Family Support and Psychoeducational Group Manual for Problem ...

Family Support and Psychoeducational Group Manual for Problem Gambling

Toula Kourgiantakis, MSW, RSW, RMFT Michael Weyman, MSW, RSW Brenda Teasell, MSW, RSW Lisa Pont, MSW, RSW

Family Support and Psychoeducational Group Manual for Problem Gambling Printed in Canada Copyright © 2013 Centre for Addiction and Mental Health, Problem Gambling Institute of Ontario, Toronto ON Facilitators offering this program have permission to download the manual and copy and distribute the handouts for use by participants. Otherwise, no part of this work may be reproduced or transmitted (for profit or otherwise) in any form or by any means electronic or mechanical, including photocopying and recording, or by any information storage and retrieval system without written permission from the publisher—except for a brief quotation (not to exceed 200 words) in a review or professional work. Contact [email protected]

This manual was produced by: Development: Colleen Tessier Editor: Nick Gamble Design: Pat Dumas-Hudecki Writers: Toula Kourgiantakis, Michael Weyman, Brenda Teasell and Lisa Pont

4803/07-2013

Contents

Family support and psychoeducational group manual for problem gambling

Introduction

2

Background information on problem gambling and families

4

Preparing for a family support group

8

Implementing the group

12

Session 1: Understanding problem gambling, recovery and treatment

15

Session 2: Communication

26

Session 3: Establishing boundaries

30

Session 4: Self-care, support and next steps

35

Alternative formats for family support

40

Testimonials

42

References

43

Suggested readings

45

1 ©2013 Centre for Addiction and Mental Health

Introduction

Introduction This manual was initially developed to provide a framework for the groups that we provide for families in the Problem Gambling Program at the Centre for Addiction and Mental Health (CAMH). This framework is flexible and can be adapted according to the group profile, as well as the style and skill of the facilitator. It is simply a guide and can be modified to fit with your agency, facilitators and participants. The manual provides information on developing and delivering a four-week psychoeducational support group for family members of people with gambling problems. Family is used as a broad term to describe anyone who has a significant relationship or role in the life of the gambling individual. Research has shown that psychoeducational groups are extremely beneficial in addiction and mental health. They provide information, validation and support, help reduce distress, and help families develop better problemsolving and coping strategies (CAMH, 2004). The four-session group addresses the following topics: 

understanding problem gambling, recovery and treatment



communication



boundaries



self-care and support.

These are the topics that in our experience at CAMH family members and gambling clients refer to most frequently as areas of difficulty or areas requiring greater skill development. While some families find a four-session group is too brief, for many it is adequate. Four-week groups permit us to offer groups more frequently, and it also ensures that family members who cannot commit to a longer duration are not excluded. We encourage families that require more support to attend a second time, or refer them to other services. That being said, it is fairly simple to add one additional session. In this manual you will find outlines for each session, information for facilitators, group exercises, handouts for clients, and suggested questions or statements to display on flipcharts. For agencies that cannot offer a four-week group, we suggest alternative formats such as a one-off information session (see page 40). We have also included



Introduction

supplementary information on topics relevant for those working with families of people with gambling problems, including the definition and prevalence of problem gambling, key clinical skills, group recruitment tips, the impact of problem gambling on families, and best practices. If you have any questions about this manual, please contact us:

Toula Kourgiantakis, MSW, RSW, RMFT [email protected] Michael Weyman, MSW, RSW [email protected] Brenda Teasell, BA, MSW, RSW [email protected] Lisa Pont, MSW, RSW [email protected].



Background information on problem gambling

Background information on problem gambling and families What is problem gambling? “Problem gambling is gambling behaviour that creates negative consequences for the gambler, others in his or her social network, or for the community” (Ferris & Wynne, 2001, p. 7). This holistic definition of problem gambling takes into account the impact of gambling not only on the individual but also on his or her family and community. Problem gambling is not just about the loss of money, but how it can affect the person’s whole life. Gambling is a problem when it: 

interferes with work, school or other activities



leads to emotional or physical health problem



causes financial problems



harms the family or other relationships.

A survey of prevalence rates across Canada and around the world found that 1.8% of Canadians experience gambling problems; in Ontario the rate is 2.4%, higher than the national average but considered “intermediate” (Williams, Volberg & Stevens, 2012). Internationally the average rate of problem gambling is 2.3%. The lowest rates are found in Europe, intermediate rates in North America and Australia, and the highest rates in Asia (Williams et al., 2012). Pathological gambling is the term used until recently in diagnosing persistent and recurrent gambling problems. In the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) (American Psychiatric Association, in press), it has been renamed “disordered gambling” and is grouped along with alcohol and drug use disorders under the heading “Addiction and Related Disorders.” Disordered gambling is the only behavioural addiction in the DSM. Family support and psychoeducational group manual for problem gambling



The impact of problem gambling on family members Research shows that problem gambling affects not only the individual with the gambling problem, but also family and friends, as well as relationships. The effects that have been reported include: 

financial and legal problems (Ledgerwood, Weinstock, Morasco & Petry, 2007



high levels of distress (Dickson-Swift, James & Kippen, 2005)

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isolation, guilt, shame and embarrassment (Dickson-Swift et al., 2005)



mental health difficulties (e.g., depression, anxiety) (Dickson-Swift et al., 2005)



traumatic symptoms resembling PTSD (McComb, Lee & Sprenkle, 2009



physical health problems (Dickson-Swift et al., 2005)



feelings of loss, betrayal, confusion, frustration, fear and anger (Grant Kalischuk, Nowatzki, Cardwell, Klein & Solowoniuk, 2010)



loss of trust (Dickson-Swift et al., 2005)



greater conflict and disorganization in families and couples (Dickson-Swift et al., 2005



reduced intimacy in relationship (Trudel et al., 2008)



parenting difficulties (Black, Shaw, McCormick & Allen, 2012)



increased rate of intimate partner violence (Korman et al., 2008



increased rate of separation and divorce (Black et al., 2012).

