help with the depression or anxiety symptoms or other harms around gambling, but not for reducing gambling behaviours itself.  So, what does gambling counselling or gambling treatment look like?  Cognitive behavioural therapy or CBT is a psychological therapy with the strongest evidence base and it is the recommended treatment for gambling.  So, this is kind of a summary of what CBT involves and it gives a good summary of what a patient may go through if they engage in gambling counselling.  So, the first step is usually psychoeducation, so, helping the patient to get a really good understanding of their gambling, of what motivates them to start a gambling session in the first place and then when they are in a session, why they keep continuing to gamble, past their limits, why they continue to chase losses and then ultimately why they continue to go back to gambling again and again despite the harms that it has caused in their life.  So, we can help the patient to understand the stuck points that are leading them to repeat the same cycles and help them to see that ultimately gambling is really just exacerbating a lot of the issues that they are experiencing in their lives.  So, CBT also involves helping a patient to identify and correct misinformed beliefs about gambling.  So, I don’t have enough time in this talk to go through this point in too much detail, but there it is a really interesting point and I will give a summary.  So, people who gamble usually have very strong and very incorrect beliefs about how their form of gambling works, and it is really these misinformed views of gambling that can be one of the factors that keep their gambling going.  So, for example people who play the pokies they have this view that machines work in some type of cycles and the more money the machine has taken in, the more likely it is to pay out.  People who gamble on horses usually have their own system of how they analyse the information on the form guides and how they use this information to pick winners, and people who gamble on roulette for example usually have superstition like beliefs about patterns and predicting what’s coming up next.  Those are just some examples of these misinformed beliefs people have about gambling and it is really these beliefs that make people think that they have a chance of winning at least in the short term.  CBT can also help a person to learn how to make better decisions around their gambling.  So, when a person chooses to gamble, they are usually just thinking in a very short-term type of way, just about the session today and hoping for a positive outcome or positive experience and CBT helps them to make clearer and more logical decisions and really consider the long-term consequences and impacts of their gambling.  It also helps them to identify and manage high-risk situations for gambling and can help them to manage some of the other impacts that gambling is having on their life, like relationship difficulties, their daily functioning and so on.  And a motivational interview is often weaved into therapy and it can help patients to resolve their ambivalence around gambling and to facilitate that change process.  So I am just going to introduce our next case study now, so, that’s Marie, she is aged 42.  Marie is a regular patient of your practice, you have seen her, her husband John, who Kate introduced earlier and their kids over the years for self-limiting illnesses, vaccinations and treated Marie for her PMD.  So, she says to you, doctor I don’t know what to do to, I have found out that John has re-mortgaged our house, he has some issue with gambling, I am so upset, I just can’t believe he has done this to us.  So, Marie is the partner of someone that gambles and she is experiencing issues in her life as a result of it.  So, the reason I bring up Marie as a case study is because I really want to bring attention to this population that are affected by gambling, but are not commonly spoken about or thought about and it’s the partners and family members of people who gamble, and family members can include parents, children, siblings probably, but it can also include grandparents and grandchildren in some cases.  And it is estimated that for every person experiencing a high level of gambling harm, six people around them are affected and the common impacts for _____ family members include impaired family relationships, mental health issues and financial difficulties.  So, in relation to financial difficulties, stories that we hear commonly are situations where a person that gambles has re-mortgaged the house to fund their gambling and of course this has impacts on the whole family unit or they have used money from a shared savings account, significant sums to gamble. And while people who experience issues with gambling themselves, so people who gamble, they can often vary in their motivation to seek help for gambling and like Kate has said before they usually don’t seek treatment for gambling until it has become a significant concern or reached a crisis point.  What we usually see is that when it comes to their partners and family members that they are actually very keen and very motivated to do something about gambling and they are often the ones who are first reaching out to try to seek support for their loved one or for themselves.  So, it is very likely that you may see someone like Marie presenting and seeking information and support around gambling.  So, it is important to know that there is counselling and support services for partners and family members too and it is also provided by GambleAware and of course all completely free of charge.  And we just sum up the concerns that partners and family members may seek support for.  So, they may be seeking information about gambling and gambling treatment and what that involves, they may want guidance on how to start a conversation about gambling and advice around how to encourage their loved one to seek professional help.  They may want to find out ways to support a loved one who is experiencing gambling harms without enabling them.  