April 2011 – Tips & Topics – april-2011-tips-topics

TIPS & TOPICS from David Mee-Lee, M.D.
Volume 9, No. 1
April 2011

In this issue

— SAVVY –The 3 Ps to Understanding the Big Picture of Healthcare
— SKILLS –Clinical Implications of the 3 Ps
— SOUL –Celebrating anniversaries
— SHARING- Some readers’ comments
— Until Next Time

Welcome to the start of the 9th year of publishing TIPS and TOPICS (TNT).  It was April 2003 when I started this experiment which has blossomed into a widely-read and appreciated resource (at least that’s what many readers tell me – the others don’t say anything- they just don’t read TNT!)


Vol. 11, No. 1

In This Issue
  • SAVVY : Words of appreciation
  • SKILLS : Ten years of anniversary SKILLS Tips
  • SOUL : What a difference in these two 19 year olds
  • SHARING SOLUTIONS : The Anniversary Deal – Tips and Topics book for $10 total

Welcome to the 10th anniversary of Tips and Topics (TNT). Perhaps this is your first edition as a new reader or your 100 edition as a longtime reader. Either way, enjoy this anniversary edition……and my party hat!

David Mee-Lee M.D.


When I turned 30 years old, my wife threw me a surprise birthday party.  It was very thoughtful of her, but I enjoy_ other_ people’s birthday parties. It’s not so comfortable when I’m the center of attention, especially when it’s a surprise.  Now, I’ve gotten a little more comfortable with attention (doing fulltime training and consulting for decades gives you lots of practice.)This month, for our 10-year anniversary of Tips and Topics, I actually _asked_ for readers’ attention!I thought it would be fun (and informative to me) to hear what you appreciate about Tips and Topics.  So here are some of your “appreciation gifts” to me to celebrate 10 years together.  I excerpted from your “gifts” so as not to be too voluminously boring.

Welcome to our Tips and Topics birthday party! (and check out SHARING SOLUTIONS for a special anniversary deal)


See if you resonate with any of the themes of these “anniversary gifts.”

I grouped readers’ comments in like categories….sort of……

Challenging our thinking and sharing TNT with others

What an honor to be asked to share how your efforts with Tips and Topics have impacted us over the years as an anniversary gift to you.

Since first becoming aware of your work and meeting you 6 years ago, I have been a faithful reader of Tips and Topics…….Over the years, I have used Tips and Topics to share with the clinical staff a deeper understanding of how they could assess a caller…  Your ability to bring so many different service delivery providers together and weave the experiences in a meaningful way that makes one stop, think and yes, sometimes even challenge how we think of providing services continued to contribute not only to our development as professionals but also to the benefit of the clients.

I have no doubt that I contributed to adding to your email list because I often encouraged people to make sure they took advantage of having such a powerful resource at their finger tips; especially the interns that I supervised. …I have entered the arena of private practice and the skills I have learned over the years from Tips and Topics come in handy with almost every client.  When I think of the ripple effect of your life works and how many it impacts I stand amazed.

I do have to say one of my favorite aspects is when you share details of your life — from your journeys home to Australia, to your kids and their accomplishments…..And just know that I am looking forward to at least another 10 years of Tips and Topics!

Happy Anniversary!

Theresa Buzek, MS, LPC-S
4009 Banister Lane, Ste 356
Austin, Texas


Thank you for the work you do and the newsletter.  I just wanted to let you know I really appreciate it, and pass it along to our staff and my peers in the field

Yvonne Jones, LCSW
Senior Psychiatric Social Worker
San Leandro, California


Your last e-mail has finally motivated me to write my appreciation to you and your monthly newsletter.  If I receive the e-mail during a particularly busy time at work, I leave it unread until I can make the time to bring my full attention to the tips and topics and have time to contemplate how to apply it to my work and life.  I not only read it myself, but share it with my colleagues and have also forwarded it on to my boss on occasion.  Your thoughts push me to think about how to approach my work differently, to question my current techniques, and how to be an effective clinician (and sometimes parent!).

Thank you very much for all you do.

Stephanie R. Steinman, LPC CSAC
UW Health Gateway Recovery
Madison, WI


I am reflecting on your upcoming ten year anniversary, and can hardly believe that you have been publishing this long!!  I recall conversations with you about my interest in searching the archives, long before you had that capability!  Guess that means I am getting old!

