CHP Conversations
Welcome to CHP Conversations, a podcast series produced by the VCU College of Health Professions. The College's mission is to create influential leaders in health care who embrace equity and model excellence through inclusive teaching and learning, thoughtful advancement of cross-cultural knowledge, meaningful service to others, innovative technologies, and scientific discoveries that promote health and health equity and eliminate health disparities. This series includes conversations with faculty, students and alumni who exemplify our mission.
CHP Conversations
Exploring gambling addiction in Virginia
Guest: Dr. Carolyn Hawley Ph.D., CRC - Associate Professor, Virginia Commonwealth University Department of Rehabilitation Counseling
Dr. Hawley recently was awarded a contract with the state to coordinate the treatment programming for gambling addiction. She is an expert in this topical area, and serves a critical role in developing and ensuring the provision of treatment for those who experience gambling addiction. This is a growing concern as the prevalence of gambling options is rapidly increasing in Virginia and online.
If you would like to contact the Gambling Addiction Hotline that Dr. Hawley mentioned, please call (888) 532-3500.
Music by Gvidon from Pixabay
Welcome to CHP Conversations: a podcast series produced by the VCU College of Health Professions. This series includes conversations with faculty, students, and alumni who exemplify our mission to create influential leaders in healthcare. Hi, my name is Jared Schultz and I am in the Department of Rehabilitation Counseling here at VCU. I'm joined today by Dr. Carolyn Holly. Welcome. Welcome, Dr. Schultz. Welcome to you, Dr. Holly. Dr. Carolyn Holly is an Associate Professor in the Department of Rehabilitation Counseling at VCU. She has over two decades of experience related to counseling, training, research, and education and employment and community service needs of people with disabilities. She completed a fellowship at McGill University's International Center on youth gambling problems and high-risk behaviors and has worked in program specializing in traumatic brain injury rehabilitation. She obtained her MS in rehabilitation counseling at the University of Wisconsin in Milwaukee, and her Ph.D. at Virginia Commonwealth University. Recently, Dr. Holly obtained a contract from the Commonwealth of Virginia to coordinate services for people dealing with problem gambling and gambling addiction. And this is gonna be the focus of our conversation today. Carolyn, it's good to have you with me. I appreciate you coming in and talking about all this. Thank you. So to start with, could you just describe the project that you're getting off the ground here in Virginia. Yes. So this is really exciting. Virginia were one of the few states that hasn't had any treatment programs available for individuals with gambling problems. So with all the gambling expansion that's happened within the state, specifically with sports betting and with casino industry growing. What we did is we lobbied really hard for this problem gambling treatment and support fund, which could be used for not only prevention activities, but treatment activities as well. So this fund is being handled with the Department of Behavioral Health and Developmental Disabilities and our role in it is going to be developing a gambling treatment workforce, as well as assisting them with the payment for these resources. We're also gonna be working in pulling together training as well as part of the development of this treatment team. Well, so you packed a whole bunch in there. Let's take it a little bit of that apart. That's how I that's how I do. So talk a little bit, if you would, about about the needs. So you've mentioned some sports gambling. What are some of the other things going on in the community where there's an increased need, right? So historically what we've seen in Virginia is there are three legal forms of gambling and that's been our state lottery, horse racing industry and then charitable gambling. So you have your church bingo, and you're fraternal organizations running bingo as well. So those have been the three main forms. Within the last few years, we've seen an explosion in regards to- First, fantasy sports. And now we're seeing all the sports betting. We know that there's casinos being developed. We have five casinos for possibly one being developed either in Richmond or in Petersburg area as well. And not to mention all of the availability of online forms of gambling as well. Wow, and the online piece. Is there any way to even quantify that? Right? I mean, it's so difficult because we have our online of some forms that you can play mobile wagering that are legal, and then you have your illegal forms that are really difficult to keep track of. And that also puts us in a position where we're currently in limbo in regards to what we call skill-based gambling that has proliferated throughout the state. And these are essentially slot machines. We like, or I should say, they state the word skill-based. There's usually not a lot of skill involved with these machines. Pulling the handle, that's a pretty significant skill. You know, I think that's what we're referring to, right? So they're currently in a state of legal limbo. They were, the General Assembly said that they were illegal. The governor came, governor Northam during the time of COVID made them legal for a period and regulated them for tax revenue to assist with, with COVID relief. And then it became illegal again and now it's up for lawsuits. And the General Assembly is gonna be doing a study and exploring this some more. So they’re currently running unregulated throughout the state. But wow. But despite all of that, I mean, really we're talking in the last ten years just exponentially. Oh my goodness. The last five years. Last five years. Wow. And so what we've had as I- as I mentioned, we've been one of the few states that hasn't had treatment mechanism available. And we know when we're working with gamblers, just like when we're working with individuals with other forms of addictions, alcohol or substance use, but