They may be seeking help for relationship difficulties, so, common issues can be around impaired trust, communication difficulties and boundaries. They may be looking to protect themselves from the impacts of gambling and this may be in a financial or legal sense and in these cases we may sometimes refer them to see a financial counsellor or legal aid who can give them professional advice around some of these concerns.  And they may also be looking for support for their own mental health, and it is very understandable that they may be experiencing stress and anxiety and depression symptoms and what we can provide is just a face for them to talk and process what’s going on, which is normally a very confusing situation for them, you know with a lot of very conflicting feelings and for a lot of partners and family members they may not feel that they can go to their usual support networks of their families or their friends to talk about the gambling because there is so much shame and stigma around that.  So, that’s something that we can provide for them.  So, revisiting John’s case study, so, John is the male patient with hypertension, he is on Ramipril 5mg, has past history of alcohol use, obesity.  He attends today complaining of insomnia and fatigue and asks for sleeping tablets.  And he says, I occasionally have a gamble, you know it’s just a bit for fun.  So, John is quite ambivalent about his gambling and doesn’t quite see it as a concern, and I just want to highlight that this is a very typical presentation of a patient that you may see in your general practice that gambles.  And it is really normal for people to have conflicting feelings about gambling and really vary in their readiness for change, and for someone like John, this may be the first time that he has even considered his gambling or discussed it with another person when you ask that initial screening question, and it is really important to remember that even if a patient is not quite ready to seek help yet, that there’s still so much value in starting that first conversation about gambling and providing them with that information for them to reflect on in their own time, and just planting that seed, because as Kate and Jenny have mentioned earlier, in the service that Kate and I work in, in gambling treatment, we usually only see people when their gambling has become a significant concern, but what you as GPs are able to do is to have that first conversation earlier and identify people who may be in that more low or moderate risk of gambling or people who may have issues but have never considered it, and help them take those first steps.  So, let’s talk a little bit about what you can do with a patient that is ambivalent or not quite treatment-seeking yet, and just some helpful tips to keep in mind.  So, the first thing is to seek to understand their ambivalence or resistance.  So, don’t make assumptions, because there are a lots of different reasons why a person may be ambivalent and this could be about lack of awareness that their gambling is creating harms, it could be shame and stigma around gambling.  It could be not wanting to give up the benefits of gambling or still seeing gambling as a potential way to win some money or solve their financial problems. Some people may still have a belief that they can manage their gambling on their own or they may have misinformed believes about what gambling treatment involves, so there’s a whole range of different reasons why a person may be ambivalent or resistant.  So, I really encourage you just take a curious and non-judgemental approach in trying to understand what the barrier is for their patient and helping them to navigate that and work through that barrier.  So, the second point is to ____ resistance and this is a concept from motivational interviewing and it is really about just normalising for the patient that it’s okay feel uncertain or unsure and just working with the patient and reading where they are at in their readiness rather than trying to force that change.  What you can also do is provide a range of support options to the patients, so, gambling counselling may be one option, but if they are not quite ready for that you could suggest doing online or phone counselling where they may just speak to someone virtually to begin with, or if they don’t want to see a counsellor yet or engage in counselling yet, those educational and self-help resources, can be a great option for them just to think and reflect on their own and then going from there.  And lastly, I really encourage you to keep the conversation going and checking at a later date, so checking in at the next appointment, how things are going with their gambling, if you gave them some resources or information to look into, asking them what they thought of it and if they have had any further thoughts about that.  So, for all of these treatment options that I have discussed, so, counselling, educational and self-help resources and self-exclusion, please refer a patient to a GambleAware provider.  So, GambleAware is a specialised gambling support service and it is funded by the New South Wales Government, so in particular the office of responsible gambling, and because of that all of our services are completely free and it is open to any person in New South Wales, no referral or Medicare is needed, and all the patient needs to do is to self-refer, is to call the intake number which is on the screen, it is 1800858858 or to go to the GambleAware website for more information.  So, this 1800 number is a centralised number and so when a person calls through they will be able to speak to someone on the other side that can answer any questions that they may have around gambling or the service or support options available and they can be linked to support that is appropriate for them, whether that’s gambling counselling or financial counselling, support for a loved one, self-exclusion, self-help resources and so on. And there’s also support available in over 40 languages, which is provided by the multicultural problem gambling service as well as culturally appropriate support for Aboriginal people and that’s all provided under the GambleAware umbrella.  