I read Tips and Topics fully, and can honestly say that every issue has caused me to pause and think; despite over 30 years in the addictions field, I learn something new each and every time.  I share access with everyone I can, and encourage others to sign up on-line in all of my trainings.    I imagine that this is just one of many competing priorities for you, but know it is thoroughly enjoyed, valued and appreciated!

Dotti Farr   LSW, LADC, CCDP-d
Director of Quality Management
Bucks County Behavioral Health System
Warminster, Pennsylvania

Useful learning and appreciating the TNT edition on Therapeutic Communities

David, we worked together briefly in Delaware and, even in a short time, I learned a great deal from you. I read every edition of your newsletter and wanted to compliment you on the Therapeutic Community article.  You handled the subject productively and ‘gingerly’.  There are probably some who would say you were too gentle but change usually requires persuasion not coercion.

Thanks for your efforts to inform and improve the field.

Colette Croze
Principal, Croze Consulting

Dr. Mee-Lee,

I certainly look forward to Tips and Topics each month, I have yet to read an edition and not get something useful from it. The edition on Therapeutic Community was especially interesting.  When I started working in the field in the late 80s …one of my first experiences was with a seasoned counselor conducting what he called “Gestalt empty chair technique”, but what actually seemed to have as its only goal to have the group make the person cry or storm out of the room…..Things have certainly changed for the better. Thank you for the publication each month.

Dan Adams, MBA, MARS
Assistant Director
Southeast Missouri Behavioral Health
Salem Center


Dear David:

My note of appreciation is simple. Somehow, you have a hidden camera in our program, in my office, and in my head. Lest you think that I fit the textbook definition of paranoia, let me say instead that you have, since I started in this position, managed to elegantly publish in your Tips and Topics exactly what I was trying to say just days before in a staff meeting, in a supervision, or in a training. I find myself EVERY month simply forwarding your email to someone else in the program or printing it out for everyone and putting it in mailboxes with a simple….”This is what I was trying to say—he says it so much better”!!!

The best example of this was in Nov 2012 with your response to Ray from Cape Cod.  Being from the “other” large substance abuse agency in Southeastern Mass, I recognized Ray Tomassi of Gosnold and his way of thinking immediately. I immediately copied that article on how we use words and how our words shape our actions and handed it out to everyone in our program—staff and clients alike. It lead to such interesting conversations-not only about those words and actions, but about the role of shame and coercion in treatment. Especially for us as a program that walks that tightrope between voluntary and “court ordered”, we look at issues like relapse and discharge daily—and struggle to be client-focused and evidence-based in our actions and approaches.

The other edition that was so helpful was your Tips and Topics that took on the sacred cow of “Therapeutic Communities”. Technically, we are by our RFR, a “modified therapeutic community”. Given our varied mandates and our population of 100% of our clients with co-occurring other mental health challenges, we find ourselves always searching for the balance between being “client centered and individualized” and “community-based” recovery. As we try to do that while following Motivational Interviewing practices across all levels of the program and integrating as many EBP’s as possible, the core of our model shifts and morphs. For some of us, that is comforting that we are always “making it up as we go along” to be as successful as possible. For others, it creates such panic that “no one is in charge and no one knows what is happening next”. This edition helped calm some of those fears and helped the “old-timers” see that there really is a method in the constantly shifting landscape and that parts of the tried and true will always be a part of what we do.

For the record, we are a pilot program in Mass—the ONE specifically funded year-long program (combination of residential(3 months or so)/community based(9 months)) jail diversion substance abuse treatment program for clients facing incarceration for crimes directly related to substance abuse issues. In year 3 of a 5 year pilot, we have such tremendous support and freedom to try to get it right….and such wise counsel both from our agency leadership and Bureau of Substance Abuse Services to help us be successful and create a program that can be replicated. Please know that I count you as one of our “distance mentors” as well.

Thank you for being part of the knowledge and wisdom that helps shape who we are and what we are doing!

