 Hello and welcome to the 212 people that we have online who have joined us for tonight's webinar and the viewers who will be watching the podcast. The Mental Health Professional Network wishes to acknowledge the traditional custodians of the land across Australia upon which our webinar presenters and participants are located. We wish to pay respect to the elders past, present and future. Remember the tradition, the culture and hopes of Indigenous Australia. Hi, I'm Rachel Rossopla and I'll be facilitating tonight's session. My clinical background is one in psychotherapy and in community mental health, but my current role is largely as Associate Professor of Nursing at Charles Birch University. I'm now going to introduce our panelists and I'd like to start by introducing Dr Paul Grimsey, a rural GP who works in Romsey, Victoria. Paul has an interest in addiction medicine and mental health and is part of the RACGP Special Interest Addiction Network and Chair of the RACGP Victorian Drug and Alcohol Committee. He's also a medical educator. Paul, can I ask you how often do you see patients who present with gambling problems as their main concern? Thanks, Rachel. It's actually a really interesting question. I had prepared my answer. Well, I thought about this and I thought, well, it's actually quite rare, but I had my first patients in many, many months and I'm directly with this on Monday, so I've got a slightly skewed response. But in general, despite the prevalence of gambling disorders in our community, it's actually quite a rare presentation for GPs to see. I suppose there's two categories of presentations. One is where the patient will come in, usually because of external issues. So that could be a family issue, such as John and his wife, Melissa, bringing in, basically encouraging him to seek help and he's attending. Or it could be a crisis with work or finances or debt. Something that's sort of triggered externally. It's actually quite a rare occasion for someone to acknowledge their issues and come in directly, presenting with that itself. And so the second presentation is often where it's hidden, and hidden because of a number of factors. So I think exploring, knowing that as a GP, you may get a presentation directly, but one of the things about the session, well, I suppose the presentation is you've got to consider, they won't necessarily present directly to us. But we've got a couple of folks exploring that. Yes. So we'll look forward to hearing from you as to much more detail about that. Let me now go on and introduce Celie Gainsbury. Celie is a clinical psychologist with over 10 years experience in gambling research. Celie, your research has focused on understanding gambling to inform the development of responsible gambling strategies and minimisation policies. But I understand you've also completed research in some other areas. Can you tell us a little bit about those briefly? Thanks. Thanks, Rachel. I've been looking at internet gambling in particular recently because it is an area of increasing concern. I'm sure you've all seen the previously action of advertisements in relation to sporting events, advertising online gambling websites. And we are seeing this new concern, particularly for young people in the community. The other area I've been looking at is treatment. We now have online treatment options. We have treatment that's relevant for culturally and linguistically diverse populations. But it really isn't necessarily just the one fit all in terms of treatment and prevention strategies. There is a lot of individual differences that we need to consider. Thank you, Celie. And it's great to know that there is a lot of research going on and such a diverse amount of research that's really practical as well. Next, I'd like to welcome Dr Clive Alcock. Clive is a semi-working psychiatrist who has spent 35 years working with people with gambling problems. And his strong interest in horse racing from management through to breeding has given him a view of gambling from the other side. Clive, what are your thoughts about the Caulfield Club and how did you get involved with helping people with gambling problems? It's one of my sins. I got involved with horses and then I discovered racing. And racing has been a part of my life for, dare I say, for over 50 years. I've been lucky enough to be involved with a couple of good horses, particularly in the 80s. My colleagues in psychiatry as I moved into that field, knowing was interested in gambling, started sending me people with gambling problems because they presumed I knew something about it. And they were completely wrong. I knew a little bit about gambling, but not a lot about problem gambling, which of course at the time was very much under-noticed and under-researched issues. I realized it was a need and I began commencing to do research and to assist problem gamblers, as you noted, for over 35 years. And I'm very happy to talk about some of the experiences and maybe pass on some of the information that I've gained. With regard to the Caulfield Club, I have to step up and say it's been a lousy race from the over the years and I will name a couple of horses, but I should apologize in advance to the connections of the horses for daring to name them. The Borough horses are a bit of a challenge and I do think the favorite, because they're good, Charles, and one at a bit of value on each way basis is a horse called Tally. It'll need a bit of luck from a wide barrier draw. But Rachel and everybody listening, gamble responsibly. Thank you, Clive. And I guess take those tips at your own risk. Exactly. Okay, and finally, I'd like to welcome Kate Roberts. And Kate is an Australian Association of Social Worker, credited mental health social worker for over 34 years, and an accredited problem gambling counsellor. Kate has worked for the past 70 years in the field of problem gambling. She was the founding chairperson of the Gambling Impact Society for New South Wales and now works as their executive officer. She's a community advocate and lobbies at both a state and national level to raise awareness. Kate, you have a special or a particular interest in a public health approach to gambling. Can you tell us about how that relates to your PhD research? Oh, thank you, yes. Well, I've had a range of journeys with gambling issues and gambling harms and currently looking at the nature of poker machine gambling in particular and the way that it perhaps undermines the agency and rebounds people into a new relationship with technology are very much based on some of the work of Donna Haraway and the content of Cyborg. And recently we've seen a very good ADC documentary that's perhaps reinforced that in lay people's terms and I'm interested in how we use that knowledge now in developing policies that look at both the harm for individuals, families but also communities and I guess that's part of my interest in the whole field of gambling not just at an individual clinical level but also with family members and communities and very much a systemic approach. Okay, thank you, Kate. And we'll look forward to reading your findings from your research in due course. Thank you. Okay, so before we go any further, I'd just like to remind you of the ground rules to make sure that we all have the opportunities to gain the most from the live webinar. I ask that every participant consider the following rules. Be respectful of other participants and panellists. Behave as if this were a face-to-face activity. Please post your comments and questions for panellists in the general chat box. If you are having technical issues, post in the technical