So, what I am showing in this map here is the way that GambleAware providers are organised in New South Wales. So there are 10 GambleAware providers that each service a different geographical region, so these regions are organised in the same way as a public health local health districts and this means that there’s a specific service catering for each of the regions that has local knowledge of the population and knowledge of support services in the area. But yeah, if any patient from anywhere in New South Wales just calls the 1800 number they will be directed to the local service that’s most appropriate for them.  And this is a screenshot from the GambleAware website, so there’s a lot of useful tools and resources and information on this website, so I really encourage you to log on and have a browse of it at some point when you have the time, but for example there are options here, if someone wants to learn more about gambling, if someone is worried about their own gambling and if someone is worried about someone else’s gambling, so that’s for family members and partners.  There is information here for health professionals that want to learn more about gambling, there’s information for people who work in the gambling industry and so on.  And for example down here, there are tools for checking in on your own gambling, so these are the self-help and self-management tools and information about self-exclusion, you can hear other’s people’s stories and so on.  So, lot’s of useful information there.  And later this year, the website is going to be expanded and patients will be able to use the website themselves to self-direct the level and type of support and treatment that they receive, so, it will enable them to seek and access support at the time that suits them and their preferences and book in directly themselves.  And for GPs, next year in 2022, there’s going to be a new feature that allows GPs to refer clients directly from this website.  So, keep an eye out for that.
And thanks Sofia.  I will just add to that point, I have had a bit of a look around on that website and it’s really terrific, it’s very clear, it’s ask really easy to navigate and as you said you can interact with it from different perspectives, whether it’s your own gambling problem and there’s lots of practical strategies or whether you are wanting to help somebody else with the problem, and there is a section there for health professionals and other sections as well, so highly recommend that GPs take a look at that, and something I sometimes do in consults is open up these websites quickly with the patient, so, actually introduce them to the website. You are together, having a chat about it, that just sort of draws their interest in and when they go home and have a good sort of dig around.  So, that’s really excellent.
Thanks for that endorsement Jenny, and that’s a great tip, especially for clients that are a bit unsure, going through it with them in the consultation and can really help them to take that step on their own, so I love that suggestion.  Just the last slide here.  So, this is just some information about further resources that you can have a look at in your own time, the links and the information on these resources will be sent out afterwards by RACGP, so, yeah, have a look at those.  That takes us to the end of the presentation, and Jenny will facilitate the Q&A now.
Okay.  Alright.  Well, thanks so much to our presenters Kate and Sofia.  I am sure everyone else like me really enjoyed listening to all of that.  I can see we have got some questions coming through on the Q&A, so I just want to encourage everybody who is out there that this your chance to ask anything you have ever wanted to ask about gambling and have a think about the practicalities, imagine yourself in the room with someone who is telling you about a problem, the sorts of queries that might come up in your mind about what do I do, how do I ask, what should I say, how do I assess this and please feel free to put them into the chat box.  The first question there from Ashwin was asking at what point of a consult is it wise to start talking about gambling, and Ashwin has said I tend to ask about it whenever I am asking about smoking or alcohol histories or any mental health discussions surrounding depression, anxiety etc.  So, Kate or Sofia.
Yeah.  Thank you for that question Ashwin, I am sure Sofia will want to comment on this as well, but I think a sensible answer is whenever you actually have time to respond if the answer is in the affirmative. I know that GPs out there are always pushed to be screening for everything really, and I think it is pretty sensible to be grouping in problematic behaviours together as Ashwin has indicated there, and you know it is a mental health condition, so I think it is really good to talk about gambling in that context as well as part of a mental health assessment or as part of a lifestyle assessment, but not in the last 10 seconds into your consultation time I suppose.  Sofia do you have another comment on that?
Yeah, I think when it comes to when to talk about gambling, there’s a lot of natural points where it can come up and I like what this person has suggested in terms of just including it as a screener with smoking, alcohol and mental health, or it could be organically when it comes up, if the person is presenting with anxiety, depression, financial issues, relationship issues and so on.  So, whenever I have the option…. even just in terms of, like Kate mentioned, lifestyle question of, do you enjoy gambling.
Yes.  Indeed.  GPs do a number of health assessments too, so it could just be as part of those standard health assessments.  I will just draw attention too, I notice the Aboriginal and Torres Strait Islander guide to preventative health guidelines, the third edition of that is out, they do have a section on gambling and they do recommend to GPs that we ask all adults, in fact they are saying from the age of 12, ask a simple question.  Have you or anyone you know had a problem with gambling and they say to us that opportunistically or as part of a health assessment once a year.
