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Mental Health Services - Compulsive Gambling Treatment and Prevention Initiatives

Indiana Problem Gambling Prevention Plan

July 15, 1998

Developed by:
Louisiana State University
School of Social Work
Office of Social Service Research & Development
311 Huey P. Long Field House
Baton Rouge, LA 70803
P: 504.388.4838
F: 504.388.0428

Reviewed by:
Louisiana State University
Medical Center – Shreveport
Department of Psychiatry, Gambling Studies Unit


Project Overview

  1. Introduction
  2. Statement of the Problem
  3. Development of Gambling in Indiana
  4. Indiana Problem Gambling Research Project
  5. Development of a Problem Gambling Prevention Plan
  6. Planning Rationale and Evaluation
  7. Recommended Indiana Prevention Plan, 1998-99

References

Appendix 1: Prevention Programs

Appendix 2: Community Readiness Assessment Questionnaire

Appendix 3: Community Problem Gambling Prevention Team Job Description

Bibliography


Project Overview

In an effort to continue its commitment to a healthy Indiana, the Indiana Family and Social Services Administration (FSSA) initiated the Indiana Problem Gambling Research Project in 1996. In the 1993 and 1995 legislative sessions, Indiana lawmakers passed legislation that approved the FSSA’s initiation of the project to ensure the development of healthful behavior surrounding gambling. The FSSA published a broad agency announcement in September 1996 for a statewide problem gambling prevention campaign.

The Louisiana State University Division of Continuing Education submitted a proposal to conduct baseline research that would determine the prevalence of problem gambling in Indiana and lay the foundation for the development of an effective problem gambling prevention plan. The LSU proposal was appealing to grant reviewers because of the social service research expertise available that had developed to address the serious problem gambling issues confronting Louisiana.

The approach proposed by the research team included quantitative and qualitative research to establish baseline data that would empirically link the scope of problem gambling in Indiana to effective social policy and action aimed at problem gambling prevention and treatment. This project was transferred to the Louisiana State University School of Social Work Office of Social Service Research and Development (LSU-OSSRD) in July 1997 and conducted through that office.

The primary goal of the research study was to determine the prevalence of problem gambling behaviors in order to develop a statewide prevention plan. From this initial information, a solid foundation for future planning and programming can be established. The plan is designed, first and foremost, to confront gambling problems before they occur and to provide programs that discourage irresponsible gambling by supporting healthy behavioral growth and development.

Indiana is confronting the early stages of problem gambling behavior development among its citizens. Young children, adolescents and senior citizens are especially vulnerable to the "glamorization" of gambling and should be educated about potential problem gambling. Underage gambling must be discouraged at all costs. A firm basis for future action is critical for the state to effectively deal with the issue of problem gambling and associated problems and to develop strategies to reduce its impact on Indiana’s families and communities.

Based on the findings from the proposed research and from a review of related social science literature on effective prevention strategies for addictive behavior, this document proposes a preliminary problem gambling prevention plan for the state of Indiana. The plan includes recommendations for targeting primary, secondary and tertiary levels of prevention through the Social Development Model that has become nationally known for its comprehensive, multi-level approach to preventing other problem addictive behaviors.

The Indiana Problem Gambling Research Project is intended for review and adaptation by policymakers, decisionmakers and the mental health treatment professionals in Indiana. The plan is designed for implementation at both state and local levels. The timing for a comprehensive Indiana Problem Gambling Prevention Plan couldn’t be better. There is a healthy attitude among policymakers, citizens and the gambling industry in Indiana concerning the potential positive and negative effects of gambling. As one industry representative said at a recent meeting, "We may work for the industry but we are all Hoosiers first. We feel the same sense of responsibility about our state". Her statement seems to reflect the cooperative and community oriented attitude that everyone involved voiced about maintaining a healthy and progressive state.


I. Introduction

Development of Gambling in the United States

Gambling activities have become increasingly widespread in the United States since the first modern state lottery was established in New Hampshire in 1964. Pari-mutuel gambling, or betting pools, began to spread across the United States, and gambling casinos were legalized in New Jersey in 1978.

Even though Nevada legalized the nation’s first casino in 1931, the extensive opportunity of gambling activities did not capture the American public’s attention until the 1970s and 1980s. Casino activities were limited to Nevada and Atlantic City until federal spending cutbacks and declining tax revenues forced state legislatures and governments to seek out additional sources of revenue (Volberg, 1996).

Betting on sports games and playing coin-operated machines have become common throughout the United States. Many of these activities were initiated innocently enough, even when they were followed by other games such as lotteries and racetrack betting. The encroachment of gambling activities was slow, as weekly and daily drawings, instant games and video games became legal in state after state. The revenue created was a welcomed relief to the economic recession in many states.

In 1988, the Federal Indian Regulatory Act opened the door to widespread casino development throughout the country. By 1993, riverboat gambling had been established in six states, and land-based casinos were legalized in several additional states. Gambling has become normalized across the nation, and various gambling activities are legal in all states except Hawaii and Utah.

The effects of the proliferation of gambling have to be carefully analyzed because the majority of people gamble for entertainment. For many people, gambling is an acceptable, inexpensive activity to enjoy several times a year. People who develop gambling problems are in the minority.

The impact of the gambling proliferation can be seen through the increase in the amount of funds legally gambled as well as gaming industry earnings. In the nation, the $17 billion gambled in 1979 increased to $247 billion legally spent in 1989. From 1989 to 1995, the total amount of money spent on legal gambling in the United States continued to increase yearly, reaching $586.5 billion in 1996 (Christiansen, 1997; National Council on Problem Gambling, 1993). The gaming industry recorded $47.6 billion in earnings in 1996, up 5.6% from the previous year (Christiansen, 1997.)

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As gambling activities have become more available, the number of people developing problem gambling behavior has increased. Because of the nature of gambling addiction, individualized problems become major and often result in hidden social problems because of the financial implications related to maintaining the addiction. State governments are now in a position where they must discourage irresponsible gambling behavior and respond to social problems affecting their communities.

Gambling Behavior:

A Differentiation in Terms

Gambling behavior must be placed in proper context so that social policy as well as prevention and treatment efforts can be appropriately directed.

Definitions of Gambling

Gambling is defined by Gamblers Anonymous (GA) as ". . .any betting or wagering, for self or others, whether for money or not, no matter how slight or insignificant, where the outcome is uncertain or depends upon chance or ‘skill’."

Shaffer et al (1997) define gambling as ". . .participants pursue monetary gain on chance outcomes without using skill." They also differentiate from other similar activities like speculation and investment. Speculation is defined as "backing one’s opinion against the market or an established opinion without sufficient information about the certainty of the outcome." Investment is defined as ". . spending time or money engaged in activities where sufficient experience serves as a guide, however uncertainty still remains."

Dr. Robert L. Custer, the pioneer in gambling treatment, described compulsive gambling as "an addictive illness in which the subject is driven by an overwhelming, uncontrollable impulse to gamble. The impulse persists and progresses in intensity and urgency, consuming more and more of the individual’s time, energy, emotional and material resources. Ultimately, it invades, undermines and often destroys everything that is meaningful in a person’s life." (Custer, When Luck Runs Out).

Different Types of Gamblers

Current data indicate that more than 80% of the American public participates in some form of gambling (Lesieur, 1993). Most people who gamble do not become problem gamblers and do not develop behavior that causes damage to their families, their communities or their places of work. Those who gamble for entertainment are called responsible gamblers or social gamblers.

Shaffer, Hall and Vander Bilt (1997) delineated three levels to describe gambling behavior. Level 1 gambling has little or no adverse consequences associated with the gambling behavior (a recreational or responsible gambler). A level 2 gambler has a pattern of gambling behavior that is associated with a wide range of adverse consequences (a problem gambler). Level 3 gambling refers to disordered gambling and has the most severe consequences associated with it (a pathological gambler). Based on their past-year activities, approximately 1.14% of adults and 5.77% of youth from the general population are pathological gamblers (Shaffer et al, 1997). The Indiana Problem Gambling Research study also utilizes these levels to describe and differentiate among the levels of gambling involvement.

Currently, the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) defines pathological gambling as "persistent and recurrent maladaptive gambling behavior" that significantly interferes with personal, family or vocational pursuits. The terms "pathological" and "compulsive" are typically used interchangeably, with treatment professionals preferring the term pathological and lay persons preferring the term compulsive. The term "problem gambling" usually refers to individuals who exhibit some signs of pathological gambling but are not significantly symptomatic to meet the full diagnostic criteria (Lesieur and Blume, 1993).

For the purpose of this document, the term problem gambling is used to describe any level of problem or pathological gambling behavior (level 2 and level 3 gamblers) and responsible gambling to describe gambling behavior that does not indicate a problem (i.e. level 1 gamblers).

Perception of Gambling as an Addiction

When the National Council on Compulsive Gambling (NCCG) was initiated in 1972, public perception of a compulsive gambler was that of a "degenerate thief who gambled out of control as a result of greed, with a total disregard for family, job, and community" (Dunne,1985). The NCCG attempted to change negative public perception of compulsive gambling so that it was recognized as a treatable illness. This change was eventually accomplished through educating the public and health care providers about the social impact of gambling.

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This effort also led to gambling being considered a disease. As recently as 1990, 50% of the public viewed just the act of gambling as a disease. (Shaffer et al, 1997). Reportedly, the belief that pathological gambling is a disease decreases the degree of guilt found in compulsive gamblers and their family members (Murray, 1993), thereby increasing the likelihood of these persons seeking treatment and not being ostracized by their friends and family members.

Robert Custer established a model of compulsive gambling and recovery which he delineated into phases. The gambler is seen as progressing through these phases, the winning phase, the losing phase and the desperation phase (as shown in Figure 1) in their progression from a social or responsible gambler to a pathological gambler. Most people begin gambling for a variety of reasons, such as fun, excitement, or the need of a quick profit. However, for some, these reasons soon become secondary and non-existent, and are replaced by an all-consuming preoccupation with the gambling activity. Custer states that this progression usually begins with a "big win" or a series of wins, which act as a "hook" to getting the person more deeply involved in the activity (i.e. the winning phase). The person will eventually lose and begin to chase their losses (i.e. the losing phase). The person may begin to borrow from their friends and family to finance their gambling and lie to cover up the extent of their problem gambling behavior. During the last phase (the desperation phase), the gambling activity is no longer a source of excitement or pleasure but a consuming activity that occupies the majority of the persons time and serves to alienate them from their friends and family. The extent of their losses may be great, both financially and socially, sometimes leading to illegal activities, depression and suicidal thoughts.

Compared to other addictions, research on gambling treatment and prevention is still in its infancy. While there is some controversy on what causes an individual to develop an addiction (biological components, behavior, etc.), professionals agree that the cause is multi-factored and must be taken into consideration when developing prevention and treatment programming.

Perhaps more importantly, but at least simultaneously, prevention efforts should be targeted at later childhood and adolescence because of the increased risk in these age groups. Prevention and treatment efforts must also be undertaken for specialized at-risk populations, such as the elderly, poverty level persons and minorities. Additionally, prevention and treatment planning must take into account the fact that gambling disorders have increased among adults during the past two decades (Shaffer, Hall and Vander Bilt, 1997).

II. Statement of the Problem

Gambling is big business. Alleged economic benefits to communities range from increased tax revenue to additional tourist dollars to more jobs. Gambling opportunities continue to spread despite increasing evidence that social problems are related to gambling behavior. Other states, including Indiana, have begun to address the impact of problem gambling on their communities by considering what educational and prevention strategies must be implemented.

As Shaffer et al (1997) point out, "...gambling is neither a financially nor a psychologically risk-free experience." The expansion of gambling activities has resulted in an increased number of people reporting serious financial difficulties in addition to a variety of psychological, legal and social problems.

Social and Fiscal Impact of Gambling Nationally

Typically, a problem gambler will face serious financial, family and work-related problems as a result of his gambling activities. Financial problems are often one of the first repercussions that will draw attention to a problem gambler’s behavior.

As the gambling problem becomes worse, lying and deception increase. The individual will often first deplete personal finances and sources of legal borrowing, usually without the knowledge of the family. When these avenues are exhausted, the risk of the individual seeking illegal means to support gambling increases. Many problem gamblers report committing robbery, forgery, insurance fraud and writing bad checks, which may lead to criminal justice problems.

Significant behavioral changes occur as adults and youth become more preoccupied with their gambling. Adults may lose time from work and have decreased productivity. For youth, problem gambling manifests itself as tardiness and truancy (Haubrish-Casperson, 1993). A problem gambler’s family may often suffer from a lack of attention and financial support. By the time a gambler seeks treatment, he is often in debt, alienated from friends and family, possibly on the brink of divorce, close to arrest (about ΒΌ of problem gamblers) and may have difficulties with depression and suicidal thoughts (Carone, Yolles, Kieffer and Krinkshy, 1982).

Additionally, problem gambling has been associated with other mental health problems. Research indicates that the most common co-morbid problems are substance abuse and depression. Ramirez, McCormick, Russo and Taber (1983) found that 97% of 51 men admitted to their gambling treatment program also met criteria for major depression. Frank, Lester and Wexler (1991) surveyed 500 Gamblers Anonymous members and reported that 21% of the participants stated they had never thought of suicide, 48% said they had thought about suicide and 13% had attempted suicide.

The impact of problem gambling on a community can also be significant. As an increasing number of states legalize a variety of forms of gambling, more people are experiencing gambling problems. Politser, Morrow and Leavery (1985) reported that the social cost of excessive gambling "ranks among the most expensive illnesses afflicting society, though it is among the least expensive to treat." In 1995, $500 billion was legally wagered in the United States. This is a dramatic increase from the estimated $17 billion wagered in 1979, just less than two decades earlier. With the exception of Utah and Hawaii, all states have some form of gambling. Lotteries are legal in 37 states as well as Washington, D.C., and 26 states have casinos. Lottery spending per capita rose from $20 to approximately $150 per year (Clotfeller and Cook, 1989; McQueen, 1996).

National trends relating to the impact of gambling are also seen on a statewide level. States must now take a closer look not only at the economic impact that gambling opportunities have provided but also the social repercussions that affect their citizens and communities. Indiana and other states where gambling has not been legal for many years are in a strategic position to curtail or lessen the effects of problem gambling.

III. Development of Gambling in Indiana

Origin of Legalized Gambling in Indiana

The development of gambling in Indiana is not significantly different from other states, with the possible exception of Indiana’s limited availability of gambling within the last few years. The Indiana Lottery initiated operation on October 13, 1989, becoming the first of four forms of legal gambling opportunities in the state. In September 1994, Hoosier Park, the state’s first horse racing venue providing wagering opportunities, opened in Anderson. In 1993, 11 riverboat gambling sites were legislatively authorized. By December 1996, boats had been launched in Evansville, Gary, Hammond, Rising Sun and Lawrenceburg. Currently, five boats are operating in Lake Michigan and three on the Ohio River (Family and Social Services Administration, 1997).

Charitable gambling is also big business in Indiana. Qualified not-for-profit organizations may conduct certain types of legal charity gaming activities. These activities include bingo, charity game nights, door prizes, festival events and raffles as well as the sale of pull tabs, punchboards and tip boards. A total of 930 Annual Bingo Licenses were issued during the fiscal year 1997. The total gross income of charitable gaming in 1997 was $516 million, which is a reported $58.5 million increase over 1996 (Indiana Department of Revenue, 1997).

