Layers of Forgiveness Relieving Trait Anger in the Compulsive Gambler

1. Layers of ForgivenessRelieving Trait Anger in the Compulsive Gambler

2. Layers of ForgivenessWorkshop Goals • Recognize the subtle and obvious signs of pathological anger; • Understand the typical roots of anger in the compulsive gambler; and • Have a firm grasp of the therapeutic tools available to relieve anger and rebuild the capacity for compassion and loving-kindness, and how this transformation arrests the gambling disease process.

3. Layers of ForgivenessWorkshop Outline • Role of Anger in Pathological Gambling • As a Cause • As a Consequence • Outcomes Study • Implications of addressing Anger • Overall impact of teaching Affect Regulation Skills • Core Emotions • Role that emotions play in survival • ALL Emotions are good (until they’re not)

4. Layers of ForgivenessWorkshop Outline • So what’s so bad about anger? • Seeking Justice • Dispensing Mercy • Working with Chronic Anger • Learning to Forgive • Using the REACH Model of Forgiveness

5. Role of Emotions in Gambling • Three Pathways to a gambling problem: • Classical and Operant Conditioning • No premorbid biological or psychological vulnerabilities (diatheses) • Compensatory Behavior • Emotionally vulnerable individuals (premorbid anxiety, depression, poor coping skills, family/developmental problems, life problems) use gambling as affect regulation • Impulsive and/or Antisocial Personality Style • Gambling results from impulsiveness • Negative emotions and life stressors trigger impulsiveness

6. Role of Emotions in Gambling • 80% of problem gamblers report gambling as a means to relieve dysphoria or escape from life stressors (Beaudoin & Cox, 1999) • Gamblers in treatment reported using gambling to manage emotional states: • Enhancing Positive emotions/arousal • Suppressing unpleasant emotions/worries • Promoting a sense of achievement • Non-Pathological Gamblers do not report using gambling to manage emotions • Tend to have a wide repertoire of emotion management techniques • (Ricketts and Macaskill, 2003, 2004)

7. Role of Emotions in Gambling • Gambling Relapse is caused by: • Cognitive errors (misperception of optimism about future gambling; e.g. “the gambler’s fallacy”) • Financial Stressors • Dealing with Negative Emotions and/or Stressors • 11% of gambling relapses • BUT much higher among women compulsive gamblers • (Hodgins and el-Guebaly, 2004)

8. Gambling and Anger • Study of 248 Problem Gamblers • 64.5% reported clinically significant anger problems • 62% reported perpetrating or being the victim of Intimate Partner Violence (IPV) • 25% reported perpetrating severe IPV • Korman et al. (2007)

9. Substance Abuse and Anger • Anger problems consistently reported in substance-treatment populations at higher rates than general population • 92% of IPV perpetrators reported using substances prior to IPV; 74% had prior arrests for substance-related charges (Brookoff et al., 1997) • Substance Use Relapse: Identified as an important relapse factor (Marlatt & Gordon, 1985)

10. Substance Abuse and Anger • Only one outcome study on comorbid substance abuse and anger: • Forgiveness Therapy was found to be significantly better than TAU for an inpatient alcohol and drug counseling population • Lin, Mack, Enright, Krahn, and Baskin (2004) • CONCLUSION: There is a relationship between addiction (substance or gambling based) and Emotional Dysregulation, including/especially anger

11. Gambling/Anger TreatmentOutcome Study • Randomized control trial of an integrated therapy for comorbid anger and gambling • Korman, Collins, Littman-Sharp, Skinner, McMain, & Mercado • Psychotherapy Research, July 2008; 18(4): 454 – 465

12. Gambling/Anger TreatmentOutcome Study • Participants: • 42 treatment-seeking, angry problem gamblers • 20 assigned to Anger & Addiction Treatment (A&A) • 22 assigned to TAU targeting gambling and substance abuse • NO significant differences demographically

13. Gambling/Anger TreatmentOutcome Study • Demographics: • 85% male; mean age = 47.6 years • Mean income = $32K • 28% married/partnered; 36% divorced/separated • 45% FT employed; 14% PT employed • 19% below High School education; 21% HS; 60% some College • 45% reported comorbid substance abuse problem (alcohol 84%; cannabis 42%; cocaine 32%; opiates 26%)

14. Gambling/Anger TreatmentOutcome Study • A&A Treatment: 12 Individual Sessions (weekly) • Modified DBT Approach used to treat comorbid Addiction and Anger (DBT includes telephone contact subsequent to non-compliance with treatment) • Clients recorded incidences of substance, gambling, and anger behaviors • First 30 – 40 minutes of each session focused on functional analysis of anger, gambling and substance use behaviors • Final 20 – 30 minutes of each session focused on teaching appropriate skills and engaging in skills rehearsal and exposure interventions • Skills were selected from anger awareness skills sets developed by Korman (2005) and Linehan (1993)

15. Gambling/Anger TreatmentOutcome Study • TAU: • Eclectic, non-manualized CBT approach • Identify cognitive distortions • Develop stimulus control responses (relapse prevention) • Well established, standard approach to Addiction Treatment

