Family Support and Psychoeducational Group Manual for Problem ...

Family Support andPsychoeducationalGroup Manual forProblem GamblingToula Kourgiantakis, MSW, RSW, RMFTMichael Weyman, MSW, RSWBrenda Teasell, MSW, RSWLisa Pont, MSW, RSW

Family Support and Psychoeducational Group Manual for Problem GamblingPrinted in CanadaCopyright © 2013 Centre for Addiction and Mental Health, Problem GamblingInstitute of Ontario, Toronto ONFacilitators offering this program have permission to download the manual andcopy and distribute the handouts for use by participants. Otherwise, no part ofthis work may be reproduced or transmitted (for profit or otherwise) in any formor by any means electronic or mechanical, including photocopying and recording,or by any information storage and retrieval system without written permissionfrom the publisher—except for a brief quotation (not to exceed 200 words) in areview or professional work. Contact PGEducation@camh.netThis manual was produced by:Development: Colleen TessierEditor: Nick GambleDesign: Pat Dumas-HudeckiWriters: Toula Kourgiantakis, Michael Weyman, Brenda Teasell and Lisa Pont4803/07-2013

ContentsIntroduction 2Background information on problem gambling and families 4Preparing for a family support group 8Implementing the group 12Session 1: Understanding problem gambling, recovery and treatment 15Session 2: Communication 26Session 3: Establishing boundaries 30Session 4: Self-care, support and next steps 35Alternative formats for family support 40Testimonials 42References 43Suggested readings 45Family support andpsychoeducationalgroup manualfor problem gambling1©2013 Centre for Addiction and Mental Health

IntroductionIntroductionThis manual was initially developed to provide a framework for the groups that weprovide for families in the Problem Gambling Program at the Centre for Addiction andMental Health (CAMH). This framework is flexible and can be adapted according to thegroup profile, as well as the style and skill of the facilitator. It is simply a guide and canbe modified to fit with your agency, facilitators and participants.The manual provides information on developing and delivering a four-week psychoeducationalsupport group for family members of people with gambling problems. Familyis used as a broad term to describe anyone who has a significant relationship or role inthe life of the gambling individual. Research has shown that psychoeducational groupsare extremely beneficial in addiction and mental health. They provide information,validation and support, help reduce distress, and help families develop better problemsolvingand 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 clientsrefer 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 thatfamily members who cannot commit to a longer duration are not excluded. Weencourage families that require more support to attend a second time, or refer themto 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, groupexercises, handouts for clients, and suggested questions or statements to display onflipcharts. For agencies that cannot offer a four-week group, we suggest alternativeformats such as a one-off information session (see page 40). We have also includedFamily support andpsychoeducationalgroup manualfor problem gambling2©2013 Centre for Addiction and Mental Health

Introductionsupplementary information on topics relevant for those working with families of peoplewith 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, RMFTtoula.kourgiantakis@camh.caMichael Weyman, MSW, RSWmichael.weyman@camh.caBrenda Teasell, BA, MSW, RSWbrenda.teasell@camh.caLisa Pont, MSW, RSWlisa.pont@camh.ca.Family support andpsychoeducationalgroup manualfor problem gambling3©2013 Centre for Addiction and Mental Health

Background information on problem gamblingBackground informationon problem gambling andfamiliesWhat 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 gamblingnot 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’swhole 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% ofCanadians experience gambling problems; in Ontario the rate is 2.4%, higher than thenational average but considered “intermediate” (Williams, Volberg & Stevens, 2012).Internationally the average rate of problem gambling is 2.3%. The lowest rates are foundin 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 andrecurrent gambling problems. In the latest version of the Diagnostic and Statistical Manualof Mental Disorders (DSM 5) (American Psychiatric Association, in press), it has beenrenamed “disordered gambling” and is grouped along with alcohol and drug use disordersunder the heading “Addiction and Related Disorders.” Disordered gambling is the onlybehavioural addiction in the DSM.Family support andpsychoeducationalgroup manualfor problem gambling4©2013 Centre for Addiction and Mental Health