particularly with gamblers. They don't have the financial resources available for treatment. Or if they do. Um, you know very often when we're looking at relapse, the money that they could use for treatment. What ends up happening is they use that for gambling. Well, so it's a vicious cycle, I mean, yeah. Okay. How do you find or what- how do people generally access services? So the one thing that we have had and the Virginia Council on problem gambling, they've been administering the Virginia problem gambling helpline, and this is funded by the Virginia lottery. So this is a 24/7 free service to all Virginia residents. So whether you're an individual who thinks they might have a problem, or a family member or a friend, or just anybody looking for information about gambling addiction, wanting to learn more, they can call the helpline and access those services. However, there's been some struggles, as I mentioned, in regards to not having a treatment force to work with individuals for those treatment needs. So a lot of the services that have been available up-to-date are a lot of self-help or peer group resources, which are good to supplement other forms of care. But we really have need treatment providers out there that can work with these individuals. So that's a great segue into what I wanted to touch on just a little bit. So what does the treatment approach look like for people who are struggling with gambling addiction? And what are some of the key components of that intervention? Well, just as I mentioned, alcohol and substance use, what you see are very similar approaches to treatment for individuals with gambling. So your cognitive behavioral therapies, motivational interviewing, these all have shown to be effective in working with gamblers. Some of the differences though, this can be more challenging for our treatment professionals, is the focus on finances. And so, you know finances- they're, they're a part of the problem when we look at this addiction and with gambling as well, it's also seen as the source of relief for their financial problems. So it can be, as you mentioned, just a cycle where you want individuals to quit gambling and they're in such financial strains. But the only way they see that they're gonna get out of the financial hole that they've dug themselves in is through gambling. So looking at also a lot of those cognitive distortions and the role and influence of money. And if you're not able to talk about that, if you're not comfortable talking about that as a counselor, that individuals just going to relapse because of that secular nature with money. Yeah. That's fascinating. I don't know of any other situation where the perceived answer is the problem. I mean, I can tell you I've recently we have a caller to the helpline, and this is an individual who's living in their car. They've lost everything to gambling. They've lost their home. They've lost their family, they lost their job. They still have their car. They do on the weekends is they go to one of the casinos in Maryland and they're known as a high spender. And so this way they're comped their room. They have food, room, shelter. So in this instance, the casino is seen as their only source of relief, the only source of safety. So that's something different that we don't find with alcohol or other forms of drug use with treatment. Wow. So what are some suggestions you might have for individuals who think they might need help? Number one, call us at the helpline, (888)-532-3500. Reach out. The sooner you get help, the easier it is to stop the progression of the illness. It's a challenging call to make, I would imagine. Family member is just asked the question. Reach out to someone. They may not like that you're asking the question about their gambling, but if you do so in a caring and supportive way and show that you’re concerned, it often starts opening up that dialogue in somebody being more willing to discuss that they need help. So for professionals working in the counseling field, if you wouldn't mind, just discuss a little bit, what are some specialized training? Because it's not just anybody can step in and be effective in this. There needs to be some, some training involved. And so what are some key pieces to that? Absolutely. So there actually is a certification for gambling treatment, so the International Gambling Counselor certification, and they have two levels. And so the first level is geared more towards individuals, perhaps in peer recovery or doing coaching level work. And then the second tier level is for individuals who hold a licensure in counseling, in social work, and in psychology, something of that nature. And at the initial level, there's 30 continuing education hours that you need to complete along with some clinical experience also. And so what we're gonna be doing in Virginia as looking at that curriculum and also providing some of those opportunities through our work here at VCU so that we can get counselors up to speed. And these are gonna be available, they're gonna be free. So I'm so hopeful that we're going to get a large interest in this and be able to fill our, our classrooms. Because there's a real need for clinicians. Absolutely. Just as I was talking about, one of the hard things of working within this specialization is we have to be honest about this in regards to having a population that can't pay. And we also have a condition that receives no federal funding whatsoever in the country, unlike what we see with alcohol and substance use. So for a clinician, I mean, we recognize you need to eat and be housed and live as well. So it can be very difficult to take on clients who you know aren't gonna be able to pay. So hopefully now that we have this fund available, we're going to have more counselors that are interested and willing to specialize. So to clarify then, the part of the contract that you receive from the Commonwealth is to provide funding so you can pay for those services that those clients may not be able to afford. Absolutely. Huge piece of what we're gonna be doing is handling that reimbursement for treatment professionals so that individuals can get those services. Wow. What are some