Betting on Recovery?

1. Betting on Recovery? A discussion of paradox, client stigma, identity, discourse, theoretical quandaries and personal insights from therapeutic conversations about addiction Murray Anderson Emily Doyle Tanya Mudry

2. Introduction • Presenter backgrounds • Social construction of addiction • Paradox of addiction and recovery • Discourses of problem gamblers

3. Reflecting on your own practice • Think about your own practice and how you would counsel someone with a gambling problem or another “addiction”?

4. A little about us… • Murray Anderson • MA, PhD candidate counselling psychology • Emily Doyle, • MC, PhD candidate counselling psychology • Tanya Mudry • MSc, PhD student counselling psychology

5. Addiction is an abstract concept. It has no objective existence and boundaries as would for example a chair or an elephant. Furthermore, it is socially defined which means that opinions can legitimately differ about what is the most suitable definition; it cannot be said that one definition is unequivocally correct and another one incorrect, only that one is more useful or is generally agreed upon by ‘experts’. Despite this, ‘addiction’ is one of the most important concepts in behavioural and clinical science. (West, 2006, p. 9)

6. Addiction and Recovery as Social Constructions • History • Attitudes • Events • Practices • Institutions • What is our role?

7. History, Attitudes & Events • Simply love to drink too much? • Industrialization and the need for self-control • Temperance movement (drunkard as a victim) • Addiction as a sign of weak character • Rediscovery of the “disease” model in the 1930’s – AA • Biological basis of addiction and taking an active role in one’s recovery

8. Practices and Institutions • Medical Model • DSM-IV-TR • Sustained by social processes

9. What is OUR role? • Research from a social constructionist perspective • Practice from a social constructionist perspective

11. Therapeutic and Research Experience • Project manager of various research projects involving marginalized / stigmatized populations. • Worked as a clinician in psychiatric outpatient clinic. • Case Manager for early psychosis intervention clinic. • Social Program Officer for a multidiscipline crisis response team. • Most 1:1, though a lot of group work in the past.

12. Reflection on Self & Practice – Three Questions • How do I ensure there is cohesion in the way I practice therapy and conduct research with the addiction/gambling population? • How do I ‘bracket’ my own thoughts/views/ideas of addiction/gambling to honor the voice/agency of those I am working with? • How do I make room for emerging theory/therapies in my work?

13. The Paradox of Addiction • Are gambling problems, shopping compulsions and some forms of overeating ‘addictions’? Really? Are behavioral addictions ‘real’, in the sense that they can be understood as a family of medical diseases that exist independently of culture, history and politics? To my mind, there are hardly less interesting questions (Vrecko,2010, p.38).

14. What is the Paradox of Addiction? • Throughout the addictions literature (Rockloff, & Schofield, 2004; Tavares, Martins, Zilberman, & el-Guebaly, 2002), especially in the neuroscience realm (Keane & Hamill, 2010; Vrecko, 2010) a widely held belief asserts that treating addiction as a disease of the brain (White, 2000b) will reduce the occurrence of shame and stigma. • The ‘addict’ is absolved of guilt, found not guilty by the moral majority. However, with absolution comes the chance of shame; now one carries a disease, an irreversible illness, never to be cured - thus, the paradox.

15. What is the Paradox of Addiction? • Such paradoxes are deeply embedded in both addiction and problem gambling therapies. • If problem gambling is conceptualized as a disease within the dominant addictions discourse, there is no cure; from this perspective, addiction is a chronic, debilitating disease that can be controlled, but not dissolved. • This paradox has the potential to diminish the ability of the field of addictions therapy to address associated client experiences of shame and stigma (Buchman et al., 2010).

16. The Paradox of Addiction – Diagnosis of Problem Gambling • Attempting to conceptualize PG is a daunting task (psychoanalytic, social learning, cognitive, and neurotransmitter theory). • To date, no single model fully explains the complex and heterogeneous nature of PG (Abbott & Clarke, 2005). • The lack of agreement on models has contributed, arguably, to the lack of subscribed therapies outside of medical models (Keane & Hamill, 2010). • Inconsistencies within such classification placed individuals behavior on a continuum ranging from being socially appropriate to socially catastrophic (Keane & Hamill, 2010).