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The Hoosier Lottery is a popular form of entertainment in Indiana with almost $600 million wagered in 1997 alone. The Hoosier Lottery’s nine varieties of lotto, including the popular Powerball and Hoosier Lotto, provided $176 million in revenue for the state in 1997. As of February 1998, various state programs received more than $1.3 billion from the lottery. Since its inception to date, total prizes awarded by the Hoosier Lottery amount to $2.5 billion (Hoosier Lottery, 1997).

The six riverboats operational throughout 1997, in addition the two boats which became operational during 1997, had a total win of $961 million (Indiana Gaming Commission). Other gambling opportunities such as the Hoosier Park pari-mutuel horse track and three off-track betting parlors had $147 million in monies wagered in 1997 with total revenue for the state amounting to $4.3 million (Horse Racing Commission, 1998).

Indiana Legislative Response

As gambling became established in the state, the Indiana legislature took action to address the social impact that would predictably develop. In 1993, the Indiana General Assembly passed a law requiring that 10 cents of each admission tax to Indiana riverboats be paid to the Indiana Family and Social Services Administration Division of Mental Health (DMH). The 1995 General Assembly amended the law to allow these monies to be used "…for the prevention and treatment of addictions to drugs, alcohol and compulsive gambling, including the creation and maintenance of a toll-free telephone line to provide the public with information about these addictions." The legislature also required that the Division "…allocate at least 25% of the funds…to the prevention and treatment of compulsive gambling."

Indiana Governor Frank O’Bannon appointed a 13-member Gambling Impact Study Commission in January 1998 and charged them with examining the effect legalized gambling has on Indiana. In the executive order establishing the commission, O’Bannon instructed its members to "…assess the impact of gambling on individuals, families, communities, businesses, social institutions and the economy. This comprehensive look at the whole picture will enable the committee to assess revenue and economic growth created by gambling as well as any problems associated with gambling such as bankruptcies, suicides and other mental health problems." Committee members representing community interests include but are not limited to representatives from the Indiana Gaming Commission, Indiana Family and Social Services Administration, Indiana Chamber of Commerce and representatives from both the House and Senate. The commission meets regularly and reports on its progress periodically. A final report will be issued to the Governor by December 31, 1999.

Role of the Indiana Family and Social Services Administration

As the state agency that deals with Indiana’s social problems, the Family and Social Services Administration (FSSA) is the appropriate organization to be responsible for addressing problem gambling and related issues. Currently, the FSSA provides services to families who have problems associated with low income, mental illness, addiction, mental retardation, disabilities, aging and children who are at risk for unhealthy development. FSSA works to strengthen the ability of families to succeed in their communities.

The Family Social Services Administration Division of Mental Health (DMH) works to assure the availability of accessible, acceptable and effective mental health and chemical addiction services for Hoosiers through community mental health centers. The DMH is the division that will handle gambling addiction and related problems. In addition to treatment of mental health problems, the FSSA is also mandated to provide prevention services throughout the state.

For a new problem gambling prevention component to be effective, it will need to "fit in" with the existing FSSA organization, philosophical framework and service delivery system. Although the provision of prevention and treatment services for problem gambling must be differentiated from other substance abuse services, there must be some type of "integration" of prevention and treatment philosophy and interaction between the systems for providing the services. Problem gambling is an addictive issue, which places it into the same social policy arena as other addictive behaviors. However, the initiation of early problem gambling behaviors, the progress into addiction and the response from the treatment field is different from other addictive diseases. For these reasons, an effective plan must integrate the current prevention services within FSSA.

Current substance abuse prevention funds in Indiana are derived from the Federal Omnibus Anti-Drug Abuse Act of 1986. Each state is required to dedicate 20% of their substance abuse block grant funds strictly for alcohol and other drug prevention services. To continually qualify for federal substance abuse funds, each state must have a prevention strategy in place. Prevention programming for problem gambling should be included in the state’s existing structure because it is a logical fit and it would be fiscally more responsible than creating a separate system.

The DMH has provided prevention services since 1987 and has distributed more than $50 million in federal block grant funding to community-based prevention programs. As the prevention system developed in the state during the past 10 years, there has been an increasing emphasis on placing prevention monies into empirically-sound services. Because prevention monies are limited, grants awards are targeted to those organizations and agencies that demonstrate need, offer services that produce effective outcomes and coordinate cost-effective programs.

The DMH established a network of 14 "Local Prevention Services Coalitions" to ensure the most effective use of prevention monies. In August 1997, Governor Frank O’Bannon announced the new $5.2 million Local Prevention Services Initiative. The initiative was designed to facilitate the provision of services across the state that were consistent with extensive effectiveness research conducted by the Indiana Prevention Resource Center in the Indiana University School of Health, Physical Education and Recreation.

The research conducted by the IU School of Health, Physical Education and Recreation examined the most effective types of prevention programs for specific populations. Researchers provided guidelines to implement the award process for program funds at the community level. It is important to note that the IU researchers promote the use of risk and protective factor theory as the framework from which effective prevention programming occurs. The effectiveness research provided by IU, as the foundation for alcohol and other drug abuse prevention services, is consistent with the theoretical framework proposed by the LSU researchers for use in developing problem gambling prevention services. This will result in a much easier implementation of gambling prevention planning and programming.

Local coalitions are in place now and are operated and managed by contractors who coordinate substance abuse prevention services in each of the defined service areas across the state. Each of the local contractors are responsible for creating, implementing and managing a Coalition of Direct Prevention Service Programs in its defined service area. The contractor must recruit collaborating member agencies to implement Direct Prevention Services Programs in the service area according to criteria established through the DMH. The regional prevention services program must implement the DMH recommended evaluation process to demonstrate process and outcome effectiveness. The regional prevention service centers are supervised and monitored through the DMH organization.

This structure will be conducive to the development and implementation of problem gambling prevention services, even though, at this time, the federal funding for problem gambling and substance abuse prevention cannot be combined. The federal funds provided to the state are for substance abuse prevention services only. The problem gambling prevention services will most likely be funded through the funds that are collected from the various forms of legalized gambling in the state. It should be feasible to maintain separate funding while utilizing the same system for provision of prevention services.

Legislative action authorized the FSSA to address problem gambling prevention needs in the state. To address this responsibility, the FSSA (DMH) established the Compulsive Gambling Addiction Services Advisory Committee in 1995 to create a system to fund problem gambling prevention and treatment. This committee met through February 1996. Members included representatives from the addiction treatment community, social service agencies, the Indiana Commission for a Drug-Free Indiana and the Division of Mental Health. Issues addressed included the continuum of care for problem gamblers, certification of service providers, eligibility standards for funding support through the DMH and prevention efforts.

The FSSA-DMH’s efforts to address problem gambling are concentrated in four major areas:

1. Toll-Free Telephone Line

In December 1995, the DMH contracted with the Governor’s Commission for a Drug-Free Indiana to provide referral information to persons requesting help with a gambling problem. This toll-free number is printed on riverboat admission tickets, all state lottery tickets and advertised in other media markets. Through January 1998, more than 1,104 calls were received.

2. Prevention

A prevention initiative emerged out of recommendations of the Compulsive Gambling Advisory Board. A broad agency announcement for a statewide problem gambling prevention campaign was released September 30, 1996. The LSU Division of Continuing Education was awarded this project. However, the project was transferred to the LSU School of Social Work Office of Social Service Research and Development. The LSU-OSSRD was then responsible for designing a prevention plan for Indiana.

The prevention planning included:

  • Conducting quantitative studies to detect the extent and scope of the gambling problem in Indiana (prevalence) and which populations (geodemographic clusters) are most likely to be affected. It also established a baseline to measure prevention activity effectiveness.
  • Devising a prevention plan tailored specifically for Indiana that is based on research results and recommendations and will set specific outcomes, procedures and responsibilities.
  • Establishing and working with an Ad Hoc Advisory Committee to review and shape the prevention plan.

3. Treatment

In April 1996, the DMH held an informational meeting for the service provider community to publicize preliminary decisions regarding the funding of gambling treatment services. The Hoosier Assurance Plan would include gambling treatment. Providers certified by the DMH as managed care providers for substance abuse (SA) and serious mental illness (SMI) could qualify for a compulsive gambling treatment endorsement. As of January 1998, 16 providers had contracted to provide these treatment services. In July 1998, 20 state-certified providers will offer services.

Clinical eligibility for services is determined by the following definitions: (a) a compulsive gambler is an individual who meets criteria for Axis I diagnosis of pathological gambling as set out in the DSM-IV, Diagnosis 312:31, and Pathological Gambling; and (b) the individual continues gambling behavior despite repetitive, harmful consequences.

To be eligible for coverage under the Hoosier Assurance Plan, the individual must have an income at or below 200% of the federal poverty guidelines. Gambling debts and payments on incurred gambling debts are used in calculating income eligibility. Clinical assessment is accomplished by the Hoosier Assurance Plan Assessment instrument (HAPI-A). The South Oaks Gambling Screen (SOGS) is also used on all persons presenting for service for a compulsive gambling problem. There are 107 people enrolled for treatment services so far this fiscal year; 31 were enrolled in SFY97.

In addition to the full continuum of care mandated for the SA and SMI populations, managed care providers for gambling services are required to offer inpatient and intensive outpatient services, linkage with self-help groups and financial management counseling. Availability of inpatient care is seen as essential because severe depression and suicide ideation are frequently present in persons presenting for treatment. Additionally, linkage to self-help groups such as Gamblers Anonymous is a part of the continuum of care. An episode rate, the dollar amount the DMH gives to a certified provider to serve an eligible consumer for a one-year period, was negotiated with qualified providers. An actuarially based rate is projected to be established for SFY 2000.

4. Training of Therapists

Recognizing the scarcity of therapists trained to work with persons with compulsive gambling disorders, the DMH contracted with the Fairbanks Training and Research Institute of Indianapolis to provide five regional workshops on the treatment of compulsive / problem gambling. Participants in these sessions, which were offered at low cost to therapists working with DMH certified managed care providers, helped qualify therapists for certification as compulsive gambling counselors by the American Council on Compulsive Gambling. It is estimated that given present patterns, a minimum of $2.4 million will be deposited in the Gamblers’ Assistance Fund each year, allowing the Family and Social Services Administration to continue to support compulsive gambling prevention efforts and treatment.

(Information provided by the Family and Social Services Administration, March 1998)

Governor’s Commission for a Drug-Free Indiana

Indiana’s commitment to community based prevention is also demonstrated by the Governor’s Commission for a Drug-Free Indiana. The Commission takes a three-pronged approach to prevention and the development of social policy regarding alcohol, tobacco and other drugs. The agency serves as an advisor to the Governor to develop policy regarding alcohol, tobacco and other drugs, collaborates with other state agencies to address concerns in the area alcohol, tobacco and other drugs, and mobilizes citizens within their own communities around the reduction of substance abuse.

The commission developed a regional technical support network consisting of five regional offices representing six regions. Each office houses three consultants to provide support for state and local coalitions. The network aims to make government more responsive to the needs of local communities. Each of Indiana’s 92 counties has a Local Coordinating Council (LCC) made up of volunteers that serves as the backbone of the Indiana drug-free effort. The volunteer coalitions are charged with identifying community drug problems, coordinating local initiatives, monitoring anti-drug activities at the local level and designing comprehensive, collaborative community strategies.

LCCs can use their own discretion of what prevention, treatment or justice programs are needed within its community. Aware of the relationship between substance abuse and gambling, few communities have already initiated programs related to the prevention of problem gambling. Clark County located on the river has included problem gambling prevention as part of their mission while other counties are beginning to address the whole spectrum of addictive behaviors.

Funding for local drug-free community initiatives is provided at both state and local levels. LCC’s must submit comprehensive action plans for review and approval by the Governor’s Commission for a Drug-Free Indiana before funding is to be allocated. The Drug-Free Communities Funds are collected from local dollars through various offender fees.

IV. Indiana Problem Gambling Research Project

Design

The first step of the Indiana Problem Gambling Research Project was to determine how gambling behavior in Indiana compared to the rest of the nation. This project was structured to assess whether problem gambling is significantly different in Indiana than national estimates. Problem gambling in Indiana needs to be quantified to establish an empirical basis for social policy and ensuing action.

To address this question, LSU-OSSRD collaborated with the Louisiana State University Medical Center-Shreveport, Department of Psychiatry, Gambling Studies Unit (LSUS-MC) to develop the instruments necessary to determine the prevalence of problem gambling in Indiana.

LSU-MC developed four surveys to determine the prevalence of disordered gambling behaviors within specific populations in Indiana. Targeted populations were adults (18 years and older), adolescents in 6th through 12th grades in public and private schools and incarcerated adult and adolescent offenders within Indiana correctional facilities. These specific populations were chosen to determine prevalence rates in both adults and adolescents in the general population, which have been reported to be different, and the prevalence of gambling behaviors and disorders in incarcerated populations. The level of problem gambling behavior has been found to be higher in incarcerated populations nationally, which is presumably due to the relationship between problem gambling and criminal behavior (to the extent that the former causes the latter). This will aid in establishing necessary levels of prevention and treatment in these populations.

To obtain feedback from the citizens of Indiana, focus groups were conducted to obtain qualitative data regarding the perceptions that citizens have about gambling. The groups included teachers, minorities, senior citizens, community service providers and a random group of the population at large. Finally, a treatment provider survey was distributed to treatment professionals in Indiana to assess their views about the prevalence of problem gambling across the state and to gather information regarding their experiences with gambling-related problem behaviors.

Surveys and focus groups were conducted by subcontractors within Indiana.

Below is a summary of each research study underscoring its method, sample size, limitations, findings, comparative national data and implications for prevention and treatment.

Telephone Survey

Shaffer, Hall and Vander Bilt (1997) delineated three levels of gambling behavior. Level 1 gambling has little or no adverse consequences associated with the gambling behavior (a responsible gambler). A level 2 gambler has a pattern of gambling behavior that is associated with a wide range of adverse consequences (a problem gambler). Level 3 gambling refers to disordered gambling that meets diagnostic criteria and has the most severe consequences associated with it (a pathological gambler). A telephone survey of 2,927 Indiana residents was completed to determine the prevalence of level 2 and level 3 gambling behaviors among adults (18 and older) and to establish baseline factors that will guide prevention planning.

Persons were selected randomly to complete a survey, which included the South Oaks Gambling Screen (SOGS). The SOGS is a 20-scorable item questionnaire based on the criteria in the Diagnostic and Statistical Manual for Mental Disorders-III. The SOGS identifies pathological gamblers. The SOGS was used to determine problem levels associated with gambling. A score of 5 or more is consistent with level 3 gambling, a score between 1 and 4 is consistent with level 2 gambling, and zero would be considered level 1 gambling.

Of the respondents, 87% reported they had gambled. The majority of the total sample were found to be level 1 gamblers (93.9%), with 5.3% being level 2 gamblers and 0.8% being level 3 gamblers. Level 2 gamblers spent 40 hours on average per month gambling, and level 3 gamblers spent 104 hours on average per month gambling. Level 3 gamblers, on average, missed almost three days from work per month.

The limitation to a study of this type is that the sample is limited to those persons who have a working phone. Thus, homeless person or persons without phone service were not sampled. Also, individuals that were not home at the time of the call were rarely successfully contacted at a later time.

School Survey

Meta-analytic studies of adolescent gambling disorder prevalence on students have resulted in estimates of possible problem (level 2) and pathological gambling (level 3) that are higher than estimates in adults (Shaffer et al., 1997). Past-year level 2 adolescent gamblers are estimated at 14.8%, and past-year level 3 adolescent gamblers are estimated at 5.8%. Indiana 6th through 12th graders were surveyed to ascertain the prevalence of gambling behavior and to assess the average age of onset for experimentation with gambling.