of the national trends that you see? So sports betting now, we've seen with a landmark Supreme Court case that it's now legal in the country. And so states, Virginia was one of the first to legalize it. And I can say from the experience here in Virginia in regards to the helpline, what we've seen is a huge increase since it's legalization last year. And the volume of calls, so 114% growth. Wow and calls for individuals who are specifically seeking health. We've also seen a huge shift with demographics. Now. Historically again, what we saw with gambling disorder is it tended to be more males versus females. And over the past decade or so, that's actually become more equitable. However, this last year with sports betting in Virginia, 74% of callers were male. So that's also a new trend that reflects the old trend, as well as younger callers. So male, younger callers and sports betting is one of the top forms of play, the actual top form of play is slot machines. We're also seeing more callers reaching out to us in regards to gaming. Internet gaming. So not gambling but but gaming. So so yeah, so a gaming addiction as well, because there's no place for them to go. We see so many parallels to what we see with, with gambling as we do with gaming. Wow, that's fascinating because I could, I could imagine that a lot of the techniques that are utilized in developing a gambling scenario where you're trying to reinforce the activity because you want to keep the person involved. Is this similar to the things being used in the gamification process, right? Right. I mean, there's some reward happening there. And people often think that money is a motivator even with gambling. But when you actually talk to individuals who have a gambling disorder, many times it's not. In fact, it's not uncommon to hear individuals talking about how upset they were. They were at their slot machine and playing and they just had a big win and that meant they had to go and stop playing and cash in their, their chips and it was frustrating. So there's something else operating there. What do you think it is? I think it's the whole process when we talk about that reward system and when we look at gambling in particular and that intermittent reinforcing as being highly addictive. People- we don't like things that are the same. We like the unknown. Things that are predictable are boring and gambling, it provides some sort of primitive need for uncertainty, just like what we see with gaming and not knowing whether or not you're going to win or you're going to lose. And we know that there's that dopamine hit, that happens when we're gambling. And dopamine is related to craving. And so over time, as you're continuing with this pleasurable activity, those associations are connecting. And the more you play, the stronger those cues become, and the stronger that compulsion becomes. And when you have somebody in active addiction, whether it's gambling or gaming or alcohol or other forms of substances. They no longer enjoy that activity. But they can't stop. The tolerance is built enough that the, that the activity itself. Exactly. And tolerance, what we see with gambling, certainly needing more and more to experience that same level of excitement. Withdrawal as well. I mean, those are some of the key hallmarks that we know that there's some form of neuroadaptation occurring. And so not surprising to hear individuals who are trying to quit gambling talk about their insomnia, their headaches, sweating, having shakes. Yeah, the physiological response. Fascinating, you could expect that from a drug or alcohol or something like that where there would be a physiological withdrawal. But from an activity (Mhm), you wouldn't necessarily (Right, right) expect that. Yes. So we used to think it's all about the substance, just like the money with the gambling, but it's that ingestion of some particular substance. So yes, certainly some substances are more addictive than others. But now that we know and we're looking at brain changes, we're looking at genetics as well, those family histories, that there's some underlying addiction mechanism. That whatever is going to be pleasurable that we as humans find joy and pleasure in that there is some propensity towards developing this addictive process. It's interesting as you are, as you were discussing the dopamine hit, I just remembered a conversation I had with a teenager talking about texting. And I was talking to him and I said So what's the what's the– I sound like an old grandpa or something, you know– what's the big deal about, you know, why why are you glued to your phone? And he said something that I thought was and he goes, it's really not even the communicating. It's the thrill of your phone vibrating (Mhm) and connecting (Right?). And that just reminds me of that. That dopamine hit. It's the intermittent reinforcement. It's going so long without something, but then it kicks in. Yes! And when you look at our social media sites, when you look at things like Facebook or Twitter, what you find is the developers of those sites that they paralleled gambling, and that intermittent reinforcement. And so you have the same strategies at play. Say for instance with Facebook, our desire to be liked, to be wanted. And so they use that intermittent reinforcement where a withholding our likes and then if we're not paying attention, doing them in bursts, so we have this release or that we're constantly checking their well-timed and they're not always in real time, just to keep us engaged. Wow, excuse rather malevolent, doesn't it? I mean, it's just frightening how (it's either genius or scary) how easy we are to um- I don't know if it's control is the right word- but, but to purchase (Influence at the very least), to participate, and yeah. And we also know also when we're talking about those mechanisms and social media as well, is that they know, particularly with gaming, that if they can get you to spend money early on upfront, the more likely you are to continue playing and to be an active user. So it's, it's a little disturbing. I mean, because you look at the similarities across all of those. And if you were to ask the average person, what's