And that would be great, and if the answer is no, then that’s quick, just one question, but if the question is yes, you can explore further from there.
Indeed.  Just coming down here, I guess it is partly a comment, so, have drug and alcohol services been changed to also counsel gambling addiction…so Ashwin has asked this as well, and observed that if someone has got a substance problem and a coexisting gambling problem, are we sort of having to send them all over the place to too many people, how does that work.  I was just wondering what comments you both might have about that.
Yeah, so, it really depends on the service, some will just be funded or trained to work in drugs and alcohol or some can work on both, I think it really depends, but I think the way we do our assessment in our service is that we obviously focus on gambling, but we also do a holistic mental health assessment where we check about drugs and alcohol and other concerns a person may have, and if a person is having significant concerns of drugs and alcohol we may also refer them to get external support around that, but the comment there is really important, which is that we also don’t want to be overloading clients with too many services right, so in that case it is kind of a clinical decision of what are the main priorities and what the patient is able to commit to at this current time. Is it both? Or do they want to focus on the gambling first and maybe consider drug and alcohol counselling afterwards, so that’s normally a decision that we would make collaboratively with the patient based on what their concerns are and what they are willing to commit to when it comes to therapy.  Did you have any comments Kate?
Yeah, just add to what you said, I think it is also part of your assessment that you will be having a think about what’s the primary concern at the moment, what might be the underlying thing that is leading to these other problems, and as you mentioned Sofia, some drug and alcohol services do treat gambling.  We do have to be pragmatic I suppose.  If you do have a specialist service in your area, which you are lucky enough to have, that addresses gambling with clinical psychologist there who can do more broad assessments.  I think there is an element of pragmatism there that you might wish to refer to that, because it is a specialist area and sometimes in rehab facilities or in drug and alcohol they do address gambling, but it might be I suppose a little bit more superficial or something, so it may be that for some clients they do wish to go through and look at other addictions first, so it is up to _____ to identify where the clients are at and when they are ready and able to access that treatment for gambling.
I guess, we as GPs, if one of our patients has elected to embark on some counselling for a gambling problem, we can still be working with them on their substance issue at the same time, so there’s still treatments going in parallel with GP and counselling as well.
Sorry Jenny to interrupt.  Sometimes what you do find is once people’s gambling improves or resolves that perhaps their drinking or something is also … you can find that there can be some cumulative positive effects there too.
Yeah, so that’s very interesting and very _____ to hear.
In particular when it comes to mental health concerns like anxiety and depression that’s usually the thing that I would suggest for people, to do an assessment to see what came first, if the anxiety and depression is a separate issue that occurred earlier than their gamble or if it has come up as a result of the gambling, because often in the latter case, if a person gets treatment for their gambling that can naturally resolve anxiety and depression symptoms as well, so, they are interrelated.
It is. It is a murky web isn’t it?  Yes indeed.  And I am just acknowledging, yeah, Quentin has just drawn attention to the high levels of comorbidities that exist, which both of you Kate and Sofia have given us a background to, and I was very struck by those levels of self-harm attempts … that’s Australian data.
That’s right.  So, that’s something that’s not really widely known and that’s higher levels of those, that type of distress that is found in other substance use disorders or alcohol use disorder for example, but that is people presenting to specialist services for gambling, too often in crisis as we have discussed this evening, quite a distressed population and I think a lot of people think that there is no way out if they have got this level of financial stress.  I think it’s quite common and very normal to have those types of thoughts in those crisis situations and hopefully you are not seeing too many of those in your general practice, but it is a common presentation.
I keep thinking, it is sort of like the a, b, c and I am going back to the a, but it’s just that importance of us as GPs remembering to just ask the question because everything else is after that, and I know as we have seen people who is distressed and we are thinking about is there substance use, what’s going on in terms of mental health here, is to remember to include a question about gambling, just a simple question that you have outlined beautifully for us, and then that starts a conversation.
And I think Jenny as well…. yes, I am sorry for keeping on interrupting you, but I think it is important to acknowledge as well that this discussion can be very protective, so having a conversation with a trusted health professional, such as your GP, that can be a really protective, normalising and empowering place to discuss the fact you are in that level of distress, so, it is really important to address it head on.
Yes, which is really, do not be afraid of asking a question, it’s like an assessment of self-harm, we know that it is actually good to ask, don’t be afraid of asking. We want as GPs to be trying to start conversations with people about this.