16. Gambling/Anger TreatmentOutcome Study • Results: Changes in Problem Gambling Severity Index: • A&A Group: • Time 1: 14.82 (Time 1 = Pretreatment, baseline) • Time 2: 4.71 (Time 2 = 14 weeks later, at end of Tx) • Time 3: 2.06 (Time 3 = 12 weeks after end of Tx) • TAU Group: • Time 1: 15.59 • Time 2: 8.45 • Time 3: 8.86

17. Gambling/Anger TreatmentOutcome Study • Results: Percentage of Monthly Income Spent on Gambling: • A&A Group • Time 1: 73.44% • Time 2: 16.6% • Time 3: 6.03% • TAU Group • Time 1: 66.41% • Time 2: 34.55% • Time 3: 31.05%

18. Gambling/Anger TreatmentOutcome Study • Results: Substance Use (# of days used in past 90 days) • A&A Group: • Time 1: 33.29 days • Time 2: 16.41 days • Time 3: 7.65 days • TAU Group: • Time 1: 35.15 days • Time 2: 23.46 days • Time 3: 38.92 days

19. Gambling/Anger TreatmentOutcome Study • Results: Anger Scores (Trait Anger) • T-Scores: All Means = 50; >60 = High • A&A Group: • Time 1: 59.29 (High Average) • Time 2: 50.53 (Average) • Time 3: 44.88 (Low Average) • TAU Group: • Time 1: 58.54 (High Average) • Time 2: 50.38 (Average) • Time 3: 52.00 (Average)

20. Gambling/Anger TreatmentOutcome Study • Results: Anger Scores (Expression) • A&A Group • Time 1: 66.29 (High) • Time 2: 60.76 (High) • Time 3: 53.76 (Average) • TAU Group • Time 1: 65.23 (High) • Time 2: 55.92 (High Average) • Time 3: 58.00 (High Average)

21. Gambling/Anger TreatmentOutcome Study • Conclusions: • Addressing Anger as part of a comprehensive treatment for substance abuse and/or gambling problems is related to: • Statistically Significant Reduction in Substance and/or Gambling Behaviors • CLINICALLY Significant Reduction in Substance and/or Gambling Behaviors. • Treatment Non-Compliance understood as PART OF the Illness, and NOT as a reason to terminate the treatment

22. Morning Break

23. Introducing Anger Into Therapy • What messages about forgiveness did you receive as a child? • What situations occurred in your family, your community, or the world that were unfair, unjust, and/or caused you pain? • What situations were you able to forgive? • Which were you not able to forgive and why?

24. Introducing Anger Into Therapy • What experiences from your childhood are you still carrying with you? • Are they weighing heavily on you? • What benefit might you receive from offering or receiving forgiveness?

26. Hold on to Forgiveness Commit Publicly to Forgive Altruistic Gift of Forgiveness (for THE Offender; for OFFENDERS) Empathize (with THE Offender; with OFFENDERS) Recall the Hurt REACH Model of Forgiveness

27. Lunch Time!

28. Open Forum on Anger • What have you observed about anger and treatment of compulsive gamblers? …substance dependent individuals? • Male Gamblers? Action Gamblers? • Female Gamblers? Escape Gamblers? • How does anger affect you? • Your relationships? • Your mental health?

29. Core Emotions • What is an emotion? • Emotions are discrete: They can be distinguished from one another • Emotions are automatic responses: We have no conscious control over the BODILY and COGNITIVE components of an emotion • Emotions are universally shared: Everyone can experience every emotion • Emotions are culturally specific: The experience of an emotion is shaped by cultural norms • Emotions are individual specific events: The experience of an emotion is shaped by a person’s life events

30. Elements of Emotions • Distinct Universals in Antecedent Events • Each Emotion is Provoked by a Specific Type of Event • Capable of Quick Onset & Brief Duration • Unbidden Occurrence • i.e. Emotions just happen • Can be Constructive or Destructive • Distinctive Universal Signals • i.e. We can recognize an emotion in anyone, regardless of race, culture, etc. • Distinctive Physiology • i.e. Each emotion has a specified physical response • Automatic Appraisal • i.e. Emotion provoking events lead to Appraisal Behaviors (e.g. vigilance)

31. Pleasant EmotionsApproach Action Tendency • Surprise: The briefest emotion • A response to a sudden unexpected event • Happiness: Feelings that are enjoyed and sought after by a person • Amusement • Relief • Excitement: high-intensity response to novelty and challenge • Wonder: response to something incomprehensible, incredible but not frightening; Combing Wonder with Fear and you have Awe • Ecstasy: self-transcendent rapture

32. Painful Emotions Affect Typical Cue Action Tendency Sadness Loss Avoidance Fear Danger Avoidance or Approach Anger I am Violated Approach or Avoidance Shame I Violate Another Avoidance or (Self-Focus) Approach Guilt I Violate Another Approach or (Object-Focus) Avoidance

33. So what’s so bad about anger? • What is Anger? • Internal state (feelings & thoughts) • External state (verbal & behavioral) • Physiological Arousal + Emotional Pain • Response to Unjust Treatment by Another • Chronic “State” Anger → “Trait” Anger

34. So what’s so bad about anger? • Psychosocial Consequences of Anger • Damaged Interpersonal Relationships • Workplace Problems • Poor Decision Making & Risk Taking • Substance Abuse • Diminished Motor Capacity

35. So what’s so bad about anger? • Medical Consequences of Anger • Coronary Heart Disease • High Cholesterol • Strokes • Cancer • Stress Related Illnesses (IBS, Chronic Fatigue Syndrome, Fibromyalgia etc.)