the connection between gaming, gambling, Facebook or social media. They might go, “I don't know. There's computers involved, I guess.” But the underlying foundation and the construction of those are very purposeful. Right. Right. The hard thing we have to, in regards to a prevention and education aspect is, what we found, particularly when we're talking to parents and things, that we have judgments about the harm of various activities. So it's not uncommon to hear parents say, “well, I'm glad my child is gaming or even gambling because that's not as bad as using a substance.” And so we just want to make people aware that an addiction can develop and it can be just as devastating, if not more devastating. For instance, with gambling, I mean, out of the addictions, what research tells us is it has the highest suicide rate for individuals with this disorder. Wow, I mean, you're talking about suicide rate and we're talking about that sort of thing. You mentioned earlier that we're seeing younger and younger. What's the range that a parent may want to check in? I mean, because a lot of times parents are like, ‘Oh, my kids only 15, they don't do that’ and (Right) they could be. So I'm curious, what- where do you see the range of people with this? Well, we know it. If you start playing, say around ten years of age, the more likely you are to develop an addiction. So not sure what's, what's happening there in regards to our brain development or socialization. But there is research that supports that level. And when you think of gambling, I want parents to understand some of the subtle ways that this happens, such as grandma getting lottery tickets for holidays, even though that's illegal, you're not allowed to purchase a ticket until you're 18 or gifted ticket to somebody under 18, that that happens, that's commonplace. Or even sitting around the table as a family and gambling together. Right now we're in the midst of March Madness. Family, friends, coworkers, everybody has been filling out their brackets and placing bets. And these are meant to be fun activities. But just as we would with say, a drink, we need to be mindful that this can be harmful. And so we have to be aware of what are some of the signs, what are some of the risks, and have discussions about this and understand that you need to set a limit, and stick to it. And if you're not sticking to it, [understand] that a problem might be developing. So let's stay on track just a little bit with that, what you just talked about in terms of the kids and the exposure. Um, I would assume that one incident doesn't create an addiction. Right. So what is what is the the path or what's the progression that you would describe if a parent is like, ‘Okay, I'm buying into this. I'm hearing the warning. But tell me how this works.’ Right. Is that clear? Yeah. Well, I think what you're talking about again is going back to some of those signs we need to we need to notice. So do you have a limit for your child that they're exposed to these devices, whether whether it's gaming or gambling? These brackets, what type of setting is this in? And so if an individual, if your child is starting to spend more time than their allotted, that's a problem. If they're starting to not engage in other activities because now they're doing that instead, that's a problem. If they're lying to you about how much they're playing, you know, you have a problem and if you have any one of these, this is a time where you need to intervene before further consequences happen. Yeah. You know, as you're describing that I was: number one, my kids have never lied to me. Never?! Children lie? Oh that doesn’t happen. But there's a challenge there for parents too. Because, you know, and this is totally personal experience where I would go to my kids and I would say, “okay, there's the limit. We're not doing that anymore.” And they're like, Oh my gosh, you think I'm going to be a terrible person because I do it this once. And it's like No. But the habitual doing of that. And kids don't necessarily understand that abstract progression. They see what's right in front of them. And so as a parent, to say “it doesn't matter what you freak out about, I'm not going to let you do this so hard.” I mean, this is very challenging because what we're talking about as well is being able to self-regulate, being able to have that impulse control. And we know that's associated to a region in our brain, our prefrontal cortex, that isn't fully developed until somebody is in their early 20s. So it makes it, the impetus is even harder on the parents because you are going to have to be the individual that really helps setting these boundaries and monitoring them. Yeah, that's a great point where the brain isn't developed to, for that capacity yet in a child or a young adult, right? And then you add the biological dopamine hit that reinforcer that. and the amazing marketing, (Yeah) the amazing marketing that knows, it's going to suck us in. Wow, Any other thoughts and fascinating conversation? Carolyn, love it. It's brilliant. Any other thoughts and what you think is important for people to know. As I said, this is such a novel and innovative approach that we're taking here in Virginia. This is so exciting because what we're doing here with our state agencies is having this truly what we're calling it as the Partnership for Gaming and Gambling Services. And this is a partnership with Virginia Commonwealth University, our Department of Behavioral Health and Developmental Services, the Virginia lottery, as well as the Virginia Council on Problem Gambling. So we have this unique group of stakeholders in here looking to help mitigate problems from gambling. What are some of the challenges of getting the word out? Um, you know I think right now, many of the challenges are getting into these various networks. People are tired. There's often time constraints and so trying to get people to understand that we need to make time for this issue as well can be a little challenging. So having the opportunity, doing things like this, it really helps get the message out there. Fantastic. Thank you so much for your time. I appreciate it. Thank you.