help chat box. Be mindful that comments posted in the chat boxes can be seen by all participants and panellists and please keep your comments on topics. If you'd like to hide the chat, click the small down arrow at the top of the chat box. Remember, your feedback is important to us so we'd ask that you please complete the short exit survey which will appear as a pop-up when you exit the webinar. Just very briefly, this interdisciplinary panel discussion is focused on giving you the opportunity at the end to describe how to engage with people who are experiencing problem gambling to implement key principles of providing an integrated approach in the early identification and treatment of mental health problems related to problem gambling and to identify challenges, tips and strategies in providing a collaborative response to assisting people experiencing mental health issues related to problem gambling. Now, I'm going to make an assumption that you've all read the case study as it was posted for you and I wonder over now to Paul to hear his perspective as a GP and his response to this particular case study. Thank you, Paul. Excellent. Thanks, Rachel. In preparing this component which is from very much a GP perspective, I really have to focus on my role as a GP and being a generalist in primary care rather than my focus which is a special interest in addiction. So really, this is a GP-focused thing and utilizing a little bit of my experience but again, just making sure it's very general. And as I've mentioned in sort of my introduction, the presentation of patients like John or patients with problem gambling do vary and John's presentation is not really out of the blue. It's something that's quite common in terms of having that external factor bringing someone like John into the issue and I suppose one of the things that hold people back from presenting themselves and we know a lot of people do not present on their own volition is the issue of stigma and the stigma is across the board with a lot of mental health and with problem gambling, it seems to be magnified. There's a particular issue or association between the gambling behaviors and the feeling of shame and that shame will hold people back in seeking help and it makes it very difficult for those people and their families to bring this up to external people such as their GP despite our efforts to try and make the consultation as open as possible. So a number of things we can do as a GP to try and facilitate this and to some extent I approach someone like John as this is the first presentation of hopefully a long-term relationship so I'm not going to focus just on the gambling and I may input it to a side for a moment but I'm really going to focus on him as a person. Now the important part about being a GP is to ensure that things such as what we're discussing clinically remains as confidential as possible and there may be a few exceptions and in this case there's nothing flagging danger to his own life or someone else's although it would need to assist that as part of our assessment. So I could reassure him that in discussing things things are going to be confidential. Probably the first thing I would do is actually thank John for coming in and potentially if he looked, I think I know his expression was I'd probably acknowledge how brave it is to actually make that first step that first step in seeking help even if it's being pushed by someone else and he's really a gutsy move and while his wife has asked him to speak I've made the appointment, he didn't have to turn up so just acknowledging that it's really important to help start developing that engagement very early. We've got a short consultation time with someone like John as we have a lot of patients in general practice so we've got to make the most of this and really getting that engagement very early. So acknowledging this company may be experiencing reassuring him that it's okay to talk about this here and also I suppose re-emphasizing the idea of confidentiality. We know a lot of males don't seek general practitioner health care and often what we consider often too late until we've actually got real big issues that are symptomatic to them so they may not be familiar with the health environment within the general practice setting so reinforcing that confidentiality is important. In terms of asking him about the gambling side of things it's worth having a few leading statements beforehand. So a normalizing statement I find is quite useful and often say that one of the normal things or one of the things I do with most of my patients is ask a few questions about their lifestyle and they may ask about smoking, about exercise, nutrition, other drugs and it's part of that lifestyle assessment then I'll throw in, I'll also ask patients about whether they've had any problems with gambling. It's nice to anchor sometimes this with a patient who doesn't present with a gambling issue, John's an exception in this case but someone may be presenting with other issues. So if you're asking about mental health issues, men's health issues, drug and alcohol, other substance issues or even just during and taking a social history it's a nice anchor then to bounce off saying a lot of people who are having trouble with their work or finding them stressful but in terms of gambling they do have this sort of problem. So it's anchoring it to part of the presentation to be quite useful in terms of leading into this area so it doesn't seem like a question out of the blue if they're not presenting with it directly. In John's case we've got that he's already let in but I think it's important for GPs to be able to screen for this as regularly as we can. It can't screen for every possible problem, every consultation but there are certain factors that will lead us to that more so. So those things are mental health issues and particularly the hyper-evil and stuff depression and anxiety are closely associated with the high correlation between problem gambling and those mental health issues. Social issues, and that could be marital problems it can be problems with isolation socially it can be workplace. So that social history that we do take especially when we're seeing patients for the first time can be an important clue for us to enter and inquire about problem gambling. The other thing that's closely associated with all these is substance use. We know a lot of people who drink alcohol to excess or use other drugs to excess or smoke to excess just smoke full stop have a higher rate of problem gambling and vice versa. So they're all options for us to get in there and so it's really a matter of choosing the right sort of question. The question I would suggest if there's lots of ways of doing it but just ask one question, have you ever had an issue with gambling? It's quite a direct question, it's simple and it takes quite a good visibility in exploring and opening questions to start this. So once you've got an opening and someone's acknowledging maybe they've got an area of gambling then it's important to reassess those other areas. So whether they've got gambling as a primary problem that you're addressing now then look further into those other areas that I've just mentioned. So it goes back and forth and it's important for us to assess that broadly. While remaining non-judgmental really opening up the discussion and giving John permissions talk about these things in his own time. Our real role though as GPs in this area is really coordinating a team and it's really essential for us to set the stage where John Phil's cultural coming back to us but we also make sure that we're