Relapse Prevention and Gambling disorderfourdirections.evergreencpg.org/wp-content/uploads/... · Therapists Must Remember – from Mikal Aasved 1. Winning is an initial motivator

Relapse Prevention and Gambling disorderWiley D. Harwell, D. Min., LPC, ICGC-II, BACCEx. Dir. Of [email protected]

Reasons for AbstinenceRoad of Recovery

Reasons for Abstinence Road of Recovery

Maintaining Abstinence (Petry p. 158)

1. Most common – recalling past gambling problems and engaging in new activities.

2. Other common responses – self-control or willpower, a sense of pride or accomplishment.

3. Less so, but also cited were – treatment, cognitive strategies, and social support.

4. By less than ¼ of respondents – spiritual reasons, limiting access to money and rewarding oneself.

a. 5 of these are cognitive exercises.

b. 4 of these are behavioral exercises.

c. 1 could and should be both – treatment.

Therapists Must Remember – from Mikal Aasved

1. Winning is an initial motivator but is not the only consideration.2. “No rational person would gamble if winning money was the only

consideration.” M.B. Walker (1992) Journal of Gambling Studies 8(3) p.245-261

3. The gambler has a set of pre-existing beliefs about their chances of winning.

4. Slots have built-in “machine reinforcement schedule” that drives the play of the gambler and their irrational thinking. M.G. Dickerson (1993)

5. With computerized and electronic machines, length of time between payoffs is not a factor in when the payoff will occur.

6. Gambler’s fallacy is based on the idea that “patterns” or ‘streaks” can determine a trend for wagering.

7. Every spin, roll of dice, or toss of a coin has its own independent odds of outcome and previous chances are no predictor of future outcomes.

8. Longer periods of play by a few players is more profitable than short periods of play by large numbers. (A statement by a casino manager.)

Relapse

Why do people relapse?

1. Most simple answer – the reaction to withdrawal symptoms when trying to cut back or quit.

2. Triggers that are beyond withdrawal symptoms (billboards, advertising, thinking about excitement of gambling, stress, invitation to gamble, extra money, access to money).

3. Relapse is more likely when gambler is depressed, anxious, stressed.

4. When motivation and maintenance are not maintained.

5. Continuous lack of social support

6. Continuous feeling of isolation

Consequences of Relapse

1. Violation of self-imposed limits resulting in shame, guilt, disappointment, frustration, anger and eventual hopelessness.

2. Relapse which is controlled gambling may give the illusion of self-control.

Stages of Change

Using self-observing and self-monitoring

To activate the “observer self” instead

of just the “active self”, “reactive

self”, the “doer”, the “seeker self”.

Precontemplation – the gambler is not really considering change. Characterized by denial of having a problem. Characterized by blaming financial pressures as need to gamble (spouse).

Contemplation – a stage of ambivalence where gambler sees the need to change but is more concerned with the price & effort of change & anticipates the feeling of loss if they quit.

Preparation – gambler is close to taking action & is taking steps necessary but still preparing for change.

Action – gambler has taken some steps toward changing behavior, i.e., (attending GA, inviting spouse to treatment, limiting gambling, cutting up credit cards, telling family of problem).

Stages of Change Model

Maintenance – change process has continued and progressed for 6 months or more.

Termination – change process is self sustaining but emphasis continues on accountability and motivation.

Recycling – knowledge by counselor that slips or relapses are common. This does not mean the process starts over but can resume in the recovery state quickly.

Stages of Change Model (continued)

Motivational Interviewing

Appropriate Motivational Strategies for Each Stage of ChangeClient's Stage of Change Appropriate Motivational Strategies for

the Clinician

Precontemplation

The client is not yet considering change or is unwilling or unable to change.

Establish rapport, ask permission, and build trust. Raise doubts or concerns in the client

about. substance-using patterns Express concern and keep the door

open.

Client's Stage of Change Appropriate Motivational Strategies for the Clinician

Contemplation

The client acknowledges concerns and is considering the possibility of change but is ambivalent and uncertain.

Normalize ambivalence. Help the client "tip the decisional

balance scales" toward change.Elicit and summarize self-

motivational statements of intent and commitment from the client. Elicit ideas regarding the client's

perceived self-efficacy and expectations regarding treatment.



Preparation

The client is committed to and planning to make a change in the near future but is still considering what to do.

Explore treatment expectancies and the client's role. Clarify the client's own goals. Negotiate a change--or

treatment--plan and behavior contract. Consider and lower barriers

to change. Help the client enlist social support.



Action

The client is actively taking steps to change but has not yet reached a stable state.

Engage the client in treatment and reinforce the importance of remaining in recovery. Acknowledge difficulties for the

client in early stages of change. Help the client identify high-risk

situations through a functional analysis and develop appropriate coping strategies to overcome these.