Background information on problem gamblingThe impact of problem gamblingon family membersResearch shows that problem gambling affects not only the individual with the gamblingproblem, 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)• 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 thisissue. However, we have found it best not to initiate these potentially distressing topicswith family groups. For most families, it is more beneficial to hear positive, hopefulstatements that draw from their strengths as individuals and as a family.Family support andpsychoeducationalgroup manualfor problem gambling5©2013 Centre for Addiction and Mental Health

Background information on problem gamblingWhy is family involvement important?Research supports the value of involving family members in treatment for problemgambling and substance use problems. Here are some salient findings:• People remain in treatment longer when a family member is involved, and thosewho stay in treatment longer have better outcomes (Ingle, Marotta, McMillan &Wisdom, 2008).• Individuals who have social support while they are in treatment have better outcomesthan those who are isolated, even if family is not directly involved in that treatment. Thebenefits 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 toinvolve 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 timetogether, and there is lower risk of family violence (Kelley & Fals-Stewart, 2002).• When couples receive therapy for problem gambling, there are improvements forchildren 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 onhelping family members develop more effective coping skills—which in turn improveoutcomes for families (Makarchuk, Hodgins & Peden, 2002).• “Pervasive loss” is a term used to describe the effects of problem gambling onchildren. Children have historically been the family members most omitted fromproblem gambling research and treatment (Darbyshire, Oster & Carrig, 2001).• Csiernik (2002) highlighted that many Ontario treatment centres do not includefamily members in addiction treatment, despite the benefits. He found that ofOntario treatment centres:– only 8% offered individual counselling to family members– only 15% offered psychoeducational or support groups to families– only 1% offered family therapy.Family support andpsychoeducationalgroup manualfor problem gambling6©2013 Centre for Addiction and Mental Health

Background information on problem gamblingBest practices in working with familiesin problem gambling treatmentA family-centred care approach is an evidence-based practice. Here are some bestpractices for involving families in treatment:• Involve families in treatment as early as possible.• 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 canshare with others).• Clarify the limits of confidentiality and develop strategies for resolving problemsrelated 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 helpavailable for families.• Discuss the impact of problem gambling on family relationships in individualsessions and group treatment for gambling clients.• Provide services for families, such as individual sessions for family members andfamily psychoeducational support groups.• Help families learn to cope and relate effectively.• Treat family members with dignity and respect; avoid judging or blaming familymembers.• Focus treatment on a family’s strengths, expertise and contribution to treatmentplanning.Sources: CAMH, 2004;O’Grady & Skinner, 2007.Family support andpsychoeducationalgroup manualfor problem gambling7©2013 Centre for Addiction and Mental Health

Preparing for a family support groupPreparing for afamily support groupRecruitment for family support groupsIt may take time to recruit family members for support groups especially when thisservice is being offered for the first time.The following suggestions may help raise awareness and promote greater participation:• Involve families in gambling clients’ individual sessions and give them informationdirectly.• 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.• Ensure that all individual and group programs for gambling clients include acomponent raising awareness of the impact of problem gambling on families (withoutblaming), and teaching communication and problem-solving skills in relationships.• If some families are enrolled but the numbers are not high enough to begin a fourweekgroup, provide a single session to reduce the risk that they may drop out. Thenencourage 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 betterunderstanding of the problem may encourage greater involvement in treatment.• Make families feel welcomed, understood and an important part of the treatmentprocess.• Believe in the cause. Every centre needs an advocate for underdeveloped services. Ittakes time, energy and perseverance.Family support andpsychoeducationalgroup manualfor problem gambling8©2013 Centre for Addiction and Mental Health

Preparing for a family support groupSample flyer textFAMILY SUPPORT GROUP—PROBLEM GAMBLINGWhere: Problem Gambling Service, 33 Russell St. (3rd Floor), TorontoWhen: 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 familymember or friend. An initial meeting with a therapist at CAMH is required. Formaximum 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 toour intake coordinator.Find tools for family members at the Problem Gambling Institute of Ontario’s website:www.problemgambling.caFamily support andpsychoeducationalgroup manualfor problem gambling9©2013 Centre for Addiction and Mental Health

