Building a Therapeutic Relationship in the Treatment of Problem Gambling

1. 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)

2. 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

3. Getting Started to Work With Problem Gambling • Conceptualization • Assessment and Formation • Establishing a therapeutic relationship

4. 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.

5. Etiology of Problem Gambling • Genetic • Biological • Personality • Emotional Management Skills • Coping Skills • Family & Peer Influence • Social and Cultural Learning • Accessibility

6. 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).

7. 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)

8. 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

9. Personality • Sensational seeking: Individual desire’s 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).

10. 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).

11. 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).

12. 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.

13. 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.

14. 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

15. 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

16. 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).

17. 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.

18. 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

19. 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

20. 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.

21. Yearnings (Universal) Behaviour Expectations (Wants) Coping (Do) Perceptions (See) Emotions (Feel) Behaviour is communication and has a meaning (Stair Model) Self

22. 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?

23. 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

24. Functions and meanings of problem gambling behaviour? • Coping with difficult feelings • Escape from problems • Revenge • Loneliness • Hopelessness and helplessness • Self prove • Attention seeking

25. 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)

27. Decisional Matrix

28. 23 14 17 Case - Ming

29. 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

30. 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)

31. 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

32. 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.

33. 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 (one’s 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

34. Four common factors: Client Factors Relationship/Alliance Factors Hope and Expectation Model and Technique 40% 30% 15% 15% What works in therapy:What Australian clients say

35. 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).

36. 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

37. Be empathic: Helping the client to feel understood First, the therapist has to understand

38. I wish ________________ would be violently killed today.

39. Questions and Discussions Thank you!