Because few schools agreed to participate, the sample could not be randomized. Attempts were made to sample all students from 6th through 12th grades of the schools that participated. A sample of 3,270 accurately completed surveys were returned and analyzed.

National statistics indicate that the first personal participation adolescents have with gambling is at age 11. This finding was essentially replicated in this survey, with median age of onset being 11 for the current study. In fact, by 6th grade, approximately 70% report having gambled before. Adolescents who believe that skill is involved in gambling tended to be more at risk to develop problems. National data indicates that 33.1% of adolescent gamblers initiate with sports betting activities, 26.3% with card playing and 10% with the lottery. Adolescents who believe that skill is involved in gambling tended to be more at risk to develop problems. Adolescents believed that sports betting and cards required the most skill. The popular gambling partners for adolescents were friends and members of their family. (Shaffer et al, 1997) The Indiana School Survey does not provide comparative data to this national information.

Table 3 provides a comparison between the lifetime involvement in various gambling activities for the national meta-analytic study by Shaffer, Hall and Vander Bilt (1997) and the current study of Indiana adolescents.

Table 3: Percent of adolescents who have ever participated in gambling activities: national statistics versus Indiana adolescents

Gambling activity National (%) Indiana (%)1
Any gambling activity 77.55 90.10
Casino games 2 7.74 5.90
Lottery 3 34.89 68.20
Sports Gambling 4 38.17 56.00
Pari-mutuel 10.88 15.75
Financial Markets -- 13.74
Non-Casino Card Games 53.46 53.47
Games of Skill 40.43 49.45
Bingo and charitable games -- 41.13

1 Number who said "yes" to activity divided by 3,270

2 Casino games include land-based and riverboat casinos

3 Lottery includes the lotto and scratch-off lottery tickets

4 Sports gambling includes betting on sports pools and / or on sports teams with friends

In general, the findings in Indiana were similar to estimates of national trends. Of children in the nation, 77.6% have ever gambled, while 90.1% of Indiana school children have gambled. Interestingly, the number of Indiana adolescents who have gambled in casinos (5.9%) was lower than the national average (7.7%), but this may not be statistically significant. This may be due to better enforcement of legal gambling age limitations in Indiana than in other areas. In terms of general trends, Indiana adolescents participated at a much higher rate in lottery and sports gambling and less so for pari-mutuel games and games of skill when compared to national rates. There are no national comparative data for financial market participation. Also, Indiana males were more likely to have participated in gambling activity than Indiana females, 93.6% and 86.7% respectively. Other studies have also shown that males tend to gamble more than females.

To assess level of probable problem gambling activity, the South Oaks Gambling Screen, Revised for Adolescents (SOGS-RA), was utilized. The scoring for this instrument is slightly different from the SOGS, with scores of 0 or 1 being level 1 gambling, scores of 2 or 3 being level 2 gambling, and scores of 4 or greater being level 3 gambling. Approximately 11.2% of the students indicated level 2 gambling based on SOGS-RA score, with 7.5% having responses indicative of possible level 3 gambling. See Table 4 for a comparison to the national meta-analysis data.

Table 4: Comparison of estimated percent level 2 and 3 gambling behavior in Indiana adolescents to national statistics

*CI=95% confidence interval
Study Level 2 Level 3
Indiana School Study 11.2
(CI: 10.1-12.3)*
7.5
(CI: 6.6-8.9)*
1997 Meta-analysis 14.8
(CI: 9.0-20.7)*
5.8
(CI: 3.2-8.4%)*

As shown in the table, the estimated prevalence of problem and pathological gamblers is similar to national estimates with both estimates falling with the 95% confidence intervals of the national meta-analysis. A major limitation to the findings of this study was the relatively low participation rate, which did not allow for random sampling. All conclusions only pertain to those sampled and cannot be extrapolated. Since most of this research was conducted within the past two to three years, it may still be too early to determine the trends in adolescent gambling disorders. The repercussions of the rapid expansion and apparent community acceptance of gambling as a form of entertainment is most likely unseen at this point because of the age that most compulsive gamblers report when the first started gambling (approximately 8-10 years of age). In the next few years, gambling studies will be critical for examining the affects of gambling upon young populations as they enter adulthood.

Corrections Surveys

Adult Offenders

Research has indicated there is a relationship between reported gambling behavior and criminal activity. This study was completed to determine lifetime prevalence of gambling problems and the types of gambling problems reported in incarcerated adults in Indiana. The SOGS was utilized in this study to determine the of level of gambling activity involvement. A score of 5 or more is consistent with level 3 gambling, a score between 1 and 4 is consistent with level 2 gambling, and a score of zero would be considered level 1 gambling. While the SOGS is used to assess past year and lifetime gambling problems, only those results pertaining to lifetime involvement will be discussed. The past year results would be affected by their incarceration status and would not be appropriate comparisons to other research. A total sample of 1,694 usable surveys were obtained, of which 60.5% were male and 39.5% were female.

Of those surveyed, 95.5% reported having gambled at least once in their lifetime, with rates for males and females being similar (96.8% and 93.5% respectively). Higher rates of gambling problems were found in this population than in the general adult population. The estimated prevalence of level 1 gamblers was 41.7%, level 2 was 39.8% and level 3 was 18.5%. Of the respondents, 4.0% (64 individuals) reported being incarcerated as a direct result of their gambling activity. Of those, 71.9% had level 3 gambling behavior and 25% had level 2 gambling. In general, more of these individuals were male than female. There are some limitations to these findings. One is that the sample did not include people under heightened security or those with mental illnesses. Second, the reading level of the survey, purportedly at the 6th grade level, may have been beyond the capabilities of some of the respondents. Third, some of the surveys for the correctional survey were received too late to be included in the reported analyses.

Adolescent Offenders

Comparatively, little research has examined the level of gambling activity in the juvenile correctional facility population. The current study attempted to assess such activity in Indiana and to determine age of onset with gambling activity experimentation. As with the school survey, the SOGS-RA was utilized to assess gambling behavior with attention focused on lifetime gambling activity due to their incarceration status. The scoring for this instrument is slightly different, with scores of 0 or 1 being level 1 gambling, scores of 2 or 3 being level 2 gambling, and scores of 4 or greater being level 3 gambling. As with the survey in the adult prison population, those persons with mental illness or those in the highest security were not sampled.

The total sample was 310, with 72.3% were male and 27.7% were female. The majority (94.8%) reported having gambled at least once with money or something of value. The median age of onset of gambling activity was 12 years. Of the 293 offenders for whom SOGS-RA scores could be tabulated, 28.7% were classified as level 2 gamblers and 38.9% as level 3 gamblers. As in the adult survey, these persons were more often male than female. Fourteen people (4.6%) reported they have been told they need professional help for their gambling. Of the fourteen, three were classified as level 2 gamblers and ten as level 3 gamblers. In contrast, a greater number of adolescents (n=27) felt they had a problem with gambling (8.9%). Five of these (18.5%) were classified as level 2 gamblers and twenty-one (77.8%) as level 3 gamblers. Interestingly, of the 21 adolescents who felt they had a gambling problem and were classified as level 3 gamblers, 5 had been told they needed professional help for their gambling. Last, 27 offenders (9.1%) reported being arrested because of gambling related activities. Of the 27, five were classified by the SOGS-RA as a level 1 gambler, four as level 2 gamblers, and 18 as level 3 gamblers. These findings together provide some indication that the SOGS-RA is measuring behavior which observers also feel is problem gambling behavior.

These findings indicate that the level of gambling problems in this population is greater than that of their non-incarcerated counter-parts in the school system. As with the adult correctional survey, the limitations of this survey include the literacy level of those questioned, the inclusion bias, and a packet of surveys that was received too late to be included in the analyses.

Focus Groups

Focus groups were conducted in Indiana

  • to determine how widespread gambling is within the state,
  • to ascertain perceptions citizens have about gaming,
  • to see what problems, if any, the group members have observed,
  • to get recommendations on how to correct any observed problems and
  • to get the general public’s beliefs and attitudes toward gaming.

There were five independent focus groups held with teachers, minorities, senior citizens, community service providers and a random group of the population at large. In general, the findings across the groups were similar. All groups felt that gambling is primarily a form of entertainment, with only a small percentage of the participants expressing negative opinions about gambling. Approximately three-fourths of all participants favored legalized gambling. Interestingly, the minority group felt that the state’s legal gambling activities had redirected revenue that was spent in illegal gaming that is historically part of the African-American community in some areas. As a result, several minority participants expressed that they would rather participate in the gambling in their neighborhoods to keep the money in their communities. The lottery and casinos were identified as gambling activities, possibly because of the amount of advertising associated with these two forms. All groups perceived the lottery as a game of the middle and lower classes and that casinos were visited predominantly by the upper class. However, problems with gambling were seen as a function of individual personality and not identified with any particular social class, gender or ethnic group.

The groups made several recommendations for the state to prevent and treat problem gambling. (Recommendations should be considered as being reflected by all or most groups, except where specifically noted.)

  • The state could develop a statewide education program to create an understanding, within the general public, of gambling problems and warning signs.
  • The state could work with health care and community service providers to provide aid through existing resources.
  • The state could create a balance to existing advertising, better informing the public of the odds of winning, balancing the overwhelming perception of "getting something for nothing" that encourages many people to play.
  • Develop educational public service announcements with phone numbers to locate help.
  • Teachers suggested that the state provide education/prevention aimed at high school youth, establish ID checks at gaming venues and build lesson plans on the internet.
  • Minorities felt the state should establish programs similar to Alcoholics Anonymous (i.e. Gamblers Anonymous) and place a limit on advertising.
  • Senior citizens felt the state should provide on-going, open-ended outreach programs, run alternative advertising that does not glamorize gambling, insert messages in Social Security checks and reduce access to customers who appear to be buying too many tickets (similar to a bartender "cutting off" a patron who has drunk too much).
  • Community service providers strongly felt the state should support existing services for families, as opposed to creating new programs, and that there be a certification for gambling counseling.

Treatment Provider Survey

One of the methods used to assess the prevalence of problem gambling across the state was to survey the various treatment providers about their experiences with gambling-related problem behaviors and the treatment modalities used to treat problem gamblers.

Questions contained in the anonymous survey designed by Dr. Rachel Volberg were comprised of three categories. The first section dealt primarily with gambling treatment history and included information such as whether or not the respondent has ever treated significant family members of gamblers or gamblers themselves, and if so, how many in the last year, and general characteristics of gamblers seen. The second section contained questions on the providers’ treatment practice, procedures and experiences. The third and final section obtained respondent classification information such as age, gender, licenses and credentials and primary treatment population. A complete listing of treatment providers was obtained. Surveys were mailed to 8,500 mental health professionals and 905 (10.6% return rate) completed surveys were returned. Noteworthy findings are discussed below for
each section.

Gambling Treatment History

The majority of respondents have never treated family members of gamblers or gamblers themselves. Only 18.7% indicated they have treated spouses, children, parents or other significant family members of problem or pathological gamblers. While 30.6% reported having treated problem or pathological gambling problems in the past, only 17.7% stated they currently treat pathological gambler (see Table 5).

Table 5. percent of providers who treat or
have treated problem gamblers.

wpe7.jpg (11511 bytes)

And, of those who are currently in the practice of treating gamblers, most have seen few in the past twelve months. Almost two-thirds (61.5%) have seen 2 or fewer gamblers in the last twelve months, and only 5% of the respondents have seen greater than 14. This indicates that few professionals are currently treating problem and pathological gamblers, and even the professionals treating this population, the large majority has seen fewer than 14 in the last year. Because so few gamblers have been seen, questions attempting to obtain the general characteristics of gamblers and the types of gambling problems these individuals are reporting are not representative and will not be reported. Many people were reporting information based on seeing 1 or 2 gamblers, which will skew the results to over-represent the characteristics of those few people.

Treatment Practice, Procedures and Experiences

Most professionals report providing individual counseling (97.5%) and family counseling (77.2%) to gamblers and their families, with some providing group counseling (40.7%). Based on responses, outpatient treatment appears to be the treatment of choice being offered and that the respondents feel is the necessary level of care for pathological and problem gamblers. Approximately two-thirds indicated that outpatient service or intensive outpatient service is necessary for most individuals (61% and 63.5% respectively), with 15% indicating inpatient treatment and 21% indicating partial hospitalization or day treatment. Additionally, respondents were asked to indicate what is the typical expected and actual length of stay in treatment. Most professionals reported providing outpatient treatment (90%).

Outpatient treatment was expected to last 22 weeks, with most clients staying 16-17 weeks in treatment. Inpatient treatment was expected to last between 11-12 weeks, with most staying between 4-5. Thus, treatment providers report that gamblers need outpatient or intensive outpatient services and that the gamblers they have seen are not staying for the length of time needed for adequate services to be provided.

Table 6: Providers’ recommendations - services necessary to treat problem gamblers
wpe6.jpg (10800 bytes)

Interestingly, the majority reported referring clients to Gamblers Anonymous (87.8%) and that they either require or strongly recommend GA as a part of treatment (85.8%). However, some persons indicated that GA is not available in their area.

Respondent Classification Information

The mean age of respondents was 47.9 years old. Two-thirds were female (65.2%). Most are highly educated, with 55.4% having at least a Master’s degree and 27.2% being either a medical doctor or having a doctorate. The majority was either social workers (69.5%) or psychologists (19.7%), with a small percentage of respondents holding other licenses or credentials (e.g., 4.5% psychiatrists, 4.5% marriage/family counselors, 0.6% chemical dependency counselors). Few respondents have received any specific training in the treatment of problem gambling (11.3%), however, some indicated they would like to receive such training. Last, not all persons completing the survey are currently treating people. The survey was intended to be sent to treatment professionals, but in order to accomplish this, the survey was mailed to all persons holding any type of degree allowing them to treat persons needing counseling. One-fifth of the respondents indicated they are not currently treating people. While these individuals hold the necessary credentials, some have retired or work in non-treatment oriented jobs. For those who are currently treating people, most work with psychiatric (72.9%) or non-psychiatric problems (47.5%), but few indicated that gamblers were a predominant part of the practice (2%). This is not surprising given the above noted findings that most treatment professionals have never treated gamblers or are not currently in the practice of treating gamblers.

This information as a whole indicates that few gamblers are currently being treated in Indiana. There are many hypotheses that may account for this finding. First, individuals with gambling problems may not be seeking treatment. Second, treatment professionals are not trained in the treatment of this disorder and do not accept these clients. Third, that there was a response bias in that many persons treating gamblers did not complete or return the survey. Fourth, that it is some combination of the above factors.

Summary of Findings

Overall, there are some findings from the previous discussion that should be highlighted. First, the telephone survey indicates that most people participate or have participated in some form of gambling activity (87%), with relatively few people developing problem gambling behaviors (approximately 6% being either level 2 or 3 gamblers). This is consistent with national data, which indicates that the level 2 and level 3 lifetime national prevalence rate among adults is 5.5% (Shaffer et al, 1997).

Second, the survey of adolescents in grades 6th through 12th was commensurate with national data on the gambling behavior of this population. Level 2 gambling is lower in Indiana adolescents but higher in level 3 gambling when compared to national data. The median age of onset for gambling behavior was 11 in both Indiana and national data. The Indiana study also demonstrated at a statistically significant level that probable pathological gamblers initiated gambling behavior at a lower age level than problem and no problem gamblers. The estimated prevalence of problem and pathological gambling fell within the confidence limits of the national meta-analytic study, with 11.2% and 7.5% of adolescents in Indiana being possible level 2 and level 3 gamblers respectively.

