People with problem gambling tend to have higher rates of trauma compared to people who do not have a gambling problem (Andronicos et al., 2015; Boughton & Falenchuk, 2007; Kausch et al., 2006; Lane et al., 2016; Ledgerwood et al., 2006; O’Donnell et al., 2014; Shultz et al., 2016). Trauma-informed care is an approach to service delivery that recognizes the prevalence and potential impact of trauma on the client’s life and accommodates them in an effort to avoid triggering trauma memories or causing further trauma (Clark et al., 2014; Jean Tweed Centre, 2013; Poole & Greaves, 2012).
People with gambling problems also have a higher prevalence of intimate-partner violence, child abuse or neglect, and other traumatic life events than people with no gambling problems (Andronicos et al., 2015; Boughton & Falenchuk, 2007; Kausch et al., 2006; Lane et al., 2016; Ledgerwood et al., 2006; O’Donnell et al., 2014; Shultz et al., 2016).
Many common procedures, processes and practices in healthcare settings can be emotionally unsafe and can cause the trauma survivor to feel re-traumatized. Trauma-informed care (TIC) is a clinical approach that recognizes that each person perceives and processes trauma differently. It acknowledges that trauma can have long-lasting effects and can impact the survivor’s well-being and ability to cope (Clark et al., 2014; Elliott et al., 2005; Harris & Fallot, 2001; Poole & Greaves, 2012; Rosenberg, 2011).
This page explores the research on trauma and its co-occurrence with problem gambling. In addition, it offers guidance on how to put trauma-informed care into practice with clients who have gambling problems. This information for providers of mental health and addiction services is based on a review of the literature and was reviewed by an expert in the field.
About trauma-informed care
Trauma is the result of an event that overwhelms a person’s sense of safety and control and impedes their ability to cope. Trauma can be the result of direct exposure to emotional or physical harm or the result of witnessing or learning about another person’s or group of people’s exposure to such harm (Clark et al., 2014; Jean Tweed Centre, 2013; Poole & Greaves, 2012).
Trauma-informed care is founded on the understanding that a person’s early experiences of trauma often become defining experiences that influence how they perceive themselves and the world. This approach is also based on the understanding that anyone can have a history of trauma and that a survivor’s behaviour may represent efforts to cope with overwhelming distress (Clark et al., 2014; Harris & Fallot, 2001; Jean Tweed Centre, 2013; Poole & Greaves, 2012).
Trauma-informed care is not the same thing as trauma-specific care, which directly addresses the survivor’s need for healing by providing counselling and other therapeutic services. Instead, trauma-informed care acknowledges the adverse effects of trauma and, when embedded in an organization’s culture, informs the conduct of its members as well as its policies and processes (Clark et al., 2014; Jean Tweed Centre, 2013; Poole & Greaves, 2012).
The basic principles of trauma-informed care include the following (Butler et al., 2011; Elliott et al., 2005; Harris & Fallot, 2001; Jean Tweed Centre, 2013; Poole & Greaves, 2012; Rosenberg, 2011):
- Understand trauma and its impact on a person’s functioning and behaviour.
- Create an environment that is physically and emotionally safe, respectful and accepting.
- Make early screening for trauma, assessment of the impact of trauma and referral to integrated trauma services common practice.
- Build rapport and promote collaboration and client empowerment.
- Use a strength-based approach and help the client build coping skills and resilience.
- Understand the whole person and acknowledge the context in which they live.
- Minimize re-traumatization.
- Obtain client input to inform program planning and design.
By providing trauma-informed care, healthcare organizations and service providers ensure clients are more engaged in treatment and have lower dropout rates. For this reason, it is important to embed the principles of trauma-informed care in organizational policies, practices and interactions.
What does the evidence say?
Emerging research points to a link between problem gambling and trauma (Najavits et al., 2011), with as many as one-third of people with problem gambling having a post-traumatic stress disorder diagnosis (Ledgerwood & Petry, 2006).
There is also a link between gambling and trauma among Indigenous people with a history of residential schooling and other traumas related to colonization, which include displacement, removal of children from their families and communities, and suppression of cultural values and spiritual beliefs (Dion et al., 2010).