And particularly when it comes to gambling, it is very rare that a patient will present and say I have an issue with gambling, they are usually presenting for their comorbidities and there’s other issues around gambling and sometimes it is only through piecing those puzzle pieces together and asking is gambling maybe a factor that is related to all of this, then a person reflects for the first time, yeah, that maybe a cause or contributing factor.
Yes, yes.  Okay.  So, I am just waking my way down here.  So, there’s another comment about is it possible for one counsellor to do both gambling and CBT issues, and there is one here from Quentin, could you please comment on the importance of addressing the gamblers’ overwhelming urge which makes it very difficult for the gambler to make critical decisions about their gambling choices and engage in _____ thoughts and they have got access to cash and the opportunity to gamble.  So, it is about eliminating gamblers’ urges through behaviour therapy, is that something that we can do?
Gamblers can then address….
Yeah, Quentin, that’s a really good comment and that’s part of the CBT treatment, quite early on we are talking about how people manage their urges to gamble and introducing skills for how they can do that and empowering them on top of what they have already tried or what they already can do, trying to add some skills there. It certainly is the case that there are cognitions that come with gambling and so that’s why the psychoeducation aspects can also be really important, because gamblers might believe for example that they can predict future events that are actually random or they might not understand perhaps how a pokie machine works.  So, these are key and important parts of the CBT process.  I am not sure if that answers your question, Sofia perhaps there is more that we can add, but CBT is the gold standard that we have at the moment.  It is from the 80s, but it still does a very good job and you know, behaviour therapy often addressing things like access to venues, access to money and looking at behavioural strategies for the time and energy that you are giving to gambling are really important parts of that process.
____ just following on from that, the GambleAware websites, so if we were to go to that, would that have sections in it that you could direct patients to that might list some simple things about addressing urges, that sort of thing?
Yeah.  There might be.  So, we have a browse of the website and there are some self-management and self-education tools and resources for the patients and that could be a really good starting point.
Yeah, sure, sure, okay.  And now Ashwin is asking about, when dealing with an older patient who has an issue with gambling, should we automatically screen for somebody’s capacity or insight as in, could there be some co-existing problem with dementia?  So, I think it’s a question about perhaps how you work with people whose cognitions might be a little bit affected, perhaps either by physical process like dementia or …?
It’s very trick, isn’t Jenny and Sofia, I mean we are looking at questions of capacity there and sometimes people are calling in distress about a family member saying, you know my dad is gambling the house from under us and are there things that I can do, power of attorney, are there things that I can put in place there and that’s a question of a capacity assessment, which your referral to a clinical psychologist for gambling treatment, usually they are voluntary processes.  So, that can be part of the evaluation with a hospital for something to do with delirium and there are things that the family members can do, so for example they can do third-party exclusions where if the person is gambling at the casino, the familiar member can ring up and say please don’t allow my dad to come into the casino.  So, I think for that specific clinical question that’s a really good idea to ring up the gambling helpline, speak to a psychologist and see what your options are there. I know that you are the GP, but it might be a way to get a little bit of clinical consultation there about specific capacity questions.
I would make the comment, I would certainly think it would be pertinent for us to screen something like mental state or some kind of screening if we are concerned about a person’s capacity and that would probably be best done early.  Okay so, thank you very much.  Somebody is asking, what do you do if somebody who gambles is at risk of self-harm and is declining to go to hospital.  GP is asking what would I do in an instance like that.  So, I think that’s really about management of suicide risk irrespective of what’s behind it, be it gambling, be it whatever factor is there, our first duty of care is to protect that patient.
So, that can be a tricky one and I think it really involves doing an in-depth risk assessment to see exactly what their level of risk is, and if the patient has a plan and intention to commit suicide and they say that they can’t keep themselves safe, that’s kind of at that level that you may need to bring in the external supports, like the mental health team or the police or so. But if a person is having thoughts of suicide, but is open to seeking help, or doesn’t necessarily have a plan or intention, that’s where the other supports of linking them in with a psychologist or social and family supports can be a good option and of course continuing to monitor for their level of risk and harm. Do you have any further thoughts on that Kate?
No, I think as Jenny really has commented that, no matter what has caused that risk, that’s the most important thing that needs to be addressed at that time as you both indicated, so, yeah, unfortunately as we said it is a common part of this presentation and it really needs to be managed as the first port of call and then the gambling is fixable, there are treatments there, there are strategies there after that crisis is passed and being managed.
Yeah, thanks for that.
And Quinton has provided a really good response in terms of assessing level of risk and resources and the numbers that you can provide the patient.
