TOWARDS A BETTER UNDERSTANDING OF WOMEN WHO ...

Bingo Scratch Tickets Slot Machines Pai GowMah Jong Roulette Blackjack Lottery Craps Horses Raffles PokerTOWARDS A BETTERUNDERSTANDING OFWOMEN WHOPROBLEM GAMBLE:Information forProblem GamblingCliniciansCGROWTHCommittee onGambling Resourcesfor Ontario WomenTo reduce Harm

AcknowledgementsThe Committee on Gambling Resources for Ontario Women Toreduce Harm (CGROWTH) would like to thank all of those who havemade this first project possible. We are grateful to Carol Gold andVincente Gammon of the Ministry of Health and Long Term Care fortheir support of this project and to Raimo Viitala, Nancy Bradley, NinaLittman-Sharp and Carol Wu for their administrative support. Wewould also like to thank Kim Gosnell and the rest of our colleaguesand acquaintances who took time out of their busy schedules toreview the documents and provide invaluable feedbackFinally, we wish to thank the women across Ontario who shared theirwisdom and experience which was documented in a report calledVoices of Women who Gamble in Ontario (VOICES). They confirmedand enriched our understanding of the unique treatment needs andissues of women who gamble at a problematic level.Project CoordinatorThis booklet was researched and written for CGROWTH by RobertaBoughton, M Ed., NCGC, Women’s Gambling Specialist, Centre forAddiction and Mental Health (CAMH), Toronto, Ontario.Please direct any enquiries or comments to:Roberta_Boughton@camh.netContributors and Committee Members of CGROWTH:CGROWTH is a committee made up of women’s specialists indesignated Problem Gambling Treatment agencies across Ontario.The goal of this Committee and this guidebook is to reduce theharmful effects of problem gambling among women and to promotespecialized services for women experiencing problems.Roberta Boughton, Problem Gambling Service, CAMH, TorontoBeth Murray, Jean Tweed Centre, TorontoJordanna Davidson, Jean Tweed Centre, TorontoGundel Lake, Amethyst Women’s Addiction Centre, OttawaSandy Byrne, Sault Area Hospital, Sault St. MarieErin Dietrich, St. Joseph’s Care Group, Thunder BayNancy Black, St. Joseph’s Care Group, Thunder BayFunding provided by The Ministry of Health and Long Term CareGuidebook for PG Clinicians, Produced by CGROWTH

When I crashed with my gamblingaddiction in 2001 I was in a constanthigh state of panic, agitation, anxiety, fear,guilt, shame and I was suicidal at the time.I had no clear thoughts.Treatment in its initial stage provided mewith structure and guidance. At that pointI’m not sure if I knew how to put one footin front of the other.I was taught about safety. How to staysafe from my own destructive behaviour. Iwas taught how to take care of myself whenI didn’t know what taking care of myselfmeant. Treatment was truly a place whereI was not judged.Guidebook for PG Clinicians, Produced by CGROWTH

A Guidebook for TreatmentProfessionals Who Work with WomenThis booklet is intended for those of you involved in the treatmentof women who problem gamble. Although written specificallyfor counsellors within Ontario agencies that form the designatedsystem, it may be of value to other professionals who treat womenwho gamble.The Committee on Gambling Resources for Ontario Women Toreduce Harm (CGROWTH) has produced this brief guide to highlightsome of the key issues and helpful approaches in working withwomen who problem gamble. The booklet provides a frameworkfor understanding how men and women experience the worlddifferently, summarizes the ways in which women’s gambling isdistinct, and provides guidelines for women-sensitive treatment.We draw on worldwide gambling research, information gatheredin a provincial study, feedback from women in treatment and bestpractices literature on the treatment of women with substance abuseand gambling issues. We hope it will provide helpful information inyour treatment practice.As treatment professionals you may already be familiar with much ofthe information about the context of gambling in Ontario, includingtreatment options. You will be aware of the rich resources availablefor the more generic treatment strategies and issues. However, it isour hope that we can help build your knowledge and expertise byhighlighting some of the important features of working specificallywith women who problem gamble.Why is it Necessary?As you know, gambling opportunities have expanded rapidlyin Ontario over the past ten years. Gambling, historically a maledomain, is rapidly becoming a mainstream activity for women.There has, however, been a lack of literature and research specificto women who gamble and problem gamble. Much that has beenwritten about problem gambling focuses on men and is applied towomen with the erroneous assumption that the gender differencesare irrelevant and that women’s and men’s needs in treatment arethe same.Guidebook for PG Clinicians, Produced by CGROWTH

ContentsQuick Facts: Gambling in Ontario 2006Quick Facts: Women’s GamblingA Quick Trip through the Gendered UniverseWhy are Women any Different Than Men When it Comes toGambling and Treatment Issues?How Women’s Lives are DifferentSocio-economic FactorsIssues of Violence and TraumaMental Health IssuesDrug and Alcohol use and AbuseInteresting DifferencesWhat does all this have to do with Gambling?Gender & Gambling Related ProblemsThe Treatment GapBarriers for WomenInternalExternalGuidelines to a Woman-Sensitive Orientation to TreatmentRecognize the Social Context of Women’s LivesEmpowerment and a non-Directive ApproachBuild Self-Esteem and Confidence: Build on StrengthsEncourage Self-CareProvide a Safe EnvironmentRemove Barriers to TreatmentHolistic Approach to WellnessEmbrace Diversity – Recognize and Respect DifferencesFirst Nations, Métis and Inuit WomenVisible MinoritiesOlder WomenLesbian and Bisexual WomenFlexibility of Treatment OptionsImportant Approaches to Working with WomenLet Her Tell Her StorySupport her Treatment GoalsNormalize the GamblingActive Facilitation & ValidationBalance Empathy and ResponsibilityTherapeutic ApproachesSkill TrainingGuidebook for PG Clinicians, Produced by CGROWTH

Engaging Women who Problem GambleOutreach to Women who GambleNetworkingDoing an In-Depth AssessmentTalking about the GamblingThe Complete Picture of a Woman’s Life…Other Helpful Screening ToolsTreatment Service Needs of OntarioWomen Who Problem GambleValue of a Woman’s Support GroupPhone CounsellingOngoing Treatment: Special NotesDealing with Cognitive Distortions around GamblingProvide Accurate InformationEducation about Gambling HooksFinancial Health and Reality CheckMoney TriggersWomen’s VOICES:The Issues for Gambling Women of OntarioVoicesDesignated SystemKey Feelings and Issues for Women in RecoveryLeisure and Social ChoicesGuilt, Shame, and Self-EsteemSelf-CareAngerGriefRelationshipsViolence and TraumaAppendix & HandoutsReferencesGuidebook for PG Clinicians, Produced by CGROWTH