17. The Paradox of Addiction – Diagnostic Tools • Three main identification tools predominate in gambling epidemiology: • South Oaks Gambling Screen (SOGS; Lesieur & Blume, 1987) - by far the most widely used; • DSM-IV-TR (APA, 2000); • Canadian Problem Gambling Index (CPGI: Wynne, 2003); • Although the SOGS is the tool most commonly used by practitioners to screen gamblers, the DSM-IV-TR is the primary text used to ascertain treatment protocols (Slutske, 2006). Such discrepancies further complicate treatment for PG.

18. The Paradox of Addiction – Diagnostic Complications • The term PG is not defined within the DSM-IV-TR (APA, 2000). • Despite attempts to unite PG and pathological gambling under the heading disordered gambling, at present, no gambling screening tools (Petry, 2009) endorse such distinctions. • Evidence suggests that clinicians do not use the DSM protocol uniformly for diagnosis, particularly with marginalized or oppressed populations (Lowe, & Widiger, 2009; Overmars, 2010). • Inclusion of PG as an extension of pathological gambling leads to confusion as to what treatment approaches are appropriate. According to these medical screening tools (CPGI, 2003; SOGS, 1987), the term problem gambler describes people who do not meet the criteria for diagnosis of pathological gambler. Such fuzzy descriptions only add to the problem of PG being treated as an addiction.

19. Emerging Research • Spoiled Identity: Problem Gamblers and the Moral Management of Stigmatized Identities through Conversational Agency. • Stigma greatest barrier in addiction treatment (Hinshaw, 2006; Horch, 2008) • Spoiled Identity (Goffman, 1963) • Identity Work (Wortham, 2000) • Moral Management (Avdi, 2005; Rapley, Kiernan & Antaki, 1995) • Conversational Agency (Strong, 2012; Zidjaly, 2009)

20. Outline of Research Initiative • Action Research Initiative (Lewin, 1948; Fals-Borda, 1982). • Situational Analysis (Clarke, 2005). • Three focus groups with addiction counsellors. • Two – 60 minute, semi-structured interviews with six problem-gamblers.

21. Why this investigation? • Whether in academia or among practitioners, there is little agreement on the constructs of addiction (gambling). • There is a movement afloat (Bailey, 2005; Marie, 2004) that suggests the social identity of being a “problem gambler” and its management in talk is far more fluid and dynamic than the static characteristic of “having a disease” or “being an addict.” • Impact of possible changes to the DSM-V from both a clinician and client perspective.

22. Research Question • How do clients agentively manage or negotiate their moral identities while in therapeutic conversation? • Focusing on what has been described as conversational ethics (Strong and Sutherland, 2007) a secondary branch of research questions emerge: How is this process of negotiation facilitated or hindered by therapists? • How do therapists infer the stated (or unstated) aims clients have in coming to therapy? • How do therapists rationalize, understand, and maneuver around potentially stigmatizing topics (e.g., Holmes, Murray, Perron, & Rail, 2006; Porter & O’Halloranan, 2009)?

23. Context of Study • Agency – conditionally defined as the socioculturally mediated capacity to act (Ahearn, 2001) is a loose concept with a lengthy, vague history. • Conversational Agency - invented term that orients us to ways in which clients participate in therapeutic dialogues (Massfeller & Strong, 2012). • One purpose of the study is to demonstrate a way of conceptualizing agency as a collaborative, and interactive achievement (Zidjaly, 2005), a conjoint action involving specific linguistic strategies (footing shifts, format roles, alignments, claiming, ratifying, and expertise) social actors draw upon in therapeutic interactions.

24. Initial Findings Therapists Gamblers Strong use of recovery discourse. Noted lack of agreement related to addiction language (“once an addict, always an addict”). Subjective nature gambling often ignored (story). Stronger indicator of success in support group situation. • Not all therapists agreed that clients were agentive in session. • Some therapists reported frustration with clients that didn’t follow treatment protocol. • High level of interest in hearing from clients – how sessions could be improved.

25. Paradox of Addiction – Final Thoughts • Problem Gambling is a highly- contested topic. • Paradox of addiction confounds the recovery process. • Addiction as disease models do not work for everyone. • Postmodern theory and therapeutic approaches are gaining credibility within the field of addictions (Diamond, 2012; Mitchell, 2006) and in particular problem gambling (Suissa, 2007). • We take addiction to be a category, a concept and a discourse rather than an unchanging historical entity Keane and Hamill, 2010, p. 53).