Very good advice.  Okay.  And Michael has said, I would love to get the panel’s thoughts on this scenario.  I remember two patients ____ decades who have had a gambling problem I have been unaware of.  They have ambushed a request for a release from barring from gambling establishments.  How do you respond to a non existent problem, I guess or in stage of change terms … a pre-contemplator.  And then he has a second part of that question which is quite separate, which we will come to in a second.  So, this is...
Apologies again.  I think I was answering your question before … sorry about that.  Yeah, but people are often precontemplative and as we said before, I am not quite sure what ambushed a request for release from barring from gambling establishments means, but, yes, family members can do third party exclusions, and I suppose, are you asking Michael perhaps that the patient has requested that you help to lift a self-exclusion, and we sometimes have those questions come through as well and patients ask us to write a letter and say that they will be okay to go into establishments and gamble after they have had a barring.  I don’t know if that’s what Michael is referring to there.  For us, we don’t tend to endorse that because that’s very difficult to clinically say.
Michael has answered yes to what you have asked.
Yeah, so it can be a nasty surprise as a clinician to say, I didn’t realise that this patient had a gambling problem.
Yeah.  It is sometimes quite shocking to find out the amount of money, it’s absolutely shocking.
And just in terms of working with someone who is in denial or really resistant to the view that they may have an issue with gambling.  You know, depending on if you have the time in the consultation and your relationship with the patient, it could be really useful just to help them explore their gambling a little bit more.  Again, that kind of, rolling with resistance attitude of just helping them to explore their gambling, where it is at, how much they gamble, how often, and how it impacts on other areas of their life and helping them to reflect on that.  That might be a start in just helping them to explore that a little bit more before pushing for treatment options if they are really expressing that they don’t want that at this stage.
I think, as GPs, you know, we talk a lot about stages and change, so thinking about that model and people who are precontemplators, they are not even at that ambivalent stage yet, they are just saying, no, I am not interested and that’s the only excitement I have got in my life and I get a thrill out of this and I just don’t want to change.  I guess we can still be asking their permission to give them information about gambling and maybe even doing things like saying, okay, you have come in to see me about x today, but would you mind if I checked in with you when you next come and see me and I will just see how you are going with that as well.  So, we have got … having that relationship with people over time, so when we do see people who are not interested in something at that point, we can make a note of it and always come back to it, that’s always been useful with people who are precontemplators.
Absolutely Jenny, but I think it can give that nasty shock and I would also want to say that it is not something that you can really identify very easily, you know, unless it is asked, unless it is disclosed, unless you are pointing to some of these things about financial hardship or whatever it is.  It can be very very difficult to identify a gambling problem.  So, if you have been seeing somebody throughout decades and you haven’t picked up on that please don’t blame yourself because it is something that’s very very difficult to see unless that person is willing to tell you that that’s what’s happening for them.
Yes, thats one of the important points I think you have been making, which is that people often carry a lot of shame and stigma around or for other reasons they may not want to disclose what’s been going on and it is very important for us to know as well.  There’s a comment about the RACGP making a stand … so we can talk to the RACGP about that.  There is another question, this often comes up when we are talking about things of a psychological nature, which is where do you find a counsellor or psychologist who is good at treating that particular problem.  So, this one is, what would be the best bet, how do I find a psychologist that’s good at dealing with gambling problems.
So with the GambleAware providers, we employ a number of different Allied Health professionals, but you know in some of the services there are psychologists and clinical psychologists, they work for us as well, so for example, in the regions that I work at, I am a clinical psychologist, so is Kate and I have colleagues that are clinical psychologists, so…. yeah, it could be through that, or like Quinton mentioned the _____ website also has information about clinical psychologists and they can list whether gambling is an area that they have experience in.
Okay.  That’s great.  Okay, Ashwin has asked… okay, back to a comment about capacity, are relatives allowed to ring a gambling establishment to bar their, for example parent, from entering it?  Or do they need to be an enduring guardian to have the authority to make that decision?
As far as I know, that is only in place at the moment for the casino in New South Wales, so the Star Casino, and I think the Crown should it open in New South Wales will also have that capacity in place.  There are some RSLs that do allow that, but I am not sure whether or not that’s legislated, but it is for the casino.  So, relatives can call and bar a relative at the moment. Your run of the mill pub, not actually.  The third-party exclusions are not part of what is offered in New South Wales at the moment; however, the minister for customer service who is sort of spearheading some of this improvement in services, is wanting to improve the technology around self-exclusions and legislate some of these aspects, so that conversation is happening in New South Wales at the moment.  So, watch this space.