The results of the adult correctional facility illustrated that more of these individuals have participated in gambling that the general population (95.5%), and that this population has a higher estimated prevalence of gambling problems. Of the incarcerated adults, 42% were level 1 gamblers, 40% possible level 2 gamblers and 19% possible level 3 gamblers. These estimates are much greater than those of the general population. The same was true for the survey of adolescents in juvenile correctional facilities. The majority has participated in gambling activity (95%). Of the adolescents, 32% were level 1 gamblers, 29% were level 2 gamblers, and 40% were level 3 gamblers. As can be seen, these estimates are also greater than that of their non-incarcerated counter-parts in the school system.

Approximately three-fourths of focus group participants were in favor of legalized gambling, which they view as a form of entertainment. The groups recognized that some individuals develop problems because of their gambling behavior but that these are the minority of gambling participants. The groups had a number of recommendations aimed at the state to alleviate problems resulting from problem gambling.

The survey of treatment providers indicated that few professionals have ever or currently treat problem or pathological gamblers. And, of those treating gamblers, few have presented for treatment in the 12 months prior to the survey. This indicates the problem gambling population is currently under-served. Last, some of the respondents indicated interest in training in treating this population.

These findings taken together indicate that some individuals in Indiana are experiencing problems as a result of their gambling behavior, and that the prevalence of gambling related problems is similar in Indiana to findings nationally.

Implications for Social Policy, Prevention and Treatment

Gambling research is still in its infancy. Obtaining accurate data is complicated by various methodological problems and the unknown affect that gambling will have on a population that has been exposed to legal gambling only for the past few years in Indiana. However, the baseline research obtained in Indiana, along with national studies, provides preliminary information to guide prevention and treatment efforts.

Based on the information obtained from the adolescent survey, it is imperative that primary prevention programs be implemented prior to the age 11, the median age when Indiana adolescents initiate gambling activities. Prevention activities need to be directed at both males and females but must be gender sensitive because males engage in gambling activities at a higher rate than females. Because national statistics demonstrate that adolescents are engaging in gambling activities with friends and family members, it is essential that prevention programming is directed at changing peer norms and that parent education and training with a non-gambling theme is included (Shaffer et al, 1997).

Prevention efforts need to focus on public policy and law enforcement surrounding legal age limits in venues such as casinos and charitable gambling establishments. The school research found that Indiana adolescents are engaging in illegal gambling activities at higher levels than national estimates.

Some research indicates that gambling problems are more prevalent among the non-Caucasian populations (Volberg, 1993). In the nation, 16.1% of the population is non-Caucasian. In Indiana, this population is 10% (U.S. Census, 1990). However, based on the focus group information, minorities seem distrustful of the gaming industry. This information is valuable to prevention and treatment providers since it may shed light on mistrust that also affects help-seeking behavior. Prevention and treatment efforts must be culturally competent by defining societal and cultural influences that affect health behavior decision-making and help-seeking behavior of specific groups and individuals.

Research has indicated that problem gamblers share certain characteristics. It is likely that they are male, are under the age of 30, earn a low income and have co-occurring psychological difficulties. Prevalence rates are higher among non-Caucasians as well. Males clearly outnumber females in the gambling participation rates and problem gambling behavior. (Shaffer, Hall and Vander Bilt, 1997; Volberg, 1993; Volberg and Steadman, 1988). Prevention programs including social marketing campaigns must target specific groups that are at risk for gambling problems. In developing programs, it is first essential to understand what influences their behavior and how they make decisions regarding their health.

The treatment provider survey indicates that problem gamblers in Indiana are currently underserved. If the explanation lies in the lack of training of professionals or that gamblers are not seeking treatment, these are conditions that should be remedied. This could be accomplished through a variety of means, such as training workshops (in addition to the five offered by FSSA) offered by professionals trained in the treatment of gambling problems, awareness campaigns to explain the nature of the problem and information as to the location and types of services available to help these individuals.

Recommendations for Further Research

  • Research targeting the behaviors of specific groups demonstrated to be at high risk for gambling addiction.
  • Research to identify regional clusters in the state of Indiana where gambling is a problem.
  • Research that identifies the type of gambling activities through which Indiana adolescents initiate.
  • Research on the accessibility of gambling to adolescents.

Specific Populations and Issues

Seniors

When developing prevention and treatment programs for problem gambling, attention must focus on the senior population. While there is little data on the prevalence of gambling problems in older adults, this population is heavily targeted by the gambling industry and may experience unique lifestyle changes that put them at risk for engaging in problem gambling behavior. Due to the large population of seniors that exists in Indiana, prevention programming must be tailored to meet the needs of this group.

There are a number of reasons why the senior population is beginning to exhibit problem gambling behavior, such as opportunity, boredom, loneliness, escape and sense of entitlement. (Wisconsin Council on Problem Gambling, 1998). Seniors often have a need for interaction with others and a lot of leisure time. They may attend casinos to fill their time and seek out social relationships with other people.

Also, opportunities to gamble are increasing over time, with the distance to gambling venues decreasing as such places increase in number. Many gambling casinos are now sponsoring bus tours for seniors, with casinos providing buses to drive seniors from their home to the casino for no charge, and sometimes including a monetary incentive for seniors (e.g., ten dollars). Seniors living in residential communities may also have opportunities to engage in gaming activities, such as bingo, on a regular basis Among seniors, gambling can also be a form of escape from the reality of their life circumstances. Man seniors may be experiencing grief from loss of their spouse, family and friends or experiencing physical difficulties and pain as a result of the aging process.

Findings from a telephone survey of Indiana adults indicated that 2.2% of the population surveyed were baby boomers (40-59 years of age) and probable problem gamblers (level 2) while .31% were baby boomers and probable pathological gamblers (level 3). The data also indicated that .83% of those surveyed were seniors (age 60 and older) and probable problem gamblers while only .03% were seniors and probable pathological gamblers.

Even though this information demonstrates that gambling problems actually decrease as one gets older, it should not be misleading. Seniors are at high risk for gambling problems since they are heavily targeted and experience unique psychological risk factors. Furthermore, once they develop a gambling problem, the effects are usually devastating and irreversible. This data does indicate that baby boomers and pre-retirees need to be targeted for prevention to circumvent problem gambling behavior that may arise from lifestyle changes due to retirement, boredom and increased time ad opportunity.

Prevention of gambling problems in seniors should be aimed at providing education to discourage irresponsible or excessive gambling. Educational programs may also include money management information as well as how to identify and address the signs and symptoms of problem gambling. Programs should provide information on how to seek help and address the obstacles that may make a senior resist help. It is essential to develop programs providing seniors with alternate activities aimed to curb many of the psychological risk factors thought to contribute to problem gambling behavior. Awareness campaigns should be developed that offset existing campaigns making gambling appear glamorous.

Prevention programs should be on-site in retirement communities and religious organizations that provide charitable gaming activities. Prevention professionals need to work with organizations that provide services for seniors such as the American Association of Retired Persons (AARP) and Seniors Unlimited to share information and provide educational programming.

College Students

Comparable to the adolescent population, problem gambling behavior among college students is on the rise. Studies have shown that college students are 4 to 8 times more likely than the adult population to experience a gambling problem. (Lesieur et al. 1991). The Harvard meta-analysis looked at more than 20 studies focusing on college student gambling behavior and found 9.3% of college students to be probable problem gamblers and 4.7% to be probable pathological gamblers. These rates are similar to adolescents but are considerably higher than that of the adult population.

As adolescents move into college, gambling behavior can become problematic for many reasons. They are out of parental supervision giving them more freedom, they may be more apt to take risks, have access to new sources of money (i.e.credit cards) and may engage in gambling behaviors along with the consumption of alcohol, tobacco and other drugs. In a study of six colleges and universities within five states, 85% of the college students reported that they have gambled, and 23% gamble once a week or more. Slot and poker machines were the most popular form of gambling with playing cards for money and casino games close behind. On a weekly basis, games of skill such as pool, golf, or bowling were the most popular games played for money. Another popular type of gambling for college students included sports betting, causing alarm for coaches that student athletes might get involved. College students also have unique access to other types of gaming activities through student organization sponsored "casino nights" and gambling on the Internet. Pathological gambling behavior was almost three times more likely in males than females and highly correlated with the use of alcohol and other drugs (Lesieur et al, 1991).

Prevention professionals need to work with Wellness Education Programs and Mental Health Departments within Student Health Centers on campuses to provide further research and prevention programs surrounding problem gambling. Educational and awareness programs regarding the dangers of excessive gambling are essential. Information regarding gambling and addiction would fit in with campus-wide mental health and substance abuse awareness campaigns. Programs that focus on impacting campus norms surrounding gambling behavior should be employed especially in those communities where gambling is the normative behavior and gambling opportunities are easily accessible. Programs need to reach both students living on campus as well as commuters. Students residing on-campus can be reached through residence hall activities and campus gathering places. Commuters, a much more difficult population to reach, can be targeted through classroom presentations, activities inside and in front of the Student Union as well as information placed strategically on signs along routes entering the school.

Internet Gambling

The proliferation of Internet gambling poses a challenge for states in their effort to prevent problem gambling. The Internet hosts hundreds of gambling sites with little regulation and protection against underage gambling. With over 175 million Internet users worldwide, it is evident that the easy access to this type of gambling activity is bound to cause problems. Concerns about consumer protection, underage gambling and gambling addiction have made studying the effects of Internet gambling a priority both in many states and at the federal level. While Internet gambling is illegal in many states including Indiana, enforcement of laws surrounding gambling on the Internet can be futile since most sites are located outside the country.

Due to poor regulation of gambling activities on the Internet, there have been increased incidences of fraud. How does the gambler know that his $1,000 wager on black in roulette was a loser? How is a gambler assured of receiving his/her due winnings (Collesano, 1997). Other concerns surround the lure of Internet gambling to students and employees with Internet access at schools and places of employment. Such concerns may lead to strict policies regarding gambling in the workplace and serve as an impetus for the development of blocking software that would decrease access to underage gamblers.

The Council on Compulsive Gambling of New Jersey has responded to the serious problem of Internet gambling with a home page dedicated to fighting cyberspace bookies, and encouraging problem gamblers to seek help (Seattle Post Intelligencer, 1997). Prevention and treatment programs need to reach people "where they are". If they receive information on the Internet, it is the most appropriate place for them to receive messages regarding the identification of problem gambling behavior and how to seek help. The dangers of Internet gambling should also be highlighted in problem gambling prevention curricula and other public awareness campaigns.

V. Development of a Problem Gambling Prevention Plan

Linking Research to Planning

For program planning and implementation to be effective, there should be a logical link between the empirical foundation established through the research and the type of programming that develops. In this case, the FSSA-DMH has consistently indicated that outcome effectiveness is a critical part of their planning and programming efforts. The effectiveness research conducted by the Indiana University School of Health, Physical Education and Recreation and the LSU-OSSRD’s research should be used to plan for prevention services. Although the IU research was conducted for substance abuse prevention, it should be linked with prevention of problem gambling.

Little is known about effective prevention of problem gambling behaviors. Examples of effective prevention strategies for other addictive illnesses offer methods that could be applied to problem gambling prevention. The application of known substance abuse prevention strategies to problem gambling will provide a starting point from which revisions and alterations can be made as more is learned about the nature of problem gambling.

To provide some background for the current state of knowledge in prevention services, selective treatment and prevention research is discussed in the next section.

Review of Related Prevention and Treatment Literature

Treatment

Gambling treatment knowledge is more developed than prevention knowledge. One of the well-known treatment models for problem gamblers is offered through Gamblers Anonymous (GA). Modeled after Alcoholics Anonymous, GA is a 12-step program for compulsive gamblers. This mode of intervention is also popular among Indiana treatment providers, with 87.8% reporting that they refer clients to Gamblers Anonymous and 85.8% either require or strongly recommend GA as a part of treatment. Programs for the families and children of compulsive gamblers include GamAnon and GamAteen. There have been few studies completed on gambling treatment that seem applicable for a majority of people. Although GA is the most frequently used treatment of gambling problems, there has been no research to date providing a systematic study of its efficacy (Knapp and Lech, 1987).

Some of the therapeutic techniques referenced in the literature include psychoanalytic treatment, self-help groups and cognitive and behavioral therapies such as aversion therapy, desensitization and Rational Emotive Therapy. Sometimes, family and marital therapy is also used as a component of treatment. Indiana providers reported using the following treatment techniques to treat gambling problems: the medical/addiction model, cognitive /behavioral and an eclectic approach.

Most professionals in Indiana report providing individual counseling (97.5%) and family counseling (77.2%) to gamblers and their families, with some providing group counseling (40.7%). Based on responses, outpatient treatment appears to be the treatment of choice being offered and that the respondents feel is the necessary level of care for pathological and problem gamblers. Approximately two-thirds indicated that outpatient service or intensive outpatient service is necessary for most individuals (61% and 63.5% respectively), with 15% indicating inpatient treatment and 21% indicating partial hospitalization or day treatment. As of yet, there is a lack of established psychological treatments for gambling (Lesieur and Rosenthal, 1991).

Prevention

Prevention refers to the identification of the onset of use or early stage problems in individuals or groups who do not yet require treatment (SAMHSA, Making Prevention Work, 1995). As applied through the Center for Substance Abuse Prevention (CSAP) approach, prevention stops the development of alcohol and other drug-related problems by encouraging people to develop positive and constructive lifestyles. The aim of successful prevention efforts is to support the healthy development of children so they will be protected against the availability of substances in their pre-adolescent and adolescent years. By reducing the personal risk factors associated with addictive behavior, the problem is prevented. Consequently, effective prevention strategies must be comprehensive, multi-level and aimed at the variety of influences upon the child as he/she develops.

The overall goal of preventive intervention is the reduction of the occurrence of new cases. To establish a comprehensive prevention plan, several levels of prevention planning should be used. These are:

Primary prevention: seeks to decrease the number of new cases of a disorder of illness ( incidence).

Secondary prevention: seeks to lower the rate of established cases of the disorder or illness in the population (prevalence).

Tertiary prevention: seeks to decrease the amount of disability associated with an existing disorder or illness.

The most effective prevention strategies are applied as primary prevention because the problem never develops. Secondary prevention efforts address prevalence and attempt to reduce the existence of the problem behavior. Finally, tertiary prevention efforts attempt to lessen the impact of the problem behavior once it has begun. The prevention strategies for problem gambling behavior must incorporate these three levels of prevention if comprehensive prevention is to occur.

CSAP stresses the importance of primary prevention and early intervention in dealing with substance abuse addiction. Early intervention efforts are also considered to be preventive in that they prevent the progression of initial indicators of abuse. For substance abuse and gambling problem development among youth, primary prevention and early intervention programs are critical to the success of any programs.

In developing an effective prevention strategy, it is not just the specific intervention to be applied, but the manner in which it is applied and to whom it is applied. Haphazardly planned prevention programs base their intervention on the belief that "one size fits all." In reality, the effectiveness of a prevention strategy is heavily dependent upon targeting the intervention to the appropriate population and delivering the intervention in the correct amount and intensity for the chosen target. It is with this background knowledge that CSAP developed its recommended strategies for implementation of the interventions that have been empirically related to effectiveness. Prevention strategies should be selected based upon the characteristics of specific populations. Mrazek and Hagerty (1994) identify three types of prevention interventions that can be used when developing a plan to address multi-levels of a community or target population, focusing on the level of risk at various segments of the population. These interventions are described by Mrazek and Hagerty as

Universal preventive interventions, which target the general public or a whole population group that has not been identified on the basis of individual risk;

Selective preventive interventions, which target individuals or a subgroup of the population whose risk of developing mental disorders is significantly higher than average and

Indicated preventive interventions, which target high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental disorders or biological markers indicating predisposition for mental disorder but who do not meet the diagnostic levels at the present time.