Quick Facts: Gambling in Ontario 2006• Opportunities to gamble in Ontario now include 4 commercialcasinos, 6 Charity Casinos, and slots at 15 raceways.• 83% of Ontario adults gamble (Wiebe, J., Single, E., & Falkowski-Ham, A., 2001).• Advertising budget of the Ontario Lottery and Gaming Commission(OLGC) to promote gambling exceeds $400 Million per year(Sadinsky, 2005).• Profits on government run lotteries, slot machines and casinosincreased over 500% in ten years - 2.7 billion in 1992 to 11.3billion in 2002.• It is estimated that Ontario derives 35% of its gaming revenuefrom problem gamblers (1-4% of gamblers) (Williams & Wood,2004).• Government funding for prevention, treatment and research isset at 2% of the gross revenue from slot machines at charitycasinos and racetracks. In 2004 this produced an allocation ofapproximately $36 Million (Sadinsky, 2005).• In 1993 a conservative estimate of the annual cost to society ofeach problem gambler was $13,200 US (Smith & Azmier, 1997).Ontario’s TreatmentGap 20051.4% - 2.2 % ofProblem GamblersSeek TreatmentGuidebook for PG Clinicians, Produced by CGROWTH

Quick Facts: Women’s GamblingBINGO• Highest Canadian gambling expenditureis on Bingo (2001 Stats Canada)• Canada’s third most frequently playedgame, 1 in 5 plays once a week.• Most popular in the Atlantic Provinces• Women 3 times more likely to play(Marshall & Wynne, 2003)A USA study finds 22% increase between1975 and 1998 in the number of womenwho ever gambled (NORC, 1999).VOICESof Women who GambleOntario has the distinction of hostingone of the rare needs assessments ofwomen gambling at a problem levelwho are not in treatment.Voices of Women who Gamblein Ontario: A Survey of Women’sGambling, Barriers to Treatmentand Treatment Service Needs(Boughton & Brewster, 2002)It involved 365 women from acrossthe province. Their contributionto our understanding of women’sgambling confirms much of theexisting literature.137,000Ontario Womenwith GamblingProblemsSlot Machines were Originally Positionedto Keep Women Occupied While TheirSpouses Played Cards, Craps or RouletteGuidebook for PG Clinicians, Produced by CGROWTH

A Quick Trip Through the Gendered UniverseWhy are Women any Different Than Men When itComes to Gambling and Treatment Issues?Gender plays a significant role in the understanding and treatmentof problem gambling. Gender impacts the type of gambling peopleengage in, how much people spend while gambling and how oftenpeople gamble. Gender also impacts the reasons why people gamble,their treatment seeking behaviours and treatment needs.As counsellors we need to be aware of and sensitive to the importanceof the social context of women’s lives. Women are often impactedby disadvantaged socioeconomic status, issues of power, socialinequality, abuse and violence. In addition, the evidence is mountingthat men and women live in different psychological worlds related tobiochemical and physiological differences.Our intention is not to argue thatwomen’s needs are more importantor their problems worse than thoseexperienced by male gamblers. Issuesof financial stress, self-esteem anddepression, for example, affect bothmen and women who gamble. Theinfluences shaping personal issuesmay, however, be different.Women experiencegambling andgambling problemsdifferently than men(Brown & Coventry, 1997)A gendered analysis is not simply about sex (physical,biochemical or genetic differences between men and women)but about “different roles, responsibilities and activitiesprescribed for women and men, based on cultural conventionsand expectation. These differences relate primarily to power— the relative possession or absence of it”.(Grant, 2002)Guidebook for PG Clinicians, Produced by CGROWTH

How Women’s Lives are DifferentA snapshot of differences in the way men and women experiencethe world is provided by looking at some of the facts on socioeconomicrealities, trauma histories and mental health data on menand women.Socio-Economic FactorsWomen are financially disadvantaged in comparison to men. Povertyor the threat of poverty is a very real issue for many women.Hot Off the Press: Women in CanadaThe average earnings of employed women are still substantiallylower than those of men, women make up a disproportionateshare of the population with low incomes and women aremuch more likely than men to work part time.(Stats Canada, The Daily March 7, 2006)Something to think about when wewonder why women gamble…Stats Canada (1997, 2006)• Women earn 71 cents for every dollar men earn• In 2003, 38% of single mothers fell in low-income category(compared to 13% of households headed by single men)Some women gamblers suffer additionalinequality and financial stress…• 49% Unattached older adult women live in poverty• Visible minority women generally earn less than do other women45%Bingo playershouseholdincomesless than 29K.(CBC Newsworld, 1999)10Guidebook for PG Clinicians, Produced by CGROWTH

Issues of Violence and TraumaViolence and trauma are a part of thefabric of many women’s lives.✓ More Ontario females than males reporta childhood history of severe sexualabuse (11.1% vs. 3.9%); severe physicalabuse is reported at the same rate for girlsand boys (9.2% vs. 10.7%) (MacMillan,Fleming, Trocme, Boyle, Wong, Racine,Beradslee & Offord, 1997).Every minuteof every day, awoman or childin Canada isbeing sexuallyassaulted(Stats Canada, 2002)✓ One half of Canadian women have survived at least one incidentof sexual or physical violenceFear of violence limitsmany women’s lives:42% of womencompared with 10% ofmen feel totally unsafewalking in their ownneighbourhood afterdark.(Stats Canada, 1995)Canadian Crime Statistics (2000)• Male on female violence accountsfor the majority (46.5%) of allviolent crime• Female on male violenceaccounted for the lowestpercentage of all violent crime(7.6%)Violence towards women is endemic to our society,a social reality often ignored by health professionals.A recent article in Psychiatric News notes the highincidence of physical (44%) and sexual abuse (34%) inthe adult lives of many women seen by psychiatrists andmental health professionals. The symptoms of abuse(including flashbacks, dissociation, mood fluctuationsand impulsive behaviours) are often misdiagnosed aspsychosis and bipolar disorder.(Boughton, 2003)Guidebook for PG Clinicians, Produced by CGROWTH 11