Women with gambling problems are more likely to have a personal history of trauma and mental health issues compared to men. They are also more likely to have partners who have mental health, substance use or gambling problems, or who are unfaithful or absent. In addition, four out of ten married women with gambling problems have experienced intimate-partner violence (Boughton & Falenchuk, 2007).
Research suggests that people use gambling to escape, dissociate, or relieve stress from past trauma (Dion et al., 2010; Felsher et al., 2010; Hagen et al., 2013; Nixon et al., 2013). These findings support the idea that it is necessary to treat the underlying trauma before addressing the gambling problem. However, people with gambling problems who have a history of trauma are more likely to seek treatment for their gambling than for their trauma because they perceive the presenting problem as being more urgent and more obviously tied to the service agency’s stated role (Harris & Fallot, 2001).
People with problem gambling who have a history of trauma are more likely to have the following problems (Kausch et al., 2006; Ledgerwood & Petry, 2006; Najavits et al., 2011):
- more severe gambling problems
- more severe mental health problems
- substance use problems
- family history of substance use problems
- higher suicide risk.
It is difficult to distinguish survivors of trauma from non-survivors unless a person discloses their history of trauma. For this reason, it is recommended that you make trauma screening a routine part of the intake process or that you implement universal precautions to avoid re-traumatizing trauma survivors (Clark et al., 2014; Felsher et al., 2010; Hagen et al., 2013; Harris & Fallot, 2001; Lane et al., 2016; Rosenberg, 2011; Zingaro et al., 2012).
How do I put the evidence into practice?
It is important that you prepare to work with problem gambling clients who may have experienced trauma and to integrate a trauma-informed care practice. Along with understanding trauma and how trauma can influence a person’s worldview, you can
prepare for this work by being a reflexive practitioner. Being a reflexive practitioner involves taking a self-critical approach to working with problem gambling clients, and strongly considering power relations and the role of power in the therapeutic relationship (D’Cruz et al., 2007; Fook, 2016).
As a reflexive clinician you should also develop an awareness of how emotion plays a role in clinical encounters, and consider issues of trust, information sharing and safety. These are described below.
Experiences of interpersonal betrayal and chronic traumatization often put survivors on guard and make it difficult for them to trust others. For this reason, the first step is to recognize the need to earn the client’s trust by making interactions with them safe and non-traumatizing. You earn this trust slowly by respecting the client’s experiences, perspectives and limitations, and by fostering their sense of dignity and control (Brown et al., 2013; Butler et al., 2011; Clark et al., 2014; Elliott et al., 2005; Greenwald, 2009; Harris & Fallot, 2001; Jean Tweed Centre, 2013).
Use a direct approach if you choose to screen all problem gambling clients for trauma. Ask whether they have witnessed or experienced (or are currently experiencing) violence, physical or emotional abuse, sexual assault or unwanted sexual touching, or threats of violence (Clark et al., 2014; Elliott et al., 2005; Felsher et al., 2010; Harris & Fallot, 2001; Rosenberg, 2011).
Your client may feel uncomfortable disclosing a history of trauma, so let them know that you are asking all clients the same question.
I'd like ask you some questions that I ask all my clients. Have you experienced or are you currently experiencing any violence, physical or emotional abuse, sexual assault or unwanted sexual touching. Have you been threatened with violence? Have you witnessed violence, physical or emotional abuse, sexual assault or unwanted sexual touching?
If a client with problem gambling discloses a history of trauma, remain calm and acknowledge what they told you. Listen attentively, acknowledge the impact the experience had on them, and let them know that their reactions, responses and ways of coping are normal. Let your client know that you are there to help them gain control over their reactions (Brown et al., 2013; Butler et al., 2011; Clark et al., 2014; Elliott et al., 2005; Harris & Fallot, 2001).
You're having difficulty with staying calm when you're in a room that's crowded and noisy. This is a normal response to the trauma you experienced as a child. I want you to know that you can learn to control these reactions and I'm here to help you do that.
If your client expresses strong emotions while disclosing their trauma, allow time for the emotions to subside by listening, being a supportive presence, and acknowledging and validating their emotions.
That must have been very painful for you to talk about. It's normal that talking about past trauma causes you to have these feelings.
Record your client’s disclosure in their file so that they will not have to retell it and risk being re-traumatized.
Ask your client what types of situations or behaviours make them feel distressed or unsafe, and what you can do to calm them. Make appropriate changes where possible (Brown et al., 2013; Butler et al., 2011).