36. So what’s so bad about anger? • Responses to Anger • When one is wronged one seeks Justice • “Eye for an eye” • When one is wronged one extends Mercy • Genuine extension of beneficence to the offender • Forgiving emphasizes Mercy over Justice • BUT does not preclude seeking Justice (but does so mercifully) • Lincoln’s 2nd Inaugural Address: • http://www.lbl.gov/IT/CIS/dp/samples/lincoln-2nd-inaug.pdf

37. Features of Anger in Forgiveness Therapy • Focused on another person or other people • Intense, at least in the short term • A learned pattern of annoyance, irritation, and acrimony w/ others who may not be the source of the anger • Can be extreme in passivity or hostility • Regressive; that is, appropriate for someone much younger • The anger abides • Based on a REAL injustice and hurt

38. Forgiveness & Transformation • Forgiving leads to several alterations • The forgiver changes previous responses toward the offender • And to others toward whom the forgiver has “acted out” • The forgiver’s emotional state changes for the better • Improved mood, lowered anxiety • Improvement in a variety of medical, stress related problems • Relationships may improve • Diminishment in “Trait” Anger

39. Definition of Forgiving People, upon rationally determining that they have been unfairly treated, forgive when the willfully abandonresentment and related responses (to which they have a right), and endeavor to respond to the wrongdoer based on the moral principle of beneficence, which may include compassion, unconditional worth, generosity, and moral love (to which the wrongdoer, by nature of the hurtful act or acts, has no right).

40. Afternoon Break

41. Working with Chronic Anger • Assumption: • Forgiveness is a process, an unfolding, that • Does not run smoothly • Is filled with starts and stops • Eventually culminates in reducing anger and enhancing compassion • Forgiveness is not a decision only • Deciding to forgive is a part of the process • Necessary, but not sufficient

42. Working with Chronic Anger • Forgiveness happens in Phases • Each phase contains several units • The phases and units are not invariant for every process of forgiving • Phases/Units provide a road map to help the therapist and client discern what route will bring relief • A blueprint for an Anger/Forgiveness Case Conceptualization

43. Hold on to Forgiveness Commit Publicly to Forgive Altruistic Gift of Forgiveness (for THE Offender; for OFFENDERS) Empathize (with THE Offender; with OFFENDERS) Recall the Hurt REACH Model of Forgiveness

44. Working with Chronic AngerThe Uncovering Phase: REACH • Recall the Hurt: • Client gains insight into whether and how the injustice and subsequent injury have compromised his/her life. • Exploration of the Psychosocial and Physiological Consequences of the “Original Sin” • Exploration of the Psychosocial and Physiological Consequences of Holding on to the need for JUSTICE • How is my anger at “the” Offender affecting my present-day behaviors toward “Offenders”?

45. Working with Chronic AngerThe Uncovering Phase: REACH • Recall the Hurt: • Motivational Issue is KEY • Willing to Change: How important is it to me to address this issue, given the psychosocial and physiological consequences • Able to Change: How confident am I that I can really change how I feel about this? • How successful have I been in the past about changing how I feel about something? • Ready to Change: Is NOW the right time to do this?

46. Working with Chronic AngerThe Decision Phase • Client gains an understanding of the nature of forgiveness and makes a decision to commit to forgiving on the basis of this understanding. • Similar to “Preparation Stage” in the Stages of Change Model • Psychoeducation about “Forgiveness” is key • What forgiveness is… • What forgiveness is not… • Commitment to Forgiveness as a PROCESS must be made before considering the next step…

47. Working with Chronic AngerThe Work Phase: REACH • Empathize: • Work toward a COGNITIVE understanding of offenders • Reframe offenders in a new light • “Humanize” offenders • Let go of “Devaluing” and “Idealizing” Behaviors • Notice any positive change in affect about • “the” offender • “Offenders” in general • About the self • About relationships

48. Working with Chronic AngerThe Work Phase: REACH • Altruistic Gift of Forgiveness • Formulate Altruistic Responses to Offensive Acts • Rehearse these Responses in Session • Exposure Therapy: Actively seek out situations in which one can respond altruistically • Monitor Responses: Client and “Offender”

49. Working with Chronic AngerThe Work Phase: REACH • Altruistic Gift of Forgiveness • Consider Altruism toward “the” Offender • Given directly to the Offender ONLY if safe to do so • Given symbolically to other Victim’s of similar offense if not safe to approach “the” offender

50. Working with Chronic AngerThe Deepening Phase: REACH • Commit Publicly to Forgive • Find meaning in the suffering • Be willing to share the offense and the new response • Seek to be more connected with others • Make Forgiving and Altruistic Responding a part of ALL relationships, not only Offender relationships