Mental Health IssuesWomen’s experiences of mental healthand addiction issues are distinct fromthose of men. Depression, generalizedanxiety and panic disorders are twiceas frequent.Women make3-4 times moresuicide attemptsthan menCanadian Mental Health Association(1999) Women % Men%Anxiety Disorder 28 17Affective Disorder 14 7Social Phobia 16 10Simple Phobia 12 5.3Depression 10 4.8Dysthymia 4 2.3Any mental disorder 36 2215-20% ofWomen WillExperiencePostpartumDepressionIn addition, women make up….• 90% of Canadians with anorexia or bulimia.• 70% of people diagnosed with borderlinepersonality disorder (Haskell, 2003).Bipolar disorder impacts men and women equally but theirexperiences are distinctly different. Women report more disruptionin their lives and more co-morbidity. Men are three times more likelyto have been jailed, arrested or convicted of a crime.Gender Differences in Drug andAlcohol Use and Abuse…• Proportion of alcohol-dependentCanadian men is 3 times that of women(3.9% vs. 1.3%).• Men are more often dependent on illicitdrugs (1.1% vs. .5%).• Women show a disproportionate use ofmedications in all categories, includingpainkillers, sleeping pills, tranquillizers,anti-depressants and diet pills (Poole & Dell, 2005).Many of thewomen who havebeen consideredborderline are infact experiencingcomplex posttraumaticstressresponses(Haskell, 2003)• Women are twice as likely to be prescribed Benzodiazepines.12Guidebook for PG Clinicians, Produced by CGROWTH

Interesting DifferencesEvidence is mounting that there are basic biological and evolutionarydifferences that suggest that men and women behave differentlybecause they think differently.The Essential Difference by Baron-Cohen (2003)Men and women think differently, approach problems differently,emphasize the importance of things differently and experiencethe world around us through entirely different filters.• Women value altruistic reciprocal relationships while men seekpower and status• Women look for empathic friendships and equality; men basethem on shared interest and competition• Women talk to bind socially while men use conversation todemonstrate knowledge, skill and status• Women talk about people, men talk about objects• Women show aggression covertly with verbal tactics such asgossip and exclusion; men are more likely to hit and pushWhat does all this have to do with Gambling?Differing psychological orientationsof men and women are reflectedin their gambling preferences andpatterns. Men generally engage theworld as individuals in a hierarchicalsocial order in which he is eitherone up or one down. It is a worldof status where independence isvalued. Women generally engage theworld as individuals in a network ofconnections where life is community,a struggle to preserve intimacy andavoid isolation (Tannen, 1990).Women are moreconcerned about beingliked than jockeyingfor status: “Havinginformation, expertiseor skill at manipulatingobjects is not the primarymeasure of power formost women. Rather theyfeel their power enhancedif they can be of help.(Tannen, 1990)These differences help to explain the typical gambling choices ofmen and women. Men’s tendencies to promote themselves in ahierarchy by beating other players or showing a superiority of skillare facilitated in card games, sports betting and handicapping.Guidebook for PG Clinicians, Produced by CGROWTH 13

Bingowinnings areusuallyshared:sharing isa way ofsustainingspecialnetworks(Dixey, 1987)Not all women avoid competition; some,particularly middle-class career womenbecome empowered through competitionin a male-dominated world (Lesieur &Blume, 1991). Generally, female prioritiesof connection and intimacy are bettermet in games where winning is not at thedirect expense of others. Ontario womengenerally prefer games that are lessdirectly combative, like games of chancesuch as Bingo, slot machines and scratchtickets (Wiebe, Single & Falkowski-Ham,2001). They often begin to gamble in asocial context in which relationships arenurtured (Dixey, 1987).Motivation to gamble often differs.Women are prone to use gamblingto escape, reduce stress, soothe ordistract. Their preference is for gamesof luck that do not require high levels ofconcentration. Men’s gambling choiceis often for games that involve mentalconcentration or higher action andstates of arousal.Problem GamesFor Women• Slots/VLT• Bingo• Scratch• TicketsWomen tend to gamble smaller amounts, which is likely a function ofmore limited earning power and different attitudes towards money.Gender & Gambling Related ProblemsThe games that women play, slots or VLT, Bingo and scratch tickets,are continuous play games. They are the most highly addictive formsof gambling because of the rapid and intermittent reinforcementpayouts, which are unpredictable small or large wins that generateexcitement and encourage continued play.VLT machines have been referred to as the“crack cocaine of gambling” (Hill, 1997)14Guidebook for PG Clinicians, Produced by CGROWTH

Internal BarriersMany women who problem gamble avoid seeking help because ofstigma and shame. These are barriers similar to those experiencedby women struggling with substance abuse (Roberts & Ogborne1999).Women’s Substance Abuse Treatment in CanadaWomen experience…• Greater stigma attached to substance abuse problemsthan do men• Greater resistance on the part of family and friends• More negative consequences attached to treatment entry(Roberts & Ogborne, 1999)Women with gambling problems are viewed more negatively thanare men (Walker, 1992). This stigma is augmented by media bias,which sensationalizes stories by focusing on maternal roles. Thisfocus is rarely taken with men who gamble (Mark & Lesieur, 1992).Women are acutely aware of the stigma applied by society to awoman who fails to meet the high moral standards expected ofwomen (Lesieur & Blume, 1991). The gambling is often shroudedin secrecy.Likely related to this, womenwho problem gamble are morelikely to seek help from informalsources. They access family andfriends twice as often as outsidesources (Schellinck & Schrans,1997-1998). The VOICES womenconfirm this, less than onehalf indicate they would seekprofessional help.Many women who problemgamble do seek help frommental health workers, medicalprofessionals or financialinstitutions in efforts to repair thefinancial and emotional stressesrelated to gambling, often withoutdisclosing the gambling.A Double StandardA male problem gambleris tolerated but not so thefemale problem gambler:There is a quality ofdissoluteness, immoralityand indecency that peopleread into it, exceedingeven that attributed tofemale alcoholics. Knowingthis, women compulsivegamblers do everythingthey can to hide theirproblem not only from theirhusbands but also fromeverybody else.(Custer, 1985)18Guidebook for PG Clinicians, Produced by CGROWTH

Ontario Women Who GambleVOICES women expressed fears of exposure and humiliation asbarriers to seeking treatment:Fear of being recognized 17%Fear of having others learn of the gambling 22%Fear of being criticized or judged 34%Embarrassment or shame 33%(Boughton & Brewster, 2002)In order to understand women’s gambling it is critical to appreciatethe complexity and variety of issues shaping women’s lives. Thebiopsychosocial model provides a framework for understanding andtreating problem gambling. This model describes a triangulationof factors (cultural and social, psychological and physiological orbiochemical) that shape or influence gambling behaviour (Grant, 2002)A gendered analysis is not simply about the physical, biochemicalor genetic differences between men and women, but about differentroles, responsibilities and activities prescribed for women and men,based on cultural conventions and expectation. These differencesrelate primarily to power — the relative possession or absence of it.External Barriers(Grant. 2002)A number of practical barriers to treatment need to be addressed tofacilitate women’s access.Access• flexible hours of operation• location safe with easy access• provision of fare for public transportation• wheelchair rampsChild Care• on-site childcare• funds for babysittingLanguage and Cultural• translation services• collaboration with treatment services that offercounselling in the woman’s preferred language• materials that are written in “plain English”Guidebook for PG Clinicians, Produced by CGROWTH 19