Preparing for a family support groupSample letter to family membersDear family member or friend of a gambling client,Is a family member or friend seeking treatment for a gamblingproblem? When people are working on changing their problemgambling behaviour, the involvement of those close to them can reallyhelp. Having a gambling problem can have negative effects on closerelationships and can create financial difficulty, damage trust andincrease stress. These effects don’t go away overnight, and the changeprocess can take time. When families work together, gambling problemsand negative effects can be dealt with more quickly. Research has shownthat individuals do better when families are involved.Here are some of the benefits:• Families and friends can share their concerns and get information,advice and support.• Family and friends often feel safer and less stressed when theylearn about the warning signs of problem gambling, and whathappens in treatment.• Information from family and friends can help the therapist workmore 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 arediscussed and dealt with.• Relapse is less likely, and if there is a slip, getting back on track canbe quicker.Family support andpsychoeducationalgroup manualfor problem gambling10©2013 Centre for Addiction and Mental Health

Preparing for a family support groupThere are many ways in which you can be involved with our services:• Phone consultation is available, for information and to answerquestions.• You may book your own appointment to discuss your concerns andoptions.• Four-week family support groups are held regularly.• You may be invited to attend treatment planning sessions togetherwith your family member.• Family and couples counselling.All of our services are free and confidential.Please contact our intake coordinator at 416 599-1322 to arrange ameeting. Whatever time you can give will be very much appreciated.Kind regardsThe Problem Gambling Service TeamCentre for Addiction and Mental Health (CAMH)33 Russell Street (3rd floor)Toronto, Ontario M5S 2S1Family support andpsychoeducationalgroup manualfor problem gambling11©2013 Centre for Addiction and Mental Health

Implementing the groupImplementing the groupObjectivesThis 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 improvecommunication• learn about the importance of establishing boundaries or setting limits in relationships• identify forms of self-care, sources of support, and other services for familiesaffected by problem gambling• share support with peers who may have similar experiences.Family support andpsychoeducationalgroup manualfor problem gambling12©2013 Centre for Addiction and Mental Health

Implementing the groupStructurePURPOSE OF GROUP: psychoeducation and supportTARGET CLIENTELE: Individuals affected by the gambling problems of a familymember or friendNUMBER AND LENGTH OF SESSIONS: four two-hour sessionsNUMBER OF PARTICIPANTS: ideally between six and eight participantsNUMBER OF FACILITATORS: can be led by one clinicianTHEMES COVERED IN FOUR SESSIONS:Session 1: Understanding problem gambling (definition, treatment/recovery, stagesof change)Session 2: Effective communicationSession 3: Setting boundaries and limitsSession 4: Self-care, support, next stepsFinances are not treated as a separate topic, but this subject is often discussed insession 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 orread related to the session’s topicHandouts are given at each session, for the benefit of participants who integrate andunderstand material better when it is written. This also applies to some families forwhom English is a second language.Family support andpsychoeducationalgroup manualfor problem gambling13©2013 Centre for Addiction and Mental Health

Implementing the groupImportant clinical skills for family groupsFamily psychoeducational support groups integrate an educational component alongwith a supportive process. The educational component of this group focuses onunderstanding problem gambling and developing more effective coping skills. It alsoprovides a forum for mutual aid and support. These combined groups require the useof a variety of clinical skills, including the ability to:• welcome, invite and include• express empathy• validate• be non-judgmental and respectful• reframe• listen reflectively• inform and educate• support• contain• refer• be self-aware.Family support andpsychoeducationalgroup manualfor problem gambling14©2013 Centre for Addiction and Mental Health