Mary R. Bettley MSW, LICSW
Program Director
Reflections-Court Alternative Program
High Point Treatment Center
New Bedford, Massachusetts

Inspirational, informative and influential

I’ve been a subscriber to your newsletter for a while now….I look forward to its arrival every month. (I confess that I also hoard them.) I’ve been working with individuals who struggle with substance use disorders for over 40 years now and there are a few individuals, including yourself, who I consider to be inspirational. You are those people who I can count on one hand (with fingers left over) who seem to be able to bring “things” into focus for me. I don’t __always__ agree with “you guys” but I love to read everything that you write and I try to hear you speak whenever I can….. I’ve been blessed to consult with other organizations in many states. I try to share your newsletter with as many of these people as I possibly can. You are very inspirational and informative. Sometimes you even manage to interject some humor! Thank you for taking the time to make an investment in my life. I believe that you’re making a difference in our world.

8495 Bluestem Court
Jacksonville, Florida


Dr. Mee-Lee, I love reading the Tips and Topics even though I don’t counsel in substance abuse treatment. I still have contact with people in recovery as a case manager in a transitional housing program.  Knowledge is always great even if you don’t use it right away.

Michael McMullen


Mahalo Dr. Mee-Lee:

For 10 years of sharing your “mana” (interpersonal power, strength, authority, efficacy) with those of us attempting to follow your lead by reading your Tips & Topics newsletter each month.

Your generous offerings and influence have been a guiding light for a me, a substance abuse counselor in a rural, island community.

I’m looking forward to 10 more years of your influence.

In the mean time, I wish you a very fond……..


Lorrain Burgess, CSAC
Makakilo, HI

A couple of suggestions

Dear Dr. Mee-Lee:

I read your TNT with great interest every month. Over the years I have saved the ones that have been particularly helpful to me, as I work in a community mental health center.

I would like to see a new category added to TNT to trumpet new and innovative approaches to Co-Occurring Disorders (COD), or old approaches that are not well known…..

Another thought I have is soliciting a Guest Column each month on something directly related to COD treatment. Along these lines, you could identify a topic such as Guidelines for the First Session, and then invite your readers to solicit brief summaries for review…..

In any case, thank you for being on the cutting edge of treatment!

Harry Ayling, LCSW, ACS
Mental Health Supervisor
Fairfax County, Virginia

Thinking outside the box


David I truly appreciate your objectivity, open-mindedness and willingness to think outside the box. In helping addicts help themselves most often the instrument for change is that non-judging compassionate empathic therapeutic alliance that springboards the person to make that most important choice for a path on the road to recovery.

Chris Keeley, LICSW


Tips and Topics is always spot on! Thanks for keeping us at the head of the curve. Your ability to eloquently bridge theory with practice has been a real gift to the addictions field!

Bob Lynn Ed.D
Clinical Systems Development
Origins Recovery
C4 Recovery Solutions
Counseling Group and Family Institute

Favorite things

I read TNT pretty voraciously each month.  One of my favorite parts is the SOUL section.  Sometimes it ties into the content from the rest of the month, and sometimes not, but it is a helpful reminder to me of the toll and the wonderfulness of the work we do, and that we face the same challenges of families throughout the lifecycle that our clients do.  I especially like the SOUL about:

Jennifer Harrison, LMSW, CAADC, Western Michigan University, my co-author for the TNT book (see later for a special anniversary offer) wrote the above appreciation note.  When I asked her how she wanted to be identified she added “and awesomest co-author ever would be great.” Jennifer is indeed a great co-author but since I have several co-authors who might read this, I’ll let her say “awesomest co-author ever.”;

Helping clinicians help others

I appreciate that you keep the focus on the idea and reality that the “illness” I see is actually an accommodation my client has made to his or her world and makes sense to the person who holds it.  To assist in the change process, I must show how what I have to offer is a better accommodation to his or her world–otherwise I am not worth my pay.  (No one pays a bully.)  I have just found myself down at the end of that alley with one of my folks–resulting in his leaving the program.  I have to own that, at first, I was relieved.  He’s gone, MY WAY is reaffirmed by events.  Then, I read through this most recent post of yours and felt the underlying guilt based on “How could I have allowed myself to fall into that old trap again!?”


That was the question I needed to ask weeks back before events worked out the way my ego had ordained that they would.  I can and will look for a way to re-engage with this person so that I can feel better about payday.  Thank you again for holding our feet to principles of good behavior, ethical treatment, and service.  Peace!

Jim Recktenwald


While I have read and enjoyed your Tips & Topics, what I have appreciated most was your willingness to help us in our struggles as clinicians. Several years ago, the agency I was working for was moving toward a one-size-fits-all model trying to get everyone to do their Intensive Outpatient Program (IOP)…..I was the Intake Specialist and believed in meeting the client where he/she was and referring them to a level of care that matched their needs at that time.