Summary: Gender Differences and GamblingThis brief overview of some gender differences emphasizes thatthe issues and concerns of women in gambling treatment may bedistinctively different from those of men:• Financial stressors and obstacles related to debt resolutionand earning potential• Issues of co-morbidity (depression, anxiety, prescription druguse, eating disorders, PTSD)• PTSD and trauma histories - issues of physical andpsychological safety• Gambling triggers, motivations, games and socialreinforcementThe following segment provides some tips on what is important inproviding women-sensitive treatment. Both structural issues and theemotional/psychological approaches to assessment and treatmentwill be considered.20Guidebook for PG Clinicians, Produced by CGROWTH

Guidelines to a Woman-SensitiveOrientation to TreatmentThe literature on treatment of women who problem gamble is in shortsupply. Best practices have yet to be established on an internationallevel (Jackson, Thomas & Blaszczynski, 2003). Moreover, thetreatment needs of women who problem gamble have been largelyignored. The recent burst of studies looking at gender differencestend to gather the same demographic and gambling data withoutactually plowing ahead to look more specifically at treatment needsand issues (Boughton, 2003b). Although a few studies identifygender differences in treatment needs, our knowledge about optimalstrategies is insufficient (O’Connor et. al., 2000: Ladd & Petry, 2002).Treatment is typically based on male models and needs to be modifiedfor use with women who problem gamble (Crisp et al., 2000).The wisdom of treatment provider’s collective clinical experience,backed up by the literature on the Best Practices in the treatment ofwomen and substance abuse and the information gathered in theVOICES study, informs and identifies some optimal strategies forworking with women who gamble.In the following section, some important features of a womensensitiveapproach to outreach, assessment and treatment of womenare highlighted.Guidelines: Woman-Sensitive Orientation to Treatment✓ Recognize the Social Context of Women’s Lives✓ Empowerment and a non-Directive Approach✓ Build Self-Esteem and Confidence: Build on Strengths✓ Encourage Self-Care✓ Provide a Safe Environment✓ Remove Barriers to Treatment✓ Holistic Approach to Wellness✓ Embrace Diversity – Recognize and Respect Differences✓ Flexibility of Treatment Options✓ Important Approaches to Working with WomenLet Her Tell Her StorySupport her Treatment GoalsNormalize the GamblingActive Facilitation & ValidationBalance Empathy and ResponsibilitySkill TrainingGuidebook for PG Clinicians, Produced by CGROWTH 21

Recognize the Social Context of Women’s LivesWomen live in different worlds than do men. Sensitivity to the socialcontext of their lives and issues such as gender stratification andpatriarchy, disempowerment, bias and oppression are importantconsiderations when providing treatment.Empowerment and a Non-Directive ApproachNo source outside the womenknows better than herself what isbest for her…This demystificationis essential if women are toachieve a sense of their ownpower in therapy.(Greenspan, 1983)Empowerment is crucial;it is about choice, selfdeterminationand sheddingthe traditional expert/patienthierarchy for a relationalmodel of treatment.A Case in PointMark & Lesieur (1992) note discomfort with the GA insistencethat all financial assets be relinquished to and controlled by thespouse: In those traditional marriages where wives are alreadysubordinate to and financially dependent on their husbands, thissuggestion only serves to reinforce the existing patriarchy.Build Self-esteem & Confidence:Build on Strengths rather than PathologizeHelping a woman to becomeempowered is also aboutbuilding self-esteem, confidenceand a sense of control over herlife. Self-esteem is often severelyaffected by sexism and traditionalsocietal ideas of women’s placein the world (Lesieur & Blume,1991).Whereas men are socializedto be powerful and dominantand may need an experienceof humility to enhance asuccessful recovery, womenare socialized to be passiveand dependent and need tobe empowered to developand maintain a positive selfimage.(Wilke, 1994)22Guidebook for PG Clinicians, Produced by CGROWTH

Encourage Self-careWomen are often caregivers, socialized to be over-responsible inrelationships, prone to de-self, putting the needs of others first,allowing too much of self to be negotiable under pressure from therelationship (Lerner, 1985).Many have not established a healthy balance between taking care oftheir own needs and the needs of others. They often feel guilty andselfish if they take time for themselves.The demand to be Superwomen,juggling family and career, hascreated a whole new set ofproblems for women who feelthat they should, but do not,measure up.(Greenspan, 1983)Women are society’scaregivers, constituting80% of people providingcare, whether or notthat care is paid for orprovided in institutionsor at home. (Grant, 2002)Women experience significant life-stress as a result of this imbalance(Blume & Lesieur, 1991). Stress–relief is often a reason for gambling.Women’s gambling can also be a way to express exhaustion andfrustration with care-taking demands. Counsellors can validate awoman’s right and need to escape but encourage her to find healthyalternatives to nurture and reward herself.VOICES Reason for Gambling:Stress Relief• Relief from stress 53%• Get a break from reality 49%• Escape problems or worries 48%• Break from responsibilities/work 46%(Boughton & Brewster, 2002)VOICES Reasons for Gambling:Autonomy• Be free to do what I want 56%• Treat myself 48%• Have time for myself 46%(Boughton & Brewster, 2002)Guidebook for PG Clinicians, Produced by CGROWTH 23

Provide a Safe and Welcoming EnvironmentPhysical and emotional safety is a priority in a treatment setting.Policies and practices need to be in place that guarantees freedomfrom violence, harassment or discrimination of any kind.Female counsellors are optimal. Posters depicting women’s diversityand strengths convey a message that all are welcome.Holistic Approach to WellnessA focus on wellness and health means treating the person, not justthe problem. Supplement gambling specific treatment with referralsto other resources to deal with mental or physical health, housing,finances, employment, trauma, family counselling or addiction asneeded.Best Practices for gambling treatmentrecommend a biopsychosocial model.It reflects a “triangulation of influencesthat includes the biochemistry of individual,psychological aspects of the individual’sfunctioning and the cultural and socialforces shaping behavior”.(Allen, 2003; O’Connor et al., 2000)24Guidebook for PG Clinicians, Produced by CGROWTH