Oh, interesting.
There’s a question about inpatient programs.  I guess that’s a question about probably people who are thinking about the substance phase, people go places with withdrawal… or I don’t know much of gambling.
I am going to say my opinion on this.
Yes.  Go for it.
There are inpatient programs, there are rehab programs for substance use and mood disorders, as you know, and we do recommend a couple of them that do talk to gambling.  It can depend on who else actually is in the rehabilitation program with you.  If there are other gamblers there then perhaps some of the inpatient programs can address gambling more fully or more specifically I suppose.  Some are better than others, but what … and I will get Sofia’s take in a minute, but what we tend to say is that if people are going inpatient there are lots of reasons why somebody might need to go in for an inpatient program.  It might be that that suite them better, it might be that their family will respond better to that, it might be that there are several other comorbidities going on for that person and it is the most suitable place for them at that time, but what we do say for gambling is that they do need that community-based support once they come back out, and that’s because you need to handle money in your life, you might need to walk past the pub, you might go down and have a beer with friends, whatever your triggers are they will be in your normal life.  So, we usually recommend to patients that they have some community-based support, and I saw some comments there on the chat about Gamblers Anonymous and that can be a support for people as well that they might want to check in with group-based support system like that.  It is not actually treatment in and of itself, but that can also be an important touch point for people too.  Sofia, I am not sure if you have anything to add.
Yeah, and I agree and these are my views as well from my experience.  There are inpatient programs, they are not funded under the GambleAware umbrella.  Some patients like the idea of going away for two weeks or a month in an inpatient program, but the reality is that they need to work on their gambling in a realistic setting where they are learning the skills to apply in day to day situations, so like Kate said, it’s the community-based support that I think is more effective long-term and yeah, with Gamblers Anonymous, it can be a useful support option, some people can find it validating to connect with other people with similar experiences and talk about their gambling and share their experiences, but it is not necessarily effective as a treatment option.
Thanks both.  Again, it’s drawing that parallel with people with substance disorders, that if we are thinking about if somebody is wanting withdrawal from a substance that time that they might spend in a withdrawal unit is really just one small part of the whole treatment program and that a lot of thought and motivational stuff has to go into that first part before anyone is even there, and of course once you walk outside the inpatient facility wherever you are, then begins the quite challenging journey of your first day without gambling or the substance or whatever and you need all those supports we are talking about.  Well, just checking the time, so we are going to finish off soon, I think there’s just time maybe for one more question here.  Just summarising, I think it’s actually about sort of how well do people do.  So, what is your experience, do gamblers once they have some psychoeducation treatment to engage and stop gambling.  Are they likely to relapse? What happens?  Depend on their severity of problem, depends on comorbidities?
Relapse is definitely possible and I guess it really depends on the person and if they are continuing to apply the skills and strategies that they have learnt from CBT, and of course when a person stops using those skills they can relapse and fall back into old patterns, so it’s about continuing to apply that in the long run, and kind of be vigilant around possible risks in future and to not get complacent, but yeah that being said, it is definitely possible for people to make long-term change if they are continuing to apply those skills and information.
Yeah, I would agree, the treatment is effective.  Usually the CBT treatment is designed so that you are introducing skills and you are also supporting that person throughout their stages of recovery over time, and hopefully arming them with their capacity to address stresses as they come up in their future life.  We do see relapse, a lot of the time people might re-enter treatment.  So, if you have established a really good rapport with somebody or they have had a really positive experience, that can sometimes be a good in for that next time, they might be much more likely to seek help should they need it in the future, but a lot of the really encouraging rates for recovery that we see with CBT for gambling disorder, because we are measuring people who stay in treatment and complete the treatment, and so we don’t get to see so much with dropouts, what happens there and if they got what they needed to out of treatment.
Interesting.  Alright.  I think we are just about time out now at 8:30, so I know everybody likes to finish on time.  So, I am afraid we will call it quits at this point, but we would really like to thank everybody for attending.  I think you all agree there has been really interesting presentations and discussions that we have had afterwards and thank you everybody for your very interesting and stimulating questions that you have asked.  I hope that you have learnt a lot and now you are a little bit more confident in assessing and treating people with gambling problems, and a really big thank you to both doctors Kate Fennessy and Sofia Tran for your participation tonight, it’s been really highly valued, thank you very much.  And goodnight everybody and I hope that you enjoy the rest of your evening.
Thanks everyone for joining us.