well supported in ourselves it's not an area that most should be familiar with. So we should have a role in looking after the medical part of him he's a 42 year old male he should be sort of having a middle aged mental health check cardiovascular risk in particular diabetes assessments drug and alcohol lifestyle assessments and we should also be incorporating other services. So someone like a psychologist would be the ideal first person that I would be looking at if John was willing to engage within this first household but may not come in as first household. So on that note I'm going to sign off for this and having mentioned psychologist I think Rachel you've got someone else to introduce. Okay. Thank you Paul. You gave us a lightning trip through the GPs role and perspective and as you suggest we're going to now hear from Sally who's going to give us the perspective from a psychologist. Thank you Sally. Thank you. So just kicking off as to follow on from Paul I as a psychologist a clinical psychologist would receive a referral from the GP outlining the client's presenting problem and from this case study it would seem though that gambling is an essential issue to be discussed. So here you can see the gambling disorder criteria. So gambling disorder is classified as behavioral addiction similar to substance used in the DSM-5. This location reflects the research findings that gambling disorder is similar to substance related disorders in the clinical expression for in origin, comorbidity, physiology and treatment as substance related disorder. The symptoms you can see there so I won't go through but it's important to note unlike substance abuse there are no visible signs of gambling problems. You can't see it in someone's eyes or smell it on their breath. Gambling is often referred to as the hidden addiction. So clinicians can look for signs and patterns so disengaging with relationships and not being so concerned with other important things in their life. Eating, sleeping, mood changes, financial difficulties or sudden spending and then unexplained absences because gambling does take up a lot of time. So in our first client meeting as Paul said you'd really assess the issue but there'd be a lot of motivation going on. There's a lot of embarrassment and shame associated with gambling and gambling problems and particularly within specific cultures this can be enhanced. In minority cultures we do see particularly difficulties with gambling and gambling problems associated with a loss of space in Asian cultures. So the first session was typically not doing a thorough assessment with the client and motivating the client to ensure they're able to begin a process of change and recovery. As with other addictions gambling problems typically follow a cycle of increasing intensity and engagement, attempts to stop and relapse so it's about assessing of where someone is in that cycle. So it's important to assess whether the goal is abstinence from gambling completely, abstinence in some forms or control due so this can also change over the course of treatment. So what we might look at is expressing empathy being very respectful and compassionate helping the client see the consequences of their gambling so creating a discrepancy between continuing gambling and achieving important goals. You would avoid any arguments and really roll with any resistance so that the client themselves can identify their own collusion. Gambling there is no signal conceptual model but it's the pathway model is proposed that taking into account that not everyone who has a gambling problem displays it in the same way or develops it in the same way. So what we call is the pathway one on normal problem gamblers are those who entering into gambling problems are linked to environmental or learning might stand from cognitive distortions. The gambler doesn't necessarily have any previous and psychological problems. And there's a second pathway of what we call emotionally vulnerable gamblers who might be using gambling as a way to manage stress or crisis in their lives and that's what we might see in this case here. And then the third biologically based pathway and those in height have multiple disorders and not seriously entering into gambling problems such as impulse control difficulty. Gambling affects people in different ways and it doesn't discriminate so gambling problems are found of cost age groups, income groups, cultures and jobs. Some people develop gambling problems quickly or some develop them over years. Finally just briefly treatment the most effective treatment we know is CBT and motivational interviewing components although there is a lot of research on gambling treatment in the different types but we also know that people can benefit from brief interventions even a single session intervention can be really effective for some people. So motivational interviewing is an important component. You'd also look at a thorough assessment to see what else is going on in their life. Psychoeducation is important and that's about understanding how for example poker machines work, understanding randomness and common irrational belief. Then you look at behavioural strategies so for example you might self exclude from a venue leave your cash at home avoid visiting places to drink to have gambling venues looking at cognitive challenging and really thinking about gambling desensitising cues to gambling so in our Australian society where there's a lot of cues to gamble which might be visiting a pub with some friends where there are poker machines it might be seen ads during sporting matches for internet gambling simply having funds available, cash in your hands and so being able to teach people how to avoid those urges. Then to look at coping with negative emotions which might be another outlet for dealing with stress, anxiety and depression, behavioural as well as cognitive strategies and this might be dealing with things that are precursors to gambling as well as emotions that have arisen in relation to gambling problems expanding and working on other problems in the larger context and then importantly relapse prevention. So it's a very brief outline of the typical things that you might look at in treatments but again that you can do a lot in just a single session and there are also now a lot of online self-help tools that individuals can use to help themselves I'm happy to discuss those more later on. Thanks Rachel. Okay, so thank you Sally and we've had the psychologist perspective but I gather from what Clive's already told us it's not uncommon for people with gambling problems to be referred to as psychiatrists and Clive, we'd like to hear from you now as to your perspective from what you'd be thinking about when you look at the gentleman in our case study today John. Thank you Rachel. I think it's a very difficult call sometimes for a general practitioner to know who to refer and when to refer and I think that's an issue that some folks in the audience might want to raise some questions about. When I started out there were virtually no services of an anonymous and there were a few people like myself. Then with funding there gained a lot of training and we have now a very good number of psychologists and other counselors who are involved and can be referred to through the various services in the different states. Not a lot of psychiatrists have a particular interest but increasingly that number is growing and the useful role is if for example in assessing John it's just a bit worried. He said it's a shorty and I'm sure he's taking a very thorough history but he feels it could be a bit more going