Embrace Diversity:Recognize, Respect and Attend to DifferencesWhile there has been little research conducted on women andproblem gambling in general, there has been even less research thatexplores the unique needs and experiences among women.Women who gamble are distinct and unique. It is necessaryto recognize, respect and attend to differences in women’s lifeexperiences. Treatment needs to acknowledge issues related tosocial, cultural and ethnic influences. There are forces impactingspecial populations of women like visible minority populations, olderwomen and lesbian or bi-sexual women.First Nations, Métis and Inuit WomenFirst Nations, Métis and Inuit womensuffer the impacts of the systemicbreak down of traditional lifestyles,cultural practices and values. Manylive with a legacy of forcible family andcommunity separation resulting fromthe residential school system imposedby the Canadian government from1874 to 1996. Many also live with theimpacts of violence and sexual abuse.High prevalence rates of problem andpathological gambling exist both onand off reservations. Levels of drugand alcohol use are high.Mortality rate due toviolence for CanadianAboriginal women isthree times that fornon-Aboriginalwomen.(Poole & Dell, 2005)77% of those whoattended a ResidentialSchool - Problemor PathologicalGamblers(OFIFC, 2000)Aboriginal people are 2-5 timesmore likely to be problemgamblers compared to non-Aboriginal populations(Wardman, el-Guebaly & Hodgins,2001)Ontario treatment system43% Aboriginals reportBingo problematic.(Rush & Moxam, 2001)In Ontario, Bingo is thegame played most oftenand with the highestaverage monthlygambling expenditure.However, casino accessis increasing for FirstNations, Métis and Inuitwomen. Older women,in particular, are luredto casinos by freetransportation, dining andgambling vouchers.Guidebook for PG Clinicians, Produced by CGROWTH 25

Visible MinoritiesA number of unique stressors may operate on women from diversecultural and ethnic backgrounds. Cultural and religious attitudestowards gambling impact women. While gambling is part of thesocial fabric of some cultures, others prohibit gambling, increasingshame. Cultural prohibitions against gambling and culturalperceptions of women’s roles may be so strong that women areafraid to acknowledge problems with gambling.Cultural attitudes towards helpseeking may also limit women’sability to utilize services. The absenceof community and support systemsleaves women feeling isolated.Women of a visibleminority make up 19% ofthe population of Ontario(Stats Canada, 2006)Culturally competent and culturally sensitive services are important.Networking with ethno-cultural services is essential in providingsupport to women accessing gambling services. Using a personcenteredapproach and allowing women to be the cultural guide(Leigh, 1998) provides opportunity for engagement and encouragesthem to share about their own unique life experiences.Barriers to treatment for ethno-culturally diverse groups of womenmight include:• lack of culturally specific outreach• lack of language–specific or translation services• lack of culturally specific programming• fear of discrimination and invisibility of specific needs• immigration or refugee status26Guidebook for PG Clinicians, Produced by CGROWTH

The issues are further magnified for women living in Canada withoutrecognized status, some of which are identified in the following textbox:Potential Issues for Visible Minority Women• Poverty• Patriarchal Family Systems• Discrimination• Racism• PrejudiceImmigration• Loss of social status and income• Separation from family/friends• Limited Supports• Isolation• Language and culture barriers• Generation/Cultural Gaps• Acculturation• Post Traumatic Stress Disorder (PTSD)from war, famine, oppression, tortureNon-status Issues• Limited access to education and health care• Unemployment/Underemployment• Exploitation• Fear of being deported• Fear of accessing 911 or emergency servicesOlder WomenOver the years, the rate of gambling among older adults has increasedsignificantly. NORC, (1999) reports a 45% increase between 1975-1997.Age related changes may bring increased incentives to gamble andincreased risks. These could include:• Changes in disposable income• Increased financial stress• Increased social isolation• Reduced leisure options• Increased health issues• Chronic pain• Cognitive impairment• Mental health problems• Issues of loss and depression• High suicide levelsGuidebook for PG Clinicians, Produced by CGROWTH 27

These factors, in combinationwith promotional enticementssuch as free transportationand financial incentives, putolder women at high risk.Some argue that problemgambling among older adultsis an unrecognized publichealth problem (McNeilly &Burke, 2001,1998).✓ 82% of seniors living athome have a chronic healthcondition(Stats Canada, 1998)✓ 1/3 of New Brunswick seniorshave taken prescriptionstrength pain medication inthe last year(Schellinick, et al.2002)27% of Ontario seniorslive off guaranteedincome supplementPlaying 2 games ofBingo a month…uses 10%of annual income(Govoni et al., 2001)Overall gambling expenditures amongolder women in treatment are higherthan any other age group. According tofindings reported by Petry, 2002, olderadult women spent in excess of 200%of their incomes. Senior women fromthe VOICES study reported gambling144% of their personal incomes;twice as much as any other age group(Boughton, 2004).Lesbian and Bisexual WomenCurrently there is no existing research that explores the connectionsbetween sexual orientation and problem gambling. Clinicalexperience suggests that there are specific life factors among lesbianand bisexual women that render some vulnerable to problematicgambling.Although a small sample,the lesbian and bisexualwomen in VOICES (n=27)report high levels of:• depression 74%• anxiety 63%• panic 44%Compared to the rest of thesample, they also reportedsignificantly higher levels ofabuse and addiction.Specific life factors that relateto addiction for lesbian andbisexual women:• “Coming-out” process• Homophobia and biphobia• Internalized homophobia andbiphobia• Loss of family support• Social isolation and alienation• Body image issues(Barbara, Chaim & Doctor, 2002)28Guidebook for PG Clinicians, Produced by CGROWTH

VOICES : lesbian & bisexual women aresignificantly more likely than heterosexual women to report:• Histories of childhood abusePhysical 67%**Sexual 70%**• Experiences of homophobia 59%• Serious thoughts of suicide 70%**• Attempted suicide 48%*• Hospitalization 41%*• Past histories of prescription 37%*and non-prescription drug use 48%**** p< .01 , p< *