Session 1 Understanding problem gambling, recovery and treatmentUnderstanding problemgambling, recovery andtreatmentSession1ObjectivesDURING THIS SESSION, PARTICIPANTS WILL LEARN ABOUT:• gambling and problem gambling• treatment services available at your agency for individuals with gamblingproblems 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.Outline1. 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 differences3. CHECK-IN• First name• Ask participants:Family support andpsychoeducationalgroup manualfor problem gambling15– Who in your family has a problem with gambling?– Is he or she currently in treatment?– What do you hope to get out of this group?©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatment4. DISCUSSION TOPICSThis is the most content-laden of the four sessions. There is usually not time todiscuss all of the topics listed below, since they are not “taught” by the facilitators butdiscussed as a group. The first topic (gambling and problem gambling) is importantto include and can be brief. Also prioritize stages of change, since it may be referredto 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 gamblingindividual is at• Problem gambling treatment– Provide brief information on problem gambling treatment: Informationprovided 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 biopsychosocialspiritualmodel• Self-care and coping– Give brief information on the importance of self-care, using the biopsychosocialspiritualmodel– Distribute Handout 1-6: Biopsychosocial-spiritual forms of self-care andHandout 1-7: Biopsychosocial-spiritual self-care plan– You may suggest that participants take a resilience quiz online to assess theirself-care (see www.lightheartedconcepts.com)Family support andpsychoeducationalgroup manualfor problem gambling16©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatment5. HOMEWORK• Read the CAMH publication ProblemGambling: A Guide for Families (CAMH, 2008)• Identify one coping strategy or form of self-care6. CHECK-OUT• Ask participants: What is one form ofself-care or coping strategy that you can usein the next week?• Ask participants: What is one word thatdescribes 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• Handout 1-3: Gambling and problem gambling• Handout 1-5: Harm reduction and abstinence• Handout 1-6: Biopsychosocial-spiritual forms of self-care• Handout 1-7: Biopsychosocial-spiritual self-care planEmergency planningDiscuss this topic if a familymember appears worried abouthis or her own safety or thesafety of the gambling individual.– Create a safety or crisis plan– Suggest the gambling individualand/or family memberkeep a crisis card includingmedical information(diagnoses, medication,doctor, any allergies), triggers,coping strategies, interventiontips, therapist and treatmentcentre information, familycontact person, and all otherrelevant information for aprofessional or personintervening.• Problem Gambling: A Guide for Families (order from CAMH or ask participants todownload it from www.problemgambling.ca/EN/GettingHelp/Pages/InformationFor-Families.aspx)Family support andpsychoeducationalgroup manualfor problem gambling17©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-1Pre-group surveyWe would like to get an idea about your needs, and your hopes for participating in theProblem 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?__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family support andpsychoeducationalgroup manualfor problem gambling18©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-2Group guidelines• Please respect confidentiality.• Use “I,” “me,” and “my” statements.• Respect differences, such as gender, ethnicity, culture, religion, sexualorientation, and personal history.• Respect the group by arriving on time and trying to attend all the sessions.• Each group participant has the right to say “no” or to pass.• Be open-minded to others’ point of view.• Try to be non-judgmental.• Ask permission from another person before giving constructive feedback.• Turn off hand-held devices.• Remember that humour is good medicine.Family support andpsychoeducationalgroup manualfor problem gambling19©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-3 aGambling and problem gamblingWHAT IS GAMBLING?Gambling is defined as risking money or something of value on the outcome of anevent, where that outcome is to some degree beyond the control of the person who istaking the risk.WHAT IS PROBLEM GAMBLING?GAMBLING IS A PROBLEM WHEN IT:• gets in the way of work, school or other activities• harms mental or physical health• has financial consequences• causes difficulty in relationships with family or friends.HARMFUL CONSEQUENCES CAN AFFECT:• finances• physical health• mental health• relationships• work• 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 tohave gambling problems. There are some risk factors that can increase the chanceof someone developing gambling problems and, also, protective factors that canreduce the risks. Important protective factors are positive relationships and supportfrom families.Family support andpsychoeducationalgroup manualfor problem gambling20©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-3 bMany clinicians and researchers use a biopsychosocial model to explain why peopledevelop and maintain a gambling problem. This model takes into account biological,psychological and social factors that contribute to the onset or maintenance of thegambling problem.GETTING HELPFree treatment and other services are available for people with gambling problems.It includes:• professional counselling through treatment centres funded by the Ministry of Healthand 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 centremay 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 supportgroup such as this one, or individual, couples or family counseling.Sometimes a person with a gambling problem may also experience difficulties withmental 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.Family support andpsychoeducationalgroup manualfor problem gambling21©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-4Stages of changePRECONTEMPLATIONdoes not recognize the needfor change or is not activelyconcidering changeRELAPSELEAVES TREATMENTCONTEMPLATIONrecognizes problem andis considering changeMAINTENANCEis adjusting to change andis practising new skills andbehaviours to sustain changePREPARATION/ACTIONhas initiated changeSource: Prochaska, J., Norcross, J. & DiClemente, C. (1995). Changing for Good: A Revolutionary Six-StageProgram 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?Family support andpsychoeducationalgroup manualfor problem gambling22©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-5Harm reduction and abstinenceWHAT ARE HARM REDUCTION AND ABSTINENCE?Harm reduction refers to strategies that help people help themselves by moving in thedirection 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 quitaltogether.WHAT ARE THE BENEFITS OF A HARM REDUCTION APPROACH?A HARM REDUCTION APPROACH:• promotes change and making choices in one’s treatment• facilitates collaboration between the client and the therapist• increases the chances that the person will stay in treatment• 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.Family support andpsychoeducationalgroup manualfor problem gambling23©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-6Biopsychosocial-spiritual forms of self-carePhysical self-care◦ Eat well and regularly◦ Exercise (e.g., dance,swim, walk, run)◦ Get regular medical carefor prevention◦ Get enough sleepEmotional self-care◦ Praise yourself◦ Read a book◦ Take some time for yourself◦ Be in the present momentand do one thing at a time◦ Find things that make you laughSocial self-care◦ Have a lovely dinner on Fridaynight or during the weekend◦ Build a social support system◦ Attend a group◦ Spend time with family or friends◦ Find an hobby or an activityyou enjoySpiritual self-care◦ Make time for prayer or meditation◦ Read inspirational books◦ Listen to relaxation music◦ Be mindful◦ Spend time in nature◦ Practise deep breathing◦ Express gratitude◦ Write a journalFor more information visit the Problem Gambling Institute of Ontario’s website:www.problemgambling.caFamily support andpsychoeducationalgroup manualfor problem gambling24©2013 Centre for Addiction and Mental Health