It is important to validate the impact of problem gambling if family members raise this issue. However, we have found it best not to initiate these potentially distressing topics with family groups. For most families, it is more beneficial to hear positive, hopeful statements that draw from their strengths as individuals and as a family.




Why is family involvement important? Research supports the value of involving family members in treatment for problem gambling and substance use problems. Here are some salient findings: 

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People remain in treatment longer when a family member is involved, and those who stay in treatment longer have better outcomes (Ingle, Marotta, McMillan & Wisdom, 2008). Individuals who have social support while they are in treatment have better outcomes than those who are isolated, even if family is not directly involved in that treatment. The benefits include lower relapse rates and higher rates of abstinence (Ingle et al., 2008). Relationships are one of the spheres most harmed by gambling, so it makes sense to involve all of those who have been affected (McComb et al., 2009). When family members are involved in treatment, their own adjustment is improved; for instance, they experience reduced distress and mental health issues (Hodgins, Shead & Makarchuk, 2007). Involving family members in treatment also improves overall family functioning, cohesion, communication and intimacy (Lee, 2008); families spend more time together, and there is lower risk of family violence (Kelley & Fals-Stewart, 2002). When couples receive therapy for problem gambling, there are improvements for children even when they are not directly part of the treatment (Lee, 2008). Family members with stronger coping skills fare better, so services need to focus on helping family members develop more effective coping skills—which in turn improve outcomes for families (Makarchuk, Hodgins & Peden, 2002). “Pervasive loss” is a term used to describe the effects of problem gambling on children. Children have historically been the family members most omitted from problem gambling research and treatment (Darbyshire, Oster & Carrig, 2001).

Csiernik (2002) highlighted that many Ontario treatment centres do not include family members in addiction treatment, despite the benefits. He found that of Ontario treatment centres:

– only 8% offered individual counselling to family members

– only 15% offered psychoeducational or support groups to families

– only 1% offered family therapy.



Best practices in working with families in problem gambling treatment A family-centred care approach is an evidence-based practice. Here are some best practices for involving families in treatment: 

Involve families in treatment as early as possible.

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Involve families in collaborative treatment planning as much as possible.



Clarify your role as a therapist (e.g., who your client is, what information you can share with others).

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Clarify the limits of confidentiality and develop strategies for resolving problems related to confidentiality. Even when clients do not consent to the release of information about their treatment, give families general information about problem gambling treatment and the help available for families. Discuss the impact of problem gambling on family relationships in individual sessions and group treatment for gambling clients.

Provide services for families, such as individual sessions for family members and family psychoeducational support groups.



Help families learn to cope and relate effectively.



Treat family members with dignity and respect; avoid judging or blaming family members.



Focus treatment on a family’s strengths, expertise and contribution to treatment planning.

Sources: CAMH, 2004; O’Grady & Skinner, 2007.




Preparing for a family support group Recruitment for family support groups It may take time to recruit family members for support groups especially when this service is being offered for the first time. The following suggestions may help raise awareness and promote greater participation: 

Prepare a flyer that promotes the upcoming group and post it throughout the agency (see sample next page).



Encourage gambling clients to inform families who are not present about the group.



Send a letter about the group to families via the gambling client (see sample on page 10)



Encourage families to bring other family members or friends affected by the problem.

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Ensure that all individual and group programs for gambling clients include a component raising awareness of the impact of problem gambling on families (without blaming), and teaching communication and problem-solving skills in relationships.

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Involve families in gambling clients’ individual sessions and give them information directly.

If some families are enrolled but the numbers are not high enough to begin a four- week group, provide a single session to reduce the risk that they may drop out. Then encourage these families to return for a potential four-week group. Promote the Problem Gambling Institute of Ontario (PGIO) website (www.problemgambling.ca) to gambling clients and family members. Gaining a better understanding of the problem may encourage greater involvement in treatment. Make families feel welcomed, understood and an important part of the treatment process. Believe in the cause. Every centre needs an advocate for underdeveloped services. It takes time, energy and perseverance.



Sample flyer text FAMILY SUPPORT GROUP—PROBLEM GAMBLING Where: Problem Gambling Service, 33 Russell St. (3rd Floor), Toronto When: Thursdays 5:30 p.m. to 7:30 p.m., from October 4 to October 25, 2013 (four sessions) This four-session group is for anyone affected by the gambling behaviour of a family member or friend. An initial meeting with a therapist at CAMH is required. For maximum benefit, you are requested to attend all four sessions. The family support group offers: 

information, education and feedback



an opportunity to share your concerns about the gambling problem



a chance to receive support from people experiencing similar issues.

Topics include: 

understanding problem gambling (definition, treatment/recovery, stages of change)



effective communication strategies



setting clear boundaries



support, self-care and next steps.