27. Research Interests • Common discourses of problem gamblers • Problem gambling and online support • Communities of practice (Wenger, 2004) • Discursive accomplishment of interactional tasks • Co-constructing identities • Negotiating membership • Establishing legitimacy • Providing and receiving support

28. Method • “Netnography” (Kozinets, 2010) • Discourse analysis (Wetherell, Taylor, & Yates, 2001) • Ethnomethodology (Garfinkel, 1967) • Data from a free Canadian 24/7 support forum

29. Forum

30. Discourse Analysis

31. Shame and Guilt Now here I am again, crying, fretting, stressed out and wondering where I will find the money to fix my car, buy groceries and buy food. It’s not just that I feel like a failure -- I am a failure.

32. Causality My Mom and her parents were/are as I know today compulsive gamblers and gambling was a normal way of living for me. I placed my first bet at [the] Race Track when I was 10 and was betting with a bookie at 16 . . . I truly believe that I missed the chaos of the family life I grew up in and set about creating my own chaos in my life with both drinking and gambling. People gamble for many different reasons, and it can become an issue when they gamble to escape from problems in their lives, if they chase losses, and/or get hooked on the buzz of winning (or almost winning).

33. Nature of Gambling Personally I don’t believe there is a thing as “Responsible Gambling” . . . people go to casino’s for fun and to lose their daily responsibilities. Casino’s are businesses and sell dreams and thrills for cold hard cash, nothing more. Anyone trying to be responsible wouldn’t be there in the first place.

34. Gambling as an Addiction or Illness Compulsive gambling needs to be treated like other addictions. Cocaine, alcohol, heroin, are all the same as compulsive gambling. All of these addicts need help to break free from their addictions, they cannot just walk away and quit. This addiction has the ability to put [people] out on the streets with nothing but the clothes on [their] back . . . Gambling addicts are like drug addicts . . . only takes one “hit” and we’re back on the dark path destroying ourselves

35. Control and Responsibility Are you aware of the self-exclusion process? You can [ask] to be voluntarily banned from the premises and should you show up they have the ability to charge you with trespassing. There are other options such as handing over all your finances to a loved one for the time being until you are back in control of your behaviour.

36. Recovery as a Process Getting over a gambling problem is not easy but it can be done. Recovery is like a journey and there are going to be ups and downs but the important thing is to keep moving forward even if you have a few setbacks. You have made a good start by coming here and deciding to talk about what is going on in your life. Talking about the problems is an important step towards understanding the problem.

37. Identity Co-Construction

38. Example • I just signed up here, I’m not even sure I know what I aim to accomplish except to quit gambling. I have been gambling all my life and it has eaten away at everything I try to achieve. I am in debt over my head and many people are very upset with me. • Since I have made my choice and also acknowledged the need to change I have been 5 weeks now without any sort of gambling and it feels very good to say that. I even had money to buy a new pair of jeans today. • Welcome to the site! Many people experience big wins in the first little while of gambling and end up in the same situation. Admitting the issue is an invaluable step - congratulations!

39. Socialization • Introduction section • This is the place to start on the GamTalk Forum. Say “Hi” to everyone and maybe say what you want to get out of the forum. Please keep your intro brief and then move on to another area… • Socialization of the introduction • Maybe you could tell us a bit about your story in the "introductions" section. Writing about your situation can help give ourself a clearer picture of what is going on, and the rest of us can have a better idea of suggestions that might help you.

40. Reflecting on Practice • Members discursively co-construct their understandings of PG and their identities as a gambler or gambler in recovery through their interactions. • Understandings about identity transformation may be of use to practitioners as an approach to recovery efforts, using identity co-construction in their work with clients. • Discourses of CoPs that are different from the clients might dissuade them away from interacting on such forums. Other barriers might include the requirement to disclose painful details, not being “ill enough” to participate, and the challenge of establishing a legitimate position in the group (Sandaunet, 2008). • Similar barriers to participation might also be evident in counselling or healthcare settings, highlighting the importance of practitioners being aware of the common discourses and norms of illness and recovery.