CSAP has developed a typology for prevention strategies that is recommended for use in the development of a comprehensive prevention plan. The strategies have been developed over the years of working with states and communities and may serve as the foundation for effective prevention planning and program development (SAMHSA, Making Prevention Work). The recommended strategies are described as:

1. Information dissemination - which is defined by CSAP as "one way communication from the source to the audience, with limited contact between the two" (p. 10). The aim of this strategy is to provide awareness, knowledge and information relevant to certain problem behaviors and/or to certain targeted populations, i.e. parents, community groups, etc. The dissemination of information includes content regarding specific problems as well as information on where to get further information or assistance. Recommended information dissemination activities include:

* clearinghouse /information resource centers

* resource directories

* media campaigns

* brochures

* radio/television PSA’s

* speaking bureaus

* health fairs

* information lines/hotlines

2. Education - described by CSAP at two-way communication, involving an educator/facilitator and participants in the process. This strategy aims at affecting critical life and social skills including decision making, refusal skills, critical analysis and systematic judgment abilities. Recommended educational activities include:

* classroom and/or small group behavior

* parenting and family management classes

* peer leader/helper programs

* education programs for youth groups

* children of substance abuser groups

* mentoring programs

* preschool alcohol and drug prevention programs

3. Alternatives - refers to the provision of the target population in activities that are free of the problem behavior, i.e. alcohol, tobacco and other drugs. This strategy attempts to offer alternatives to the deviant behavior, assuming that constructive and healthy activities provided at the right time can minimize the attraction to other activities that meet certain needs. Recommended alternative activities include:

* alcohol, tobacco and other drug free dances and parties

* youth/adult leadership activities

* community drop-in centers

* community service activities

* outward-bound type programs

* recreation activities

4. Problem Identification and Referral - primarily used as an early intervention activity for those youth who have engaged in initial or inappropriate use of alcohol, drugs and tobacco. This strategy is not aimed at determination of need for treatment, but identification of initial use that can be reversed through education efforts. Recommended early intervention activities include:

* employee assistance programs

* student assistance programs

* DWI type programs

5. Community-Based Process - described as the process of enhancing the community’s ability to provide effective prevention and treatment services for alcohol, tobacco and drug related disorders. These activities aim to enhance efficiency and effectiveness of existing services, implementation of those services, collaboration across the community, coalition building and networking. Basically this strategy attempts to foster community mobilization and empowerment to address identified problems. Recommended community-based activities include:

* community and volunteer training

* systematic planning

* coordinating and collaborating with other agencies

* accessing services and funding

* community team-building

6. Environmental - described as activities undertaken to change written and unwritten community standards, codes and attitudes, thereby influencing incidence and prevalence of the abuse of alcohol, tobacco and other drugs in the general population CSAP differentiates these activities into ones that address legal and regulatory initiatives and ones that address service and action oriented initiatives. Recommended environmental activities include:

* promoting the establishment or review of alcohol, tobacco and drug use policies in schools

* providing technical assistance to communities to maximize local enforcement procedures

* governing availability and distribution of alcohol, tobacco and other drugs

* modifying alcohol and tobacco advertising practices and product pricing strategies.

The discussion on CSAP recommended strategies has been taken from the SAMHSA publication Making Prevention Work, pps. 10-12. The six-point classification system is identified as the Comprehensive Public Health Model. Although these strategies developed out of alcohol and other drug prevention theory, the methods would be revised for specific compulsive gambling issues.

Effectiveness Research on Specific Prevention Activities

Little research currently exists evaluating specific prevention of gambling. This may be partly due to the fact that few states are currently employing such programs, and existing programs are relatively new and have not been evaluated for efficacy. Gaboury and Ladouceur (1993) assessed a prevention program developed for adolescents in Quebec. The aim of the program was to increase knowledge of gambling, decrease amount of money spent and frequency of gambling activity and to change attitudes towards gambling. Three 75-minute sessions were utilized during which information was provided concerning the above-noted topics. The results were not encouraging but informative. Adolescents who participated in the sessions performed better on a post-test, compared to control subjects not exposed to the information. However, this was not maintained at six-month follow-up.

Additionally, the program did not seem to significantly affect gambling behavior or attitudes and improvements in social skills obtained by the experimental group were also not maintained at follow-up. The researchers concluded that increased knowledge may not be sufficient to modify behavior and attitudes and coping skills may require intensive practice and feedback to resist extinction. However, this study comprises only one component of a prevention program. And, as noted by the authors, having been exposed to the experimental material may still result in an increased likelihood that the experimental participants will seek treatment if problems arise for themselves or their family members and friends, due to their sensitization of the issues surrounding gambling.

In a discussion of prevention research, Volberg (1996) cited the 1993 Gaboury study as the only one on prevention. She further described current prevention efforts "in states where services are now being established, they will most likely consist of hotline or crisis counseling, training for addictions and mental health professionals who may already be seeing gambling-related problems among their clients, and education and information activities, including development of brochures and public service messages for broadcast and print media."

Findings in Youth Substance Abuse Prevention Relevant to Problem Gambling Prevention

SAMHSA has also reported findings based on a decade of experience and research in prevention that may prove relevant to the current effort. Although the particular issue being addressed is youth substance abuse prevention, several of the findings are relevant to gambling prevention.

1. Initiation of substance use

Adolescent perceptions of the risks and benefits of alcohol and other drug use correlate with the likelihood of initial use.

Parental use, or parental attitudes toward the use, of alcohol, tobacco and illicit drugs tend to correlate with adolescent attitudes toward the use of these substances.

A lack of close relationships in the family tends to correlate with adolescent substance abuse.

Students who perform poorly in school or who have a perception of themselves as academic failures are more likely than other youth to engage in early alcohol use.

2. Effectiveness of prevention activities

Teaching life skills (e.g., problem solving, decision making, social skills) is effective in reducing the incidence of substance abuse among youth when it has a non-substance abuse theme instead of targeting general goals.

Interpersonal counseling, mentoring and other forms of intensive interaction strengthened protective factors against drug use among youth at high risk.

3. Program implementation

Turf conflicts and time constraints are most often cited as barriers to the creation of successful community prevention coalitions.

Longer-term interventions and delivering booster sessions are associated with more effective outcomes.

Simultaneous efforts to operate a wide variety of prevention-related activities among an adolescent population reduced effectiveness of the intervention.

4. Cost and financing of substance abuse prevention

Drug-free recreational and cultural activities are often the most costly element of community-based prevention programs

Even cost-effective, community-based prevention efforts quickly erode without stable, dedicated funding.

Although these findings apply to the substance abuse problems, many of them will be applicable to gambling addiction problems. They are important to consider in the development of a comprehensive prevention plan.

Social Development Strategy Model

Based on the current literature, the best prevention strategies are aimed at strengthening individual resiliency to problem behavior, reducing risk factors that promote addictions, developing clear and consistent community standards for appropriate behavior and teaching children the skills they need to follow community standards (DRP, 1993). Because of the comprehensive nature of the Social Development Strategy Model, the plan being proposed for Indiana will largely be focused on this model.

Risk-focused prevention was developed through the research of Dr. David Hawkins and Dr. Richard F. Catalano. It is a comprehensive prevention strategy aimed at preventing adolescent health and behavior problems. Risk-focused prevention is based upon the theory that children and adolescents face certain risk factors that inhibit their ability to develop in a normal, healthy manner. The risk factors may exist throughout various domains in which the youth must function. There are various risk factors that youth may face in their neighborhoods, their schools or their families, in addition to other settings. Applying this theory to gambling addiction is highly recommended.

An additional part of Catalano and Hawkins’ theory is that children and youth may also maintain certain protective factors that make them more resilient to the risks that they will face as they develop. The Social Development model focuses on the reduction of known risk factors and the enhancement of protective factors to achieve a balance that will help youth develop as healthy as possible. Risk-focused prevention is primary prevention, and it attempts to prevent problems from happening by identifying the known risks and enhancing protective factors that will address the hazardous situation.

Catalano and Hawkins (DRP, 1993) have identified four primary areas of risk. These include community, family, school and individual/peer risk factors. Within each of these areas, the risk factor predicts the type of problem the adolescent will face when specific areas of risk are present.

Community Risk Factors include:
Area of Risk Predicted problem Behavior
Drug availability Substance abuse
Laws/norms favorable to drug use, firearms and crime Substance abuse, delinquency and violence
Media portrayals of violence Violence
Transitions and mobility Substance abuse, delinquency and school dropout
Low neighborhood attachment and community disorganization Substance abuse, deliquency and violence
Extreme economic deprivation Substance abuse, deliquency, violence, teen pregnancy and school dropout
Family Risk Factors include:
Area of Risk Predicted Problem Behavior
Family history of problem behavior Substance abuse, delinquency, violence, teen pregnancy and school dropout
Family management problems Same as above
Family conflict Same as above
Favorable parental attitudes and involvement in behavior Substance abuse, deliquency and violence
School risk factors include:
Area of Risk Predicted Problem Behavior
Early and persistent anti-social behavior Substance abuse, delinquency, violence teen pregnancy and school dropout
Academic failure in elementary school Same as above
Lack of commitment to school Same as above
Individual/peer factors include:
Area of Risk Predicted Problem Behavior
Alienation, rebelliousness and lack of bonding to society Substance abuse, delinquency and school dropout
Friends who engage in problem behavior Substance abuse, delinquency, violence, teen pregnancy and school dropout
Favorable attitude towards the problem behavior Same as above
Early initiation of the problem behavior Same as above
Constitutional factors Substance abuse, delinquency and violence

The identified protective factors either reduce the effect of the risk factors or they change the individual response to risk. The most important protective factors to guard young people against risk are those that promote positive behavior, health, well-being and personal success (DRP, p.11). The Catalano and Hawkins research has also identified certain categories of protective factors.

Protective Factors:

Individual characteristics- described as a resilient temperament or a positive social orientation.

Bonding - positive relationships that promote close bonds; warm relationships with family, teachers, adults, close friendships

Healthy beliefs and standards- when clear standards for healthy behavior are presented by parents, peers, families, schools.

The Catalano and Hawkins theory continues to describe other characteristics of risk factors, especially when considering the potential impact of specific protective factors. These include the belief that risks exist in multiple domains. Domains in which risk factors have been identified include the family, peer group, school, neighborhood, environment and society. The individual domain is also included as a critical area in which to provide protection, for example, with children who have poor temperaments or developmental disabilities. Additionally, the Social Development Theory also stresses that the more risk factors that are present, the greater the risk for the youth.

Programs based on the Social Development Model are designed to:

  • Strengthen children’s bonds by providing opportunities, skills and recognition,
  • Reduce risk factors in a way that strengthens protective factors,
  • Develop clear and consistent standards for behavior across families, schools and communities and
  • Teach children the skills they need to be able to follow clear standards

( the material on the Social Development Model was taken from the Communities that Care publication, Developmental Research and Programs, Inc., 1993)

To develop an effective problem gambling prevention plan, the risk and protective factors affecting a community’s children must be discussed. Certainly, in the field of gambling, there are diverse ranges of the problems across the state, depending on factors such as poverty, availability or access to gambling and community norms. Prevention planning efforts must address each community’s identified needs.

Building Cultural Competence in Prevention Programming

When developing prevention programming for individuals from a variety of backgrounds, it is essential to create educational strategies that are based on diverse perspectives. Curriculum that is based on a narrow perspective often fails to engage youth from diverse racial, cultural and socioeconomic backgrounds. Because gambling addiction is more prevalent among specific groups and each community has its own sense of culture, the diversity within local communities must be examined before creating plans for the implementation of the problem gambling prevention plan.

Culture is defined as "a body of learned beliefs, traditions, principles and guides for behavior that are commonly shared among members of a particular group. Culture serves as a road map for both perceiving and interacting with the world." (Advocates for Youth, 1994). Indiana must use the culture of its state - such as demographic make-up, attitudes, opinions, and beliefs of various racial, cultural, and socioeconomic groups - to guide the planning of cultural competent prevention programming.

Research has indicated that problem gamblers share certain characteristics. It is likely that they are male, are under the age of 30, earn a low income and have co-occurring psychological difficulties. Prevalence rates are higher among non-Caucasians as well. (Shaffer, Hall and Vander Bilt, 1997). Not only does prevention programming need to target these groups, but also it needs to be based on a comprehensive understanding of what influences their health behavior and help-seeking behavior.

Cultural Competence moves beyond the concepts of "cultural awareness" (knowledge about a particular group primarily gained through reading and studies) and "cultural sensitivity" (knowledge as well as some level of experience with a group other than one’s own). Instead, cultural competence is achieved through a long-term process that requires some level of skill development to occur. In other words, achieving cultural competence can be seen as a process rather than a goal. Culturally competent individuals have a mixture of beliefs/attitudes, knowledge and skills that help them establish trust and communicate with others (Advocates for Youth, 1994).

Advocates for Youth propose a four-step model of building Cultural Competence for working effectively and respectfully with youth from a variety of backgrounds. The following excerpts have been taken from Advocates for Youth, A Youth Leader’s Guide to Building Cultural Competence, p. 4-6, with slight modification. The four steps are:

  • learning about culture and important cultural components,
  • learning about one’s own culture through a process of self-assessment that includes examining one’s culture’s assumptions and values and one’s perspectives on them
  • learning about the individual young people within the program and
  • learning as much as possible about important aspects of participants cultural backgrounds with a focus on health beliefs and decision-making behaviors.

Beliefs/Attitudes - The culturally competent individual is:

  • aware of and sensitive to his/her own cultural heritage and respects and values different heritages,
  • aware of her/his own values and biases and how they may affect perception of other cultures,
  • comfortable with differences that exist between her/his culture and other cultures’ values and beliefs and
  • sensitive to circumstances (personal biases, ethnic identity, political influence, etc.) that may require seeking assistance from a member of a different culture when interacting with another member of that culture.

Knowledge - The culturally competent individual must:

  • must have good understanding of the power structure in society and how non-dominant groups are treated,
  • acquire specific knowledge and information about the particular group(s) she/he is working with and
  • be aware of institutional barriers that prevent members of disadvantaged groups from using organizational and societal resources.

Skills - The culturally competent individual can:

  • generate a wide variety of verbal and nonverbal responses when dealing with difference,
  • send and receive both verbal and nonverbal messages (body language) accurately and appropriately and
  • intervene appropriately and advocate on behalf of people from different cultures backgrounds.

Community-wide Approach to Implementing a Prevention Plan

Even though the Family and Social Services Administration is planning a statewide approach to problem gambling in Indiana, each local community will need to be assessed for risk and protective factors. Plans must be made to address the identified problems of priority specific to each local community. Engaging support at the state level for prevention planning, as in this case, can only strengthen the efforts of local communities.

Certainly, in the field of gambling, there are diverse ranges of the problems across the state, depending on factors such as poverty, availability or access to gambling, community norms, etc. Research suggests that prevention strategies with a community-wide approach are more likely to result in long-lasting changes by impacting community norms, values and policies as well as developing a broad base of support and collaboration ensuring that no single organization carries the burden of responsibility (DRP, 1997).

According to Catalano and Hawkins (Communities That Care), community-wide prevention approaches are likely to produce the following outcomes:

  • Reduced costs for intervention and treatment.
  • More effective use of resources through collaborative planning and program implementation.
  • A more integrated support network for young people and their families, resulting in fewer young people "falling through the cracks".

Catalano and Hawkins’ Communities That Care offers a process for mobilizing a community to implement risk-focused prevention.