If you would like to attend, either speak to your CAMH therapist or call 416 599-1322 to speak to our intake coordinator. Find tools for family members at the Problem Gambling Institute of Ontario’s website: www.problemgambling.ca




Sample letter to family members Dear family member or friend of a gambling client, Is a family member or friend seeking treatment for a gambling problem? When people are working on changing their problem gambling behaviour, the involvement of those close to them can really help. Having a gambling problem can have negative effects on close relationships and can create financial difficulty, damage trust and increase stress. These effects don’t go away overnight, and the change process can take time. When families work together, gambling problems and negative effects can be dealt with more quickly. Research has shown that individuals do better when families are involved. Here are some of the benefits: 



Family and friends often feel safer and less stressed when they learn about the warning signs of problem gambling, and what happens in treatment.

Information from family and friends can help the therapist work more effectively with the person who has the gambling problem.



Treatment planning can take the family’s needs into account.



Relationships can improve more quickly when the stresses are discussed and dealt with.



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Families and friends can share their concerns and get information, advice and support.

Relapse is less likely, and if there is a slip, getting back on track can be quicker.



There are many ways in which you can be involved with our services: 

Phone consultation is available, for information and to answer questions.

You may book your own appointment to discuss your concerns and options.



Four-week family support groups are held regularly.



You may be invited to attend treatment planning sessions together with your family member.

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Family and couples counselling.

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All of our services are free and confidential. Please contact our intake coordinator at 416 599-1322 to arrange a meeting. Whatever time you can give will be very much appreciated.

Kind regards The Problem Gambling Service Team Centre for Addiction and Mental Health (CAMH) 33 Russell Street (3rd floor) Toronto, Ontario M5S 2S1




Implementing the group Objectives This family support group aims to help family members and friends:




gain a better understanding of problem gambling and its treatment



learn about obstacles to effective communication and ways to improve communication



learn about the importance of establishing boundaries or setting limits in relationships



identify forms of self-care, sources of support, and other services for families affected by problem gambling



share support with peers who may have similar experiences.



Structure PURPOSE OF GROUP: psychoeducation and support TARGET CLIENTELE: Individuals affected by the gambling problems of a family member or friend NUMBER AND LENGTH OF SESSIONS: four two-hour sessions NUMBER OF PARTICIPANTS: ideally between six and eight participants NUMBER OF FACILITATORS: can be led by one clinician THEMES COVERED IN FOUR SESSIONS: Session 1: Understanding problem gambling (definition, treatment/recovery, stages of change) Session 2: Effective communication Session 3: Setting boundaries and limits Session 4: Self-care, support, next steps Finances are not treated as a separate topic, but this subject is often discussed in session 3 when examining boundary setting. GENERAL BREAKDOWN OF EACH SESSION: 1. Check-in: each participant responds briefly to a question (about 40 minutes) 2. Discussion of the session’s topic (about 40 minutes) 3. Activity related to the session’s topic (about 30 minutes) 4. Check-out: each participant responds to a question with one word (about 10 minutes) 5. Homework: participants are given an exercise or something to reflect upon or read related to the session’s topic Handouts are given at each session, for the benefit of participants who integrate and understand material better when it is written. This also applies to some families for whom English is a second language.




Important clinical skills for family groups Family psychoeducational support groups integrate an educational component along with a supportive process. The educational component of this group focuses on understanding problem gambling and developing more effective coping skills. It also provides a forum for mutual aid and support. These combined groups require the use of a variety of clinical skills, including the ability to:




welcome, invite and include



express empathy

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validate



be non-judgmental and respectful



reframe



listen reflectively



inform and educate



support



contain



refer



be self-aware.


Session 1 Understanding problem gambling, recovery and treatment

Understanding problem gambling, recovery and treatment Session

1

Objectives DURING THIS SESSION, PARTICIPANTS WILL LEARN ABOUT: 

gambling and problem gambling



treatment services available at your agency for individuals with gambling problems and their families



different goals for problem gambling treatment (abstinence and harm reduction)



recovery and the process of change (the stages of change model)



forms of self-care and coping strategies.

Outline 1. INTRODUCTION TO THE FACILITATORS AND THE GROUP



Distribute Handout 1-1: Pre-group survey



Facilitator introductions



Purpose of group



Housekeeping (e.g., time and location of group, location of washrooms)

2. GROUP GUIDELINES



Distribute Handout 1-2: Group guidelines



Emphasize the importance of confidentiality and respecting differences

3. CHECK-IN



First name



Ask participants:

– Who in your family has a problem with gambling? – Is he or she currently in treatment? Family support and psychoeducational group manual for problem gambling

– What do you hope to get out of this group? 15 ©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatment

4. DISCUSSION TOPICS This is the most content-laden of the four sessions. There is usually not time to discuss all of the topics listed below, since they are not “taught” by the facilitators but discussed as a group. The first topic (gambling and problem gambling) is important to include and can be brief. Also prioritize stages of change, since it may be referred to in subsequent sessions. This topic tends to take more time. If there is time, facilitators usually select additional topics based on questions asked by the group. 