Understanding problem gambling, recovery and treatmentHANDOUT 1-7Biopsychosocial-spiritual self-care planPhysical self-care____________________________________________________________________________________________________________________________________________________________________________________________________________________________Emotional self-care____________________________________________________________________________________________________________________________________________________________________________________________________________________________Social self-careSpiritual 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.Family support andpsychoeducationalgroup manualfor problem gambling25©2013 Centre for Addiction and Mental Health

Session 2 CommunicationCommunicationSession2ObjectivesDURING THIS SESSION, PARTICIPANTS WILL LEARN ABOUT:• learn about communication and forms of communication• identify obstacles that can interfere with effective communication• develop strategies to improve communication.Outline1. 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 survey3. QUESTIONS OR COMMENTS ABOUT THE LAST SESSION4. 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 notesome obstacles they experience in the left column (leave the right column blankfor now)• Distribute Handout 2-2: Improving Communication and review thecommunication strategies listed• Referring back to Handout 2-1, ask participants to write down strategies in theright column for the obstacles they listed earlierFamily support andpsychoeducationalgroup manualfor problem gambling26©2013 Centre for Addiction and Mental Health

Communication5. HOMEWORK• Try using one communication strategy thatwas discussed, and observe the results. If thestrategy doesn’t work the first time, considerwhat may have been an obstacle, adjust thestrategy and try again.Other ways to practicecommunication:Role play effective or ineffectivecommunication in pairs or inlarge 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 communicationFamily support andpsychoeducationalgroup manualfor problem gambling27©2013 Centre for Addiction and Mental Health

CommunicationHANDOUT 2-1Improving communicationWhat are some of the obstaclesto communicating effectivelywith your family member?What are some waysto overcomethose obstacles?Family support andpsychoeducationalgroup manualfor problem gambling28©2013 Centre for Addiction and Mental Health

CommunicationHANDOUT 2-2Improving communicationWhen does communication break down? Often, it is when people feel judged ormisunderstood.COMMUNICATION TIPSLISTENING• Try not to react too quickly; avoid interrupting.• Validate – e.g., “I know this has been hard for you, too.” Validating the other person’sfeelings does not mean you approve of their behaviour.RECEIVING• Family members will be more likely to express themselves if they think what they saywill 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.Family support andpsychoeducationalgroup manualfor problem gambling29©2013 Centre for Addiction and Mental Health

Session 3 Establishing bounderiesEstablishing boundariesSession3ObjectivesDURING THIS SESSION, PARTICIPANTS WILL:• 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.Outline1. 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 ormaintain boundaries (e.g., finances, communication, parenting, intimacy)• Ask what makes it difficult to maintain boundaries that have been set (obstacles tosetting 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• Discuss responses that participants would like to shareFamily support andpsychoeducationalgroup manualfor problem gambling30©2013 Centre for Addiction and Mental Health