Other RACGP online events

Originally recorded:

29 September 2021

People with gambling problems can experience harm because of gambling in different parts of their life which include financial, health, relationships, education and employment, social and psychological well-being. It is estimated every person who has a gambling problem will affect six people.

General Practitioners (GPs) play an important role in identifying people with gambling problems and can refer them to available resources. GPs are invited to attend this webinar to improve their awareness of gambling harm, so they are equipped to offer solutions to help those in need.

Although this webinar is applicable on a national scale to GPs, the content of this webinar will focus primarily on NSW resources and services available.

This webinar is proudly funded by the NSW Government.

This webinar will cover:
  • What is Gambling Harm?
  • Prevalence of Gambling and public health impact in Australia and NSW
  • Case studies and screening tool examples
  • Use of psychoeducation
  • Co-morbidities- psychological, physical, and social
  • Strategies for referral
We are running this webinar again on Tuesday 26 October. If you'd like to attend this live webinar click here.

Learning outcomes

  1. Explain gambling harm and public health issues
  2. Identify co-morbid conditions and gambling problems
  3. Utilise a range of tools for screening for gambling in the general consultation
  4. Demonstrate strategies for providing psychoeducation to patients for reducing gambling harm
  5. Explain strategies for appropriately referring to gambling support services
This event attracts 3 CPD points

This event attracts 3 CPD points

This event is part of Gambling harm awareness training for General Practitioners. Events in this series are:


Dr Jenny James
MBBS, DCH, MPM, General Practitioner and GP trainer

Jenny has enjoyed working as a general practitioner for many years and works with the General Practice Drug and Alcohol Support Service at South West Sydney Local Health District. She previously worked at the Mt Druitt Aboriginal Medical Service for 23 years and coordinated the activities of the Substance Misuse Program within the Aboriginal Medical Service. She has a Masters in Psychological Medicine and has been a GP supervisor for many years. Her interests include doctor’s well-being and resilience, and program planning that integrates physical, mental and drug health care within primary health care settings. She loves talking with fellow GPs about all matters of addiction.


Dr Kate Fennessy
Senior Clinical Psychologist

Kate Fennessy works as a senior clinical psychologist at St Vincents Hospital, and is the manager and clinical lead of GambleAware South Eastern Sydney. The service is responsible for service delivery to people affected by gambling in the South Eastern Sydney LHD geographical region. Kate holds a Doctor of Clinical Psychology and Master of Science from the University of Sydney. Kate has worked in public health settings for the last eight years, with a core value of equitable access to quality psychological treatment. Kate is also a conjoint lecturer at the School of Psychology, ACU.

Sophia Tran
Clinical Psychologist & Supervisor

Sophia Tran is a Clinical Psychologist and Supervisor at the Gambling Treatment and Research Clinic (GTRC), University of Sydney. She holds an Honours degree in Psychology and a Masters degree in Clinical Psychology, both from the University of New South Wales. Sophia has in-depth experience providing individual and group treatment to problem gamblers, counselling services to family members of gamblers, and delivering presentations and workshops to health professionals and community organisations about problem gambling. She has also been involved in the development of an innovative cognitive-based treatment program for problem gambling.

Gamble Aware


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