Types of Change Strategies for Limiting or Reducing Gambling Behaviors and their Perceived Helpfulness: A Factor Analysis American Psychological Society (2018)

By: Rodda, S.N., Bagot, K.L., Cheetham, A., Hodgins, D.C., Hing, N., Lubman, D.I. Vol. 32, No. 6, 679-688.

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 1. Cognitive

Remind yourself of negative consequences – 92%

Think about how your money could be better spent – 92%

Remind yourself sometimes people win at gambling, but the system is designed for you to lose – 91%

Remind yourself of positive consequences of not gambling – 90%

Compare costs and benefits of continuing to gamble – 90%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 2. Feedback

Calculate money and time spend gambling – 85%

Accept that gambling needs to change – 81%

Complete a questionnaire that gave me feedback on gambling problem – 73%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 3. Planning

Plan ahead and limit amount of money you carry – 84%

Plan ahead and leave credit cards and nonessential cash at home – 80%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 4. Urge Management

Distract yourself or do something else until urge to gamble passes – 80%

Keep busy to avoid thinking about or engaging in gambling – 81%

Use alternative strategies to deal with gambling triggers – 74%

Postpone gambling until a later date – 69%

Count days since you’ve made a change in your gambling – 69%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 5. Well-Being

Eat a healthy balanced diet – 83%

Engage in regular exercise – 76%

Take it easy on yourself or take it slow – 75%

Ensure your physical health needs are met – 72%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 6. Behavior Substitution

Engage in a new form of entertainment – 80%

Engage in an activity that gives you a feeling of achievement – 78%

Complete daily activities around the house – 76%

Take a long walk – 70%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 7. Social Support

Spend less time alone – 69%

Disclose to someone else the extent of your gambling – 67%

Be more open and honest with family and friends about gambling – 67%

Ask family or friends to help or support you – 59%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 8. Information Seeking

Read information on signs or consequences of problem gambling – 80%

Read information on responsible gambling – 78%

Read information on how gambling works – 79%

Read firsthand accounts of other people’s experiences – 73%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 9. Limit Finances

Keep track of money by setting up a budget and tracking spending – 70%

Don’t borrow money from friends or family, banks, or loan sharks – 60%

Keep limited funds in online or loyalty gambling accounts – 49%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 10. Avoidance

Avoid gambling when feeling down, depressed, or otherwise vulnerable to gambling – 68%

Avoid gambling alone – 64%

Avoid being near/passing gambling venues – 63%

Avoid gambling with heavy gamblers – 57%

Avoid family/friends who gamble – 54%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 11. Consumption Control

Avoid chasing losses – 83%

Set spending limit for each week or month – 77%

Schedule gambling sessions so that they do not interfere with important activities – 62%

Don’t drink alcohol or use drugs while gambling – 60%

Schedule other activities after gambling to limit session time – 60%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 12. Financial Management

Regularly contribute to a savings plan – 61%

Consolidate debts and implement payment plan – 59%

Pre-purchase goods or bills to reduce spare cash – 57%

Give cards or cash to a family member or friend to limit access – 53%

Keep money in joint account with partner or family member – 50%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 13. Exclusion

Self-exclude or ban yourself from a land-based or online venue – 54%

Limit or restrict internet access – 44%

Close online accounts related to gambling – 44%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 14. Self-Monitoring

Make a list of strategies that worked for you in the past – 53%

Talk to a health professional about your gambling – 52%

Practice relaxation strategies like yoga, meditation – 52%

Write about progress, thoughts, achieve3ment, or struggles related to gambling –45%

Create a physical reminder to limit your gambling – 45%

Percentage of Responses that were most helpful to the Questionnaire of Change Strategy 15. Spiritual

Remain hopeful about your future – 72%

Volunteer your time or help someone in need – 49%

Engage in prayer or meditation – 41%

Hand over to a higher power – 38%

Attend church or spiritual meeting – 36%

Motivational interviewing & customer service

STRATEGIES USED TO CHANGE: Consciousness raising – bring to awareness the depth & level of the

gambling problem. Social liberation – a process that changes social environments.

Emotional arousal – use of intense feelings to counteract gambler’s indifference to the erroneous consequences of behavior. For example: The Gambler focuses on the high of the gambling experience and forgets about the ride home.

From: Joseph W. Ciarrachi, “Counseling Problem Gamblers”


STRATEGIES USED TO CHANGE: cont. Self-revelation – gambler examines their personal values vs. behavioral

conflicts. Commitment – begins to tell others about their desire to change. Countering – substitutes adaptive for maladaptive behavior.



STRATEGIES USED TO CHANGE: cont. Environmental control – makes the relapse less likely by changing the

environment. Rewards – give incentives after achieving goals related to new behavior. Helping relationships – provide support to keep people on track.



