By Oblio Stroyman, M.Ed, LMFT, NCGCII Presented at the 2011 Oregon Problem Gambling Services Spring Training, Salem, OR. Please contact author for publishing/sharing rights.

1. Healing Families in Problem Gambling Treatment OblioStroyman, M.Ed, LMFT, NCGCII

2. Overview This training is intended to offer PG staff an overview of Family Tx and is in no way a replacement for more advanced training/certification in couples and family therapy The information base will include an examination of; the relative phases of recovery for both problem gamblers and their loved ones; the nuances of working with family systems in problem gambling treatment, and specific models of therapy that are useful in doing this work.

3. Who’s Who in the Room Systemic therapeutic models work from the idea that a family's patterns of behavior influences the individual and therefore may need to be a part of the treatment plan. In marriage and family therapy, the unit of treatment isn't just the person - even if only a single person is interviewed - it is the set of relationships in which the person is imbedded. (http://www.aamft.org/faqs/index_nm.asp#what Oregon’s ISSR 309-032-1505(44) defines"Family" as the biological or legal parents, siblings, other relatives, foster parents, legal guardians, spouse, domestic partner, caregivers and other primary relations to the individual whether by blood, adoption, legal or social relationships. Family also means any natural, formal or informal support persons identified as important by the individual.

4. Community Query Who is presenting to therapy in your practices? What are the differences you notice in recovery when the SO’s are engaged in therapy? Are there differences in treating different kinds of SO’s.

5. Family Systems and PG By the time a gambler seeks treatment, there is frequently a disruption in the family system, preceding or surrounding the addiction. Many individuals with a pathological-gambling partner report coping with the gambling in a dysfunctional manner (Rychtarik & McGillicuddy 2006; Lorenz & Shuttlesworth, 1983; Zion, Tracy, & Abell, 1991). In a family system, each part is dependent upon every other part. When one part is unhealthy, it affects the rest of the system. Research suggests that having a significant other involved in the treatment of a problem/pathological gambler significantly increases abstinence success rates and retention in PG (Ingle et al., 2008).

6. Family Systems and PG “Homeostasis” is the way in which a family systems seek to maintain its customary organization and functioning over time with rules, boundaries, roles and defense mechanisms. The ability of a family system to regulate and maintain its emotional and behavioral functioning when addiction is present becomes maladaptive. Families are often unable to recognize their own “homeostasis” and maladaptive functioning without outside assistance. The recovery process can be significantly aided or impeded by the recovery environment.

7. Phases of PG and Recovery

8. Phases of Recovery for SOs of Problem Gamblers

9. Effect of PG on SOs Depression, anxiety, and high levels of anger also are common among the partners of problem gamblers (Rychtarik & McGillicuddy 2006; Lorenz & Yaffee,1988) Attempted suicide in PG populations have been reported at three times the rate of the general population (Lorenz & Yaffee, 1988). Research suggests that distress seen in SOs results largely from stress brought on by the partner’s gambling problem and the “ineffective coping skills” to deal with it. (Rychtarik & McGillicuddy 2006) .

10. Effects of PG on SO’s Pathological gamblers affect the lives of 8 to 10 other people (Petry, 2007) Individuals living with a pathological-gambling spouse or partner often experience significant physical and emotional distress (Rychtarik & McGillicuddy 2006; Heineman, 1992). Lorenz and Yaffee (1988) report that nearly half of the partners of a sample of pathological gamblers had frequent headaches, intestinal disorders, and asthma-related problems.

11. Getting SOs Engaged Approximately 1 in 5 gamblers have SOs enrolled in treatment Obstacles: SO believes it is the gambler’s problem Time and inconvenience Making contact with the SO SO is unaware of gambling treatment and how it may be useful for them personally Problem gambler’s own resistance to involving SO

12. Getting Gamblers Engaged When a family members presents without a gambler, encouraging the gambler to attend family therapy rather than gambling treatment to begin. Ask current clients “Do you view gambling as a problem in any of your interpersonal relationships?” Presentations to local agencies, including your own! Lectures in clinical training facilities Assisting local agencies to include PG screening (lie bet question) Tabling and distributing literature on PG

13. Getting SOs Engaged Family Treatment Team Recommendations: Make counselors accessible to clients when the client calls in to inquire about treatment Set the tone for what is expected in treatment “who would you like to be involved in your treatment” Provide the client and family member with education regarding increased success rates for recovery with family involvement Obtain an ROI and invite family member to attend one session Have groups available for family members Send home a welcome-invitation letter

14. Primary SO Presenting Concerns Trust Codependency and enabling Communication Financial Concerns Financial instability Financial abuse of the elderly, disabled, and children Violence/Crisis Management/Suicidality Interpartner violence Child abuse and neglect Anger Isolation