Gambling and problem gambling

– Discuss gambling and problem gambling – Distribute Handout 1-3: Gambling and problem gambling 

Stages of change

– Distribute Handout 1-4: Stages of change – Discuss the stages of change model – Ask family members what stage they are at and what stage the gambling individual is at 

Problem gambling treatment

– Provide brief information on problem gambling treatment: Information provided on services available in your agency and externally – Refer to Handout 1-3 – Discuss treatment goals (harm reduction and abstinence) – Distribute Handout 1-5: Harm reduction and abstinence – Clarify the concepts of recovery and cure, and introduce the biopsychosocial spiritual model 

Self-care and coping

– Give brief information on the importance of self-care, using the biopsychosocial spiritual model – Distribute Handout 1-6: Biopsychosocial-spiritual forms of self-care and Handout 1-7: Biopsychosocial-spiritual self-care plan – You may suggest that participants take a resilience quiz online to assess their self-care (see www.lightheartedconcepts.com)




5. HOMEWORK

Emergency planning Discuss this topic if a family member appears worried about his or her own safety or the safety of the gambling individual. – Create a safety or crisis plan – Suggest the gambling individual and/or family member keep a crisis card including medical information (diagnoses, medication, doctor, any allergies), triggers, coping strategies, intervention tips, therapist and treatment centre information, family contact person, and all other relevant information for a professional or person intervening.

 Read the CAMH publication Problem Gambling: A Guide for Families (CAMH, 2008)



Identify one coping strategy or form of self-care

6. CHECK-OUT  Ask participants: What is one form of self-care or coping strategy that you can use in the next week?  Ask participants: What is one word that describes how you feel as you leave today?

Resources 

Attendance sheet



Flip chart



Pens and clipboards



Name tags



Participant information sheet



Handout 1-1: Pre-group survey



Handout 1-2: Group guidelines

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Handout 1-3: Gambling and problem gambling

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Handout 1-5: Harm reduction and abstinence

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Handout 1-6: Biopsychosocial-spiritual forms of self-care

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Handout 1-7: Biopsychosocial-spiritual self-care plan



Problem Gambling: A Guide for Families (order from CAMH or ask participants to download it from www.problemgambling.ca/EN/GettingHelp/Pages/InformationForFamilies.aspx)




HANDOUT 1-1

Pre-group survey We would like to get an idea about your needs, and your hopes for participating in the Problem Gambling Family Support Group. What would you like to get out of participating in this group? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

What skills or knowledge would you like to gain during this group? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________




HANDOUT 1-2

Group guidelines


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Please respect confidentiality.

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Use “I,” “me,” and “my” statements.

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Respect differences, such as gender, ethnicity, culture, religion, sexual orientation, and personal history.

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Respect the group by arriving on time and trying to attend all the sessions.

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Each group participant has the right to say “no” or to pass.

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Be open-minded to others’ point of view.

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Try to be non-judgmental.

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Ask permission from another person before giving constructive feedback.

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Turn off hand-held devices.

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Remember that humour is good medicine.



HANDOUT 1-3 a

Gambling and problem gambling WHAT IS GAMBLING? Gambling is defined as risking money or something of value on the outcome of an event, where that outcome is to some degree beyond the control of the person who is taking the risk.

WHAT IS PROBLEM GAMBLING? GAMBLING IS A PROBLEM WHEN IT: 

gets in the way of work, school or other activities

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harms mental or physical health

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has financial consequences

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causes difficulty in relationships with family or friends.

HARMFUL CONSEQUENCES CAN AFFECT: 

finances

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physical health

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mental health

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relationships

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work

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trust.

WHY DO SOME PEOPLE HAVE GAMBLING PROBLEMS? It is usually not possible to identify one cause in a person’s life that leads them to have gambling problems. There are some risk factors that can increase the chance of someone developing gambling problems and, also, protective factors that can reduce the risks. Important protective factors are positive relationships and support from families.




HANDOUT 1-3 b

Many clinicians and researchers use a biopsychosocial model to explain why people develop and maintain a gambling problem. This model takes into account biological, psychological and social factors that contribute to the onset or maintenance of the gambling problem.

GETTING HELP Free treatment and other services are available for people with gambling problems. It includes: 

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professional counselling through treatment centres funded by the Ministry of Health and Long-Term Care the Ontario Problem Gambling Helpline (1 888 230-3505 or www.problemgamblinghelpline.ca)

online tools and support from the Problem Gambling Institute of Ontario (www.problemgambling.ca)



12-step self-help through Gamblers Anonymous (http://www.gamblersanonymous.org)

PROFESSIONAL TREATMENT MAY HAVE DIFFERENT FORMATS, INCLUDING: 

individual, group, couple or family counselling (the types of services at each centre may differ)



residential treatment.

Treatment centres may have an abstinence or harm reduction philosophy (see Handout 1-5). Help is also available for family and friends. It may take the form of a family support group such as this one, or individual, couples or family counseling. Sometimes a person with a gambling problem may also experience difficulties with mental health and/or substance use. Additional help is available for these problems. For more information visit the Problem Gambling Institute of Ontario’s website: www.problemgambling.ca.




HANDOUT 1-4

Stages of change PRECONTEMPLATION

does not recognize the need for change or is not actively concidering change RELAPSE LEAVES TREATMENT CONTEMPLATION

recognizes problem and is considering change MAINTENANCE

is adjusting to change and is practising new skills and behaviours to sustain change

PREPARATION/ACTION

has initiated change Source: Prochaska, J., Norcross, J. & DiClemente, C. (1995). Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Avon Books.

What stage of change do you think you are at?

What stage of change do you think your family member is at?




HANDOUT 1-5

Harm reduction and abstinence WHAT ARE HARM REDUCTION AND ABSTINENCE? Harm reduction refers to strategies that help people help themselves by moving in the direction of reducing the harm in their lives. Harm reduction can include abstinence. Abstinence refers to approaches that insist on a person stopping gambling altogether.

WHY IS HARM REDUCTION USED? This approach is aimed at reducing the risk of harm when a person is not ready to quit altogether.

