People with gambling problems have a higher prevalence of intimate-partner violence, child abuse or neglect, and other traumatic life events than people with no gambling problems.1-7
Many common procedures, processes, and practices in healthcare settings can be emotionally unsafe and can cause the trauma survivor to feel re-traumatized.8,10-14
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 wellbeing and ability to cope.8,10,12-14
This webpage explores the research on trauma and its co-occurrence with problem gambling, and offers guidance on how to put trauma-informed care into practice with problem gambling clients. 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 and Trauma-informed Care
Trauma is the result of an event that overwhelms a person’s sense of safety and control, and their ability to cope.8-10,13 Trauma can be the result of direct exposure to emotional or physical harm, but also the result of witnessing or learning about another person’s or group of people’s exposure to such harm.8-10
Trauma-informed care is founded in the understanding that a person’s early experiences of trauma often become defining experiences that influence how they perceive themselves and the world.8-10,13
This approach is based on the understanding that anyone can have a history of trauma and that a survivor’s behaviours may represent efforts to cope with overwhelming distress.8-10,13
Trauma-informed care is not the same thing as trauma-specific care, which directly addresses the survivor’s need for healing by providing counseling and other therapeutic services.8-10 Trauma-informed care is a framework that 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.8-10
The basic principles of trauma-informed care can be summarized as follows:9,10,12-15
- 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 have clients who are more engaged in treatment and have lower dropout rates.8-10,16 For this reason, it is important to embed the principles of trauma-informed care in organizational policies, practices, and interactions.8-10,16
What does the evidence say?
Emerging research points to a link between problem gambling and trauma,17 with as many as one third of people with problem gambling having a post-traumatic stress disorder diagnosis.7
There is also a link between gambling and trauma among Indigenous Peoples with a history of residential schooling and other traumas related to colonization, including displacement, removal of children from their families and communities, and suppression of cultural values and spiritual beliefs.18
In addition, women with gambling problems are more likely to have a personal history of trauma and mental health issues compared to men.2 They are also more likely to have partners who have mental health, substance use, or gambling problems, or who are unfaithful or absent. Among married women with gambling problems, four out of ten have experienced intimate-partner violence.2
Research suggests that people use gambling to escape, dissociate, or relieve stress from past trauma.19–22 These findings support the idea that it is necessary to treat the underlying trauma before addressing the gambling problem.19-22
Yet 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.13
People with problem gambling who have a history of trauma are more likely to have the following problems:
- more severe gambling problems7
- more severe mental health problems3,7,17
- substance use problems3
- family history of substance use problems7,17
- higher suicide risk.3,17
Unless a person discloses their history of trauma, it is difficult to distinguish survivors from non-survivors.8,11-15 For this reason, it is recommended that trauma screening be a routine part of the intake process or that universal precautions be in place to avoid re-traumatizing trauma survivors.4,8,13,14,20,21,23
Putting the Evidence into Practice
It is important for you to prepare to work with problem gambling clients who may have experienced trauma and to integrate a trauma-informed care practice.24,25 Beyond understanding trauma and how trauma can influence a person’s worldview, you can prepare for this work by being a reflexive practitioner.24,25
To be a reflexive practitioner, you would take a self-critical approach to working with problem gambling clients, and especially consider power relations and the role of power in the therapeutic relationship.24,25
As a reflexive clinician, you would also develop your awareness of the role that emotion plays in clinical encounters and consider issues of trust, information sharing, and safety.24,25 These are described below.
Experiences of interpersonal betrayal and chronic traumatization often put survivors on their guard and make it difficult for them to trust others.8,11-13,15,26 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. 8,11-13,15,26
You earn this trust slowly, by respecting the client’s experiences, perspective, and limitations, and by fostering their sense of dignity and control.8,9,11-13,15,26
If you choose to screen all problem gambling clients for trauma, use a direct approach.14,20 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.8,12-14,20
Your client may feel uncomfortable disclosing a history of trauma, so let them know that you are asking all clients the same question. 8,12-14 Listen to this audio clip for an example.