Flexibility of Treatment OptionsThere is not, nor could there be,a template of unilateral treatmentfor women with gamblingproblems. Female gamblers arenot a homogeneous group anymore than are female alcoholics(Walker,1992, Underhill, 1985).✓ Develop a multifaceted, flexibleand eclectic treatment approach,borrowing from the wisdom ofdiverse approaches in meetingthe needs of women whoproblem gamble.✓ Provide an integrated treatmentapproach. Utilize external orinternal referrals to supplementspecific treatment of thegambling.✓ Provide women with a range oftreatment options using a stepcareapproach of increasingintensity to match needs.Women differ in the amountand type of intensive workneeded to change the directionof their lives. Gambling maybe the last of a long line ofmaladaptive coping strategiesthat evolved over the years,or a recent blip in the screenof a generally well-adjustedlife. It may have roots thatreach deep into the fertilesoil of a traumatic childhood,or be a result of entrapmentfrom advertising hype aboutthe ease of winning a fortune.How we address the gamblingis very much a function ofclient needs, learning stylesand presentation. These varyacross individuals and acrossthe change process of anindividual client.(Boughton, unpublished)Some women who engage in treatment are already active in makingchanges. Often, it is sufficient to set goals around the gamblingand address relapse prevention strategies. These women oftenmatch Blaszczynski’s description of normal gamblers. The processof reaching out for assistance, when met by encouragement andvalidation, is enough to help the women consolidate changes in thegambling behaviour.Other women fall into the vulnerable group described by Blaszczynski.They may have considerable ambivalence about making changes.Gambling has served as an escape or coping strategy. These womenoften need more intensive work to deal with the triggers to gambling,both past and present. The extensive emotional and relationshipproblems necessitate more comprehensive treatment programs(Mark & Lesieur, 1992) and a referral to a residential or intensive dayprogram may be optimal.30Guidebook for PG Clinicians, Produced by CGROWTH

Important Approaches to Working with WomenLet Her Tell Her StoryBeing listened to is one of the more powerful needs of women. Thisis both client-centered and critical to developing a good therapeuticrapport. Research into the effectiveness of various therapies indicatesthat the particular therapeutic approach is less important to thetreatment outcome than the therapeutic relationship and therapistqualities of empathy and authenticity.Support Treatment GoalsIdentify, clarify and support individual treatment goals specific togambling. This may involve discussion about program expectationsaround abstinence. An obstacle to seeking treatment for many womenis the fear that they will be required to give up all gambling. Whengambling has served as a coping strategy or source of recreationand leisure, this threatened loss creates considerable apprehensionand sometimes defiance. Women visibly relax when assured thatthey are free to choose their own goals around gambling.Some variation of the Miracle Question, a technique of solutionfocused brief therapy, can help identify long-term goals (Kim Berg& Briggs, 2002). It also serves as a powerful tool to fuel hopes andhelps to create a vision of a more positive future.Normalize the Gambling BehaviourNormalize the gambling behavior and struggles that women maybe having around trying to control the gambling. Women oftenperceive themselves or their situation as hopeless and deviant, aself-image exacerbated by the isolation and secrecy that surroundproblem gambling. Providing relevant feedback and informationabout women and problem gambling helps provide a more realisticframework and reassurance that these issues can be effectivelyaddressed.Guidebook for PG Clinicians, Produced by CGROWTH 31

Active Facilitation & ValidationRemaining silent when listeningto women’s pain and despair mayincrease their shame and discomfort.Active facilitation involves moreengagement by providing sensitiveand empathic responses to what isbeing disclosed (Haskell, 2001).Validation of women’s experiencesis essential to keeping lines ofcommunication open. Validationinvolves a nonjudgmental therapeuticattitude and continual search for theessential validity of each client’sresponses (Linehan, 1993).Tasks of Validation:Active FacilitationReact so clientsunderstand how you arethinking and feeling aboutwhat they are disclosing.Make a direct statement,such as “I now understandwhy you feel…”. Thisreflects empathicreactions, whereas simplyasking…” How did thatexperience make youfeel?” asks her to disclosemore information withoutreceiving any feedback.(Haskell, 2003)1) Help women observe and describe their emotions, thoughtsand behaviours.2) Communicate empathy and understanding (though notnecessarily agreement).3) Communicate that women’s responses make sense in thecontext of their life.4) Communicate to women that “I believe in you”.Balance Empathy and ResponsibilityAn empathetic approach in working with womenencourages change. It is equally important toemphasize that women need to be accountableand responsible for their own healing.Integrate praise& accountability(Najavits, 2002)Empathy without a belief that the client is able to make changesto help herself results in disempowering the client. On the otherhand therapists who emphasize change and responsibility withoutexpressing empathy for their clients struggle in making thesechanges may be perceived by the client as critical and blaming.(Haskell, 2003)32Guidebook for PG Clinicians, Produced by CGROWTH

Therapeutic ApproachesThere is no accepted bestpractice in gambling treatment(Blaszczynski, 1999). Moreover,despite controversy about themost effective treatments, there isevidence that different therapies areequally effective. The most effectivepredictors of success are the client’sreadiness to change (motivation)and therapeutic rapport.Because of the unique issues forwomen who problem gamble, anintegrated approach that addresses“cognitive, behavioural, andinterpersonal domains” (Najavitis,2002) as well as their emotionalwellbeing is necessary.No one school of therapyis superior but certaineffective ingredients cutacross different schoolsof therapy. An exampleis the disconfirmationof pathogenic beliefs.Proponents argue thatresearch comparingcognitive, experiential andinterpersonal therapieswould find no significantdifferences because all ofthe therapists would bedisconfirming patients’pathogenic beliefs albeitwith different techniques.(Persons & Silberschatz, 1998)Skill TrainingLimited coping skills are often an issue forwomen who problem gamble. They can benefitfrom the provision of a range of structuredskill training that targets emotional coping,cognitions, interpersonal skills, leisure, financesand behavioral change.It could be argued that all psychotherapeuticinterventions are a form of skill training, whetheraimed at problematic emotions, behaviours orthought processes. Some techniques are highlystructured, while others are more informal.Do not losetouch ofthe centraltherapeutic goal:giving clientsthe tools andknowledge theyneed to feelempowered andto learn skills(Haskell, 2003)Skill Training• Present and problem oriented• Educational• Directive and collaborative• Teaches self-control strategies• Emphasis on rehearsal of new skills• Homework• Commitment strategies (Najavits, 2003)Guidebook for PG Clinicians, Produced by CGROWTH 33

Learning new skills and making changes requires practice.Cognitive behavioural therapists promote the use of homework andcommitment strategies to encourage women to take action to makechanges.CGROWTH plans to develop a manual that addresses skilltraining for women who problem gamble. Some currentresources that address women struggling with drug andalcohol addictions, PTSD and BPD that can be adaptedinclude:• Lisa Najavitis: A Woman’s Addiction Workbook. YourGuide to In-Depth Healing• Lisa Najavitis. Seeking Safety. A Treatment Manual forPTSD and Substance Abuse• Sandi Harmer (Amethyst Women’s Addiction Centre):Women Juggling Roles: Skills for Change• Mary Ellen Copeland: The Depression Workbook: AGuide for Living with Depression and Manic Depression• Marsha Linehan: Skill Training Manual for TreatingBorderline Personality Disorder34Guidebook for PG Clinicians, Produced by CGROWTH