Establishing bounderies3. HOMEWORK• Reflect on boundaries and try to identify one area in which you would like to setclearer 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 discussiontoday about boundaries.Resources• Attendance sheet• Flip chart• Pens and clipboards• Name tags• Handout 3-1: Establishing boundaries• Handout 3-2: Boundaries tableFamily support andpsychoeducationalgroup manualfor problem gambling31©2013 Centre for Addiction and Mental Health

Establishing bounderiesHANDOUT 3-1Establishing boundariesBoundaries, or limits, are what you think is acceptable or what you can toleratein a relationship.WHY ARE BOUNDARIES IMPORTANT?Boundaries allow us to practise self-care, to establish safety and to ensure that ourpersonal 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.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family support andpsychoeducationalgroup manualfor problem gambling32©2013 Centre for Addiction and Mental Health

HANDOUT 3-2 aEstablishing bounderiesBoundaries table, page oneArea where theremay not currentlybe an effectiveboundaryWhatI canacceptWhatI can’tacceptEXAMPLERelapse A slip, if hetalks to meabout itA slip thathe does nottalk to meabout andI find outanother wayHow I will carry this through Coping strategiesSteps:I will discuss this boundary with my familymember, and will let him know theconsequences if it is not respected.A slip that he tells me about:I am supportive and appreciate that hetold me. Discuss triggers and relapse preventionstrategies.Talk to friendCall ProblemGambling Helpline(1 888 230-3505)Read materials atproblemgambling.caA slip that he does not tell me about:I will follow through with what I said I’ddo in order to take care of myself in thissituation.Talk to therapistUse other self-carestrategiesDiscuss how to deal with the situationdifferently next time.©2013 Centre for Addiction and Mental Health33Family support andpsychoeducationalgroup manualfor problem gambling

HANDOUT 3-2 bEstablishing bounderiesBoundaries table, page twoArea where theremay not currentlybe an effectiveboundaryWhatI canacceptWhatI can’tacceptHow I will carry this through Coping strategies©2013 Centre for Addiction and Mental Health34Family support andpsychoeducationalgroup manualfor problem gambling

Session 4 Self-care, support and next stepsSelf-care, supportand next stepSession4ObjectivesDURING THIS SESSION, PARTICIPANTS WILL:• identify forms of self-care• identify sources of support• discuss next steps.Outline1. CHECK-IN• Ask participants: Have you reflected since the last session on any boundaries thatyou 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 careof 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 overcome 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 thatsupport may take different forms (e.g., it may be emotional, informational, problemsolving, social, financial or instrumental)• Discuss responses that participants would like to share• You may also ask if there are types of support that they would like to developFamily support andpsychoeducationalgroup manualfor problem gambling35©2013 Centre for Addiction and Mental Health

Self-care, support and next steps3. RESOURCES AND NEXT STEPS• Provide information about other support services• Give information about the Problem Gambling Helpline 1 888 230-3505 andthe 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 thatgambling individuals or family members using the tools section of the websiteare required to sign in order to be able to monitor their own progress. Thiscan still be anonymous as clients can create a new email address whichdoes not identify him/her.• Distribute the flyer for the next family support group, and let participants knowthey are welcome to return• Ask participants to share their next steps4. 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 comments5. CHECK-OUT• Ask participants: What is one word that describes how you feel about endingthe group?• Ask participants: What will you try applying from the group?6. GROUP EVALUATION• Distribute and have participants complete Handout 4-2: Group EvaluationFamily support andpsychoeducationalgroup manualfor problem gambling36©2013 Centre for Addiction and Mental Health

Self-care, support and next stepsResources• 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 websiteFamily support andpsychoeducationalgroup manualfor problem gambling37©2013 Centre for Addiction and Mental Health

Self-care, support and next stepsHANDOUT 4-1My support systemmeWho are your sources of support?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________What type of support do they provide?____________________________________________________________________________________________________________________________________________________________________________________________________________________________________Family support andpsychoeducationalgroup manualfor problem gambling38©2013 Centre for Addiction and Mental Health