THANK YOU for your hard work and dedication!

Carol Goulette LCPC, CCS


I just want to thank you for this regular piece of sanity in my mailbox. Some days it is hard to put one foot in front of the other in the midst of non-client/programmatic madness.  Seeing your words reminds me that I’m not alone and neither my clients nor I are crazy.

Staci Hirsch, Psy.D. – Program Supervisor
Supportive Housing/Bridges
Detroit, Michigan

Subject: How Tips and Topics have helped me.

Dr. ML,

My brother, Bill, died on Feb. 4, 2013.  He was diagosed with schizophrenia in his twenties.  He was probably ill since his teens.  He was “hyper-religous”, “hyper-alcoholic”, and smoked as many cigarettes as he could get his hands on.  In retrospect, I think that he sought a community of accepting people (religion), an escape from psychic disturbance (alcohol), and probably an element of the first two conditions in socializing and rewarding himself with what relaxed him (cigarette smoking).  He was a very bright man. People questioned why he didn’t just “take his medications” and “fly right”.  I think, in his own way, that is precisely what he did.  I think of the John Nash story, “A Beautiful Mind”, where, under what might be considered more optimal conditions, people encouraged him to follow his treatment regimen. Why? What is a person giving up to trust another to do what is in their best interest?  I think the Tips and Topics literature has helped me to ask this question.  Why should a person who has many gifts give someone like me an opportunity to assist them in living in a way that others might consider “better”?  What stage of change am I in?  Keep up the good work.


Peter Fuller, LCSW, LADC

And now for an appreciation note from me

  • Firstly, my heartfelt thanks to you all for signing up for TNT and for the many readers who through the years have taken the time to write notes of appreciation. Your telling me when a certain tip or topic spoke to you and helped you personally/professionally is very gratifying as a writer. Without readers and without knowing if ‘message sent’ is actually ‘message received’, all these words could just be traveling into outer cyberspace. So thank-you.
  • Secondly, if there have been some long and complicated sentences that left you scratching your head, I probably wrote those and they weren’t caught by my life partner and TNT editor, Marcia, my wife without whom none of the 10 years of TNT editions could have been successfully communicated to you in the straight forward and efficient sentences you usually receive and understand when you read TNT each month. (The long sentence is a joke, sort of, but the appreciation is real.)

Each month, I churn out the first draft. Then Marcia and I ‘fight’ over what I meant in some obscure paragraph and how to make it shorter, readable and comprehensible. She keeps me honest and keeps you reading. So thanks to my editor too.


Join me in a retrospective of April’s SKILLS Tips – from year 1 to year 10!TIP 1

See which TIPS take your fancy and click on the link to read more.

April 2003

When assessing the severity or level of function (LOF) for each ASAM dimension, it is useful to consider the three H’s:

History; Here and Now; and How Worried Now.

April 2004

The more the identified client is ambivalent or resistant to recovery, the more you focus on _who has the power_ in the client’s system…

April 2005

Ask “How much?” and “How often?” questions, rather than “Do you?” or “Have you?” questions…

April 2006

Every client who is talking to you in an assessment, treatment session or outreach visit is treatment-ready…

April 2007

Tune into what your clients are feeling on that first visit. Identify what methods you use to effectively engage a reluctant client. Here are what probation officers see and do (in no particular order)…

April 2008

For alcohol, the NIAAA one question is a good start: How many times in the past year have you had 5 or more drinks in a day (men); 4 or more drinks in a day (women)?

April 2009

When clients are ambivalent, don’t always argue for the healthy choice: “You can hangout with those friends if you want to. Why not continue going to parties with them?”

April 2010

Even if there was not the current political focus on healthcare reform, we would need to re-think how we do behavioral health care.

Identify one innovation you are willing to do in at least one of the following three C’s – even if you have to start small.

April 2011


April 2012

Conflict is normal. Not resolving conflict is the problem.  See more SAVVY Tips.


As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. After May 31, it will revert to regular pricing of $19.95 plus shipping.Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place, “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive)

You can buy in two ways:

    1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
    2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.



On Friday, April 12, 2013, on National Pubic Radio’s Science Friday program, I was introduced to Zachary Sawyer (“Zack”) Kopplin.  Zack is 19 years of age and is an American science education activist from Louisiana.