Engaging Women who Problem GambleOutreach to WomenDespite the fact that many Ontariowomen are encountering gamblingrelated problems, only 1-2% seektreatment. As a result, outreachservices to women who problemgamble is an essential component ofthe step-care approach to problemgambling services in Ontario.Women-SensitiveOutreach Services• Address fears• Articulate what to expect• Convey sensitivity• De-stigmatize• Information sharing• NetworkingOutreach services provide a level of support that focuses onreducing barriers women may experience in accessing services. Anempowerment approach to outreach addresses women’s needs andfears, de-stigmatizes women’s experience of gambling, providesinformation about the range of services and shares informationabout what to expect in treatment.Outreach services may vary depending on the unique needs ofwomen, communities and availability of other allied services. Forexample, in VOICES, the socio-economic context of the lives ofthe Bingo and slot players played a clear role in shaping both theirgame choice and treatment needs. Outreach services may focus onspecific groups of players to address their unique treatment needs.Ontario Women Bingo Versus Slot Players:Significant DifferencesBingo Players➤ less well-educated➤ lower personal and family incomes➤ more addiction & mental health in the family system➤ more often victims of abuse➤ more co-morbidity (depression, bi-polar, anger, panic)➤ more suicidal behaviours➤ more often struggles with other problem behaviours suchas compulsive shopping or drug/alcohol abuse➤ gamble smaller percent of personal incomes➤ as likely to be problem or pathological gamblers(Boughton, 2003)Guidebook for PG Clinicians, Produced by CGROWTH 35

NetworkingDeveloping and fostering links with community services, such asmental health programs, can be a vital component of providingoutreach to women in facilitating efforts to engage, educate andsupport women who gamble. As women often live with secrecy andshame surrounding gambling issues and avoid accessing gamblingtreatment services, it is important to engage them where they mayalready be accessing services. Networking strategies to involveauxiliary services might include:• Provision of brochures and posters geared to prevention,education and treatment of women gambling issues.• Educate service providers about women’s gambling and relatedissues, helpful ways of asking exploratory questions aboutgambling, available treatment and the referral process.• Enlist allied service providers to weave gambling screens andinformation sessions into existing programming.• Collaborate with service providers to serve as a consultant ifthey are able to address gambling awareness and issues as partof their ongoing treatment with their clients. This is extremelybeneficial where language is a barrier to treatment.These collaborative efforts provide a supportive and non-threateningapproach to increase women’s awareness of the risks of gamblingand support services available for gambling concerns.Doing an In-Depth AssessmentIt is critical to routinely complete in-depth assessments with womenwho problem gamble. It is important to ask women about all aspectsof their life, not just about gambling.Using effective engagement skills sets the tone during the assessmentprocess for women to explore their gambling related issues andother life areas that may have contributed to the gambling and mayneed to be addressed in treatment.36Guidebook for PG Clinicians, Produced by CGROWTH

An in-depth assessment:✓ Identifies barriers that may limit treatment options (e.g.,financial, legal, child care).✓ Places her gambling within a broader context.✓ Increases awareness of how gambling may be connected topast and present life events.✓ Assess possible safety issues to identify and respond to issuesof abuse, unsafe housing and suicidal ideation.Setting the Tone• Establish rapport• Be non-judgmental and neutral• Be respectful• Be positive and caring• Focus on strengths• Empower her to make choices• Normalize the development ofgambling problemsTalking about the GamblingWhen asking women about theirgambling activities consider thatthere may be misconceptionsof what types of games areconsidered forms of gambling.Women may not consider Bingo,scratch tickets, Mah Jong, cardswith friends or raffle tickets asgambling so it is important to namethe games.Women who gamble may reactstrongly to the term “problem” asit relates to their gambling. Theword may feel accusatory andshaming which may impact on theengagement process. It is helpfulto have a conversation about theconcerns they might have abouttheir gambling activities.It is important to address anypotential barriers to serviceaccess, as early as possible.This provides an opportunityto appropriately direct theassessment and subsequenttreatment planning.Assessment Tasks✓ Obtain backgroundinformation about herlife situation, culturaldynamics and gamblingbehaviours✓ Identify specific issuesthat may need to beaddressed to supporther change efforts✓ Explain what to expect intreatment & expectations✓ Offer treatment options✓ Develop a personalaction plan together✓ Make referrals toadjunct or alternativeprograms and resourcesdepending on need✓ Decide on a treatmentand follow-up planGuidebook for PG Clinicians, Produced by CGROWTH 37

The designated gambling treatment system uses a number of toolsto assess and report gambling problems (CATALYST). You will alsobe familiar with others from the gambling literature. These will notbe repeated in this booklet. Listed below are some of the gamblingspecifictools used.TOPICGambling Screens &Impact ToolsSituational determinantsof playSelf-efficacyTOOLSOGS, Gambling Impact Scale, DSM-IV,CPGI (or the short form-PGSI)Inventory of Gambling Situations(IGS)(Developed by Nina Littman Sharpe& Nigel Turner)Gambling Self-Efficacy Questionnaire(May, Whelan, Steenberg& Myers, 2003)The Complete Picture of a Woman’s Life…Exploring life areas other than gambling will help determine criticalnext steps in assisting women to develop realistic and achievabletreatment goals. Consider asking questions in these areas:1. Sexual/Physical/Emotional Health2. Disordered Eating3. Substance Abuse4. Prescription Medications5. Mental Health6. Money Management7. Care-Taking8. LeisureThe Assessment & Screening section in the Appendixoffers a detailed guideline of content areas to exploreduring the assessment including issues relevant towomen’s lives (e.g., prescription drug use, eating issues,physical or sexual violence).38Guidebook for PG Clinicians, Produced by CGROWTH

Helpful Screening ToolsThe assessment process may highlight areas or concerns that supporta more detailed exploration, such as mental/emotional health,substance use, financial stress or signs of trauma. Listed beloware a few brief screening tools that will help flag primary area(s) ofconcern. The first three of these screens can be found, in full, in theAppendix. Please note that a women’s report of extremely severesymptoms on one or more item may suggest a need for referralto another program/specialist/agency to provide additional support.The fourth and fifth screens can be utilized in CATALYST by mostagencies.1. Brief Psychiatric Rating Scale (BPRS)Helps determine presence and severity of psychiatric symptoms.2. Primary Care PTSD ScreenA helpful screen when women report a history of trauma orsymptoms consistent with past trauma experiences.3. Financial Check-upThe financial screen provides information that might suggestthe need for Credit Counselling services.4. Behaviour and Symptom Identification Scale (BASIS-32)Explores two areas among others, known to be prevalent towomen experiencing gambling problems: depression and anxiety.It can be useful with both adults and adolescents.5. Psychoactive Drug History Questionnaire (DHQ)This tool can be used regardless of age or gender to gatherdetails on alcohol/drug use patterns. It assists in decisionmakingabout concurrent substance abuse issues to prioritizetreatment needs (i.e., stabilization/withdrawal management,relapse potential).Some women may have difficulty sharing and speaking aboutpainful aspects of their lives. In such cases, it is importantto respect a woman’s comfort level. It is better to have lessinformation about a woman than to have her not come backbecause she feels she had to tell you things she really did notwant to reveal, she feels she has no more defenses, she doesnot want to be seen as a bundle of problems, or she feelsembarrassed or ashamed about what she has already told you.(ARF, 1996)Guidebook for PG Clinicians, Produced by CGROWTH 39