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.8,11-13,15 Listen attentively, acknowledge the impact the experience had on them, and let them know that their reactions, responses, and ways of coping are normal.8,11-13,15 Let them know that you are there to help them gain control over their reactions.8,11-13,15 Listen to this audio clip for an example.
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 they express strong emotions while disclosing their trauma, allow time for the emotions to subside by listening and being a supportive presence and acknowledge and validate their emotions. 8,11-13,15 Listen to this audio clip for an example.
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 be at risk of being re-traumatized.15
Ask your client what types of situations or behaviours make them feel distressed or unsafe, and what you can do to calm them, and make appropriate changes, where possible.11,15 Listen to this audio clip for an example.
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.12,15 Describe your role in the relationship, what you can expect from each other, and the boundaries that define your therapeutic relationship.12,15
Use simple language, avoid clinical jargon, and maintain a calm and consistent manner. 12,15
Trauma survivors are often hyperaware of their environment and their sense of safety, so foster spaces that are physically, emotionally, and culturally safe.9
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 are listed below: 9
- 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, symptoms, coping skills, and support needs.8,12,13,15
Empower clients to set their own goals and make decisions on their care, ensuring that treatment goals are realistic and allow the client to achieve a sense of control. 8,12,13,15,26 For example, give them a list and description of available supports and services and ask them to choose those that are most appropriate.8,12,13,15,26 Listen to this audio clip for an example.
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.9,12,15
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.9,12,15 This means asking questions about their history, experiences, and feelings, and listening attentively to their answers.9,12,15 Listen to this audio clip for an example.
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.9,15 If possible, use an interpreter, a bilingual colleague, or a “culture broker” to bridge or mediate between you and your client.9,15
When working with an Indigenous client, focus not only on the individual but also on their family and community.27 Adapt your therapeutic approach to meet their needs.19,27 It is also important to see 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.27
For these clients spiritual healing may play an important role in healing from trauma and reducing problem gambling.21,27 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).27
People can experience trauma without actually being physically harmed or threatened with harm. That is, secondary traumatic stress, also known as compassion fatigue, can happen simply by learning about a traumatic event.28 Therefore, anyone who is close to a trauma survivor, including clinicians, can experience compassion fatigue.28
Supervisors can help prevent vicarious trauma through regular supervision of clinicians who work with trauma survivors, emphasizing the positive aspects of clinician’s work, supporting clinicians in their work, addressing clinicians’ responses to clients’ disclosures, highlighting the potential for secondary trauma, and encouraging them to engage in ongoing self-care.29
Resources for Clinicians
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 for use 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).
This video clip shows a fictitious therapist and client session for teaching purposes.
In this scenario, the therapist and client (Jack) have worked together for several sessions and have developed a trusting therapeutic relationship. In the video clip, the therapist asks Jack directly if he would like to discuss the life experiences that have had an impact on his life. When Jack starts to describe his history of trauma, the therapist takes a minute to let Jack know that he can choose to share or withhold his trauma history and that he wants Jack to feel safe and comfortable when sharing this information. After Jack shares his information, the therapist acknowledges how difficult it must have been for Jack to divulge his history of trauma and recognizes that it took strength and courage to do so.
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- Boughton, R., & Falenchuk, O. (2007). Vulnerability and comorbidity factors of female problem gambling. Journal of Gambling Studies, 23(3), 323–334. https://doi.org/10.1007/s10899-007-9056-6
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- Shultz, S. K., Shaw, M., McCormick, B., Allen, J., & Black, D. W. (2016). Intergenerational childhood maltreatment in persons with DSM-IV pathological gambling and their first-degree relatives. Journal of Gambling Studies, 32(3), 877–887. https://doi.org/10.1007/s10899-015-9588-0
- Ledgerwood, D.M. & Petry, N. M. (2006). Posttraumatic stress disorder symptoms in treatment-seeking pathological gamblers. Journal of Traumatic Stress, 19(3), 411–416. https://doi.org/10.1002/jts.20123
- Clark, C., Classen, C.C., Fourt, A., & Shetty, M. (2014). Treating the Trauma Survivor: An Essential Guide to Trauma-informed Care. New York, NY: Routledge.
