Embedding a Relational Focus in Gambling Treatment

Transcription

1 Embedding a Relational Focus in Gambling Treatment Alberta Gambling Research Institute 14 th Annual Conference Critical Issues in Gambling Research March 26-28, 2015 Bonnie Lee, PhD, Associate Professor, Faculty of Health Sciences, University of Lethbridge

2 Overview Relationship factors in mental disorders and GD Integrative systems model Relational gap in research and treatment Synergies in Alberta

3 RELATIONSHIPS & MENTAL DISORDERS

4 Relational Factors Individual factors Demographic characteristics Types of gambling Comorbidities Relational factors --- between two or more individuals Couple distress Family and Intimate partner violence Childhood maltreatment

5 Couple Distress Depression (Beach, 2001) Anxiety (Calvocoressi et al., 1995; Daiuto et al., 1998; Durham et al., 1997) PTSD (Johnson & Williams-Keller, 1998) Substance use disorders (Fals Stewart, Birchler, & O Farrell, 2003)

6 Depression Meta-analysis of 10 studies (Whisman, 2001): mean correlation between marital distress and major depression = 0.66 Evidence that marital distress predates onset of major depression Spouses unhappy with marriage 3x more likely than happily married spouses to develop and episode of major depression over a 12-month period (Whisman & Bruce, 1999)

7 Depression Relationship dissatisfaction predicts increased risk for a major depressive episode in the subsequent year, even after controlling for history of depression (Whisman & Bruce, 1999) Poor marital adjustment at the end of active individual depression treatment is a risk factor for increases in depression severity during follow-up (Whisman, 2001).

8 Substance Use Disorders Marital functioning predicts likelihood of relapse and time to relapse in alcoholic patients (O Farrell et al., 1998) 40-60% of married or cohabiting SUD patients report episode of partner aggression a year preceding entry into treatment (Fals-Stewart & Kennedy, 2005) Problematic drinking predicts increases in marital distress and likelihood of divorce or separation a year later (Leonard & Roberts, 1998)

9 Relational Distress Etiology Maintenance Relapse Treatment Outcomes Demonstrated comorbidity between relationship distress and many physical and mental disorders (Heyman, et al., 2009; Snyder & Whisman, 2003; Whisman & Uebelacker)

10 Couple Treatment Significant impact of the relational dissatisfaction on behavioural, cognitive, affective, and neurophsiological systems Attention to relationship problems is essential for the appropriate management of mental health and addiction disorders (Heyman et al., 2009)

11 Chicken or Egg? Bi-directional and Recursive (Snyder & Whisman, 2004; Lee, 2012a)

12

13 Faultlines (Lee, 2012) Limited range and depth of communication Limited range and depth of communication Overfunctioning or Underfunctioning Separate activities Emotional and physical abuse

14 Life Transition Stress Gambler Andy Harry Mita Shaun Greg Fred Ethel Tom Transition/Stressor Adolescence Marriage; Father s death Immigration; Loss of profession; Parenthood Parenthood Parenthood; Job Loss Retirement Burnout, Financial Loss Demotion

15 Couple Relationship Before and After Pathological Gambling Five Circuits (Lee 2012) C4 Relapse C2 Pressure pt. Relapse Family of C1 Fault Line PG R 1 R 2 Origin Congruence C = Circuits R 1 = Distressed relationship R 2 = Congruent relationship Exacerbation C3 C5

16 REVERSING THE SPIRAL

17 Congruence (Lee, 2009) Awareness Acknowledgment Alignment

18 A House with Four Doors (Lee, 2009) INTRAPSYCHIC: PSYCHOLOGICAL INTERGENERATIONAL: FAMILY OF ORIGIN INTERPERSONAL: COMMUNICATION UNIVERSAL-SPIRITUAL: YEARNINGS, WORTH ESSENCE

19 INTERPERSONAL INTER- GENERATIONAL COMMUNICATION ``Water Line`` INTRA-PSYCHIC FEELINGS FEELINGS ABOUT FEELINGS PERCEPTIONS & BELIEFS EXPECTATIONS UNIVERSAL -SPIRITUAL YEARNINGS SELF: I AM The Iceberg: Satir et al., 1991; Banmen, 1994; Lee, 2009l., 1991; Banmen, 1994; Lee, 2001, 2009

20

21 Sample N=30 Baseline PG score (DSM-IV): 8.7 Retention: 89% at 2 month follow-up High percentage of lifetime traumatic experience: gambler (70%); spouse (55%) Gamblers more mental distress than spouses at baseline and post-treatment Spouses better family systemic functioning than gamblers at baseline and follow-up

22 Gamblers Spouses Gender Male = 66% Female = 34% Age (Mean in years) 49.3 (range: 35-62) 48.9 (range: 36-70) Education completed University =27%; 2-year College=50%; High school = 23% Employment Participants Demographics Household Income Employed = 87%; Unemployed=6%; Retired=7% $80,000 CAD p.a. Province Ontario = 6 couples; Alberta = 9 couples Years Mean = 18 years married/together Sexual Orientation Heterosexual = 100% Ethnicity Caucasian = 73%; Asian=24% ; Aboriginal=3% Immigration 37% landed immigrant Religion Christian=50% ; Atheists=20% ; Jewish=7%; other=14% DSM-IV PG score Mean = 8.7 out of 10 Amount of money Mean = $87,000; most common gambling type: lottery, slots lost Co-addiction 57% reported co-addiction; most common: nicotine, alcohol, marijuana