WHAT ARE THE BENEFITS OF A HARM REDUCTION APPROACH? A HARM REDUCTION APPROACH: 

promotes change and making choices in one’s treatment

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facilitates collaboration between the client and the therapist

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increases the chances that the person will stay in treatment

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builds confidence and hope.

WHERE CAN I EXPECT TO FIND EACH APPROACH USED? 

Some treatment centres, such as CAMH, use a harm reduction approach.



12-step programs such as Gamblers Anonymous, and some residential programs, use an abstinence approach.

For more information visit the Problem Gambling Institute of Ontario’s website: www.problemgambling.ca.




HANDOUT 1-6

Biopsychosocial-spiritual forms of self-care

Physical self-care

Emotional self-care

 Eat well and regularly  Exercise (e.g., dance,  Get regular medical care

 Praise yourself  Read a book  Take some time for yourself  Be in the present moment

 Get enough sleep

 Find things that make you laugh

swim, walk, run) for prevention

Social self-care

and do one thing at a time

Spiritual self-care

 Have a lovely dinner on Friday  Make time for prayer or meditation night or during the weekend  Read inspirational books  Build a social support system  Listen to relaxation music  Attend a group  Be mindful  Spend time with family or friends  Spend time in nature  Find an hobby or an activity  Practise deep breathing you enjoy  Express gratitude  Write a journal

For more information visit the Problem Gambling Institute of Ontario’s website: www.problemgambling.ca




HANDOUT 1-7

Biopsychosocial-spiritual self-care plan

_______________________ _________________________ __________________________ ____________________________ _____________________________ _____________________________ ______________________________ ______________________________ Social self-care _____________________________ _____________________________ ____________________________ __________________________ _________________________ _______________________ _____________________ __________________ ______________

Emotional self-care _______________________ _________________________ __________________________ ____________________________ _____________________________ _____________________________ ______________________________ ______________________________ Spiritual self-care ______________ _________________ ____________________ _______________________ _________________________ __________________________ ____________________________ _____________________________ _____________________________

Physical self-care

Are there some areas that require greater attention?

For more information visit the Problem Gambling Institute of Ontario’s website: www.problemgambling.ca.



Session 2 Communication

Communication Objectives DURING THIS SESSION, PARTICIPANTS WILL LEARN ABOUT:

Session

2



learn about communication and forms of communication



identify obstacles that can interfere with effective communication



develop strategies to improve communication.

Outline 1. CHECK-IN



Ask participants: What was one form of self-care you used over the past week?

2. SUMMARIZE THE RESPONSES TO Handout 1-1: Pre-group survey 3. QUESTIONS OR COMMENTS ABOUT THE LAST SESSION 4. DISCUSSION: COMMUNICATION



Discuss as a whole group and write responses on the flipchart:

– What is communication? – Why is it important? – What are various forms of communication? – What are some obstacles to communication?  Distribute Handout 2-1: Communication obstacles, and ask participants to note some obstacles they experience in the left column (leave the right column blank for now)  Distribute Handout 2-2: Improving Communication and review the communication strategies listed  Referring back to Handout 2-1, ask participants to write down strategies in the right column for the obstacles they listed earlier



Communication

5. HOMEWORK  Try

using one communication strategy that was discussed, and observe the results. If the strategy doesn’t work the first time, consider what may have been an obstacle, adjust the strategy and try again.

Other ways to practice communication: Role play effective or ineffective communication in pairs or in large group.

6. CHECK-OUT

 Ask

participants: What is one word that describes how you feel as you leave today?

 Ask

participants: Which communication strategy do you think you’ll try this week?

Resources




Attendance sheet



Flip chart



Pens and clipboards



Name tags



Handout 2-1: Communication obstacles



Handout 2-2: Improving communication


Communication

HANDOUT 2-1

Improving communication What are some of the obstacles to communicating effectively with your family member?

What are some ways to overcome those obstacles?



Communication

HANDOUT 2-2

Improving communication When does communication break down? Often, it is when people feel judged or misunderstood.

COMMUNICATION TIPS LISTENING 

Try not to react too quickly; avoid interrupting.



Validate – e.g., “I know this has been hard for you, too.” Validating the other person’s feelings does not mean you approve of their behaviour.

RECEIVING

Family members will be more likely to express themselves if they think what they say will be heard and accepted.



Accept what is being said.



Let the other person know that you have heard and understood what they’ve said.



EXPRESSING 

Choose a good time.



Use “I” messages – e.g., “I feel _____________,” “I was disappointed,”

“I’m worried,”

“I need _____________” or

“I would like ____________.”



Avoid criticizing, blaming or judging.



Avoid absolutes, such as “You never____________” or “You always____________.”



Make it brief and discuss one issue at a time.

Some positive messages can go a long way.



Session 3 Establishing bounderies

Establishing boundaries Objectives DURING THIS SESSION, PARTICIPANTS WILL:

Session

3



learn the importance of establishing boundaries (or limits) as a form of self-care



identify limits that family members would like to set in their relationships.