Self-care, support and next stepsHANDOUT 4-2Group evaluationWhat 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 andpsychoeducationalgroup manualfor problem gambling39©2013 Centre for Addiction and Mental Health

Alternatives formats for family supportAlternatives formatsfor family supportInformation sessionsInformation sessions can be offered at or prior to admission for both gambling clients andfamily members. The goal of these sessions is to provide information on problem gamblingand treatment options for families and individuals. It allows family members to becomeinvolved and informed early in treatment. Sessions may include information on whatcomprises problem gambling, prevalence rates, services that are available, likely treatmenttrajectory, and ways for family members to be involved in treatment. An information sessionmay be an opportunity to admit clients into your program or refer them to other servicesSingle sessionsSingle sessions can fill a gap when four-week groups cannot be given or when the timebetween four-week groups is too long. It is impossible to cover all of the informationgiven in the four-week groups in a single session, but it can be helpful to extract some ofthe most relevant information from the four topics covered in the groups.Single sessions of two hours work best with a psychoeducational approach. Time shouldbe allotted to answer questions.Lengthening the four-week groupSome family members request that the four-week group be lengthened to six or eightweeks. They may find that they start becoming a cohesive group just when the four weekgroup is close to ending. If you decide to offer a six-week group, you do not need to developnew topics –instead, you can spend more time exploring the four topics covered in thismanual.For some agencies, a lack of resources precludes a longer group. In addition, some familymembers may be unable to commit to a longer group because of child care, employmentcommitments or other reasons. And some participants find that the four-week group meetstheir needs.Family support andpsychoeducationalgroup manualfor problem gambling40©2013 Centre for Addiction and Mental Health

Alternatives formats for family supportIndividual family sessionsWhen it is not possible to offer a group, you can invite family members in for anindividual psychoeducational family session. In this case, families still benefit fromreceiving information about problem gambling, more effective coping and problemsolvingskills.Couple and family counsellingAnother option for family support is couple and family counselling. This would involvebringing the client with the gambling problem together with their partner or with their familyfor a series of counselling sessions. It may not be possible to provide couple and familycounselling in all agencies owing to a lack of capacity or resources. In this case, a referral to afamily service organization or a qualified couple and family therapist can be an alternative.PGIO website, problemgambling.caThe Problem Gambling Institute of Ontario (PGIO) offers a suite of online self-helptools and educational materials through its website (problemgambling.ca). While it isbest for family members to meet with a counsellor in person, the PGIO site providesanother option in the continuum of care. It can be an adjunct to other services or canbe helpful for families and gambling individuals who are not ready to seek help froma 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 forFamily and Friends” comprises a set of interactive, web-based worksheets. This helpsfamily members to learn about problem gambling and develop new skills to deal withthe difficulties that it causes. It is designed to help even if the person with the gamblingproblem is unwilling to change their gambling behaviour.Family support andpsychoeducationalgroup manualfor problem gambling41©2013 Centre for Addiction and Mental Health

TestimonialsTestimonialsIn this section, we share some of the feedback we have received when we have offered theprogram outlined in this manual at CAMH. We hope these comments will inspire you to offer theprogram at your agency!I just want to thank you for the workshops that you are presenting. This is giving me somuch more knowledge and acceptance and understanding, which is the start of the healingprocess for me. I feel like a sponge in the classes and I can’t get enough . . . I would like youto know how much I thank you for doing this! This program is giving me back the son I lovedand 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 gaveme 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 thatothers face the same issues.”Participating in the family group made me realize that I was having normal reactions to anabnormal situation. It mostly gave me hope for the future.”The topics for the group were very well chosen. Practical information was provided, plushaving a place to discuss my challenges with others struggling with the same issues mademe feel less alone.”The most beneficial part of the family group was learning communication skills and how toset 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.”Family support andpsychoeducationalgroup manualfor problem gambling42©2013 Centre for Addiction and Mental Health