15. Family Dynamics in the Room Who do you want in the room? Is it safe/beneficial to have the gambler and the SO together initially. Children in the room, pros and cons; when appropriate and when not Set the expectation for the structure of family therapy (i.e. may ask people to leave the room in moments, no secrets policy) Invite as many people to be involved early on as are willing, then determine who will be involved in therapy and how. (Helps family members become part of support system and provides collateral info, potential ROI)

16. Clinician’s Initial Goals with Families Risk Assessment Assessment Engaging the client Motivational Interviewing Joining

17. Risk Assessment with Families DV, inter-partner violence, and suicidality should be assessed during the first phone call, on intake paperwork and with each individual in their first session. Time out contracts (in packet) Suicide assessment and safety planning assess for suicide directly and individually, not in couple/family session include as many family members as possible in safety planning encourage other family members to be direct (are you feeling suicidal today?) develop a safety plan

18. Initial Family Interventions Risk assessment Validation and normalization Education on PG Resources and treatment opportunities Identifying support systems Emphasizing the role of family systems in the recovery process Offering at least one tangible activity/action the client can do/take that offers them a sense of being proactive

19. Setting the Tone Make the covert overt Share common couples/family therapy concerns and open the door for the client to address them (i.e. alignment, no secrets policy) Share that the therapeutic relationship is built upon mutual trust Share observations of the analogue communication from the onset and explore them with clients, asking for their participation Ask what they know/share what you know about gambling addiction and what the recovery process may look like

20. Managing Family Dynamics Boundaries have never been so important. The therapist models healthy communication and limits The therapist must identify and name the cycles that provoke escalated communication and behaviors The therapist needs to be more directive when working with couples and families (i.e. setting ground rules, interrupting, asking that they take specific actions)

21. Managing Session Dynamics How do you manage dynamics when they get out of hand? Address the problem behavior directly and in the moment Refer to previously agreed upon ground rules Slow down or stop session If separation is necessary, the most emotionally activated client stays in the room Grab another therapist to de-escalate Do co-therapy

22. Group Therapy with Families Formats: Education Process Workshops Numbered sessions Open/closed Populations (pros and cons): Family members only Gendered Couples (no kids) Kids only Whole families Culturally focused

23. Group Therapy with Families Screening: Is the client appropriate for the group (i.e. format, population, stability)? Discusses group culture prior to their attendance, set expectation (i.e. confidentiality, appropriate sharing) Working with problem dynamics that come up during the group session Discuss it overtly in the group process if appropriate Normalize conflict, triggers and communication challenges Take a break Get assistance from another therapist (especially if the client has to be asked to leave)

24. Community Query What challenges are you concerned about, or have you faced, in working with SOs in groups?

25. Treatment Planning for PG Examples of family goals related to problem gambling behavior: safety planning financial protection/barriers to money engaging the gambler into treatment healthy boundaries and communication addressing risk factors for relapse supporting the gambler while remaining healthy (co-dependency, enabling) assessing levels of commitment and healthy possibilities for the relationship Make sure you outline the impact to the family system when one client does their assignments and another does not

26. Overview: The Franklin Reality Model The model identifies 4 components as basic human needs. To live, to love and be loved, to feel important, and variety. The model teaches that all people have a “belief window” and it is shaped by principles that we believe will help satisfy those 4 needs. Our “belief windows” have to change or our behaviors never will change. There are seven “natural laws” that accompany the model. 1) If the results of your behavior do not meet your needs, there is an incorrect principle on your belief window. 2) Results take time to measure. (Is it serving your purpose over time?) 3) Growth is the process of changing principles on your belief window. 4) If your self-worth is dependent on anything external, you are in big trouble. 5) Addictive behavior is the result of deep and unmet needs (of the four human needs mentioned above). 6) The mind will naturally seek harmony when presented with two opposing principles. 7) When the results of your behavior do meet your needs you experience inner peace. Analyzes the system and response through the 6 steps of the Model, which is drawn out on paper/board (good for gamblers)

27. Franklin Reality Model

28. Implications of FRM for PG Treatment Offers a linear and concrete cognitive process. Provides a visual tool, which works well with gambling populations. Provides a tool clients can utilize individually and together for any behavior they want to examine during and after therapy. Reassures the client that THEY are not “the problem” but the problem is a result of unmet needs, and the beliefs they hold around these needs. Helps clients “make sense” of their reoccurring problematic behaviors through putting these beahviors in the context of their motivations and beliefs (needs and values). It offers a different point of intervention then simply the behavior, which probably has not worked for them in the past.