CBT Treatment is Relapse Prevention

Hodgins, D.C., Peden, N., Cognitive-behavioral treatment for impulse

control disorders. (2008)

CBT techniques used in treatment of pathological gambling

1. Stimulus control and exposure with response prevention Stimulus control

Avoid high-risk situations or routes of risk; maintain control of money.

In vivo exposure with response prevention

In vivo exposure forces client to experience the urge to gamble and response preventions helps them learn to resist the urge in a self-controlled way.


Imaginal desensitization

Imagine responding to high-risk situations while in a relaxed state


Cognitive restructuringRecognition and modification of cognitive distortions including selective memory for wins not loses, the gambler’s fallacy, concept of randomness, overestimating the odds, and superstitious behaviors.

Behavioral techniquesBehavioral chain (identify high-risk situations, develop strategies to avoid or deal with high-risk situations; problem solving).

Relapse preventionPrevent a slip; manage a slip

Multimodal techniques used in treatment of pathological gambling

•Identify triggers for gambling, patterns of gambling, and consequences of gambling.

Functional analysis

•Stimulus controls (avoid high-risk situations; limit access to money; stay away from gambling; inform others of the plan).

Manage triggers

•Gradual relaxation techniques, engage in a distracting activity, complete a cost-benefit analysis of the gambling.

•Extend time frame of decision to gamble. •Problem solving.

Handle urges


Financial analysisHow to manage finances, repay debts, and prepare for financial problems as a trigger for gambling Referrals to GA, consumer credit organizations, and bankruptcy lawyers.

Handle interpersonal conflict

Positive communication training, role playing, social skills training.

Reinforce non-gambling behavior

Activities are usually inexpensive or free, and ideally compete with the gambling behavior in terms of high-risk times. Goal is to increase enjoyment from life.


Relapse Prevention Prepare for future events and possible stressors that may affect decision

to gamble.

Other techniques used in treatment of pathological gambling

Cost-benefit analysis of gambling

Identify, challenge and replace irrational thoughts

Functional analysis

Identify triggers for gambling, patterns of gambling, and consequences of gambling.

Deal with urgesHandle urges by thinking (self-talk) or by acting (behavioral activities to deter from gambling).

Other techniques used in treatment of pathological gambling

Stimulus control Stay away from gambling; limit access to money

Cognitive restructuring

Identify and replace irrational thoughtsUnderstand the concept of randomness

Relapse prevention

Plan aheadPrepare for slipping and relapseDeal with other life problems

Relapse Prevention

1. Education of the disorder and all its dynamics

2. Education for the family members

3. G.A. groups are often not all versed in the in-depth dynamics of Pathological Gambling. Lead public awareness meetings and invite G.A. members.

4. Look for ways to talk about relapse prevention at each stage of the change process.

5. Find ways and techniques to enhance motivation because motivated people are less likely to relapse.

6. Help client track and reinforce all levels of success – improved and more clear cognition, feels better, etc.

Relapse Prevention (continued)

7. Help client with mental rehearsal of successful coping responses.

8. Teach clients the value of “Pause” – recognize the stimulus or trigger and wait – it will pass.

9. Work with client for all levels of harm reduction.

10. Involve entire family which serves many goals and increases accountability.

11. Good financial planning and asset protection for the spouse.

12. Helping client grieve the levels of excitement.

13. Help client rediscover forms of entertainment and normal living before gambling.

Warning Signs of Relapse

1. Continued denial

2. Illusion of control

3. Lack of insight into thoughts/behavior

4. Abstinence but not in Recovery.

5. Lack of surrender to Higher Power

6. Defensive stance maintains and supports behavior

7. No relief of depression

8. Not working or co-occurring chemical dependency

9. Just not working a recovery program

Triggers and Relapse Risk Factors

Lifestyle Factors

Wheeling and dealingRisk takingAntisocial lifestyle

Dishonesty/Self Deception

Poor coping skills Stress; Going on tilt

Unresolved life issues/trauma

Relapse Risk Factors

Poor Treatment Compliance Missing appointments

No budget or money management

Non-compliance with medication

Not attending GA

Cognitive-Behavioral Model of Relapsemodified from Kadden, 1995

Coping with Urges and

Cravings

Avoid High Risk Situations

Identify triggers and risk factors

Which can be avoided

Coping with Urges and Cravings

Distracting Activity/Redirect AttentionSimple, engaging activity (mental calculations, counting, exercise, hobby, etc.)Delay acting on urgeTime

Urge Surf

Relaxation techniquesAcceptanceStudy the craving, changes, ebbs and flows, etc.

Coping with Urges and

Cravings cont.