on. He'd like to get an observation particularly around depression whether there's a need for medication. So he makes the referral. Now I'd just like to make the point that at one stage in my life I was running a private clinic and I was running a public clinic for gamblers and obviously with the general practitioner referrals to my private clinic sometimes in good faith the general practitioners would have described as an antipresence because they really think the person has come through the door and they said I'm feeling rather sad I'm feeling rather low and so a prescription is handed over. What intrigued me because there's always about a two to maybe even six weeks waiting list before they saw me is how many people have either not taken the tablet or had taken the tablet but then stopped because they didn't like some of the side effects. One of the main reasons was that quite often having that first appointment and then maybe having a second appointment with the psychiatrist lifted the mood enormously and so I think it's important to make a difference between people feeling understandably unhappy about their situation and a serious depression which will have some of the biological signs early morning, weight being, weight loss, even so to say later, retardation to decide whether I'm not going to necessarily leap straight in and provide a prescription and get people started on medication. We know that around about 60% of people presenting will meet the criteria for depression but sometimes those criteria are a little vague and they don't take into account the normal reaction of sadness. Quite frankly as a commission I used to get a little worried sometimes when people weren't unhappy with their situation and I found over time that those were the people who didn't do as well as those who were unhappy and were motivated so the first call would be to just wait and not immediately think about an antidepressant. Now if it is needed, what is the right source? Well, the older tricyclics I don't think have showed any benefit. There are some studies that used in some of the more modern serotonin, selective reuptake inhibitors, the noradrenal and serotonin reuptake inhibitors may help if there's a serious depression that does require medication. A couple of caveats there one of them is venous axion or sexor. At high doses is actually also a dosamine reuptake inhibitor and has been associated with problem gambling. And another drug to bear in mind is if you're also treating somebody for Parkinson's disease some of the medications have been associated with an increase or a creation of a problem gaming situation and something like 7% of people on those medications may have a problem that is contributed to significantly if not totally caused by their antiparcus and medication and those are issues that have to be brought around. One of the things that also happened at more recent times was that everybody's reading Dr. Google these days and I would have some people come in and say, Doc, I want to be put on our trek soon. It's an opioid antagonist and Paul would know a lot about that in terms of its role and helping people with alcohol and drug issues. The problem is that it's not available specifically for gambling. If you can find an alcohol problem and you think there's a case for it it can be considered. But in my view the problem is not yet convincing that it's something to be considered semi-automatically for almost every gambler. If there is a family history of alcohol and if there is a current history of alcohol there may be a subgroup within the whole group of problem gamblers who will actually specifically benefit from an altrexone. But it's something to bear in mind. I think the studies are questionable because they use very high doses of an altrexone. They were for a short period of time three months and there was a high placebo response. But you will find in the field if you're in the medication side of things that some patients will talk to you about that and maybe it's worth considering that not automatically. I'd be happy to return to either of those issues and the question and answer. I just want to have a quick look to close out on the question of other diagnoses. We've talked about depression and anxiety. As I said some of that can be understandable but at the extreme it may be something that alcohol and drugs are very much associated. Probably 20% of people with a gambling problem will also have an alcohol problem. Probably about 10% will also have a problem with drugs. One of the I guess slightly forgotten issues that are popping up a bit more in consideration these days is the question of the personality component. And there are suggestions now that there are a range of factors that can contribute to making a person vulnerable to the problem of gambling. Because the majority of people gamble, the majority do not have a problem. So what tries to separate out those people into the different groups of those who do have a problem. And antisocial trades, certainly narcissistic trades in young people, at OCD may have a factor with some people. I note that John has been accounted, there might have been some obsessive compulsive trades there which has been assisting him this career. Perhaps one of the stresses is that he's now been given treatment, he's not able to handle that and he's turned to booze and then to gambling as a way of dealing with it. Bipolar, you note that I put two ahead of one, some people have argued that the swings of the bipolar disorder that is not quite far polar one with the extreme main air and extreme depression, that's a contributing factor. It's a diagnosis of some contention. I have seen some people with bipolar one who in a manic episode have gone off and gambled a lot. Clearly the treatment of the bipolar disorder is important. I thought the mentions could be freer in passing because while you very rarely have somebody who has a delusional system that leads to their gambling, perhaps the prime example is I had a gentleman who was quite convinced he'd been working for ASIO but because he'd been spying for ASIO the only way he could get paid was to receive $30,000 through the poker machine and of course he was playing the poker machines in order to allow the $30,000 to come his way and it never did and he lost considerably more than that over time. But that sort of delusional pattern is rare. Most of the people who have schizophrenia and who have a problem with gambling do so because they're bored and if you're on a DSP and you're wondering how to fill in your days gambling can easily take a hold and provide you with some entertainment, some time filling but also some major cost factors as well in your lifestyle. Now I think I'll leave it at that point and as I said I'm very much open to any questions that people might want to raise in the question and answer and hand it back to you Rachel. Thank you Clive. And finally let's hear from Kate and hear your perspectives as a social worker and working with individuals and families. Thank you Rachel. Well I guess as a specialist in the gambling field there are quite a lot of overlaps that we do look at the psychological interventions that Sally has been talking around. But obviously for this presentation I wanted to concentrate on some of the other areas that we would touch on. So I've really taken this from the public health perspective which is a strong passion of mine and just really putting up that framework drawn from the Productivity Commission report in 1999 when we first looked into gambling industries in Australia we were really looking at the gambling individual characteristics