Outline 1. CHECK-IN



Ask participants:

– Did you try a communication strategy? – Did it work? – If it didn’t, what were the obstacles? 2. DISCUSSION: BOUNDARIES  Facilitate a group discussion about what boundaries are and why we need them, and write responses on the flipchart



Ask if participants use a different term, such as “limits”



Distribute Handout 3-1: Establishing Boundaries

 Ask participants to identify areas in which they find it difficult to establish or maintain boundaries (e.g., finances, communication, parenting, intimacy)  Ask what makes it difficult to maintain boundaries that have been set (obstacles to setting boundaries can be emotional, cognitive or behavioural)




Discuss responses that participants would like to share



Distribute Handout 3-2: Boundaries Table



Ask participants to identify on the handout one boundary they would like to set



Give participants some time to fill in the handout





Establishing bounderies

3. HOMEWORK  Reflect on boundaries and try to identify one area in which you would like to set clearer limits or boundaries. This can be written in the table in Handout 3-2.

4. CHECK-OUT



Ask participants: What is one word that describes how you feel as you leave today

Ask participants: What is one thing that stands out for you from our discussion today about boundaries.



Resources




Attendance sheet



Flip chart



Pens and clipboards



Name tags



Handout 3-1: Establishing boundaries



Handout 3-2: Boundaries table



HANDOUT 3-1

Establishing boundaries Boundaries, or limits, are what you think is acceptable or what you can tolerate in a relationship. WHY ARE BOUNDARIES IMPORTANT?

Boundaries allow us to practise self-care, to establish safety and to ensure that our personal needs are met. When there is a gambling problem, it may be difficult to maintain good boundaries in: 

managing finances



resolving conflicts or solving problems



parenting



intimacy



dealing with relapse.

Name one area in which it is important for you to establish or maintain boundaries. ____________________________________________________________________________________

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________



33

©2013 Centre for Addiction and Mental Health


Relapse

EXAMPLE

Area where there may not currently be an effective boundary A slip, if he talks to me about it

What I can accept

A slip that he does not talk to me about and I find out another way

What I can’t accept

Boundaries table, page one

HANDOUT 3-2 a


Discuss how to deal with the situation differently next time.

A slip that he does not tell me about: I will follow through with what I said I’d do in order to take care of myself in this situation.

A slip that he tells me about: I am supportive and appreciate that he told me. Discuss triggers and relapse prevention strategies.

Steps: I will discuss this boundary with my family member, and will let him know the consequences if it is not respected.

How I will carry this through

Use other self-care strategies

Talk to therapist

Read materials at problemgambling.ca

Gambling Helpline (1 888 230-3505)

Call Problem

Talk to friend

Coping strategies

34

©2013 Centre for Addiction and Mental Health


Area where there may not currently be an effective boundary

What I can accept

What I can’t accept

Boundaries table, page two

HANDOUT 3-2 b


How I will carry this through

Coping strategies

Session 4 Self-care, support and next steps

Self-care, support and next step Objectives DURING THIS SESSION, PARTICIPANTS WILL:

Session

4

identify forms of self-care  identify sources of support  discuss next steps. 

Outline 1. CHECK-IN

Ask participants: Have you reflected since the last session on any boundaries that you would like to clarify or establish?



2. DISCUSSION: SELF-CARE AND COPING STRATEGIES



Distribute again Handout 1-6: Biopsychosocial-spiritual forms of self-care

 Introduce topic of self-care and facilitate a group discussion on how we take care of ourselves



Distribute again Handout 1-7: Biopsychosocial-spiritual self-care plan



Ask group participants to complete table on Handout 1-7



Ask group members if there are areas that require greater self-care

 Introduce the topic of social support and the importance of support to help over come adversity




Distribute Handout 4-1: My support system



Ask participants to fill in the handout, explaining that supports can be formal (e.g., counsellors and physicians) or informal (e.g., friends and relatives), and that support may take different forms (e.g., it may be emotional, informational, problem solving, social, financial or instrumental)






You may also ask if there are types of support that they would like to develop


Self-care, support and next steps

3. RESOURCES AND NEXT STEPS

Provide information about other support services



 Give

information about the Problem Gambling Helpline 1 888 230-3505 and the PGIO website (problemgambling.ca). Provide a flyer outlining the tool “Self-Help for Family and Friends” on the PGIO website, or provide the link: http://www.problemgambling.ca/gambling-help/HomePage.aspx. Explain that gambling individuals or family members using the tools section of the website are required to sign in order to be able to monitor their own progress. This can still be anonymous as clients can create a new email address which does not identify him/her.

 Distribute the flyer for the next family support group, and let participants know they are welcome to return



Ask participants to share their next steps

4. REVIEW  Briefly summarize the topics of the group: awareness of problem gambling, communication skills, boundary setting, self-care and follow-up resources



Ask participants: What stood out for you?



Ask for any questions or comments

5. CHECK-OUT

Ask participants: What is one word that describes how you feel about ending the group?





Ask participants: What will you try applying from the group?

6. GROUP EVALUATION  Distribute and have participants complete Handout 4-2: Group Evaluation




Resources




Attendance sheet



Flip chart



Pens and clipboards



Name tags



Handout 4-1: My support system



Handout 4-2: Post-group survey



Handout 1-6: Biopsychosocial-spiritual forms of self-care



Handout 1-7: Biopsychosocial-spiritual self-care plan



Flyer for next group



Flyer for the tool ”Self-Help for Family and Friends” on the PGIO website



HANDOUT 4-1

My support system

me

Who are your sources of support? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ What type of support do they provide? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________




HANDOUT 4-2

Group evaluation What was most helpful for you about the family support group? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Were there any topics you found less relevant or topics you would have liked to discuss? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Other comments ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Family support and psychoeducational group manual for problem gambling


Alternatives formats for family support

Alternatives formats for family support Information sessions Information sessions can be offered at or prior to admission for both gambling clients and family members. The goal of these sessions is to provide information on problem gambling and treatment options for families and individuals. It allows family members to become involved and informed early in treatment. Sessions may include information on what comprises problem gambling, prevalence rates, services that are available, likely treatment trajectory, and ways for family members to be involved in treatment. An information session may be an opportunity to admit clients into your program or refer them to other services

Single sessions Single sessions can fill a gap when four-week groups cannot be given or when the time between four-week groups is too long. It is impossible to cover all of the information given in the four-week groups in a single session, but it can be helpful to extract some of the most relevant information from the four topics covered in the groups. Single sessions of two hours work best with a psychoeducational approach. Time should be allotted to answer questions.

