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

Sean Sullivan PhDABACUS

What is intimate partner violence?

Intimate partner violence

Controlling behaviour

Isolating partner, monitoring,

restricting access

Physical violenceHitting, kicking,

beating

Sexual violence

Emotional violenceInsults,

humiliation, threats

Some research-based factors for IPV

Intimate Partner

ViolenceAlcohol & drug use

Personality disorders

Economic stress

Low self esteem

Insecurity

Depression

Anger control

Increased Risk in PGNZHS; Kessler 2008;Zimmerman 2006;Korman 2008;Cunningham-Williams 2007;Petry 2005

Disorder General Population PGAlcohol (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• Anecdotally, many PG Practitioners may consider their gambling clients to typically be quiet, withdrawn, isolated, and unlikely to be violent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 PGsMassachusetts Council PG

Gambling Problem

73% alcohol disorder

38% drug use

disorder 60% nicotine

dependent

Personality disorders & violenceFountoulakis et al 2008

• Personality disorders associated with violence include– Borderline PD– Antisocial PD– Narcissistic PD– Paranoid PDAll of these PDs are elevated in PGs!

Prevalence of Personality Disorders

PD General prevalence Prevalence in PGSteel & 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 genderSuomi, 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-riskEcheburua 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 researchDowling 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 moreDo 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 yesIn 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 yesIn the last year, have you ever used non-prescription or recreational drugs more 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 unhappy or worried after a session of gambling? (if you do not gamble, just tick no) no yesDoes gambling sometimes cause you problems? 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 often been bothered by feeling down, depressed or hopeless? no yesDuring 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 yesWhat 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 yesIs 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