23 Instrument Treatment and Control Groups (MANOVA OUTPUT) Number of Dependent Manova here Participants Variable F Sig. Partial Eta Squared Observed Power GSAS (F (1,14) ) Tx(n)=8 Control(n)=8 BSI (F (1,27) ) Tx(n)=16 Control(n)=13 Pre Post ** Followup * Pre Post *** Followup * DAS (F (1,28) ) Tx(n)=16 Control(n)=14 Pre Post STIC (IPS+ FOO+ RWP) (F (1,24) ) Tx(n)=14 Control(n)=12 Followup Pre Post * Followup

24 FRIEDMAN TEST Treatment Friedman here Control Instrument Pre/Post/FU P-Val Pre/Post/FU P-Val GSAS BSI.000***.353 DAS.002**.504 STIC.000***.076

25 Acceptance Favourably accepted by counsellors and couples O2: Gamblers satisfaction: M=6.44 out of 7 (n = 8) Spouses satisfaction: M=6.55 out of 7 (n=8) O3: Gamblers satisfaction: M=7 out of 7 (n = 4) Spouses satisfaction: M=6.75 out of 7 (n = 4)

26 RESEARCH GAP

27

28 Meta-analysis of Systemic Therapies (2014) Systemic Theoretical lens Reciprocity Interactive; types of questioning Changing the conditions of the social system May records identified on systemic therapies 45 articles fit 8 criteria of definition, approach and RCT quality 8 on SUD/addiction

29

30

31 SERVICE GAP

32 From the Field Family Program 12-step tradition Lack of training

33 Mapping the Mind-Swamps (Lee et al., 2013) Two Calgary Addiction Treatment Agencies Years of experience in addiction and mental health: 57% have over 6-10 years Missing: link to childhood adverse experience; individual symptoms; minimal mention of relationships and communication; coping but unclear. Fragmented, piecemeal, lack coherence

34 GAP-MAP (Wild et al, 2014) 20% of adult Albertans (614,861 people) experienced an addiction and mental health problem in % reported unmet needs for one or more services Unmet needs for counselling

35 Services based on reactive, acute-care model Unmet needs for information Technologies are under-utilized Inadequate tracking of client outcomes (78% said they needed additional support to document program effectiveness)

36 Underserved Populations (p. 96) Children & Youth Participants indicated that services and supports are needed for children and youth impacted by parental addiction and mental health problems, early psychosis, substance abuse and addiction

37 Family (p. 96) Lack of services and supports available to families in Alberta. To address mental health and addiction problems rooted in individuals relationships with their family members. Specifically, respondents identified a need for mental health and addictions counseling that adopts a family system perspective, rather than simply focusing on the individual as separate from the family.

38 Dual Diagnosis and Complex Needs (p.97) Services for complex needs clients: Concurrent Disorders; PTSD

39 System Needs Training Families Children and youth Concurrent disorders (cross-training, specialized training)

40 EMBEDDING A RELATIONAL FOCUS IN TREATMENT SYSTEM

41 STEP 1: Identifying the Need Informal -- conversations with the field, listening to clients and service providers Formal provincial systematic survey

42 STEP 2: NETWORKING AND RELATIONSHIP BUIDLING Alberta Family Wellness Initiative Translate scientific research into policy and practice Provide resources and symposia to bring key stakeholders together Create a common framework of understanding

43 RECOVERY FROM ADDICTION 3-YEAR SYMPOSIA Cuts across sectors Experts Conversation & Discussion Relationship Trust Team work

44 AHS ADDICTION AND MENTAL HEALTH STRATEGIC CLINICAL NETWORK Identified priorities: Depression Addiction: prevention through treatment, priority alcohol misuse Child & Youth Mental Health Complex High Needs Users Campus Alberta researchers

45 STEP 3: PLANNING MEETING CIHR Partnerships for Health System Improvement Planning Grant March 13-14, participants Clear focus on relational counselling Mix of participants: AHS directors, managers, supervisors, evaluators, university researchers, endusers, interprovincial representation Multi-modal research evidence, end-users testimonials, agencies, role-play demonstration, interactive activities cognitive and experiential Priorities Teams

46 STEP 4: MOMENTUM INTO GRANT APPLICATION (JUNE 2014) AGRI Major Grant ( ) Gambling Disorder vs Alcohol Use Disorder: Comparing Treatment Outcomes with Congruence Couple Therapy Researchers: Bonnie Lee, Darren Christensen, Andy Greenshaw, Kathy Aitchison, Olu Awosoga Partner: Alberta Health Services (4 zones)

47 CANADIAN DEPRESSION RESEARCH AND INTERVENTION NETWORK (CDRIN) INNOVATION + COLLABORATION = TRANSFORMATION

48 CIHR Canadian Research Initiative in Substance Abuse Regional Node CRISM (Wild, Aubrey, Dell, Hodgins et al., ) Build teams Academic researchers and service providers Common projects in substance misuse Efficacious, tailored, feasible, applicable interventions easily accepted by service providers

49 A Rising Tide

50 Research as Social Construction of Knowledge

51 Questions? Thank you!