Research shows that in Ontario, about 30 per cent of people with a gambling problem have a co-occurring mental health problem, and more than three per cent have a co-occurring substance use problem.2 It is therefore important to do routine screening and assessment of clients seeking treatment for mental health and substance use problems.
This webpage explores the evidence on screening and assessment for problem gambling, and outlines recommended approaches you can use in your clinical practice. 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.
Why do screening and assessment?
Screening and assessment for problem gambling are two distinct activities, although these terms are often used interchangeably.3 Screening helps you determine whether your client has a problem and whether they will need a full assessment.4,5 Routine screening is brief and narrow in scope, and can help you identify problems early.3,4
On the other hand, an assessment helps you get a more comprehensive view of the client’s situation and helps you develop a treatment and relapse prevention plan that is tailored to their specific needs and preferences.3,6
What does the evidence say?
Individuals with gambling problems are more likely than the general population to have a variety of medical problems and they use medical and behavioural health services at a higher rate.7 Therefore, an effective approach for identifying individuals with a gambling problem is to screen them when they seek health services in the community.8
Screening and assessment tools are frequently based on “pathological gambling” criteria outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).8 The APA reclassified and renamed pathological gambling as “gambling disorder,” and now defines it as “repeated problematic gambling behavior that causes significant problems or distress.”9
Putting the evidence into practice
Screening
Guidelines recommend routinely screening clients who seek mental health services as well as those who belong to groups that have high rates of problem gambling.10 Guidelines also recommend using a validated age-appropriate tool to screen young people.11,12
Before screening or assessing a client for problem gambling, make sure they understand the purpose and consent to answering the questions.4,6 Use non-threatening and non-judgemental language to explain the benefits and limitations of screening or assessment, how long it will take to complete, how you will use the results, and what you will do to keep their results confidential.4 Listen to this audio clip for an example.
Show transcript
Would you be willing to complete a questionnaire about your gambling behaviour? It will help us understand the impact that your gambling may be having on your life. It will take about 10 minutes to complete and we'll keep your answers strictly confidential. Once you’ve completed it, we’ll take a few minutes to discuss the results.
Discuss the results immediately, as well as any follow-up assessment, treatment, or referral they might need.4 If the screening results are positive, conduct a full assessment, if possible, or refer your client to specialized services.4,6
When reviewing the results, it is important to go beyond the score and instead engage the client in a nuanced discussion about their specific behaviours and triggers. Listen to this audio clip for an example.
Show transcript
You’ve let me know that you’re having lots of problems with trust and conflict in your relationships. That’s something you also endorsed in this questionnaire.
There are a wide range of screening tools that you can use; some take only a couple of minutes while others take up to 20 minutes to complete. Some of the most reliable and commonly used tools are listed below.
South Oaks Gambling Screen (SOGS). This 20-item scale is perhaps the most well-known screening tool.12,13 The SOGS has been shown to accurately identify clients with problem gambling, but was developed using DSM-III criteria so it does not reflect the DSM-5 criteria.12,14,15 It has also been revised and validated for use with adolescents.11
NODS-CLiP. This three-item screening tool is a subset of the 17-item National Opinion Research Centre DSM-IV Screen for Gambling Problems (NODS).12 CLiP refers to the three questions in the tool, which focus on loss of control (C), lying (L), and preoccupation (P) with gambling.14 The NODS CLiP is effective to identify clients with moderate to severe gambling problems, but not for mild cases.8,16,17
Problem Gambling Severity Index (PGSI). This nine-item screening tool can be self-administered or administered by a clinician.18 It is an briefer version of the 31-item Canadian Problem Gambling Index.13 It uses a four-point scale (“never” to “almost always”) to describe gambling behaviour over the previous 12 months.19 An online version, called the Gambling Quiz, is available in
English and in
French.
Brief Problem Gambling Screen (BPGS). This five-item screening tool combines items from other widely-used tools to capture different levels of gambling behaviour.20 While it has not been fully validated,20 a recent study showed it was the only tool to accurately identify all levels of problem gambling in clients seeking mental health treatment.8
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Toolkit. This toolkit provides information and tools that you can use to identify and help individuals with problem gambling using the Screening, Brief Intervention, and Referral to Treatment (SBIRT) process.21 The toolkit includes a variety of screening tools, a protocol for brief intervention, and a list of Ontario-wide problem gambling supports.21
Assessment
An assessment helps you understand your client’s personal, social, and cultural context, their strengths, and their treatment needs.4,6 It should include the following items:6
- Full personal and family psychiatric history
- Detailed assessment of gambling behaviour
- Negative consequences of the behaviour
- Reasons for the consultation and expectations
- Motivation to change
- Mental health and substance use assessment
- Suicide risk assessment.
One tool that is useful for conducting assessments for problem gambling is the
Inventory of Gambling Situations (IGS). The IGS contains 63 items that look at a client’s gambling frequency over the past year in different situations to identify triggers for high-risk gambling.22 This well-validated tool helps you and your client gather information that will help you develop a treatment and relapse prevention plan.22 When the online version is used, a client profile is generated that highlights the situations that put the person at greatest risk of gambling and suggests ways to address the top four triggers.22 Read more about the IGS. Listen to this audio clip for an example of how you might discuss the IGS results with your client.
Show transcript
Let's look at the results together. This graph shows that your three highest risk situations are Urges and Triggers, Chasing Losses, and Unpleasant Emotions. If it's OK with you, those are the areas that we'll focus on first.
If the client consents, it is also useful to get input from their partner or spouse, a family member, or a friend.6 Listen to this audio clip for an example.
Show transcript
With your consent, we could have your family member or someone close to you join us briefly. They can hear about our services and learn about what is available to support them. We know that folks who have family involved in treatment do better in the long run.
A full assessment will help you build rapport with your client, help them see the extent of the problem and enhance their motivation to change.6 When discussing their gambling behaviour with your client, be sensitive to any potential shame they may feel that may cause them to withhold information.6 Listen to this audio clip for an example.
Show transcript
For many people, gambling is something that they hide from everyone else in their lives. They feel such shame and stigma. In North American society, we tend to have a difficult time talking about money. We’ll share about our big wins but we hide our losses. Our goal here is to create a safe space to work together on supporting you as you make changes in your life.
Use clear and non-judgemental language both during the assessment and when explaining the results.4,6 Include a description of their strengths, the identified problem, and the recommended treatment options or referrals.4 Listen to this audio clip for an example.
Show transcript
Your score on the questionnaire indicates that you’ve been experiencing some pretty concerning issues with your family, such as hiding debts and other problems. At the same time, you also indicated in our discussion that you made a decision to quit gambling about 3 weeks ago. That’s a real testament to your strength and determination! You’ve let me know that you’ve done this by not carrying cash and debit/visa cards, getting support from your friend, and keeping busy.