A week later on CNN, I was introduced to Dzhokhar Tsarnaev.  Dzhokhar is also 19 and is an alleged bomber, charged with using a weapon of mass destruction to kill in Boston, Massachusetts.  He was found hiding in a boat about three miles from where we lived for 17 years.

Both 19 year olds have been in the media quite a bit for just being 19.  Zack and his tireless campaign to elevate the importance of science education in the USA has been covered in hundreds of newspapers and radio and television interviews.  He has been interviewed in both national and international media, including Vogue Magazine, MSNBC, and the Washington Post.

Dzhokhar has been interviewed by a special team of federal investigators at Beth Israel Deaconess Hospital in Boston, and his radio and video presence now far outstrips Zack’s for many sad and tragic reasons.

What a contrast in two young men- one with focused energy to do good and the other to destroy.   One who channels his youthful idealistic fervor to build; the other who channels his to tear down and terrorize.  It is easy to deify or demonize and that is not what this is about.

What it is about is the important responsibility we all have to nurture our children and youth: to harness their idealism for good, to protest peacefully, to preserve and uphold life, not destroy and kill; and to speak up for what they believe while respecting the rights of others to differ.

Somehow Zack got that message and Dzhokhar didn’t. One has his life ahead of him to keep being a force for positive change. The other will languish incarcerated forever, or may even be killed as he allegedly did to others.


As a special anniversary celebration, I am offering the Tips and Topics book for a $1 for each year. So for $10 total (shipping and handling free), you can receive the TNT book if you purchase in April and May. After May 31, it will revert to regular pricing of $19.95 plus shipping.Get selected relevant clinical and systems tips from the years of Tips and Topics all in one place, “Tips and Topics: Opening the Toolbox for Transforming Services and Systems” by David Mee-Lee, MD with Jennifer E. Harrison, MSW. (158 pages; usually sells for $19.95 plus shipping but through May 31, $10 all-inclusive)

You can buy in two ways:

    1. Go to http://www.changecompanies.net/products/product.php?id=TNT and buy online; or
    2. call The Change Companies at (888) 889-8866 and ask for the anniversary deal for the Tips and Topics book.

Until next time

Thanks for joining in the 10th anniversary celebration. I look forward to seeing you in late May.


Getting Real about Gambling Disorder and Speeding again

Vol. 14, No. 1

Welcome to the beginning of our 14th year of Tips and Topics. It is hard to believe thirteen years ago I published our first Tips and Topics.  Thanks for starting a new year with us.

David Mee-Lee M.D.


I recently received this message from a long-time Tips and Topics reader:


“Hi Dr. Mee-Lee:


I’ve enjoyed Tips and Topics for a number of years and sometimes use excerpts from it as teaching and supervision tools for our students. I was also present for your keynote address to the National Conference on Problem Gambling (NCPG) last year and appreciated your thoughts about removing Substance Use Disorders and Gambling Disorder from their separate silos to help addictions clinicians and programs develop stronger competencies in both areas.


I do have a suggestion for Tips and Topics. Most of the insights in your newsletter relate well to the challenges counselors face working with problem gamblers and their family members, yet almost invariably when Tips and Topics refers to addictions, only Substance Use Disorders (SUDs) are mentioned. I’m wondering if, in the spirit of your keynote address to the NCPG conference, Gambling Disorder can be included, where appropriate. It could help raise the consciousness about this among your readers.


Thanks for taking the time to read and consider this.



Director, Problem Gambling Services

Lewis & Clark Graduate School of Education and Counseling

4445 SW Barbur Blvd. Suite 205

Portland, Oregon 97239

E-mail: eberman@lclark.edu


I can’t always respond to all suggestions readers make, but in this one, Rick has a point. I’ve talked before about addiction being more than just substance-related. Moreover, in The ASAM Criteria (2013) on pages 357-366 we even have a whole chapter on Gambling Disorder. Yet I have written or spoken of gambling hardly at all in Tips and Topics.


So this month’s edition fixes that problem a bit. I will share excerpts of my presentation on July 10, 2015 at the 29th National Conference on Problem Gambling in Baltimore, Maryland: “Getting Real about Gambling Disorder: How The ASAM Criteria Can Help“.



Why Consider Gambling Disorder?