ReferencesReferencesAmerican 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, childhoodmaltreatment, and family dysfunction: A controlled study of pathological gambling. Journal ofClinical Psychiatry, 73, 1293–1297.Centre for Addiction and Mental Health (CAMH). (2004). Putting family-centred care philosophyinto practice. Report prepared by Community Research, Planning and Evaluation Team andCommunity Support and Research Unit, CAMH. Toronto: Author.Centre for Addiction and Mental Health (CAMH). (2008). Problem Gambling: A Guide forFamilies. Toronto: Author.Csiernik, R. (2002). Counselling for the family: The neglected aspect of addiction treatment inCanada. 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 andyoung people living in a family where parental gambling is a problem. Journal of GamblingStudies, 17 (1), 23–45.Dickson-Swift, V.A., James, E.L. & Kippen, S. (2005). The experience of living with a problemgambler: 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 tothe Canadian Centre on Substance Abuse (CCSA).Grant Kalischuk, R.G., Nowatzki, N., Cardwell, K., Klein, K. & Solowoniuk, J. (2006). Problemgambling 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 psychologicaldistress among concerned significant others of pathological gamblers. Journal of Nervous andMental Disease, 195 (1), 65–71.Ingle, P.J., Marotta, J. McMillan, G. & Wisdom, J.P. (2008). Significant others and problemgambling treatment outcomes. Journal of Gambling Studies, 24, 381–392.Family support andpsychoeducationalgroup manualfor problem gambling43©2013 Centre for Addiction and Mental Health

ReferencesKelley, M.L. & Fals-Stewart, W. (2002). Couples- versus individual-based therapy for alcoholismand drug abuse: Effects on children’s psychosocial functioning. Journal of Consulting and ClinicalPsychology, 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 andtreatment prognosis of pathological gamblers with and without recent gambling-related illegalbehaviour. Journal of the American Academy of Psychiatry and the Law, 35, 294–301.Lee, B. (2008). Congruence couple therapy for pathological gambling. International Journal ofMental Health and Addiction, 7 (1), 1–26.Makarchuk, K., Hodgins, D.C. & Peden, N. (2002). Development of a brief intervention forconcerned 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 gamblingas 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. Ouellette-Ngocsoeng, M. (2008). Couple et jeu de hasard. Report submitted to the Fonds Québécois deRecherche 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 problemgambling: Methodological influences, standardized rates, jurisdictional differences, and worldwidetrends. Report prepared for the Ontario Problem Gambling Research Centre and the OntarioMinistry of Health and Long Term Care.Family support andpsychoeducationalgroup manualfor problem gambling44©2013 Centre for Addiction and Mental Health

Suggested readingsSuggested readingsCONCURRENT DISORDERSO’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 THERAPYFriedlander, M.L., Escudero, V. & Heatherington, L. (2006). Therapeutic alliances in couple andfamily 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 skillsin 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 thepractice of marriage and family therapy. Boston: Pearson Education.FAMILY-CENTRED WORKCentre for Addiction and Mental Health. (2004). Putting family-centred care philosophyinto practice. Report prepared by Community Research, Planning and Evaluation Team andCommunity Support and Research Unit, CAMH. Toronto: Author.Csiernik, R. (2002). Counselling for the family: The neglected aspect of addiction treatment inCanada. Journal of Social Work Practice in the Addictions, 2 (1), 79–92.GROUP WORKBrown, N. (2011). Psychoeducational groups: Process and practice. New York: Routledge.MODELS/APPROACHESAndrae, D. (2011). General systems theory: Contributions to social work theory and practice. InF.J. Turner (Ed.), Social work treatment: Interlocking theoretical approaches (pp. 242–270). NewYork: Oxford University Press.Family support andpsychoeducationalgroup manualfor problem gambling45©2013 Centre for Addiction and Mental Health

Suggested readingsGehart, D. (2010). Mastering competencies in family therapy: A practical approach to theories andclinical 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: Theoverlooked foundation for effective practice. New York: Guilford Press.PROBLEM GAMBLINGDickson-Swift, V.A., James, E.L. & Kippen, S. (2005). The experience of living with a problemgambler: 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: Asystematic review. Manuscript submitted for publication.SUBSTANCE USESloss, C., Bubbra, S., Kelly, C., Shenfield, J. & Tait, L. (2008). Families care: Helping families copeand relate effectively. Facilitator’s Manual. Toronto: CAMH.Family support andpsychoeducationalgroup manualfor problem gambling46©2013 Centre for Addiction and Mental Health