In the history of addressing addictions, gambling disorder–related research and treatment are relatively new. Widespread stigma and misunderstanding still surround gambling addiction. However, rapidly expanding efforts at the local, state, and federal levels are focused on changing this situation. One such effort is the Massachusetts Council on Compulsive Gambling's collaborative work with the Massachusetts Department of Public Health, Bureau of Substance Abuse Services (DPH/BSAS), to integrate gambling disorder services into traditional substance disorder prevention and treatment systems.
The Council (a private, nonprofit health agency) was founded in 1983 by the late Thomas N. Cummings, who appealed to the Massachusetts legislature in 1987 to fund problem gambling services. Cummings, who previously had struggled with a gambling problem, believed that a state that sponsored, endorsed, and promoted gambling needed to take responsibility for gambling's related problems. Since then, the Massachusetts legislature has been committed to responsible gambling-related public policy and has worked to ensure that funding from the Massachusetts State Lottery and the Massachusetts Racing Commission is allocated to provide problem gambling education and treatment services.
DPH/BSAS, in turn, manages these funds. For 20 years, DPH/BSAS has worked closely with the Council to oversee its services while helping to build the treatment system's capacity to offer services to people with gambling problems, their loved ones, and their communities. Throughout this relationship, the Council and DPH/BSAS have strived to educate addiction treatment providers and community-based professionals about gambling disorders and the need to address gambling alongside other addictions within the treatment system.
The project to integrate problem gambling services into the DPH/BSAS treatment system began in 1988, with one DPH/BSAS-contracted agency offering problem gambling counseling services (out of more than 200 eligible agencies DPH/BSAS contracted with). In 1998, DPH/BSAS contracted with 16 substance abuse agencies for problem gambling services, where at least one counselor at each location had attended Council trainings on treating gambling disorders. While this was a great accomplishment, a number of hurdles affected the agencies’ ability to treat clients:
Many of the challenges the Council faced involved retaining trained problem gambling counselors at the agencies. Counselors often would leave the agencies and move on to other jobs. Lack of communication about the staff changes created confusion about where people could be referred for treatment.
Agencies were not relaying how many people they were treating for gambling problems. Part of the problem was that forms used by the agencies did not have an area for documenting problem gambling services.
DPH/BSAS reimbursed only covered treatment for the indigent and uninsured. This left many people in the difficult position of paying for treatment services out of pocket or being unable to participate.
The DPH/BSAS outpatient treatment system paid clinicians on a fee-for-service basis, which made Council training and meeting attendance difficult because clinicians were not paid for their time away from seeing clients. In addition, clinicians often performed case management services without any reimbursement.
A More Effective System
By 2002, DPH/BSAS and the Council agreed that a new approach was needed and began work on a plan to increase the system's capacity for addressing gambling disorders. Among the steps taken:
Highlighting the comorbidity link.
One of the first steps was to help alcohol, tobacco, and other drug treatment providers understand the high comorbidity rates between gambling and other addictions. Research shows that about half of all compulsive gamblers have had problems with alcohol or other drugs. Conversely, it is estimated that 25 to 35% of all people with alcohol and drug problems have had gambling problems. To show this connection, DPH/BSAS included language to this effect in its request for responses (RFR), which is Massachusetts’ term for request for proposals for service contracts.
There are several reasons the comorbidity of problem gambling and other addictions might not be obvious to clinicians. Clients might not bring up a gambling problem if they are being treated for another addiction. Clinicians might think that because problem gambling is similar to other addictions in many ways, it should be treated the same. Yet treatment is similar but not identical. Clinicians also might not be comfortable talking about the financial issues involved in problem gambling. Finally, agency forms do not prompt clinicians to screen for gambling problems.
Training clinicians to become problem gambling specialists.
Since 1987, the Council has offered an annual statewide conference and several regional training opportunities for clinicians. The goal is to identify and train counselors in each agency to become problem gambling specialists who can screen, assess, treat, and/or refer clients affected by a gambling problem. By attending this annual training event counselors can earn the Massachusetts-based Problem Gambling Specialist Certificate, developed by DPH/BSAS and the Council. To receive state reimbursement for problem gambling services, counselors are required to have earned this certificate and are subject to its accompanying Clinical Supervision Program for DPH/BSAS providers.