and behaviour. There are only parts of the story there and I won't go through it all but we're really looking like many other public health issues such as alcohol, tobacco control etc but there are a whole conglomerate arrangements around how gambling is offered in the community and therefore how that also contributes to gambling harm. But when we come to look at the individual who is presented to a service line usually that contact happens over the phone and therefore we've already had that discussion but in that first session I guess the reason why I'm interested in the public health perspective is also to be able to convey that to the client. We've talked about the amount of stigma and shame that people who have developed the gambling problem often come into treatment with that very clear perspective that they are flawed individuals and I guess part of my approach in normalising that is starting to look at those systemic aspects of the offerings in the community and how that with that comes along a number of risks when we talk about what we call in public health products of dangerous consumption and that really is aimed at helping to encourage a discussion that is beyond just individual characteristics and seeing this in the context of a bigger social system if you like and in doing that try and help reduce the stigma and shame and put things into context with the individual before we really start getting into obviously how that relates to him. So in terms of John it would be the invitation to explore his individual story, his individual experiences of gambling and how does that sit with him socially, culturally and spiritually and how does he experience the harms from gambling and really how does this develop in his life. So very much a listening with poor building exercise because people are often at a point of almost like a pressure cooker coming into treatment and in some respects it's a great release to be able to start really talking about the reality of this and then through that process obviously we're going to be assessing the extent of gambling behaviour as a number of things that I've put up that are common in clinical use and discussing with John just how that has developed for him and along with that we know that gambling problems can also have significant suicide risks. I think one in five we're finding in suicide or presentations there. So it's very important to assess the client's safety and to also start looking at those comorbid conditions with thoughts about depression and in-hand and also other stress related disorders. So again a number of screening tools. I mean generally a first session people when they make contact expect people to put aside at least an hour, an hour and a half for this kind of initial assessment and discussion. And one of the things I like to do with clients is to introduce what we call the psych of problem gambling which is a model to sort of explore whether this affects with their perception. And also for clients it can be a way of just getting a picture of what's been going on for them and this is a very common model that was developed a good few years ago now but it really tries to help explain what the person may have been directly experiencing in terms of the drivers to gamble, the patterns of developing the chasing behaviour which does become so destructive and then the sense of how that can then go into this vicious cycle and then gets clouded around with ways of shifting the world a little bit so that we're not actually facing up to that. It's very difficult when you become involved in gambling, something that appears quite social and entertainment wise becomes a growing problem and sometimes it's really hard to discern when it has become a problem. And I find this model helps people start to just identify that and we can talk about where we can help people put in the brakes on that if they're interested in looking at that calm minimisation approach and so it's very much building rapport with John, exploring his perspectives on gambling, what have been the benefits but also what have been the costs in his life with this behaviour what have been the impacts on himself what have been the impacts on the lives of the children and starting to get him to think a little bit about the cost benefits in that and explore what his goals might be with the change what's actually brought him here what's his expectations of therapy what would a change look like for him again a bit of a solution-focused approach there starting to build a picture and some difference from what he's experiencing at the moment without obviously sweeping aside that he's obviously in a very stressed situation and very much acknowledging what may be some of the challenges I've been to some immediate self-help strategies there and within that often exploring the model of change people may be familiar with that and helping him see where he sees himself in that model and giving the concept of hope that there are possibilities of change but it's not a quick fix it's something that people take some time and they may move within and around that model but really again normalising the recovery process helping John understand that this is a process and this is really again as Paul was saying acknowledging the first step that he's made to come and seek and support and develop some open discussion around some immediate practical strategies to reduce harm for the immediate period that may be next week, next month looking at some self-help strategies around cash management what are the immediate triggers and risks and maybe introduced at this day to the notion of self-exclusion which is a process where people can actually ban themselves from the venue and then of course explore more broadly what his expectations are for ongoing support and also not only for him but for Melissa his wife and his family in all and whether they would be open to some couples therapy or some individual an ongoing therapy and what might be the mix in that and certainly I've been very used to working with people who come up in an individual basis but the invitation's been to the partner and then working out with the couple how they may want to move forward with that so really starting to in-write some ongoing work and then really discuss how John would like to see that develop what other practical supports he may need, what other referrals he may need and along with that that may include some additional resources for him to take home there's a number of supports here that I've listed informational resources and also practical resources and also telling him about the 24 hour council support the crisis sort of help that's available between sessions or independent of sessions, the online services, local support groups and then there's a number of consumer based resources and on the gambling impact we have some personal stories up there that people can sort of again explore other people's experiences so again trying to help him see that while this has become a major issue in his life for him to take a step to come forward with support that he's obviously not alone in this there are many opportunities to help him move through and that this is just the beginning of the journey so I'm happy to talk some of those things as we progress make sure. Okay, thank you Kate and thank you for the resources can I just remind participants that in the folder there's also some additional resources and information there for you. Like now we'll proceed to questions and I thought that we might start Paul I'd start by asking you what do you do what happens when you you've got someone who has a gambling