Challenge and change your thoughts Play through to negative consequences

Recall benefits to recovery

Recall moment of clarity, ambivalent motivation

Recall list of rational thoughts

Imagery of craving (devil, degenerate, etc.)

Talk about craving

Write about craving

Talk to craving – what are you trying to tell me?

Mindful awareness Being present with each client takes practice

Formation of Self Concept

“….each of us literally chooses, by his way of attending to things, what sort of a universe he shall appear to himself to inhabit.”

William James – Varieties of Religious Experience

Judson Brewer, MD, Ph.D.

Addictions and Habits follow this pattern:

Trigger ______ Behavior _______ Reward

Triggers

Stress

Withdrawal symptoms

Preoccupation with gambling, or obtaining money to gamble

Family

Marriage

Boredom

Behavior

The ritual of getting ready to gamble

The gambling event/activity

The shift of the brain into default mode that is now conditioned to escape unresolved issues

The shift of the brain into a default mode to chase levels of excitement, or to live on the edge

Reward

The escape or excitement

The elevation of neurotransmitters that match the escape or excitement

Wins/near wins

Anticipation of wins

Money in terms of credits, jackpots, chips

Judson Brewer, MD, Ph.D.

Prefrontal Cortex 1. Cognitive control tries to help us stop a negative behavior. 2. But, it is the first thing to go off line when we are stressed. 3. When we fall off line - we are more likely to fall back into our bad habits.

4. Becoming really conscious of what we are experiencing allows us to feel disgusted with our behavior and at a very visceral level.

5. Mindfulness – being curious about what we are experiencing. Especially at the level of our triggers, i.e. – Stress

6. When our triggers turn into craving - we are experiencing fear and want to relieve the emotion.

Default mechanism – in the post cingulate region which carries our self identity, we resort to soothing yet unhealthy patterns.

Mindfulness is a way of living not just sitting on a cushion Mindfulness is connected to the practice of:

Love/compassion

Values

Ethics

Wisdom

Daniel J. Siegel, M.D. – The Mindful Therapist

9 middle pre-frontal functions: 1. Regulating our bodies 2. Attuning to others (attuned communication) 3. Having emotional balance 4. Calming fear (fear modulation) 5. Pausing before acting (flexibility of response) 6. Having insight 7. Having empathy 8. Being moral in our thinking and actions 9. More access to intuition

MindfulnessMindfulness is harmony and balance practiced by

the therapist in the counseling session, producing an environment of:

1. nonjudgmental.

2. equanimity (evenness of temper even under stress).

3. awareness of what is happening as it is happening.

4. ability to describe with words our internal world

Mindfulness

In turn, our clients develop:

1. Flexibility

2. Adaptive

3. Coherence

4. Energized

5. Stability

Daniel Stern

“ Moments of meeting cannot be planned – they happen. The moment of meeting is the event that rearranges implicit relational knowing for both the patient and the therapist”.

Kathy Steele (2009)

“If we pour more information and interpersonal experience into the neuroplastic mind – it strengthens synapses, alters neural networks and increases regulation of neurotransmitters and hormones”.

This quiets the old rehearsed/familiar neural pathways of self, creates a pause and allows room for something new.

Richard J. Davidson

“Instead, the brain has a property called neuroplasticity, the ability to change its structure and patterns of activity in significant ways not only in childhood, which is not very surprising, but also in adulthood and throughout life.”

The Role of the Therapist

Philip Flores – Addiction as Attachment Disorder

“Addiction hijacks the attachment system”.

“Long term recovery requires ongoing attachment relationships to ensure Central Nervous System homeostasis”.

Dopamine vs. Oxytocin

Philip Flores› “Addiction is a disease of isolation”.

› We find our clients who are willing to take the “dopamine effect” and ignore the experience of relationships/connection which is the natural experience of Oxytocin.

› Where is my son, daughter, husband, wife, etc.


Philip Flores “Until an addict, alcoholic, or gambler, develops the capacity to establish

mutually satisfying relationships, they will remain vulnerable to relapse and to the continual substitution of one addiction to another”.

P. Ornstein

“Being understood as an adult has the same effect as being held as a child”.


Drugs/Alcohol/Gambling hijacks the individual’s ability to have genuine relationships. With conditioning – the addict will choose the “dopamine” effect over the oxytocin until the pain of the addiction is greater than the chase.

Dopamine and Oxytocin flow along the same brain pathways. If we substitute dopamine it prohibits oxytocin and actually prefers the dopamine.

Wiley D. HarwellD. Min., LPC, ICGC-II, BACCEx. Dir. Of [email protected] www.smartplayok.org

mailto:[email protected]

http://www.oapcg.org/

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Relapse Prevention and Gambling disorderfourdirections.evergreencpg.org/wp-content/uploads/... · Therapists Must Remember – from Mikal Aasved 1. Winning is an initial motivator