Building a Therapeutic Relationship in the Treatment of Problem Gambling

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Building a Therapeutic Relationship in the
Treatment of Problem Gambling

• Elda Chan
• Certified Problem Gambling Counsellor, Train the
  Trainer
• Coordinator of Even Centre
• Tung Wah Group of Hospitals
• (Hong Kong)

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Structure of the workshop

• Day 1
• Part one Building a Therapeutic Relationship in
  the Treatment of Problem Gambling
• Part two Managing Defensiveness in Gambling
  Counseling?
• Day 2
• Part one Facilitating Problem Gamblers to Manage
  Common Cognitive Biases
• Part two Working with Families of Problem
  Gamblers

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Getting Started to Work With Problem Gambling

• Conceptualization
• Assessment and Formation
• Establishing a therapeutic relationship

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Before Intake

• Counselors own understanding and
  conceptualization of the problem would profoundly
  affect their attitudes towards the problems and
  help-seekers and their ways to conduct assessment
  that guide the treatment direction.

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Etiology of Problem Gambling

• Genetic
• Biological
• Personality
• Emotional Management Skills
• Coping Skills
• Family Peer Influence
• Social and Cultural Learning
• Accessibility

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Genetic

• Some researches found that problem gamblers were
  more likely to carry a particular genetic variant
  related to Dopamine D2 receptor that was also
  found to be associated with substance dependency
  (Comings et al., 1996).
• Study on twin suggested that familial factors
  have a strong link to the diagnosis of problem
  gambling (Eisen et al., 1998).

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Biological

• Decreased brain activities in frontal,
  orbitofrontal and left ventromedial cortex, which
  are the areas responsible to decision making and
  rewards analysis (Potenza et al., 2003).
• History of brain injury due to trauma, prenatal
  complication, and had impaired concentration,
  memory executive functions (Regard et al.,
  2003).
• Neurotransmitter dysfunction including
  serotongic, norepinephrine, and dopaminergic
  abnormalities (DeCaria et al., 1996 Blanco et
  al., 1996 Bergh et al., 1997 Stojanov et al.,
  2003)

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Co-mobility

• Connection of gambling to mental illness and to
  substance addiction - as many as 30 of gamblers
  are also diagnosed with substance addiction and
  25 of gamblers are also diagnosed with
  psychiatric disorders (Janine Regosin, 2004) .
• Pharmacological approach- increase usage of
  psychotropic medication

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Personality

• Sensational seeking Individual desires for
  seeking an aroused state (Coventry Norman,
  1997).
• Impulsivity Behaviors such as orientation to the
  present, difficulty in delay gratification, risk
  taking, poor ability in organizing and planning,
  boredom proneness, hedonism and reward
  sensitivity (Petry, 2000).

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Emotional Management Skills

• Research found 3 common aspects of emotions
  associate with gambling arousal, sense of
  achievement, and using gambling to manage
  negative emotions (Ricketts Macaskill, 2004).
• Lower emotional intelligence was found related to
  problem gambling (KaurNicola et al., 2006).

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Coping skills

• Research found that problem gamblers may have
  deficits in coping skills and tended to adopt
  avoidance-focused rather than task-focused coping
  (Bergevin et al., 2006).
• Coping skills deficit was found in problem
  gamblers, e.g. inability to control autonomic
  arousal, challenge irrational gambling beliefs
  and utilize constructive problem solving skills
  (Sharpe, 2002 Dickerson Baron, 2000 Sharpe
  Tarrier, 1993).

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Family Peer Influence

• Research (Magoon Ingersoll, 2006) found
• Parental gambling, problems of trust and
  communication with parents increased the
  likelihood of adolescents developing problem
  gambling
• Healthy parental attachment decreased the level
  of adolescent gambling
• Peer influences could be moderated by parental
  influences.

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Family Peer Influence

• Parents attitudes on youth gambling (Tung Wah
  Group of Hospitals, 2006)
• Parents had underestimated their children
  gambling behaviour.
• Young people who had parents engaged in regular
  gambling were more likely to gamble more in the
  past 12 months and started to gamble at a younger
  age.
• Parents had a faulty perception that they had
  delivered adequate preventive education to their
  children.

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Family Influence

• Modeling and over learning
• Introjected self-image
• Maintaining problem gambling through interactive
  sequential behavior patterns eg. co-dependency
• Polarized perception
• Ambivalent interpersonal relationship

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Social and Cultural Learning

• Micro-settings (immediate environment) and
  macro-settings (societal and ecological
  processes)
• Cultural perceptions and values
• Specificity in gambling myths and distortions
• Myth-making and distorted schemes may be
  developed to strengthen the sense of power and
  control
• Cultural tolerant and acceptance of gambling
  activities
• Help seeking behaviour

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Accessibility

• In US, research found that the presence of a
  casino within 10 miles associated with the level
  of problem gambling (Welte, 2004).
• The National Opinion Research Center (NORC)
  found that for adult respondents, living within
  50 miles of a casino were more likely to develop
  pathological or problem gambling (NORC, 1999).