problem and you suggest to them that you refer them to see someone else what are you going to do or what should you do what works when they say not going I only want to see you not hearing Paul at this stage sorry Paul you've just muted yourself. Sorry about that can you hear me now I'm assuming it's okay it's a good question I have we encounter this quite regularly actually yeah if you're a psychologist this is this you probably only get to see the once the referrals happen there's a lot of work that often doesn't get to a secondary health professional and GPs take a lot of the workload on themselves so through decisions personally enjoy that work or very commonly because the patient wants to retain within the GP sitting only I suppose there's two main factors with that one is again coming back to the area of shame and not wanting to share this and really there's a lot of barrier in this question to one person with or another person another one is once you've given someone like your GP a very personal account of how you're struggling with things there is a bond and an empathy within that consultation and they can feel it very therapeutic needs so often they don't want to go anywhere else what do we do with that situation it's a good question I think the important part about general professional we're general so we won't be anywhere near as good as a psychologist or a physiotherapist or a financial counsellor or a surgeon or a psychiatrist or whatever that needs are but we have little skills in all those areas and we've really got to utilise a lot of the time it takes time that's really just sitting with the patient utilising what skills you can do it may be just simple strategy settings like Sally mentioned just how to avoid situations where the life needs to gamble the financial controls within the family system problem solving sort of approaches but it really is about engaging the patient longer term and often patients do see themselves not improving despite that help will eventually be open to that but it takes a lot of time so it's really about engaging your patient long term at the beginning and hopefully they'll come to the party and I actually find sometimes even without long term things I don't feel I'm actually being actively very helpful but just that presence and continuity with healthcare professionals willing to listen actually makes a difference and patients make their own changes without actually being actively pushing that direction. Thanks Paul I noticed that some of the questions have been around suicide and I wonder if some people from the panel could comment on this Kate you identified the importance of assessing for risk of suicide I wonder if there are any statistics on the proportion of gamblers who do complete suicide Do you want me to talk to that? Whoever would like to The difficulty is that there's not a lot of reporting by coroners although I think it was maybe two years ago that Victoria a study over a decade had 128 cases certainly when the productivity commission in 1999 they were recording 2900 suicide attempts for gambling and again the numbers were quite low but based on the research out of the Office Mental Health Unit that was asking specific questions around gambling for suicidal attempts and as I said about one in five somewhere around 70.5% to 20% is estimated which works out roughly about 400 people a year that are likely to be completing suicides related to gambling problems and of course let's also remember that this isn't just the person who has developed the gambling problem around about 85% thousands considered that they have a serious health issue in relation to living with someone with a gambling problem and they are equally at risk of suicide Thanks Kate we can see that this is really a significant issue in our community and I guess that given that we've got a team here with multiple multidisciplinary teams I'd like to hear some comments from the panel as to how you think we can work together most effectively we've all brought to a specific expertise but how do you collaborate together most effectively Rachel can I start Yes I suppose one of the key roles of a GT is to be both a gatekeeper to other services so that we're using our resources appropriately but also the coordinator of those services and I think one of the areas that can be very good but also poor in some areas and a certain practitioner on both sides of the equation is the communication some referrals are very thin and some reports back either are not as well so if we can really foster that communication we can actually see we're on the same page I've actually got a question to Sally regarding this thing when you're seeing a patient is there anything that I as a GT can do in my consultations when I'm reviewing the patient that would help reinforce or cement some of the work you're doing or is there anything that GTs do to undermine potentially the work you're doing inadvertently how can we work better even if we're not communicating on those services it would be ideal Thanks Paul that's a great question I think gambling certainly is a type of issue that can be dealt really effectively with in a step care approach because gambling issues are related to such a broad variety of things you have clients presenting with obviously the gambling related issues there's financial difficulties there's family issues that Kate's spoken about there's co-morbid issues often some of the gambling problems will need to see a range of professionals including health and other lives so it is really important that we do communicate so with a GP someone can actually have a GP and a psychologist they could also have a GP help them as they get support online using some of the online resources like gambling health online where they can have online counseling they can actually work through a sort of self-help program of gambling and using the resources and try some strategies themselves and then report back to their GP for more general support and to talk through those strategies so that's on really effective way for GP to assist people with gambling problems but then also that communication for example dealing with I suppose the most disruptive issues first and then taking a step back and saying well now we also need to deal with a wider issue you know what's going on that's causing stress or anxiety or depression when we learn how to deal with those broader strategies so really gambling is something that affects such a broad range of issues and the people around you we also see people not just with the gambling problems but the family members themselves as catered so I think communication across the whole sort of team if you will of people who are helping someone work through a gambling related issues whether it be their own or their family and loved ones is really important to have that consistent care that someone does need. Thanks Sally that's really helps to reinforce what can be helpful and I guess Tate one of the things that you know from your perspective is working with families if I have a family member who is gambling how can I help and how as a clinician can I help that family member to support the problem gambler because I suspect that often the things that family members attempt to do can make things worse can you help us with that one Kate? Yes look I think generally and I've been working now with the University of Bath and Burning and Honour program called the 5% program for family members that people with drug alcohol and gambling problems and really the research that's come out of that is that we haven't done such a fantastic job in the past but working