Define your community through an understanding of the geographic boundaries and the diverse make-up of the people who live there. Diversity needs to be thought of in terms that go beyond racial diversity to include class, religious and political backgrounds, as well as health belief systems and differences in help-seeking behavior.

Involve key leaders in your community. These influential individuals should represent the schools, government, law enforcement agencies, social services, business, religious and cultural groups within your community. Involving key leaders is essential to the success of the implementation phase of the prevention plan. They have the status, position and authority in their communities to launch a prevention project of this magnitude. Their involvement will not only provide credibility but also will access resources and remove barriers supporting prevention. Key leaders may be asked to sit on a community prevention board or may assist in the recruitment process of members. In some instances, they may appoint an appropriate individual to represent them.

Create a community-wide prevention board. This group should be made up of diverse and concerned community members representing all the significant areas affecting young people: educators, government officials, law enforcement, juvenile justice personnel, social service providers, parents, religious and cultural leaders, business people and young people. This prevention team or community board is different from a statewide Ad Hoc Committee or Advisory Group which has been formed to oversee the process of developing prevention strategies on a statewide level. This local prevention team is a working group for the implementation of risk-focused prevention within a local community (See Community-Wide Prevention Board Member Job Description in Appendix).

Assessing community readiness is perhaps the most important step before mobilizing a community to implement a problem gambling prevention plan. Before introducing a prevention plan into a community, board members need to identify the organizations and people likely to support or hinder efforts to institutionalize risk-focused prevention.

Since the first step to addressing a problem is to acknowledge it, it is crucial to assess whether major groups within a community are aware of problem gambling behavior. Do they regard this as a problem for adolescents in their community? It is also important to determine a particular group’s view of prevention. Do they see prevention as one of the solutions to problem gambling? Finally, a community must look at its history to determine its ability to work together through establishing collaborative relationship in the pursuit of a solution. (See Assessing Community Readiness Questionnaire in Appendix 2)

Every community will have building blocks and stumbling blocks among the major constituencies in each of these areas. The above process will help to build upon the strengths in each community and minimize the challenges. The statewide Ad Hoc Committee that has been established through the Family and Social Services Administration can serve as a support network for local initiatives to implement a problem gambling prevention plan.

Identification of Specific Prevention Activities

As discussed earlier, the CSAP literature strongly recommends the use of activities aimed at the individual, family, school, community and workplace levels. The tables on the following pages present the types of activities that may be considered within communities across the state.

DOMAIN: INDIVIDUAL/PEER

Strategy Possible Interventions
Education

K – 6th grades

(Implement through public and private schools)

Teacher training in age appropriate information about consequences

Implement curriculum on probability information (Harvard’s "Facing the Odds" curriculum; Minnesota’s "Improving Your Odds" curriculum)

Introduce at 3rd and 4th grade

Schedule "booster sessions" for all knowledge / information curricula

After-school programs to enhance academic performance

School-sponsored parental education, family management skills enhancement

Education

School Age Youth

6th-12th

Classroom / peer led curriculum specific compulsive gambling issues- gambling, financial management, addictions, probability (North American Training Institute’s "Wanna Bet?" Curriculum; Nova Scotia’s Department of Health’s "Drawing the Line." Curriculum)

Life Skills training

Social Skills- develop healthy friendships, effective communication skills, overcome shyness

Resistance Skills

Increase awareness

Correct misconceptions

Active learning of refusal skills

Booster session at 7th grade

Self-Management Skills

Personal control

Independence

Self-mastery

Problem solving

Decision making

Critical thinking

Assertiveness Training

Coping mechanisms

Develop life skills training curricula to fit local profile

After-school programming to include gambling education information

Develop culturally competent programming

Peer / leader programs

Mentoring programs

After-school programs that include gambling education curriculum

Revise and replicate Minnesota "Improving Your Odds" curriculum, including new title

Information Dissemination

School media type campaigns

PSAs to youth radio stations and popular youth programs on television

Famous speakers at schools to speak

Alternatives

Recreational activities focused on non-gaming, non-addiction (would focus on recreation that is drug and alcohol free)

Youth / adult leadership activities

Problem Identification and Referral

Student assistance programs

Compulsive gambling family case study education program

Peer counseling

Community-Based Process

Community service programs

Community level PSAs

Alternative community recreational activities

DOMAIN: FAMILY

Strategy Possible Interventions
Education

Parent Education/parenting skills training

Parent Education/family therapy

Parent Education/problem behavior identification

Task-oriented family education sessions combining social skills training to improve family interaction

Information Dissemination

Provide information to PTAs about problem gambling

Alternatives

Recreational activities for families focused on non-gaming, non-addiction

DOMAIN: SCHOOL

Strategy Possible Interventions
Education

Curricula with negative effects of gambling

Curricula to support positive peer relationships

School-based support group and skills development class

Tutoring, peer tutoring, homework assistance programs

Information Dissemination

In school presentations

Website

Problem Identification and Referral

Student Assistant Programs

Train teachers and counselors to recognize signs of problem gambling

Community-Based Process

Creating supportive school communities to strengthen bonding to school

DOMAIN: COMMUNITY

Strategy Possible Interventions
Education

Education to alter perception of societal norms/expectations

Media messages supporting problem gambling prevention

PSAs warning of dangers of excessive gambling and other risk taking behaviors

Work with Indiana Public Television to create problem gambling prevention programs

Information Dissemination

Develop pamphlets to be provided to targeted at risk groups

Develop mass media campaign for community awareness for continuous, on-going effort.

Create a community speaker’s bureau

Alternatives

Community drop-in centers

Community service activities?

Community-wide activities with a non-gambling theme

Problem Identification and Referral

Employee Assistance Programs

Enhancement of referral resources

Resource directory to regional FSSA offices

Update gambling hotline on related gambling information and referral sources

Enhance awareness of GA and GamAnon

Community-Based Process

Targeted enforcement against underage gambling

Establish minimum age requirement for bingo

VI. Planning Rationale and Evaluation

In planning for system-wide prevention programming, it is important to:

  • Clearly identify the behaviors or circumstances that are the target of change
  • Examine the underlying rationale or assumptions driving the need for change
  • Select appropriate methods for targeting the change effort.
  • Delineate the desired outcome of the change effort
  • Determine how effectiveness of the change effort will be measured
  • Establish evaluative feedback mechanism to continuously revise methods for optimal desired outcome.

It is easy enough to identify situations or behaviors that need to be changed, but for change efforts to be effective, the parties involved in effecting the change must have some common beliefs about the nature of the problem and the reason it must be changed.

The entire issue of gambling, gambling behaviors and the societal impact of gambling, both short and long term, evoke such a multitude of emotions and responses from the community that the prevention planning process is critical to use in developing a system to prevent problem gambling. One reason that such a process must be followed is because of the diverse views on the effects of gambling and the questions raised concerning appropriate social policy response and regulation.

If the specific issue of gambling can be placed into a larger societal context, support for prevention and treatment efforts may be more forthcoming. Gambling is not the real social problem. Pathological gambling is simply an indication of a bigger social problem. The real social issue to consider is the unhealthy person who becomes a problem gambler and the havoc that this person creates in communities across the nation. The "havoc" may be seen in financial outcomes, family dissolution, marital strain, poor job performance, absenteeism, psychological problems, suicide, bankruptcies, criminal behavior, substance abuse and potential violence. To a large extent, the social issue becomes individual addiction, its effects and the eventual outcome for society.

When placed in this type of context, the point of prevention is clear. Prevention efforts should be directed to prevention of the development of the unhealthy characteristics, beliefs and values that propel a person into addictive behavior, whether it is gambling, drinking or drugs. This type of prevention addresses long term individual and societal change. It is primary prevention and it focuses on the development of programs and services that ensure a person is healthy enough to avoid problem gambling behavioral development.

Secondary prevention efforts may be aimed at preventing the further development of a problem. Secondary prevention efforts in the gambling arena may be aimed at those persons whose behavior indicates they are on the pathway to developing pathological gambling problems. Although limited, the literature indicates that many of those behaviors or risk factors are well known and prevention outcomes would be aimed at stopping the progression of the problem. Again, gambling in itself is not the problem; rather it is the characteristics and circumstances of the person that lead them into the problem behavior.

For primary prevention efforts to be effective, the community standards, social policies and laws must support the development of healthy beliefs, values and behaviors in childhood or the strengthening and reinforcement of these values as a person progresses in life. Resiliency to problem behavior is especially important when a person enters a "high risk" category or is moving through an unstable transitional period in life (i.e. senior citizen status, college, unemployed, etc.) Individual values and beliefs must be strong enough to maintain responsibility through the natural stresses and pressures of life. Secondary prevention efforts attempt to intervene with persons who are already showing unhealthy behaviors and who are in a "high risk" category for developing unhealthy behaviors, i.e. senior citizens, neglected children, school failure/drop-outs.

The Social Development Model focuses on the development of resiliency to the stresses of life and this type of resiliency generally has to be learned early in life for optimal effectiveness.

One of the significant findings from the Indiana school survey was that an earlier age of onset was significantly related to progression into pathological gambling behaviors. This finding is comparable to the substance abuse field, where prior research has clearly shown that the earlier a youth begins to drink alcohol, the greater the possibility that he/she will become a problem drinker. For these reasons, underage gambling should be heavily discouraged and prevention planning should address this goal.

Tertiary prevention efforts should also be considered in planning so that the effects of pathological gambling can be reduced. Although these types of efforts are aimed at the reduction of the pathological gambling problem within an individual, the rationale for prevention efforts is different, relying on the treatment community to ameliorate the individual disabilities resulting from the pathological gambling behavior.

In system-wide or community planning initiatives, there are rarely enough resources to comprehensively address all three levels of need. The community need and the effects to be gained from multi-level intervention must be assessed and the prevention strategies clearly prioritized to meet the defined need.

In summary, to facilitate an effective prevention planning process, agreement on the problem, the rationale for change and the outcome expected from change efforts must be clearly defined. The Indiana Problem Gambling Research Project as the initial part of the planning process, has identified the baseline problem through multiple data gathering methods and has conducted research to understand the rationale for change in the state.

The FSSA has interacted with the research project team and has provided continuous feedback on the direction in which the state wants to move in regard to gambling prevention activities. An "ad hoc" committee was also appointed to review the initial prevention plan. The desired outcome for problem gambling prevention efforts has been obtained through focus groups, Indiana officials and professional "ad hoc" committee members. Through this information base, accountability and evaluative outcome is presented, followed by a discussion of the primary prevention strategies and sample evaluative process and outcome measures.

Accountability and Evaluation in Prevention Planning Efforts

Since Indiana is in the early stages of problem gambling prevention planning, it is strongly recommended that an evaluative system be established to document activities and measure the progress of the prevention and early intervention efforts. Through a well-planned evaluation, the state can develop good process evaluative procedures to demonstrate accountability with funds and resources. Secondly, the FSSA can establish criteria for short and long term outcome data so that programming effects can be consistently measured across the state. As funds are dispersed to local communities to implement prevention programs, the FSSA will be in a good position to require process and outcome data on individual programs as a part of the funding requirements.

Specific process and outcome measures are exemplified on pages 52 - 58 in the discussion on prevention strategy development. In general, the process evaluation will document the activities that are undertaken as prevention programs are established. Process data will provide information on the number of activities, the participants involved, the actual tasks carried out, etc. This type of information is critically important to a new prevention plan, as new knowledge is consistently available to improve the manner in which prevention services are provided. For example, what is the content of a particular school based curriculum? Is attendance at one type of program better than at another type of program? Was a particular subgrant program accountable for the services they provided? Were the services provided in the manner in which they were proposed? Process data are a reliable way to demonstrate accountability with funds.

Outcome data provide information on the actual impact of a program. Did the program reduce problem gambling in the long run? Were interim indicators of success present? Did a group of students or parents increase their knowledge or change their attitudes after participating in a prevention program? Did the program achieve the desired effect? Outcome data in prevention are not readily available for many years, in most cases. If Indiana implements a statewide problem gambling prevention program, is the prevalence or incidence of problem gambling reduced in ten years?

Since outcome data take so long to reveal change, interim indicators should be set up to measure progress towards the object of change.

The essential point for the state and FSSA to consider is the opportunity that is being presented now to document expenditure of funds and set up the structure for long term outcome of prevention programs for problem gamblers.

The common prevention strategies are presented below, with an identification of underlying assumptions, sample programs, desired outcomes and sample outcome measures (Office of Substance Abuse Prevention, 1991).

1. Raise awareness in the Community

Assumption: Members of the community are not sufficiently aware of the problems associated with gambling in their neighborhood.  Such knowledge could then lead to new program initiatives, and greater concern and monitoring of the activities of the community's children, friends or neighbors.

Sample program: Targeted social marketing campaigns, mass-media campaigns, community speaker's bureau, public service announcements.

Desired outcome: Education of community, over time, a reduction in problem gambling activity.

Desired outcome: Increased knowledge of the effects of problem gambling on their community.

Process measures Outcome measures
Documentation of activities

Brief evaluation form for speaking engagements

Short term

Community attitude surveys to measure pre and post effects of the social marketing campaign

Pre/post measures of increased knowledge for targeted population

Long term

Survey research to track problem gambling prevalence data to show reduction in problem behavior

2. Community Involvement Activities

Assumption: The more segments of the community that are involved, the more successful prevention efforts will be.

Sample Program: Local Community Coalitions or Prevention Teams are formed across the state to address local issues within their communities.

Desired Outcomes: Increased community knowledge and reduction in problem behavior.

Process measures Outcome measures
Documentation of activities conducted

Description of community involvement plan

Minutes from coalition meetings

Rosters of community membership to reflect diversity

Attendance data

Short term

Pre/post testing of community sample exposed to coalition activities

Qualitative surveys with coalition or prevention team members or participants

Long term

Prevalence survey research; research on related problems – for example related crime, bankruptcies, qualitative or quantitative survey of treatment professionals.

3. Increase knowledge of teachers, parents and students

Assumption #1: If adolescents understood the dangers associated with excessive gambling they would not engage in the behavior.

Assumption #2: If parents and teachers have accurate information they can communicate this to students and if they understand the signs and symptoms of problem gambling, they can identify it early and take steps to prevent continued problem behavior.

Assumption #3:  Research suggests that adolescents are engaging in gambling activity with their parents.

Sample Programs: School-based programs that include classroom/peer led curriculum specific to compulsive gambling issues, parent and teacher training regarding problem behavior identification.

Desired Outcome: Increase in knowledge of parents, teachers, and students regarding the dangers of excessive gambling. Reduction in gambling behavior.

Note:  These programs are generally not effective if they are not part of a broader base prevention effort.

Process measures Outcome measures
Documentation of school based program;

Preparation of school based program model for replication

Documentation of education curriculum

Training curriculums and agendas

Description of youth participation/rosters

Short term

Pre/post testing of parents or students on increased knowledge

Focus groups with youth for qualitative outcome data

Long term

Prevalence survey data in schools with program

Prevalence research in community

4. Change norms and expectations surrounding gambling

Assumption: Youth that are engaged in problem gambling behavior believe that this behavior is okay and will not have negative effects on them. Change norms by promoting youth attitudes that are negative toward problem gambling behavior.

Sample Programs: Peer led curricula regarding dangers of problem gambling

School and community activities with a non-gambling theme.

Desired Outcome: Create a culture that is intolerant of problem gambling behavior and that promotes healthful behavior.

Process measures Outcome measures
Prevention program curriculums

Documentation/description of school/community activities

Attendance/participation rosters

Short term

Pre/post attitudinal school test

Pre/post group interviews

Key leader survey to assess norm/culture

Long term

Prevalence survey data in schools with programs

Prevalence research in community

5. Enhance parenting and positive family influence

Assumption: Evidence exists that youth who become involved in problem gambling behavior come from families where there is poor discipline, poor supervision, and poor parent child communication. Strategy aims at enhancing parenting skills including parent-child communication, organizational and networking skills. Enhancing these skills will lead to increased parental involvement with the child and more effective supervision and discipline.