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Biopsychosocial Model

• Behaviour is an integral part of the person and
  their environment
• General System Theory as a meta theoretical
  framework behaviour of any person can be
  understood by the interaction of the many
  different hierarchical levels or systems.

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Bio-Psycho-Social Model withDiathesis-Stress
Perspective
Problem/Pathological Gambling
Disorder
Early winning and other life experiences and
situation could reinforce and lead to false hope
and false belief
Developmental Experiences and upbringings affect
and shape our core emotion and belief system and
behavior pattern
Biological Vulnerability
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Spirituality

• Spirituality ?religiosity
• Spirituality is about how a person make sense of
  his/her relationships with
• Oneself, others, the world
• Higher being/culture and history
• Sense of contentment
• World view and life goal

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Principles

• Causation is multi-directional and multi-causal
• Changes in one aspect of the system will
  reverberate and facilitate changes throughout the
  system
• The person must be assessed in relationship to
  his/her entire unique context
• Assessment on underlying issues and dynamics help
  to understand the meaning of behaviour.
• Develop individual formulation to guide the
  choice of intervention strategy.

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Behaviour is communication and has a meaning
(Stair Model)
Self
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Two questions in assessment

• What are the functions and meanings of problem
  gambling behaviour?
• How has the problem gambling behaviour been
  maintained in the system?

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Development of Gambling Distortions
I can win from gambling by wearing yellow today
I need to have lots of money to be a worthy person
I feel sad that I am not a successful and worthy
person
I want to be a worthy person
I want to be respected and appreciated
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Functions and meanings of problem gambling
behaviour?

• Coping with difficult feelings
• Escape from problems
• Revenge
• Loneliness
• Hopelessness and helplessness
• Self prove
• Attention seeking

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• Chinese G-Map
• 17 factors grouped in 5 domains
• Beliefs about Winning Domain (Cognitive Problems)
• Feelings Domain (Emotional Problems)
• Situations Domain (Life Situations Related to
  Pathological Gambling)
• Attitudes to Self Domain (Self-Concept and
  Psychological Problems)
• Social Domain (Social Influences)

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Decisional Matrix
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Case - Ming

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Case - Ming

• Introduced to Soccer betting by a colleague who
  was the only person talk to him at work.
• Relied on tips from his colleague and own
  analysis. Felt proud of himself after number
  early winning experiences.
• Chasing losses - would couple the bet in next
  session.
• Refuse to pay the debts even when he won, wanted
  the parents to pay for him as a revenge.
• Being bullied at school, feelings of anger, fear,
  shame, inaccuracy
• Impulsive, outburst of anger
• Interpersonal problems, distance family
  relationship

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Assessment - Ming

Wanted to be connected and built a good peer
relationship Fun and exciting - searching for
meaning (Loneliness, boredom, emptiness)
To prove I am accurate, I am able (Anger,
inaccuracy, shameful, hurt and unsafe)
Revenge - reaching out, wanted to be understood,
wanted to be loved, protected and cared
for (Anger, hurt, worthless)
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Intervention

• Identify feelings of anger, inaccuracy, hurt and
  unsafe, and explore in detail the development of
  these feelings
• 2. Identify in-depth needs and yearnings
• 3. Promote a sense of healing through increase of
  awareness and acceptance
• 4. Create insight into the function and meaning
  of problem gambling behaviour in relation to the
  identified needs and yearnings

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Intervention

• 5. Identify the cycle of problem gambling
  including triggers that led to a chain reaction
  of emotions, cognitive bias and behavioral
  response.
• 6. Identify and develop for new behaviour
  including communication skills, problem solving
  skills increase autonomy by taking responsibility
  of his gambling behaviour, etc.
• 7. Relapse prevention identify risky situation
  and response, develop life goal and meaning.

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Therapy

• The therapist is responsible for creating a
  context in which change can take place
• Change comes as a result of accurate assessment
  and management of the resistance to change
  existing in the system (ones world view).
• The role of the therapist is to break up the log
  jam and channel the family members back into the
  proper stream of movement.
• Eriksonian Approaches to Hypnosis and
  Psychotherapy, Edited by Jeffrey K. Zeig, 1982

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What works in therapyWhat Australian clients say

• Four common factors
• Client Factors
• Relationship/Alliance Factors
• Hope and Expectation
• Model and Technique

• 40
• 30
• 15
• 15

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The Importance of Therapeutic Relationship

• Research about the effectiveness of gambling
  counseling suggest that the therapeutic alliance
  was found to have the strongest predictive
  power(Smith, 2001).

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Building a therapeutic relationship

• Tips
• Identify and get in touch with clients secondary
  emotions
• Be empathic
• Probe for the function and meaning of behaviour
• Be a coach rather than teacher or doctor
• Induce hope
• Meaning of change intrinsic vs. extrinsic
• Managing defensiveness skillfully and patiently

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Be empathic Helping the client to feel
understood

• First, the therapist has to understand

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• I wish ________________ would be violently killed
  today.

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• Questions and Discussions
• Thank you!