with family members in their own right and that program is really about working with the person where they're at and without judgement looking at how they are currently coping very much listening to their side of the story and helping them develop that strategy for self care and provide some very concrete information about various disorders. Now what that means in practice is that we do have a range that certainly needs that world very specific gambling help services that provide counselling services through psychologists, through social workers through other counsellors and they are all open to family members unfortunately the take up isn't very large by family members and I think that is an issue out in the community that we need to regard obviously as a family system affair family members can be very crucial in helping people attain support and in fact many times it is family members that come forward looking for support perhaps for the person themselves so again I come at this very much from a systemic approach and if a family member comes to see me then I will be working in both of psychoeducation and also on issues and looking at self protections as well as how they might best respond to some of the issues that come up around various coding mechanisms some of which may be more constructive than others but very much in a non-judgmental manner but I'm also very interested and when I get that opportunity to work with families as a whole I've had rooms full of families, cousins, aunts, uncles and the person themselves but most often it is working with couples and working in a way where you're working both with individuals on their individual needs but also then looking at the family and couple relationship in many respect is like having a third party in that relationship and helping that couple work around with this issue in their lives collaboratively. Thank you Kate Kelly if we can come back to you and from your research perspective the emphasis for all of us as healthcare professionals is on using evidence based practice can you give us some ideas of what models of care we have evidence for where we should start as the most effective treatment modality for problem gambling. Great question, thanks Rachel actually there is a not as much respect as you would expect given how big your problem gambling is. I think in Australia gambling really adjusts as a problem and it is included as a sort of now but we don't have as much treatment research as we do in other addiction fields. We do know from the studies that have been done that the most evidence is for cognitive behavioural therapies and motivational interviewing and these can often be combined but at the same time there is also evidence for a brief intervention so we are seeing in our research that even a single session can really be effective in motivating someone towards change. In terms of the different treatments as you will know across mental health treatments you know the therapist factor is very important so having that rapport whether it be with the GP or the therapist that is really essential and feeling really understood particularly with something like problem gambling or just sort of gambling there is a lot of stigma, a lot of shame so someone really needs to feel there has to be a non-judgmental approach compassion to help someone motivate to what we call the stages of change from just thinking about changing to really being motivated to an action change and putting steps in because ultimately it is the individuals themselves that have to implement change in their lives whether it be using something like self-exclusion or challenging their rational thoughts about gambling and understanding the chances of winning so we need a combination of approaches cognitive behavioural therapy has the most support, motivation in interviewing but also brief interventions I think it's important to people who are potentially going to come in contact with you something sort of overwhelmed by how insurmountable some of the issues may seem and to break it down just go step by step in helping someone along that road to recovery and that's what the evidence does support that just any intervention can really be helpful in having support for someone in a non-judgmental fashion Okay thanks Sally so it's not just the intervention as it's actually the as always the power of the relationships that can be a significant factor now Clive we've lost his video but he can still hear us and we will be able to hear him and Clive I wonder if you could comment so the idea of actually chasing losses I've lost something lost with an amount and I'm going on to see if I can get it back effective or how much impact or relevance do you think that has in the causation the maintenance and consequence of a gambling problem or disorder Thanks very much Rachel I guess having lost the camera is actually to everybody's advantage because it's getting bit later in the night so I'd just like to back up Sally's comment as well because quite a bit of research has shown that the therapeutic model is important but the contact with the therapist is really the crucial thing and maybe contributes about 70% of the outcome to revert back to chasing for those who are not familiar with the terminology this means trying to win back what you've lost and for most people who don't have a problem with gambling they will accept that they've lost a little bit of money and they can live with that some days they might lose a bit more than they want to but for people who are a bit vulnerable for whatever reason because they're down or they're depressed or they're overly confident about their ability to make money at their form of gambling I believe that chasing is a very, very significant factor and I think there are two reasons for that one is that there's a people with negative recency now to explain what that is briefly this means that the belief it's there that whatever has happened recently will change to give you a good classic example of a sit in the 1930s there was a casino in South America where black came up 29 times in a row and that the sound of champagne corks popping was only matched by the sound of pistol shots of course it's dependent on whether you're better to win or to continue or to stop and the longer something goes on like that black coming up more and more people get this way that there's going to be a change so they'll keep risking their money the other relevant factor is the thing called behavioural finance is the factor of the pain of a loss is felt twice as powerfully if not more than the joy of a win in the emotional circuits of the brain so nobody likes losing and to somebody who's in a vulnerable state they've come to gamble they've hoped for some winning, some excitement which is a factor as well but that loss becomes very powerful and it hurts and the only way you can get rid of that is of course by winning and so you have the idea I haven't had a winner for a while or the machine hasn't paid out for a while so therefore it's you or I'm you and then you just keep going until the losses mount up and then of course you get yourself into a financial situation and very often your only way out is to hope for a win that comes along and you'll get that so I think chasing is very important and needs to be explained as part of the cognitive therapy how difficult it is and people have to accept that what they've lost they've lost they're never going to get back and if they go into gambling again and it took me a few years to realise this sort of grief about loss is there if they go back to gambling to try and get it back to try and restore