Sample Programs: Parenting skills training, task-oriented family education sessions combining social skills training to improve family interaction.

Desired Outcomes: Reductions in problem gambling behavior. Improved parenting skills, improved parent-child communication, and more consistent and effective discipline practices. The creation of parent networks and increase in parental awareness of the dangers of excessive gambling.

Process measures Outcome measures
Copy of parenting program

Attendance rosters

Description of participants with related problem identification

Short term

Brief evaluation from participants

Satisfaction surveys

Pre/post testing of increased knowledge

Pre/post measure of interaction levels

Qualitative interviews with families

Long term

Prevalence data on problem gambling

Follow-up on families-interviews, related data tracking, i.e. Arrests, marital status, etc.

6. Enhance student skills

Assumption: Youth that become involved in problem behavior have a difficult time resisting peer pressure, making good decisions, and coping with the everyday social and interpersonal demands of their lives.

Sample Programs: School based life skills training and social skills training including assertiveness, communication skills, healthy friendships.

Desired Outcomes: Enhancement of peer resistance skills, coping skills, and stress reduction skills.

Note: Need to focus specifically on gambling or targeted behavior.

Process measures Outcome measures
Copies of curriculums

Participant rosters

Short term

Pre/post testing of knowledge/skills

Follow-up interview or data collection from school

Long term

Prevalence data at school with program compared to control school with no program

Prevalence data on problem gambling

Participant follow-up for stress-related problems

7. Increase involvement in school by parents and students

Assumption: Increased involvement in non-gambling activities leaves little time for gambling-involved activities.

Assumption 2: Increasing parental involvement in school and school functions contributes to the prevention of gambling problems by involving parents in a setting that includes their children and their neighborhood increasing a sense of community and cohesion.

Assumption 3: Parents are more likely to know what is going on in their child’s life and may be instrumental in encouraging achievement of school goals.

Sample Programs: Opportunities for parents and children to come together through school clubs, social activities, and other school sponsored events

Desired Outcome 1: Increased student attendance, participation rates, parent attendance and the reduction of absenteeism and dropping out.

Desired Outcome 2: Satisfaction with school, enhanced education aspirations,and improvements in school climate.

Process measures Outcome measures
School attendance records

Participation records

Parental involvement documentation

Documentation of activities

Short term

Pre/post measure of attendance and school progress by participants

Track incidence of dropouts

School satisfaction exit tests

Target school prevalence research

Long term

Comparison with control group school

School prevalence survey

Community prevalence rates

Follow-up with participant and younger siblings

8. Increase involvement in healthy/legal alternatives

Assumption: Provides youth with choices for other types of recreational activities than gambling activities.

Sample Programs: Recreational activities focused on non-gaming, non-addiction. Youth/adult leadership activities.

Desired Outcomes: Increased number of youth participation and activities initiated.

Measurement Outcomes: Measure, document

Process measures Outcome measures
Documentation of recreational activities provided

Copies of leadership training curriculums

Short term

Pre/post survey of youth

Qualitative interview with leadership groups

Focus groups to assess outcome

Long term

Prevalence research

Tracking of participants

Follow-up questionnaires to participants

Comparative study with other strategies

9. Increase Support Services for students, teachers and parents

Assumption: With additional support, youth may receive the help they need to resist gambling activities and to cope with problems and pressures in more productive ways.

Assumption 2: Parent support groups may help parents become more aware of the problems facing their community youth and gives parents a forum to share ideas and solutions.

Assumption 3: Allows more time for teachers to spend with students and gather student input making the school experience more enjoyable thus decreasing drop outs.

Assumption 4: Support service directories for parents and teachers so they can seek assistance before a gambling problem becomes very serious.

Sample Programs: Peer Counseling, student assistance programs, Parent and Teacher training to recognize the early signs of problem gambling.

Desired Outcomes: Increased sense of support and involvement, greater confidence in coping with problems, and increased use of support services.

Process measures Outcome measures
Documentation of programs

Attendance rosters

Documentation of types of student problems

Training curriculums

Short term

Pre/post measure of related behaviors

Satisfaction surveys for services

Participant evaluative form for programs

Teacher surveys for increased identification, etc.

Records of early identification

Utilization rates

Long term

Prevalence research

Comparative research on service types

Analysis of outcome by type of service and characteristics of participants

Incidence data collection

10. Deterrence through regulatory and legal action

Assumption: If you make it more difficult to engage in under age or illegal gaming activities by better enforcement of existing laws it will deter this behavior.

Assumption 2: To be used in conjunction with other prevention techniques to reduce risks across populations.

Sample Programs: Enforcement of existing laws regulating gambling. Monitoring of legislative activities to ensure knowledge of gambling related policy level activities for example age of legalized gambling.

Desired Outcomes: Violations for those that violate existing laws.

Process measures Outcome measures
Document policies/laws targeted and outcome

Document efforts to change/methods and type of support

Monitor enforcement with compliance checks

Describe legislative changes

Short term

Immediate policy/law changes

Improved compliance check rating

Attitudinal surveys of legislators

Industry recording of illegal attempts over years

Long term

Compliance checks reveal minimal violation of laws

Industry report of minimal recording of attempts

Prevalence surveys to show reduction if problem behavior

Institutionalized legislative support for enforcement

VII.& Recommended Indiana Prevention Plan 1998-99

The 1998-99 interim statewide program gambling preention plan has been developed to establish an infrastructure for comprehensive planning on a long-term basis.  The purpose of hte proposed plan is to ensure that prevention begins across the state as the baseline data are compiled that more specifically define the extent of the program in Indiana.  The following plan is a possible strategy for addressing the prevention needs that are known to exist across the state and that can be accomplished at the current funding level.  Once the interim plan is implemented, the FSSA staff and the Ad Hoc Prevention Committee will assist local prevention teams to begin athe process of establishing a long-range plan that will address anticipated problems during the next five years.  The recommended plan's activities include:

Activities Date of Completion Person Responsible
I. Establishment of a statewide structure and process to address problem and compulsive gambling
a. Formalization of the existence and activities of the FSSA Ad Hoc Problem Gambling Prevention Committee or Advisory Group will be established to provide statewide input into gambling prevention and treatment needs. Additionally, the Committee will work with the FSSA to establish a long-term problem gambling prevention plan as research further defines the problem. This committee will ultimately provide support and guidance to local/regional community prevention teams charged with adapting the plan to meet the needs of their community.
b. Formal designation of one regional level FSSA staff person to be responsible for regional gambling prevention and treatment activities. This person may be an interim assignment until a long-range plan is in place.
c. Develop a risk/protective factor profile on each of the regions, ensuring that specific gambling related issues are included.
d. As other epidemiological data are collected throughout the state, ensure that a section related to gambling behaviors and risk factors is included.
e. Establish university based research component to conduct research, analyze results, develop effective programs, and work with the Advisory Group and local regions to link prevention activities to empirically based effectiveness models and strategies.
II. Activate Initial Public Awareness Strategies
a. Develop regional and statewide public awareness campaigns.
b. Develop billboard campaign for use across the state.
c. Establish public media plan to continually "get out the message" about the social impact of problem gambling.
d. Develop a targeted social marketing campaign demonstrating the benefits of not gambling.
e. Segment target audiences and obtain information regarding what motivates them and the media messages they respond to.
f. Ensure stable and consistent access to information through telephone directory listings and Toll-Free Telephone Referral Line.
g. Ensure that compulsive gambling prevention materials are in public libraries across the state.
III. Primary Prevention Strategies
a. Legislative/Policy Related -

Monitor legislative activities to ensure knowledge of gambling related policy level activities, for example, age of legalized gambling.

Examine needed legislative change or policy related action that must be passed through the legislature. Secure relationships with representatives and senators who have aided in the addiction and/or problem gambling arena.

Identify and ensure legislative action needed for 1999 session.

Work closely with the Governor’s Gambling Impact Study Commission.

b. Conduct baseline research throughout state on prevalence of problem gambling across age, gender, and geographic and cultural and high-risk populations. Include data on related areas such as the relationship between homeless status and gambling problem, suicide incidence, etc.
c. Monitor enforcement of existing laws regulating gambling, including lotteries, casinos, bingo, etc.
d. Determine process for implementing effective school based prevention programs, including education and awareness. School based programs would include classroom strategies as well as working with parent groups.
e. Work with universities’ student health centers to provide responsible gambling education for students
IV. Secondary Prevention Strategies
a. Assess and intervene with high-risk populations, including juvenile delinquency populations and older citizens. Lower criteria for receiving treatment from pathological gambling to problem gambling. Problem gamblers outnumber pathological gamblers six to one in Indiana.
b. Develop programs or strategies to impact the high-risk populations.
c. Develop training program for counselors who will deal with persons experiencing problem or compulsive gambling behaviors. Contact licensing boards for training and information dissemination.
d. Select one-two pilot sites for school based program implementation and evaluation.
e. Complete gambling resource directory for use across the state.
V. Community Mobilization Activities
a. Enlist the participation of key leaders with influence within local communities. Form a Key Leaders Group to assist in the development of local or Regional Community Prevention Teams.
b. Create Community Prevention Teams at either the regional or local level. Provide training and orientation for members regarding problem gambling behavior.
c. Use Readiness Assessment Questionnaire to assess communities readiness for implementing a problem gambling prevention plan.
d. Involve community groups who can consistently mobilize their own community-wide membership, including:

faith community
corporate and business community
justice/legal community
school system
Council on Aging
Cultural Groups

e. Facilitate community efforts and empower local communities to address specific problem gambling concerns.
f. Link local efforts to existing providers in the community to ensure community-wide support, including:

local court or correctional programs, e.g. drug courts
probation and parole regional offices
school corporations
social service/mental health providers

g. Work with Governor’s Commission of Drug-Free Indiana for a working template or design for effective community organization and local prevention initiatives.

Prioritization of Prevention Activities

Determining which activities can produce the most effective outcomes is a difficult task, but generally necessary because of limited resources. This case will probably be the same for Indiana as it is for most other states that have struggled with the problem gambling issue. The selection of strategies must be based upon the identification of the types of problems across the state or community and the desired outcomes for the change effort.

Normally, the desired outcomes will be for both short and long-term results. In other words, policy makers want to see an immediate outcome in terms of problem reduction. However, in prevention programming, the effects of the programs or interventions are not seen for many years – when the effects of community education or targeted school programming begins to, hopefully, show reductions in the prevalence or incidence of the problem behavior. The aim of prevention programming is to deter the development of some behavior or activity, so the outcome may not be evident for 10-20 years, depending on the type of problem.

An example of prevention programming effects may be seen in the tremendous campaign aimed at prevention of lung cancer. After 20 years, there is finally a sign that adult behavior has changed, most likely as a result of the strong educational messages that began when current adults were 10-12 years old or younger. Unfortunately, the educational message has been less effective for today’s teens as there has been an increase in tobacco use among youth. Again, there is a massive prevention plan underway. Indicators of successful intervention will be measured through continuous school surveys, purchasing habits, compliance checks, etc. However, the desired long-term effect will only be seen as illness related to using tobacco is decreasing.

The same is true for problem gambling behavior or underage drinking. Tremendous prevention efforts may go into these two problem areas, but it will be another generation before there is enough time passed to determine if underage drinking has been curtailed.

However, there are numerous "interim" indicators to show whether a prevention strategy is accountable and if it is demonstrating some type of interim effect. In the gambling area, one indicator might be a decreasing number of underage gamblers attempting to obtain entrance to casinos.

All of these issues must be considered when selecting the strategies most important for immediate implementation.

Indiana officials have indicated that they are interested in not only the sustained outcomes related to long term prevention of problem gambling behavior, but they are also interested in accountability measures related to prevention programming and the short term effect that can be expected from certain strategies. At this point, the state may be interested in prioritizing programming that will yield the "best bang for the buck".

Effective primary prevention is expensive in the short term because it must be targeted and part of an overall prevention strategy. The question is: "Is the output of funding now going to ensure less cost in the future because of reduced problem gambling and its effects on society?" Unfortunately, there is no firm answer to that question, but it is clear that prevention of problem and pathological gambling behavior is much more cost efficient than dealing with the problem once the effects are being seen. This does not mean that secondary prevention efforts should receive less attention. For example, the treatment of problem gamblers now will surely be more cost effective than allowing them to become pathological gamblers. In reality, some balance of the competing issues must be achieved. In general, the long-term decrease in problem or pathological gambling behaviors is the desirable outcome. However, both primary and secondary efforts must be developed to achieve that goal.

Considering the various arguments that can be made in support of one type of prevention effort over another, the recommended prioritization of strategies is presented for consideration by the Indiana decisionmakers:

1. Primary prevention efforts with school-age children

This is the recommended first priority because of the elevated prevalence rates from the Indiana School Survey. Although the school survey was limited in scope, its interpretation suggests that youth in Indiana are involved in some type of gambling behavior at an early age and the prevalence rate for probable problem gambling among Indiana youth is slightly higher than related prevalence research.

This type of programming involves school-based programs, including education, awareness, specialized curriculums, skills development, student assistance programs, teacher training and education programs and parental education and awareness programs. These programs must be targeted to a specific age group and problem area. It is also suggested that school based programming be tailored to local needs.

Programs addressing the school age population can be provided somewhere other than schools.

Community centers, religious institutions, summer recreational programs and housing community programs can all deliver effective primary prevention with school-aged youth.

2. Secondary prevention activities targeting adolescents>

Since this is the group that responded to the current school survey, it is recommended that secondary prevention efforts begin with this "high risk" category. Programs addressing this priority area include family involvement and education, school-based programs, community programs and specialized summer recreation alternatives.

Compliance checks by law enforcement of gambling opportunities for adolescents to ensure that laws are being enforced and community action to review and make any necessary changes to social policy are also critical parts of this effort.

Community standards and practices must be consistent in discouraging underage gambling.

3. Secondary and tertiary prevention efforts to address immediate problems

There are a number of possibilities for good short-term outcome in preventing the progression of problem gambling Indiana. For example, secondary prevention initiatives are useful in lessening the social costs of a problem behavior. Currently, a person must be a pathological gambler to receive treatment serves through the DMH. Research indicates that problem gamblers outnumber pathological gambler in Indiana six to one, demonstrating a need to intervene before a gambling problem meets the diagnostic criteria for pathological gambling. In order to reach more individuals with gambling problems, it is recommended that the DMH lower its criteria to receive treatment to a problem gambling diagnosis instead of pathological gambling. Based on the ratio of problem to pathological gamblers in Indiana, it is estimated that the DMH could reach 186 individuals, compared to the 31 people assisted in 1997.

These priorities are suggested because they progressing address the population that is presenting the greatest danger to the state at this time. However, Indiana should develop some type of site specific program in the next several years to address "high risk" population issues, which may include minorities, unemployed persons, lower socio-economic males, etc. FSSA and the treatment community are advised to track the progression of pathological gambling problem development so that the highest risk groups can be identified for specialized programming.

There will also be a good short-term benefit to specialized training of treatment professionals to learn to recognize and treat those persons with problem and pathological gambling behaviors.

However, community coalitions, citizen groups, etc. are advised to establish legislative monitoring efforts to ensure that Indiana laws and the enforcement of those laws are consistent with community standards and practices since these efforts impact all levels of prevention.