American Society of Addiction Medicine (ASAM) Definition of Addiction


* The Definition of Addiction adopted by the ASAM Board of Directors in April 2011 states that persons with addiction can be seen as “pathologically pursuing reward and/or relief by substance use and other behaviors.” One of those “behaviors” is gambling.

* This definition does not state that Alcohol Addiction, Opioid Addiction, Nicotine Addiction and Gambling Addiction are separate conditions. It states that addiction can be involved with various substances and behaviors. (Nicotine addiction is the other neglected addiction).

* People with addiction manifest a pathological pursuit of reward or relief, and have a “disease of brain reward, motivation, memory and related circuitry” which is “characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response.”  


Statistics on Gambling Disorder


* Gambling Disorder is widespread and often co-exists with substance-related disorders as well as other mental disorders. Various estimates indicate that 1-2% of U.S. adults and 2-4% of U.S. adolescents are diagnosable with Gambling Disorder. (The ASAM Criteria, 2013)

* Lifetime prevalence is about 0.4%-1% – females about 0.2%; males about 0.6%; African Americans about 0.9%; whites about 0.4%; Hispanics about 0.3% (DSM-5, page 587, 2013)

* “Up to half of individuals in treatment for gambling disorder have suicidal ideation, and about 17% have attempted suicide.” (DSM-5, page 587, 2013)

* For 6-9 million Americans, gambling is a damaging behavior that can harm relationships, family life, and careers. (SAMHSA – http://blog.samhsa.gov/?s=Gambling+Disorder#.VYXAHGCnRfQ)



Getting Real about Health Coverage for Gambling Disorder


(The ASAM Criteria 2013, page 358)

* In contrast with substance use disorders, it is currently uncommon for commercial or governmental health plans to offer payment for treatment in residential or inpatient levels of care unless there are co-occurring medical or psychiatric problems, which would, in and of themselves, justify reimbursement for such placements.

* Most insurance companies that do not categorically exclude coverage for the treatment of gambling disorder have had benefits for the treatment of gambling disorders. But those benefits do not include payment for residential or inpatient treatment unless there is another, primary diagnosis such as major depressive disorder. It is the major depressive disorder which generates the reimbursement, not the gambling disorder. A state or local drug and alcohol authority could elect (and some do) to pay for the treatment of gambling disorder, regardless of level of care.

* Even partial hospitalization or intensive outpatient treatment programs for gambling disorder have historically been considered a “non-covered benefit”; patients needed to meet criteria for a substance use disorder or a separate mental disorder in order for payment to be authorized when the treatment focus would otherwise be the person’s pathological gambling.  

* “Across all states, there was a lack of uniformity regarding what types of problem gambling services were funded. Some states funded a comprehensive array of services ranging from prevention through multiple levels of treatment, while other states provided only one service (e.g., a problem gambling helpline or a prevention program).”

* “Among state agencies this variability in services provided was often rooted in the legislation that originally established the problem gambling program. Some states had legislation that restricted the use of funding to specific service areas. Another driving factor for which services were funded was linked to budget pragmatics, such as having insufficient funds to expand the range of services offered.” (2013 NATIONAL SURVEY OF PROBLEM GAMBLING SERVICES, March 2014)



Getting Real about Staff Credentials and Competence for Gambling Disorder


(The ASAM Criteria 2013, page 358)

* Staff providing treatment to patients with gambling disorder should have a state-sponsored or -approved Gambling Counselor Certification.

* Not all states have such credentialing – some states accept a national credential such as the National Certified Gambling Counselor (NCGC), provided by the National Council on Problem Gambling.

* State certification or licensure as an Alcohol and Drug, Chemical Dependency, or Substance Abuse Counselor should not be considered a substitute for or equivalent to a Gambling Counselor Certification.

* In the future, the evolution of professional training and professional certification, possibly being influenced by the 2011 ASAM Definition of Addiction, may mean that all addiction counselors will receive sufficient training in addiction associated with gambling, and thus separate certification will not be necessary. But at this time, there are relatively few well-trained and certified Gambling Treatment counselors.



Getting Real about Filling Gaps for Gambling Disorder



Survey participants were asked to identify one item as their state’s “greatest obstacle in meeting service needs to address problem gambling.”


* “Inadequate funding” was most frequently identified as the largest gap.