29. Overview: Narrative Therapy The assumption is that narratives or stories shape a person's identity, and when there is a disturbance, it is a problem-saturated story Assumes that the problem is the problem, the client is not the problem An "externalizing" emphasis, such as naming a problem so that a person can: assess its effects in their life come to know how it operates or works in their life relate its earliest history evaluate it to take a definite position on its presence, choose a relationship to it. The therapist helps the client ”re-story self-defeating cognitions” through looking at “unique outcomes” or exceptions to the problem that does not make sense in the context of the current narrative Advocates for the creation and use of documents (i.e. good-bye letter to gambling)

30. The Therapeutic Alliance Role of therapist as investigative reporter, the client is the expert. The therapist must listen actively to client's existing family and cultural narratives to get a sense of how the clients view themselves, how they define their challenges and solutions, and their attitudes towards change (Woodcock, 2001; Freeman and Couchonnal, 2006). The therapist must be as aware of their existing preconceptions as possible. Narrative therapists must explore their own personal stories, cultural stories, and past experiences to minimize the impact of their own stories, and to “avoid inadvertently filtering out of the client's relevant narrative details” (Coulehan et al., 1998; Woodcock, 2001; Androutsopoulou et al., 2004).

31. Client as Expert It is crucial in developing rapport and supporting clients’ self-efficacy to acknowledge the agency of clients to name their challenges and define their own reality. One strategy to help clients define their challenges is asking the client to give their narratives a title, which reflects their view of the challenges and themselves. (Woodcock, 2001; Androutsopoulou et al., 2004; Jones, 2004; Freeman and Couchonnal, 2006). Clients who are not validated for their perception of their situation tend to discredit therapists as unable to understand them or as insincere. The client and therapist work together as coauthors in the mutual exploration of perceived problems (Nicholas and Schwartz, 2006). While this effort is collaborative, the therapist acts as the facilitator of the conversation, creating space for new stories and meanings.

32. Externalizing the Problem Narrative therapists believe that “people are not their problems, that problems are the problems,” an “external” factor that influences people’s beliefs and behaviors. Therapists can encourage clients to label, objectify or personify problems to foster them to be seen as separate from the client as a person (e.g. people are not anxious, but overtaken by anxiety) (Coulehan et al., 1998; Woodcock, 2001; Dallos, 2004; Nicholas and Schwartz, 2006). This technique can serve to decrease helplessness, foster empowerment and open up new avenues for change. A second technique is "mapping" the problem, which involves posing questions that encourage people to determine for themselves the degree to which the problem is affecting their lives (Jones, 2004; Nicholas and Schwartz, 2006). Such questions as "How does anxiety create trouble for you?" can lead to an exploration of how clients can exert their own influence over the problem at hand.

33. Re-authoring Stories “Deconstructive readings” or readings that offer alternative perspectives are used as part of a “larger interpretive strategy that aims to destabilize cultural hierarchies” (Legg and Stagaki, 2002; Boston, 2005). This practice of re-authoring offers alternatives to problem-saturated personal narratives, destructive dominant societal norms, and maintains the therapeutic alliance as equal (Boston, 2005). Deconstruction and re-authoring are prequels to the process of “narrative reconstruction.” In listening to client's stories, therapists attempt to identify dichotomies, exclusions, exceptions, hierarchies of characters or voices, and possible alternative plots or meanings buried within the narrative (Androutsopoulou et al., 2004; Boston, 2005; Freeman and Couchonnal, 2006; Nicholas and Schwartz, 2006).

34. Re-authoring stories (cont) Therapists may point out their observations to clients with rhetorical or circular questions, such as "What would have to happen to change this story's ending?" (Legg and Stagaki, 2002) or asking them to speak from the perspective of a subordinate voice (Boston, 20055). In effect, deconstruction and re-authoring serves to "read between the lines" of the given narrative to reveal new meanings and initiate the authoring of a new and more useful story (Nicholas and Schwartz, 2006).

35. Unique Outcomes and Strengths At the core of narrative therapy is the seeking out and utilization of client strengths. (Nicholas and Schwartz, 2006). The therapist seeks to identify “unique outcomes” that make the problem-saturated story untrue. As client and therapist work together to define challenges and deconstruct the story, previously unrecognized competencies and strengths are often revealed. Clients often take for granted their own abilities. The therapist can bring "unique outcomes" to the forefront by asking about times when the person or family has overcome a particular problem, or when the problem was less noticeable or stressful (Freeman and Couchonnal, 2006; Nicholas and Schwartz, 2006).

36. Unique Outcomes and Strengths Clients are sometimes resistant to acknowledging strengths and focus on the negative, not believing that they possess strengths or narratives of competence (Jones, 2004). It may be easier for clients to begin by relating stories about a mentor or public figure who has overcome similar obstacles, which can then be tied to their own exception stories (Freeman and Couchonnal, 2006). By identifying exceptions and strengths, the focus of the therapy begins to shift towards the future and creating a new narrative.

37. Implications of NT on PG Treatment All parties in the family have their stories heard and validated, when they may have been suffering a lot of invalidation. Gambling becomes the problem rather than the gambler, and the family can rally around solving the problem. Likewise, as other family problems arise, the problems become the problems rather than individuals. The client begins to feel empowered to choose their relationship with problems, a subject rather than an object. Clients begin to release judgments for past choices, choosing a different relationship with their past to empower their future. Clients begin to see themselves and their families from strength-based places rather than deficits. Offers clients tools in which they can use post-therapy to evaluate future problems.