Conclusions

It is important to reiterate the opportunity that Indiana has to establish an effective problem gambling prevention program aimed at the development and strengthening of healthy beliefs, values and standards that encourage responsible behavior in all potential problem areas. Problem and pathological gambling can be prevented through coordinated and empirically related community prevention programs. Research increasingly indicates that prevention and treatment programs work and can be accountable in outcome.

The array of persons and agencies involved in the Indiana Problem Gambling Research Project has clearly indicated an initiative to establish an effective program for the state. There seems to be a clear commitment from the elected officials, the treatment and academic communities and the gambling industry to work with the FSSA to develop an effective statewide initiative of which the state can be proud.

The coordination efforts at the state and community level and the interest demonstrated by the participants in the project clearly show that the ensuing prevention planning effort will be effective and a positive experience for the state.


References

Advocates for Youth. (1994). A youth leader’s guide to building cultural competence.

Christiansen, E. M. (1997). The U.S. 1996 gross annual wager. International Gaming & Wagering Business (Special Supplement).

Clotfelter, C. T., & Cook, P. J. (1989). Selling hope: State lotteries in America. Cambridge, MA: Harvard University Press.

Custer, R., & Milt, H. When luck runs out: Help for compulsive gamblers and their families. New York: Facts on File, Inc.

Developmental Research and Programs, Inc. (1993). Communities that Care: Risk-focused prevention using the Social Development Strategy.

Dunne, J. A. (1985). Increasing public awareness of pathological gambling behavior: A history of the National Council on Compulsive Gambling. Journal of Gambling Behavior, 1(1), 8-16.

Frank, M. L., Lester, D., & Wexler, A. (1991). Suicidal behavior among members of Gamblers Anonymous. Journal of Gambling Studies, 7, 249-254.

Gaboury, A., & Ladouceur, R. (1993). Evaluation of a prevention program for pathological gambling among adolescents. Journal of Primary Prevention, 14(1), 21-28.

Haubrich-Casperson, J. (1993). Coping with Teen Gambling. New York: Ro0sen Publishing Group, Inc.

Knapp, T. J., & Lech, B. C. (1987). Pathological gambling: A review with recommendations. Advances in Behavior Research and Therapy, 9, 21-49.

Lesieur, H. R. (1993). Understanding compulsive gambling. Center City, MN: Hazelden.

Lesieur, H. R., Blume, S. B. (1993). Pathological gambling, eating disorders, and the psychoactive substance use disorders. Journal of Addictive Diseases, 12(3), 89-102.

Lesieur, H. R., & Rosenthal, R. J. (1991). Pathological gambling: a review of the literature. Journal of Gambling Studies, 7, 5-39.

McQueen, P. A. (1996). North American lottery sales report. International Gaming & Wagering Business, 17(10), 73-76.

Mrazek, P. J., and Haggerty, R. J., Es. (1994). Reducing risks for Mental Disorders: Frontiers for Preventive Intervention Research. Washington, D.C.: National Academy Press.

Norman, E., Turner, S., Zuzn, S., & Stillson, K. (1997). Prevention programs reviewed: what works? In Elaine Norman (Ed.), Drug-Free Youth: A Comendium for Prevention Specialists, (pp. 22-45). New York and London: Garland Publishing.

Politzer, R. M., Morrow, J. S., & Leavey, R. (1985). Report on the cost benefit/effectiveness of treatment at the Johns Hopkins Center for Pathological Gambling. Journal of Gambling Behavior, 1, 131-142.

Ramirez, L. F., McCormick, R. A., Russo, A. M., & Taber, J. I. (1983). Patterns of substance abuse in pathological gamblers undergoing treatment. Addictive Behavior, 8, 425-428.


Appendix I:  Prevention Programs

Few prevention programs exist that address problem gambling behavior because of the newness of the field. However, five programs discussed below have set a trend for problem gambling-based curricula aimed at adolescents and older adults. These include: Drawing the Line: A Resource for the Prevention of Problem Gambling, Volume I (Junior High); and Volume II (Senior High); Improving Your Odds: A Curriculum about Winning, Losing, and Staying out of Trouble with Gambling; Wanna Bet? Preventing Adolescent Compulsive Gambling and Gambling Away the Golden Years. The following programs can be adapted to meet the needs of adolescents and older adults in Indiana.

Drawing the Line: A Resource for the Prevention of Problem Gambling, Volume I (Junior High)

This three-year prevention program was designed as a supplement to Nova Scotia’s junior high course, Personal Development and Relationships (PDR), for students in grades seven through nine. Five lessons are included in each grade level, beginning with daily risk-taking and concluding with a detailed analysis of the stages of compulsive gambling.

Grade seven’s Drawing the Line program is entitled Life is a Gamble. Gambling is presented within a larger context of daily risks. Youth learn to differentiate between positive and negative risk taking and apply the skills of responsible risk-taking. They also examine the relationship between risk-taking and self-esteem, and become aware of how factors such as peers and excitement can influence gambling behavior.

Be a Winner is the title of grade eight’s prevention program. Social forces that influence students’ gambling-related values and decisions are explored. Youth also examine their own values and irrational beliefs regarding gambling, and learn that being a "real winner" only results from self-acceptance and the realization that gambling makes false promises.

Grade nine’s prevention program is entitled When Gambling Becomes a Problem. Substance abuse prevention (to which gambling prevention principles are similar) is stressed. Students’ learn how a gambling problem can develop and progress. A video challenges youth to examine their own gambling behaviors and attitudes.

Methods used in lesson activities include: a) providing information necessary for value development, b) aiding in the exploration of social and personal influences which predispose students to compulsive gambling, c) maximizing student participation and experiential exercises, and, d) providing tasks which develop personal and social skills (e.g., problem-solving skills).

Youth participating in this program learn the skills needed to recognize the difference between low-risk social gambling and high-risk compulsive gambling. It is hoped that students who complete this three-year program will leave junior high more informed of how to lead a healthy lifestyle and how to "draw the line" when gambling opportunities arise.

Drawing the Line: A Resource for the Prevention of Problem Gambling, Volume II (Senior High)

Drawing the Line for Nova Scotian senior high students, a prevention program with lesson activity methods and program goals identical to those of the junior high version, was developed as a supplement to three high school courses. These include: Career and Life Management, Math 231/432, and Economics 331.

Three program lessons are incorporated into the Career and Life Management (CALM): Self-Management course, which include: a) How does gambling become a problem? b) Gambling as an addiction, and, c) Values. Youth explore their own values, beliefs, and attitudes in regard to gambling, while becoming more conscious of the consequences and risks of this activity. Youth who have completed this course will be better prepared to make responsible decisions regarding their own gambling behaviors. Math 231 and 432: Probability also contain three program lessons which help students realize that participation in gambling results in inevitable loss. Students calculate the odds of winning three commercial gambling games, the roulette wheel, video gambling machines, and the lottery. Through probability exercises and examples, students learn to recognize types of irrational thought that deny the real odds. Through this use of math, students challenge their own irrational thinking.

Two lessons are included in Economics 331: Gambling as an Industry, Industry Profile, and Costs and Benefits. These aid youth in understanding the social context of gambling better by examining political, economic, and social forces that affect policy-making procedures. Through class exercises, students become better prepared to function as informed consumers and decision makers in areas where gambling is a popular form of amusement.

Improving Your Odds: A Curriculum about Winning, Losing, and Staying Out of Trouble with Gambling

Improving Your Odds was designed to aid teachers and youth leaders in helping youth living in Minnesota make choices about when, whether, and how much to gamble. Although the program manual does not specify which age groups are targeted, materials are to be incorporated into the regular classroom curriculum. This program can be completed in four to ten hours, depending on the time spent on class discussion and completion of activities.

This prevention program’s curriculum, which is characteristically less experiential and more instructive than both volumes of Drawing the Line: A Resource for the Prevention of Problem Gambling, is divided into six sections. These sections aid students in exploring the role of gambling in our society and in their own lives. Youth learn about the risks and advantages of gambling and explore their own attitudes, feelings and opinions regarding gambling. Program activities guide students in developing values related to their own views on gambling. Topics such as how to identify a gambling problem, how to confront someone who is gambling, and where to seek help, are also addressed.

All sections of Improving Your Odds contain activities that are designed to promote classroom sharing, mutual learning, and the development of a social support system. Each section requires participation at least once. The activities in Section I- Gambling in Minnesota emphasize the history of gambling in Minnesota, current gambling activity in the state, and related problems. Section II- Gambling: Choices and Guidelines, Part 1 and 2 help youth to ascertain personal guidelines about if, when, and how much to gamble. Activities in Section III-Gambling Problems review types of gamblers and the characteristics of pathological gambling. Section IV-What to Say, What to Do When Some-one’s Gambling Concerns You teaches students sound ways to confront a problem gambler. Activities in Section V-Gambling Expansion in Minnesota allow students to consider the positive and negative effects of expanding gambling opportunities. The purpose of Section VI-Evaluation and Enrichment is for teachers, youth leaders, and students to integrate information from other sections and evaluate whether learning objectives have been achieved.

After completion of this program, it is hoped that students will be able to: a) describe the history of gambling in Minnesota, b) describe the types of gambling available in Minnesota, c) explain the impact of gambling in Minnesota, d) explain characteristics and statistics of gambling and gambling problems in Minnesota, e) identify three societal influences that encourage gambling, f) describe six types of gamblers, g) identify common characteristics of problem gambling, h) establish and follow personal guidelines about whether, when, and how much to gamble, i) share concern with a friend or family member who is gambling in a high-risk way, j) list three helping resources for problem gamblers.

Wanna Bet? Preventing Adolescent Compulsive Gambling

This brief gambling prevention program teaches middle school students in grades five through eight how to think critically about gambling. Program curriculum, consisting of three lessons, may be incorporated in health, math, social studies, English, or life skills classes, or in combination with an existing prevention program. Youth evaluate their own attitudes towards gambling by applying lessons learned through experiential activities. Each lesson, which is supplemented by transparency materials, only takes 40 minutes to present and may be taught in blocks of one, two, or three days.

The first lesson of Wanna Bet?, Games of Chance, reviews the concepts of probability and underage gambling, games of skill versus games of chance, gambling addictions, and warning signs of adolescent gambling addictions. It also explores how societal trends and family attitudes have influence on students’ views of gambling.

The Power of the Win, in which students learn about the three phases of compulsive gambling, is the title of Wanna Bet’s second lesson. A video entitled "Andy’s Story" accompanies the class presentation so that students can better understand how gambling can progress into compulsive behavior. This short video specifically designed for teenagers is about an 18 year-old male athlete who develops an unsatiated taste for blackjack. He and his family tell his story and answer questions about his gambling problem, recovery, and experience in jail. A class discussion of "Andy’s Story" follows.

The third lesson, Quit While You’re Ahead, challenges students to clarify what they would do to resist invitations to gamble. Students prepare a set of refusal responses and role-play them.

The goals of Wanna Bet? are to: a) dissuade underage gambling and enrich critical thinking by: focusing on the realities of gambling and the increased risk for teenagers, b) confirm that odds oppose the gambler, c) identify behaviors which lead to a gambling addiction, and, d) stress that underage gambling is illegal in the United States and results in serious consequences.

Gambling Away the Golden Years

The Gambling Away the Golden Years program was developed to prevent the onset of compulsive gambling in senior citizen populations. Due to retirement and other stressful life transitions occurring in midlife, (e.g., finding oneself in an "empty nest"), gambling has heightened potential to become a high-risk hobby.

Materials used in this program include pamphlets and a short video entitled "Gambling Away the Golden Years," which provide heartfelt stories told by spouses and adult children of gamblers and gamblers themselves regarding the fear, loss, pain, and shame related to compulsive gambling. These materials also examine gambling as an addiction, review early warning signs of problem gambling, and list the three phases of compulsive gambling. In addition, the necessary components for recovery and information regarding where to seek help are presented.


Appendix 2:

Community Readiness Assessment Questionnaire

The following questionnaire will give you an opportunity to identify the prevention building blocks and stumbling blocks for various groups within your community. To complete this activity think of two groups in your community who are likely to have divergent views on the issue of problem gambling prevention. Answer the questions from the point of view of each of these different groups. Brainstorm a list of community stakeholders who could assist in developing a positive plan for your community. Use this worksheet with other key leaders or members of your team back in your community.

Awareness of the Problem

1. What problems do you think adolescents have in your community?

Substance Abuse Violence

Problem Gambling School Drop-out

Juvenile Delinquency Other: ____________________________________

Teen Pregnancy

2. What is the level of awareness in your community of adolescent problem behaviors related to gambling?

Very aware Not aware at all

Somewhat aware Other: _________________________________________

3. What do you think are the views of key leaders within your community with regard to adolescent problem behaviors?

 

4. What community groups are most affected by adolescent problem behaviors?

Families Government agencies

Schools Children

Service Providers Business and industry

Community organizations Other:___________________________________

5. Who are the stakeholders in the community who are likely to represent different positions on the issue of problem gambling?

 

6. Who in the community could facilitate the development of a positive strategy involving these different stakeholders?

 

View of Prevention

1. Does the group view prevention as one of the solutions to adolescent problem behaviors? Yes     No

How do they view prevention?

 

2. What other solutions have been tried? How were those efforts viewed?

 

 

3. Will key group leaders support or block prevention efforts.

Please give an explanation for your answer.

 

4. Will key institutions, businesses and social services in the community block or support prevention efforts?

Please give an explanation for your answer.

 

5. Who are the stakeholders in the community who are likely to represent different positions regarding prevention programming?

 

 

6. Who in the community could facilitate the development of a positive strategy involving these different stakeholders?

 

Community Relationships

1. What challenges do you foresee for the implementation phase of a problem gambling prevention plan?

 

2. Can problems be openly identified and discussed?

Yes     No     Sometimes      It depends on the problem.

Examples:

 

3. Is there a history of successful community change?

Yes     No     Sometimes      It depends on the problem.

Examples:

 

4. Are community leaders and citizens able to work together to identify community problems and needs?

Yes     No     Sometimes      It depends on the problem.

Explain:

 

5. Do grass-roots groups work cooperatively with community leaders, and are they involved in community decision-making?

Yes     No     Sometimes      It depends on the problem.

Explain:

 

6. What organization(s) and or people should be responsible for the implementation of the Problem Gambling Prevention Plan? (Both management and funding.)


Appendix 3

Community Problem Gambling Prevention Team
Job Description

Title: Community Prevention Board or Team Member

Responsible to: Community Prevention Board Chairperson and Key Leaders Group

Responsibilities:

  • Participate in training to learn the risk factors for adolescent problem behaviors, the Social Development Strategy for prevention and a process for planning based on a community risk and resource assessment.
  • Participate in training related to gambling opportunities and problem gambling behavior in Indiana.
  • With the Board, conduct a community risk and resource assessment, analyze results and report to Key Leaders Group and the Family and Social Service Administration.
  • With the Board, prioritize which risk factors need to be address within your community. Develop plans based on suggestions in statewide prevention plan.
  • Mobilize the community to implement the plan to reduce risk factors and increase protective factors.
  • Attend regular and special meetings of the board.
  • Maintain records of meetings and activities in order to facilitate evaluation of this strategy.

Qualifications:

  • Must be appointed by Key Leaders Group.
  • Adequate time to ensure effective participation.

Time Commitment:

  • Board members must commit to a two-year term.
  • Meetings will be on a monthly basis.

Benefits:

An opportunity to:

  • Promote the welfare of young people in your community.
  • Help Indiana be one of a few states with a comprehensive prevention plan to combat problem gambling behavior among adolescents.
  • Network with colleagues, community members, and young people.

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 Last Revised: Tuesday, 29-Jun-2004 16:11:16 EST