Are there any situations or behaviours that make you feel distressed or unsafe? What sorts of things help to calm you down when you feel distressed or unsafe?
Explain your confidentiality policies and therapeutic process. Describe your role in the relationship, what you can expect from each other and the boundaries that define your therapeutic relationship (Butler et al., 2011; Elliott et al., 2005). Use simple language, avoid clinical jargon and maintain a calm and consistent manner.
Trauma survivors are often hyperaware of their environment and their sense of safety, so it is crucial to create spaces that are physically, emotionally and culturally safe. Consider how your client might perceive your clinic’s physical space. Does it demonstrate sensitivity to safety issues and allow your client to have choices for personal safety? Some suggestions for creating safe clinical spaces include the following (Jean Tweed Centre, 2013):
- Provide comfort items (such as blankets, soft pillows or stress balls).
- Have a separate quiet space.
- Ensure that hallways, exits and entrances have security cameras, are well lit and are well marked.
Be conscious of the power imbalance in the therapeutic relationship. Recognize that your client is an expert in their own life, their symptoms, their coping skills and their support needs.
Empower clients to set their own goals and make decisions regarding their care, while ensuring that treatment goals are realistic and allowing the client to achieve a sense of control (Butler et al., 2011; Clark et al., 2014; Elliott et al., 2005; Greenwald, 2009; Harris & Fallot, 2001). For example, give them a list and description of available supports and services and ask them to choose those that are most appropriate.
I hope that our relationship will be based on respect and mutual collaboration. I recognize that you're an expert in your own life, so I hope you feel you will have the ability to set your own goals and make your own decisions.
Remember that your clients have diverse needs based on their culture, sexual orientation, religion, age, economic class, disability status, race or ethnicity (Butler et al., 2011; Elliott et al., 2005; Jean Tweed Centre, 2013).
Becoming culturally competent does not mean that you must understand each client’s culture, but that you should make every effort to understand the influence of culture on your client’s response to trauma. This means asking questions about their history, experiences and feelings, and listening attentively to their answers (Butler et al., 2011; Elliott et al., 2005; Jean Tweed Centre, 2013).
We see people from a whole range of countries in our clinic. Every country and every culture has its own traditions and customs. Often a person's response to trauma is influenced by their cultural background. I'd like to know about yours? What was it like to grow up in your family?
When working with problem gambling clients who are immigrants or refugees, pay special attention to cultural and linguistic barriers. If possible, use an interpreter, a bilingual colleague or a “culture broker” to bridge or mediate between you and your client (Butler et al., 2011; Jean Tweed Centre, 2013).
When working with an Indigenous client, focus not only on the individual but also on their family and community. It is also important to view their own trauma and gambling behaviour in a broader social context by exploring the impact of public policy and historical traumas (such as the residential school legacy and colonization) on their personal and family histories (Menzies, 2012). Spiritual healing may play an important role in healing from trauma and reducing problem gambling for these clients (Hagen et al., 2013; Menzies, 2012). For this reason, it is important to engage the help of other supports (such as elders, cultural teachers and Indigenous counsellors) and to consider the use of traditional ceremonies and celebrations (such as healing circles)
People can experience trauma without actually being physically harmed or threatened with harm. Secondary traumatic stress, also known as compassion fatigue, can happen simply by learning about a traumatic event (Figley, 1995). Anyone who is close to a trauma survivor, including clinicians, can therefore experience compassion fatigue.
Supervisors can help prevent vicarious trauma through regular supervision of clinicians who work with trauma survivors, emphasizing the positive aspects of their work, supporting them, addressing their responses to clients’ disclosures, highlighting the potential for secondary trauma and encouraging them to engage in ongoing self-care (Hayden et al., 2017).
Emotional Dysregulation and Problem Gambling Workbook: This workbook is designed for use with individuals experiencing gambling-related harms and emotional dysregulation who are receiving outpatient treatment from clinicians with knowledge, training and experience in gambling and mood disorders. It is designed to be used in a treatment setting that endorses a harm reduction approach. This workbook was prepared by a multidisciplinary team led by psychiatrist Dr. Daniela Lobo at the Centre for Addiction and Mental Health (CAMH), as part of a pilot project funded by Gambling Research Exchange Ontario (GREO).
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