Lengthening the four-week group Some family members request that the four-week group be lengthened to six or eight weeks. They may find that they start becoming a cohesive group just when the four week group is close to ending. If you decide to offer a six-week group, you do not need to develop new topics –instead, you can spend more time exploring the four topics covered in this manual. For some agencies, a lack of resources precludes a longer group. In addition, some family members may be unable to commit to a longer group because of child care, employment commitments or other reasons. And some participants find that the four-week group meets their needs.



Alternatives formats for family support

Individual family sessions When it is not possible to offer a group, you can invite family members in for an individual psychoeducational family session. In this case, families still benefit from receiving information about problem gambling, more effective coping and problemsolving skills.

Couple and family counselling Another option for family support is couple and family counselling. This would involve bringing the client with the gambling problem together with their partner or with their family for a series of counselling sessions. It may not be possible to provide couple and family counselling in all agencies owing to a lack of capacity or resources. In this case, a referral to a family service organization or a qualified couple and family therapist can be an alternative.

PGIO website, problemgambling.ca The Problem Gambling Institute of Ontario (PGIO) offers a suite of online self-help tools and educational materials through its website (problemgambling.ca). While it is best for family members to meet with a counsellor in person, the PGIO site provides another option in the continuum of care. It can be an adjunct to other services or can be helpful for families and gambling individuals who are not ready to seek help from a treatment centre. The site is free, anonymous and accessible any time. It is also selfdirected, so people can use the materials however they choose. The tool “Self-Help for Family and Friends” comprises a set of interactive, web-based worksheets. This helps family members to learn about problem gambling and develop new skills to deal with the difficulties that it causes. It is designed to help even if the person with the gambling problem is unwilling to change their gambling behaviour.



Testimonials

Testimonials In this section, we share some of the feedback we have received when we have offered the program outlined in this manual at CAMH. We hope these comments will inspire you to offer the program at your agency! I just want to thank you for the workshops that you are presenting. This is giving me so much more knowledge and acceptance and understanding, which is the start of the healing process for me. I feel like a sponge in the classes and I can’t get enough . . . I would like you to know how much I thank you for doing this! This program is giving me back the son I loved and still love!” I’m comforted to know that some of the problems are universal.” This group helped me understand how this problem was affecting me emotionally and gave me strategies to help communication and establish boundaries with my son’s behaviour.” Learned a lot of useful tools to help with my partner. Enjoyed my time!” This group was beneficial in that it helped me feel less alone. It was comforting to realize that others face the same issues.” Participating in the family group made me realize that I was having normal reactions to an abnormal situation. It mostly gave me hope for the future.” The topics for the group were very well chosen. Practical information was provided, plus having a place to discuss my challenges with others struggling with the same issues made me feel less alone.” The most beneficial part of the family group was learning communication skills and how to set boundaries. I started using some of the listening strategies and it helps a lot.” Understanding the person with the gambling problem a little better was beneficial.” What was most beneficial for me was understanding the importance of self-care.”



References

References American Psychiatric Association. (In press). Diagnostic and statistical manual of mental disorders, 5th ed. Washington, DC: American Psychiatric Association. Black, D.W., Shaw, M.C., McCormick, B.A. & Allen, J. (2012). Marital status, childhood maltreatment, and family dysfunction: A controlled study of pathological gambling. Journal of Clinical Psychiatry, 73, 1293–1297. Centre for Addiction and Mental Health (CAMH). (2004). Putting family-centred care philosophy into practice. Report prepared by Community Research, Planning and Evaluation Team and Community Support and Research Unit, CAMH. Toronto: Author. Centre for Addiction and Mental Health (CAMH). (2008). Problem Gambling: A Guide for Families. Toronto: Author. Csiernik, R. (2002). Counselling for the family: The neglected aspect of addiction treatment in Canada. Journal of Social Work Practice in the Addictions, 2 (1), 79–92. Darbyshire, P., Oster, C. & Carrig, H. (2001). The experience of pervasive loss: Children and young people living in a family where parental gambling is a problem. Journal of Gambling Studies, 17 (1), 23–45. Dickson-Swift, V.A., James, E.L. & Kippen, S. (2005). The experience of living with a problem gambler: Spouses and partners speak out. Journal of Gambling Issues, 13, 1–22. Ferris, J. & Wynne, H. (2001). The Canadian Problem Gambling Index. Final report submitted to the Canadian Centre on Substance Abuse (CCSA). Grant Kalischuk, R.G., Nowatzki, N., Cardwell, K., Klein, K. & Solowoniuk, J. (2006). Problem gambling and its impact on families: A literature review. International Gambling Studies, 6 (1), 31–60. Hodgins, D.C., Shead, N.W. & Makarchuk, K. (2007). Relationship satisfaction and psychological distress among concerned significant others of pathological gamblers. Journal of Nervous and Mental Disease, 195 (1), 65–71. Ingle, P.J., Marotta, J. McMillan, G. & Wisdom, J.P. (2008). Significant others and problem gambling treatment outcomes. Journal of Gambling Studies, 24, 381–392.