* The second most commonly endorsed service gap was a lack of public awareness about problem gambling.

* Problem gambling treatment availability.

* Need to increase the number of treatment providers.

* Improve research.

* Increase the number of prevention providers.

* Improve information management services.

* Increase the size of administrative staff.



American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013.



Prepared by Problem Gambling Solutions, Inc. for Association of Problem Gambling Service Administrators (APGSA) and the National Council on Problem Gambling (NCPG). March 2014


Mee-Lee D, Shulman GD, Fishman MJ, and Gastfriend DR, Miller MM eds. (2013). The ASAM Criteria: Treatment Criteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The Change Companies.

For more information on the new edition: www.ASAMcriteria.org


“The Definition of Addiction” Adopted April 12, 2011.



Note the following about gambling:

  • Gambling problems are assessed under ASAM Dimension 3, Emotional, Behavioral or Cognitive Conditions and Complications.
  • Gambling commonly co-occurs with substance use disorders (SUD).
  • Either gambling or substance use may act as a trigger for relapse to the other disorder.
  • Screening for gambling problems should be a routine part of SUD assessment.



Getting Real about Screening and Assessment for Gambling Disorder

(The ASAM Criteria 2013, page 361)


The purpose of screening is to conduct a preliminary inquiry to rule an individual “in” or “out.” If “ruled in,” the next step is to perform a comprehensive diagnostic assessment using the DSM-5 criteria for Gambling Disorder.


Once a Gambling Disorder diagnosis is established, the next question – answerable by use of The ASAM Criteria – is: What is the severity of the disorder? Severity of illness guides the clinician to an intensity of service recommendation for the patient.

  • There are over 27 instruments for identifying disordered gambling, though there is debate about them and what they measure.
  • An appropriate instrument should be able to screen for gambling disorders in both the general population and a population of persons who have a substance use disorder.

Two screening tools are recommended.


A. The first is the two-item “Lie/Bet Screen.”

* Advantage is that it is only two questions, and is more likely to be used in community and clinical settings where clinicians feel overwhelmed with current assessment responsibilities and other paperwork.


The “Lie/Bet” two item questionnaire are:

1) Have you ever had to lie to people important to you about how much you gambled?


2) Have you ever felt the need to bet more and more money?


B. The second and better-known and researched screening instrument is the South Oaks Gambling Screen (SOGS), a 16-item scorable questionnaire, which is in the public domain and can be found on the Internet.




Compare and Contrast ASAM Multidimensional Assessment for Substance Use Disorders versus Gambling Disorder. 

ASAM Multidimensional Assessment (The ASAM Criteria 2013, page 362-363)        

Here are examples of questions that would be asked in a multidimensional assessment of individuals with substance use disorders; and questions as they would apply to individuals with gambling disorders. The italics identify the differences.  There are such common characteristics between assessment of both disorders, with the least overlap being in Dimension 1: Acute Intoxication and/or Withdrawal Potential. The assessment questions of the other dimensions are generally a very close match.


ASAM Criteria Dimension 1:  Acute Intoxication and/or Withdrawal Potential

Sample Questions:

1. Substance Use Disorder:

  • Are there current signs of withdrawal?

1. Gambling Disorder:

  • Are there current signs of withdrawal (restlessness or irritability when attempting to cut down or stop gambling)?


2. Substance Use Disorder:

  • Does the patient have supports to assist in ambulatory withdrawal management if medically safe?

2. GamblingDisorder:

  • Does the patient have supports in the community to enable him/her to safely tolerate the restlessness or irritability when attempting to cut down or stop gambling?

3. Substance Use Disorder:

  • Has the patient been using multiple substances in the same drug class?

3. Gambling Disorder:

  • What forms of gambling has the individual engaged in?  Has the patient also been using psychoactive substances to the point where alcohol or other drug withdrawal management is necessary?


ASAM Criteria Dimension 2: Biomedical Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment?

1. Gambling Disorder:

  • Are there current physical illnesses, other than withdrawal, that need to be addressed or which complicate treatment? Does the individual manifest any acute conditions associated with prolonged periods of gambling (e.g., urinary tract infection)?

2. Substance Use Disorder:

  • Are there chronic illnesses, which might be exacerbated by withdrawal (e.g., diabetes, hypertension)?