- Jean Tweed Centre. (2013). Trauma Matters. Guidelines for Trauma-Informed Practices in Women’s Substance Use Services, (March), 196. Retrieved from http://jeantweed.com/wp-content/themes/JTC/pdfs/Trauma%20Matters%20online%20version%20August%202013.pdf
- Poole, N., & Greaves, L. (Eds.). (2012). Becoming Trauma Informed. Toronto, ON: The Centre for Addiction and Mental Health.
- Brown, V. B., Harris, M., & Fallot, R. (2013). Moving toward trauma-informed practice in addiction treatment: A collaborative model of agency assessment. Journal of Psychoactive Drugs, 45(5), 386–393. https://doi.org/10.1080/02791072.2013.844381
- Elliott, D. E., Bjelajac, P., Fallot, R. D., Markoff, L. S., & Reed, B. G. (2005). Trauma-informed or trauma-denied: Principles and implementation of trauma-informed services for women. Journal of Community Psychology, 33(4), 461–477. https://doi.org/10.1002/jcop.20063
- Harris, M., & Fallot, R. D. (2001). Envisioning a trauma-informed service system: a vital paradigm shift. New Directions for Mental Health Services, (89), 3–22. https://doi.org/10.1002/yd.23320018903
- Rosenberg, L. (2011). Addressing trauma in mental health and substance use treatment. The Journal of Behavioral Health Services & Research, 38, 428–431.
- Butler, L. D., Critelli, F. M., & Rinfrette, E. S. (2011). Trauma-Informed Care and Mental Health. Directions in Psychiatry, 31, 197–210.
- Giordano, A. L., Prosek, E. A., Stamman, J., Callahan, M. M., Loseu, S., Bevly, C. M., … Chadwell, K. (2016). Addressing trauma in substance abuse treatment. Journal of Alcohol and Drug Education, 60(2), 55–71.
- Najavits, L. M., Meyer, T., Johnson, K. M., & Korn, D. (2011). Pathological gambling and posttraumatic stress disorder: A study of the co-morbidity versus each alone. Journal of Gambling Studies, 27(4), 663–683. https://doi.org/10.1007/s10899-010-9230-0
- Dion, J., Cantinotti, M., Ross, A., & Collin-Vézina, D. (2015). Sexual abuse, residential schooling and probable pathological gambling among Indigenous Peoples. Child Abuse and Neglect, 44, 56–65. https://doi.org/10.1016/j.chiabu.2015.03.004
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- Felsher, J. R., Derevensky, J. L., & Gupta, R. (2010). Young adults with gambling problems: The impact of childhood maltreatment. International Journal of Mental Health and Addiction, 8(4), 545–556. https://doi.org/10.1007/s11469-009-9230-4
- Hagen, B., Kalishuk, R. G., Currie, C., Solowoniuk, J., & Nixon, G. (2013). A big hole with the wind blowing through it: Aboriginal women’s experiences of trauma and problem gambling. International Gambling Studies, 13(3), 356–370. https://doi.org/10.1080/14459795.2013.819934
- Nixon, G., Evans, K., Grant Kalischuk, R., Solowoniuk, J., McCallum, K., & Hagen, B. (2013). Female gambling, trauma, and the not good enough self: An interpretative phenomenological analysis. International Journal of Mental Health and Addiction, 11(2), 214–231. https://doi.org/10.1007/s11469-012-9413-2
- Zingaro, L. (2012). Trauma learning. In Becoming Trauma Informed (pp. 29–36). Toronto, ON: The Centre for Addiction and Mental Health.
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