References

Kelley, M.L. & Fals-Stewart, W. (2002). Couples- versus individual-based therapy for alcoholism and drug abuse: Effects on children’s psychosocial functioning. Journal of Consulting and Clinical Psychology, 70, 417–427. Korman, L., Collins, J., Dutton, D., Dhayananthan, B., Littman-Sharp, N. & Skinner, W. (2008). Problem gambling and intimate partner violence. Journal of Gambling Studies, 24, 13–23. Ledgerwood, D.M., Weinstock, J., Morasco, B.J. & Petry, N.M. (2007). Clinical features and treatment prognosis of pathological gamblers with and without recent gambling-related illegal behaviour. Journal of the American Academy of Psychiatry and the Law, 35, 294–301. Lee, B. (2008). Congruence couple therapy for pathological gambling. International Journal of Mental Health and Addiction, 7 (1), 1–26. Makarchuk, K., Hodgins, D.C. & Peden, N. (2002). Development of a brief intervention for concerned significant others of problem gamblers. Addictive Disorders and Their Treatment, 1, 126–134. McComb, J.L., Lee, B.K. & Sprenkle, D.H. (2009). Conceptualizing and treating problem gambling as a family issue. Journal of Marital and Family Therapy, 35 (4), 415–431. Trudel, G., Poirier-Arbour, A., Harvey, P., Boyer, R., Villeneuve, V., Anderson, A. OuelletteNgocsoeng, M. (2008). Couple et jeu de hasard. Report submitted to the Fonds Québécois de Recherche sur la Société et la Culture. Montreal, Quebec: Université du Québec à Montréal. Williams, R.J., Volberg, R.A. & Stevens, R.M.G. (2012). The population prevalence of problem gambling: Methodological influences, standardized rates, jurisdictional differences, and worldwide trends. Report prepared for the Ontario Problem Gambling Research Centre and the Ontario Ministry of Health and Long Term Care.



Suggested readings

Suggested readings CONCURRENT DISORDERS O’Grady, C.P. & Skinner, W.J. (2007). A family guide to concurrent disorders. Toronto: CAMH. Skinner, W. (Ed.) (2005). Treating concurrent disorders: A guide for counsellors. Toronto: CAMH. COUPLE AND FAMILY THERAPY Friedlander, M.L., Escudero, V. & Heatherington, L. (2006). Therapeutic alliances in couple and family therapy. Washington, DC: American Psychological Association. Gehart, D. (2010). Mastering competencies in family therapy. Belmont: Brooks/Cole. Nichols, M.P. (Ed.). (2005). Family therapy: Concepts and methods (7th ed.). Boston: Pearson. Patterson, J., Williams, L., Edwards, T.M., Chamow, L. & Grauf-Grounds, C. (2009). Essential skills in family therapy: From the first interview to termination. New York: Guilford Press. Wilcoxon, S.A., Remley, T.P., Jr., & Gladding, S.T. (2012). Ethical, legal, and professional issues in the practice of marriage and family therapy. Boston: Pearson Education. FAMILY-CENTRED WORK Centre for Addiction and Mental Health. (2004). Putting family-centred care philosophy into practice. Report prepared by Community Research, Planning and Evaluation Team and Community Support and Research Unit, CAMH. Toronto: Author. Csiernik, R. (2002). Counselling for the family: The neglected aspect of addiction treatment in Canada. Journal of Social Work Practice in the Addictions, 2 (1), 79–92. GROUP WORK Brown, N. (2011). Psychoeducational groups: Process and practice. New York: Routledge. MODELS/APPROACHES Andrae, D. (2011). General systems theory: Contributions to social work theory and practice. In F.J. Turner (Ed.), Social work treatment: Interlocking theoretical approaches (pp. 242–270). New York: Oxford University Press.



Suggested readings

Gehart, D. (2010). Mastering competencies in family therapy: A practical approach to theories and clinical case documentation. Belmont, CA: Brooks/Cole. Gurman, A.S. (Ed.). (2008). Clinical handbook of couple therapy (4th ed). New York: Guilford Press. Nichols, M.P. (Ed.). Family therapy: Concepts and methods (7th ed.). Boston: Pearson Education. Sprenkle, D.H., Davis, S.D. & Lebow, J. (2009). Common factors in couple and family therapy: The overlooked foundation for effective practice. New York: Guilford Press. PROBLEM GAMBLING Dickson-Swift, V.A., James, E.L. & Kippen, S. (2005). The experience of living with a problem gambler: Spouses and partners speak out. Journal of Gambling Issues, 13, 1–22. Petry, N.M. (2007). Gambling and substance use disorders: Current status and future directions. American Journal on Addictions, 16, 1–9. Van Wormer, K. & Rae Davis, D. (2013). Addiction treatment. A strengths perspective. (3rd ed.). Belmont, CA: Brooks/Cole. Kourgiantakis, T., Saint-Jacques, M.C. & Tremblay, J. (2013). Problem gambling and families: A systematic review. Manuscript submitted for publication. SUBSTANCE USE Sloss, C., Bubbra, S., Kelly, C., Shenfield, J. & Tait, L. (2008). Families care: Helping families cope and relate effectively. Facilitator’s Manual. Toronto: CAMH.