2. Gambling Disorder:

  • Are there chronic medical conditions such as hypertension, peptic ulcer disease, or migraines that might be exacerbated by either cessation or continuation of the gambling behavior?


ASAM Criteria Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications

Sample Questions:

1. Substance Use Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of addiction illness, or do they appear to be separate?

1. Gambling Disorder:

  • Do any emotional/behavioral problems appear to be an expected part of the gambling disorder, or do they appear to be separate?

ASAM Criteria Dimension 4:  Readiness To Change

Sample Questions:

1. Substance Use Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has an addiction problem?

1. Gambling Disorder:

  • If willing to accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?


ASAM Criteria Dimension 5:  Relapse, Continued Use or Continued Problem Potential

Sample Questions:

1. Substance Use Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to use? 

1. Gambling Disorder:

  • How aware is the patient of relapse triggers, ways to cope with cravings, and skills to control impulses to gamble?o accept treatment, how strongly does the patient disagree with others’ perception that s/he has a gambling problem?


ASAM Criteria Dimension 6:  Recovery Environment

Sample Questions:

1. Substance Use Disorder:

  • All Recovery Environment questions similar between SUD and gambling disorder. An additional question listed for Gambling Disorder

1. Gambling Disorder:

  • Are the patient’s financial circumstances due to the gambling or associated legal problems an obstacle to receiving or distraction from treatment, or a threat to personal safety (e.g., loan sharks)?


What do January 2006, May 2010, October 2011 and April 2016 all have in common? Before you feel bad these might be some historical events you should know about, let me hasten to say that these dates only matter to ME.


You might be thinking: So why are you talking to me about dates that only matter to you? Because, there but for the grace of God go you. Actually, as I think about it, it has nothing to do with the “grace of God”. It has all to do with inattention, lack of commitment and risky behavior.


I did it AGAIN! I landed a speeding ticket this week, driving in Maine after a full day of training in Portland, Maine. If you’ve been a Tips and Topics reader for some years, you may remember the speeding topic has come up before in SOUL. Here are the links if you want to feel superior to me:

January, 2006 https://www.changecompanies.net/blogs/tipsntopics/2006/01/

May, 2010 https://www.changecompanies.net/blogs/tipsntopics/2010/05/

October 2011 https://www.changecompanies.net/blogs/tipsntopics/2011/10/


I don’t have a speeding addiction. That’s not “denial”; it is just a fact that by comparing my speeding with the “Lie/Bet” two item questionnaire for gambling disorder, I am zero-zero. I understand that’s a screening tool for gambling addiction not speeding, but it is comparable, trust me. I compared my speeding with the diagnostic criteria for gambling disorder and I didn’t come close to the required threshold for addiction. As well, I don’t want to trivialize the devastating disease and real tragedy of substance-related and gambling addiction by throwing around the word “addiction” and my speeding.


This is not to say, however, that I can sound like a person not yet in recovery from addiction. Here are reasons I am not addicted to speeding:

  1. Three of the four times I received a speeding ticket, I was driving a rental car. In my familiar car at home, I can feel when I’m speeding. (Oh, so they don’t have speedometers in rental cars that you can look at and monitor your speed?!)
  2. In the 2010 incident I was driving a brand new Prius, not yet used to the feel of speeding like in my old familiar car. (Oh, so again, the Prius didn’t have a speedometer to look at and monitor your speed?!)
  3. I thought I was following the flow of the traffic, so I bet I wasn’t the only one speeding. Why didn’t they catch them? It was probably racial or professional profiling, picking on Australian-born Chinese psychiatrists. (Yeah, right.)
  4. This latest speeding ticket was only for 79 mph in a 70 mph zone. Well actually the police officer took pity on me. Since it was decades since I have had a violation in Maine, he reduced my “speed” from the 83 mph to 79 (and saved me some dollars.) (79 mph and certainly 83 mph are both breaking the law and are both speeding – 70 mph is 70 mph, not 79 mph or 83.)
  5. The police are just trying to raise revenue by ticketing good citizens like me. They should be out there stopping real criminals like burglars and murderers. (So your illegal behavior is not as bad as those crimes, so you should get a break?!)

I surrender. My inattention, lack of commitment to not speeding, and risky behavior got me the ticket. I’m telling you now in hopes that my fine, my bank account and my public confession will change my speeding ways.

Interactive Journaling:

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Until next time

Thank you for joining us this month. See you in late May.