Out-patient group therapy with pathological gamblers potential and limitations. Marianne Hansen, Blue Cross Centre,, Oslo Norway

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1 Out-patient group therapy with pathological gamblers potential and limitations. Marianne Hansen, Blue Cross Centre,, Oslo Norway EASG Malmö 2. July 2005

2 Blue Cross Centre is an out-patient clinic - alcohol addiction Pathological gambling from 2000 Approximately 600 persons in treatment for PG since then About 50% of the patients referred are PG Demand for treatment are increasing

3 Outline of presentation Our frames Potential; why group therapy? Limitations what are we missing? An ideal approach?

4 Treatment frames A first interwiev, assessment - diagnostic (SOGS-R R and DSM-IV) - current situation - motivation - anamnesis Treatment group, seven meetings á 2 hours - the basic treatment Relatives participates once - relatives are also invited to the first interwiev Couple/family cosultation during the group therapy when needed/requested requested. Follow-up group therapy

5 Potential group therapy resources Establish norms early in the groupprocess - Social comparison between members - A positive group pressure - Loyalty; both - and process. Gives a feeling of cohesion, but also the risk of being excluded

6 The group an example - Per,, 29, single, odds/internet internet, embezzlement, imprison, motivated - Sonja,, 63, married, children grown-up up,, bingo/ slots, depressed - Mona,, 35, single mother, slots, ashamed, ambivalent - Steinar,, 40, live together with girlfriend, children, slots, home loan to finance gambling, motivated - Rune,, 47, married, children,, horses, high debt/debt collection, horse expert - Kristian,, 18, slotmacines, has been bullied, no debt, ambivalent - Kjell,, 54, separated from wife, children, slots, borrowed money, inpatient psych ward after suicid attempt - Abdi,, 40, divorced, four children, slots, language problems, ashamed, desperate

7 Per Abdi ambivalence Sonja Kjell money debt divorce resignation Pathological lie gambling relapse suicide shame depression Kristian Steinar Mona Rune

8 Content and focus 1. meeting Introduction and presentation - information, rules for the group - who are you? why are you here? - gambling history - expectations to the group Clarify each groupmembers treatment goal - abstinence or controlled gambling? Focus on identification and safety -This is often the first time the gambler can speek freely with other pathological gamblers about their problem

9 Motivation 2. meeting Videofilm about pathological gambling - Increases the engagement - Discussion about the film Risksituations - When and why? Theory of change (Prochaska & DeClemente) - Where are you? What is needed to move forward? Motivation for change (self efficacy)

10 Prochaska & DiClementes theory of change Maintenance Precontemplation Relapse Contemplation Action Preparation

11 Assessment of motivation How important is it for you to quit gambling (on a scale from 1 (not important at all) to 10 (the( most important issue for me)). How much do you believe that you are able to quit gambling if you decide to quit (on a scale from 1 (not confident at all) to 10 (very( confident)).

12 Ambivalence 3. meeting - Explore risksituations; when do you gamble; where do you gamble; what happens to you while gambling etc. - Introduce the notion of ambivalence - Assess positive/negative aspects with and without gambling

13 Mapping of automatic cognitions/gambling 4. meeting cognitions Cognitions who leads to gambling and makes you continue when you have started gambling Why is cognitions, beliefs and self-instructions so important? What is an automatic cognition? - Sorting out automatic cognitions - Challenge automatic cognitions

14 Relatives and PG 5. meeting Relatives and the relation to the surroundings Increased focus on negative consequenses Trust/mistrust how to continue in the relationship? How to handle money Is controlled gambling possible? How to handle a relapse The importance of meeting other relatives and gamblers

15 Group therapy gives possibilities The relatives are meeting other relatives with similar experiences - Often the relatives experience loneliness and shame in being relative to a PG The PG meets other relatives - Some times it is easier to listen to and understand other peoples relatives The importance of increased knowledge and awareness for relatives

16 Desicionmaking and relapse prevention 6. & 7. meeting The importance of a durable desicion; ; a desicion who can endure adversity Be aware of as if desicions Relapse prevention Long-term perspective Reward yourself Risksituations - again When you have a relapse then what? Utilize the group experience on the way

17 Why group therapy?

18 Unmotivated? Resignation? Resignated groupmembers or group-members in the precontemplation fase: - It is motivating to say motivating statements These participant does not hear statements like this in their surroundings - BUT they have the opportunity to hear motivating statements from other groupmembers - Probably more useful than statements from family and therapists

19 Grouptherapy gives opportunities Some people are not available to intervention: - Grouptherapy opens a potential for indirect intervention

20 Recognition and identification To recognize own problems in others To talk about the gambling problems without explaining everyting or to defend oneself To find understanding and sympathy To meet support Moderates the feeling of shame

21 Knowledge and infomation Increased effect of learning when more people learn toghether Common reflection around the magical and biased cognition The degree of knowledge about gambling differs Different experiences on what works when quitting gambling

22 Consciousness and awareness Start a process of change Be able to make an informed choice as a gambling consumer Increased dissonance makes i more difficult to continue gambling Awareness of alternative solutions

23 Motivation Encouragement from others Commitment Be aware of own ambivalence To see and hear that change is possible!

24 Hope See other people manage to quit gambling Even if everything seems hopeless it is possible to find solutions Manageable goals reachable within reasonable time

25 From a group participant To be aware of my problem. Have more expertise about gambling. Learn about automatic cognitions and how to handle them. Meet other people in the same situation,, and to open up my problems toward others.. To see that other nice people have the same problem as I have

26 Are we losing something? Focus on the individual - A comprehensive view for each person - Debt and economy - Group therapy not suitable for everyone (language, reduced cognitive functioning, serious comorbidity etc. - Some need more - A challenge when the group are too mixed (nothing in common) - Time

27 What would be a better approach? A question of resources Short time group therapy also a pragmatic solution - a way to reach more people with lesser resources - suits many, but some needs more

28 A better approach? Flexible solutions - Grouptherapy as a basis - but - Open up for more individual follow-up before,, during and after the group is ended, when needed Extended focus - Debt counselling, work with payback - In-patient treatment - More focus on relatives, family and children - Co-morbidity