the ego to try and restore their finances to try and restore the relationship they're going to end up losing more and giving more money back and I think it's part of that they need to say I'm not going to give them any more and accept that what's gone is gone but that's sometimes very easy to say it's very hard to achieve Can I just talk to this from a public health perspective for a moment? Yes thanks We'll finish this I've also noticed a number of questions coming in about the incidence of gambling or the prevalence of gambling problems and I guess Australia does have a high exposure of gambling in the community and there's been comments about the amount of gambling that people may have the order flush on the Melbourne cart that's really not what we see is the problem and what we have in Australia 23 billion dollars being lost on gambling and 11 billion of that coming from poker machines and I think we also have to look at the product component in this in terms of chasing what we know is that there are certain design features within electronic gaming machines that are actually there to encourage people to believe that they're winning when in fact they are losing and there has been quite a lot of studies done on the design features of machines that sort of suggest that this is actually not about human agency necessarily being independent from the machine and that if you have a product that is specifically there helping you to develop false perceptions then you can't really start saying that people are losing their perceptions of their specific design and what we've known since 2001 through Mark Tickerson's work is that of people who play or gamble on electronic gaming machines once a week or more 50% of them will develop some level of problem with them just playing or gambling on the machine the way it is designed so I think from that point of view we have to also look at the product just as we've done that with other products in the community the level of harm cannot rest and responsibility cannot rest with just the individual. Thank you Kate and I think that we might actually take that message that you've just given us Kate as your message for us to take away that this is the multi-factorial problem and that it requires a concerted approach across all portions of the community all parts of the community and I'd like to invite the rest of the panel now and we'll start with Paul to just give us one key message that you'd like the participants to take away with them tonight about this topic. Thanks Paul. I think the important thing for any GP is that gambling is only one part of the patient and really it's an opportunity to explore other parts that came all the parts and really see this as an opportunity to engage your patients long term and with that therapeutic relationship then we can actually address these issues and we've got some crisis that's settled down but also a long term plan so I think my team if it's here don't lose hope with the small wins and losses it plays a long game and don't get on the long game. Thanks. Thank you Paul. Sally can we hear from you now your message that you'd like the participants to take away with them? I think it's important to be in mind that there's a solution to addressing stigma about gambling problems. There is no stereotype of someone who has a gambling problem that really affects everybody across Australian society. There's no age or gender or particular cultural group who is immune to having gambling problems. So I think we need to use inclusive language we need to normalise speaking support using prevention strategies just like we put a seatbelt on in the car like the fact of doing things like setting yourself a limit or leaving your ATM cards at home and to increase the comfort that people do have of talking about gambling and raising the issue of putting their hand up when they think only responding to crisis like under treatment. Thank you. The message that you'd like participants to take away from your perspective on this particular issue. I think it's a way that I would be echoing Paul and saying it's terribly important to ask about gambling. I used to give lectures which I encourage people to take what I called a dag history drug, alcohol and gambling because gambling is still very often forgotten it's often not asked for. It should be a part of every interview by a GP or psychiatrist or psychologist seeing somebody for the first time trying to assess what's going on even if a lot of the times you'll get a negative answer at least you've asked because sometimes you get a real surprise when it crops up. It should be part of every hospital admission particularly every emergency department assessment it really is important to recognize that it's there and it's often under asked for and if you don't ask it then people aren't going to offer it it has been commented during the night if you're drunk you're drunk so they're using drugs you're using drugs and it becomes obvious but gambling is very often hidden and often hidden from family members as well so there's a need to keep mindful of it and keep asking questions for it. Take a dag history folks Thanks Rachel. Thanks Claude That's to me that's the thought too because I personally will be adding that to my history taking and Kate we've got a couple of minutes to give you the opportunity to give us another final message. I just encourage people to yes develop skills there's some very good resources out there the Gambling Impact Society has developed a specific resource for frontline staff for helping professionals and financial counselors and really take over opportunity for training this is a hidden issue we need to encourage people to put their hand up and when they do make sure that those who are citizens of that request to respond and focus on a lot and basically create safety for people to be able to say I'm having difficulty in this area it's out there, it's common and we need to be building our skill base for that. Thank you and I'd like to now take a moment to say thank you to our panel members and to I guess in summing up to say how much I've learnt personally and I hope that as participants you've also learnt from the range of perspectives that we've had and the key messages that will help us and I certainly remember that to ask about Gambling given the hidden nature of this and the impact that it has and if I go even further the risk that it places people at in their future so as we proceed to the finishes of this webinar can I ask each of you to complete the exit survey when you log out or before you log out the peers on your screen after the session closes we're really interested in your feedback and that helps us in our future planning please remember that you'll get a certificate of attendance and that's in two weeks and you'll also be sent a link to the online resources that are associated with this webinar I'd like you also to keep an eye out for upcoming webinars the next one from responding to and treating post-traumatic stress disorder and we have one coming up on caring for young people with gender dysphoria if you're not part of Ray's special interest network I'd encourage you to think about setting up one if there isn't one in your area and I understand that mental health professional network currently supports 380 networks around Australia so these give you the opportunity to connect with people now finally before I close I'd like to acknowledge the consumers and carers with mental illness in the past and those who continue to live with mental illness in the present thank you to everyone for your participation this evening thank you