NOTES40Guidebook for PG Clinicians, Produced by CGROWTH

Treatment Service Needs of OntarioWomen Who Problem GambleThe service options that theVOICES women found asmost helpful were individualcounselling, women’s onlygroups, flexible service hours,phone counselling and femalecounsellors.The Value of a Women’sSupport GroupTreatment Service Needsof VOICES Women• Individual counselling• Female counsellors• Women’s groups• Phone counselling• Flexible extended hours• 24 hour crisis phone access(Boughton & Brewster, 2002)Support groups for women who problem gamble can be vital andadvisable in early recovery (Mark & Lesieur, 1992).Women only groups provide:• Women time to focus on strengthening themselves in a safeenvironment.• An environment that encourages freedom to safely share onissues such as sexuality or intimacy, body image, the impact offactors such as PMS, pregnancy, menopause and experiences ofviolence.• Opportunity for women to learn to value self and other womenwhile being role models for one another.• Opportunities for women to understand and share experiences.• Opportunities to normalize women’s gambling problems andreduce the isolation and shame connected to their gamblingissues.• Empowerment of women to share strengths, encouragement andsolutions with each other.• An environment that centers on equality.A single-sex treatment group for women produces positiveresults for women in terms of increased self-esteem and senseof personal power.(Wilke, 1994)Guidebook for PG Clinicians, Produced by CGROWTH 41

The group processes of normalizing, sharing and supporting arecritical therapeutic factors in change. It brings hope and energyto recovery.Group members often form bonds of friendship that result inadditional social support and recreational opportunities that providesolutions to underlying issues of isolation, boredom and loneliness.Exploring alternative leisure and recreational options is critical tomeet the fundamental needs of women.If your agency does not carry sufficient numbers of women whoproblem gamble to support exclusive groups, it may be feasibleto develop women only groups by joining together women withsubstance abuse and women with gambling issues (Lesieur & Blume,1991).Women who gamble in Ontario:Significant difference between the perceivedvalues of women’s and co-ed groupsWomen’s group 59%Co-ed group 33%(Boughton & Brewster, 2002)Potential Drawbacks of Co-ed Groups• There has been a masculine tilt in treatment creating difficultiesfor some women who problem gamble to gain acceptance.• Women’s histories of harmful or painful relationships with mencreate barriers for safe disclosure and sharing in co-ed groups.• Socially conditioned gender roles and power dynamics: Males tendto dominate in mixed groups, speaking more often, interuptingothers. Women use more language that connotes uncertaintywhen men are present.• Tendency of women to nuture others, to de-self and underfunctionin groups with men.42Guidebook for PG Clinicians, Produced by CGROWTH

Phone CounsellingThe option of phone counselling is invaluable to support womenwho problem gamble. The multiple benefits of phone counsellingapply to women in both rural and urban areas.Phone counselling reduces barriers for women created by….• Fear of recognition or exposure at local agencies• Fear of discrimination based on sexual preference, culture, age• Stigma• Distance from treatment• Limited hours of service• Child care concerns• Lack of female counsellors• Financial obstacles to accessing treatment• Waiting lists• Lack of language appropriate servicesPhone counselling also increases access to services…• More flexibility in hours (i.e., lunchtime, evening calls)• Reduced disruption of busy lives• Eliminates concerns about child care• Eliminates travel concerns(i.e. time, expense, lack of transportation)• Increases availability of language appropriateservices• Increases sense of confidentiality and privacy• Reduces fear of discovery by partner• Increases sense of safety• Reduces concerns about discriminationVOICES on Phone Counselling55% Very or extremely helpfuloption(Boughton & Brewster, 2002)2005: Problem Gambling Service of CAMH (Toronto)16% of counselling with women were phone contacts(compared to 4% for male clients)VOICES46% thoughttreatmentservices wereonly for womenhaving veryserious problems• Appeals to women whose gambling has not yet become seriouslyproblematic and who believe that treatment is only for those with‘serious’ gambling issuesGuidebook for PG Clinicians, Produced by CGROWTH 43

Ongoing Treatment: Special NotesDealing with Cognitive Distortions around GamblingCognitive therapists suggest that false beliefs about the possibilityof being able to predict or control the outcome of a future event fuelgambling persistence. Individuals who problem gamble often havedifficulties understanding the essence of randomness (chance),that all events are independent and therefore unpredictable. Inmisunderstanding the odds connected with gambling, they maycreate alternative meaning to their activities, such as having anillusion of control, which can motivate individuals to develop winningstrategies.Cognitive treatments aim to explore the basic irrationality in systemsor gambling strategies. The basic assumption is that an accurateassessment of gambling expectations will deflate the urge to gamble(Ladouceur & Walker, 1996; Sylvain, Ladouceur, Boisvert, 1997;Toneatto, Blitz-Miller, Calderwood, Dragonetti & Tsanos, 1997).Generally, a cognitive approach has merit and needs to be threadedinto the work with women who problem gamble. It is also importantto be aware of the unique issues connected to women’s gamblingactivities given that for women, gambling has an emotional base andenergy with hope fueling the gambling irrespective of its stark reality.This, in combination with secondary gains that gambling offers,such as the escape or social reinforcement, is enough to sustain thegambling activity.Using positive terms such asbeliefs or meaning (Najavitis,2002) can encourage women tosafely explore these issues andbring them into consciousness,as they recognize the connectionsthey may have created betweenthe perceptions of luck or controland their gambling.Provide Accurate InformationA word of advice:It’s probably best not to adoptthe language of the cognitivetherapists when talking aboutirrational beliefs. This termhas a negative meaning andmay be viewed by women ascriticism.(Boughton, 2003)Cognitive therapists often include discussion and education aboutrandomness and erroneous beliefs in counselling. Information aboutmathematical odds, probabilities and the house advantage may helpcounter false beliefs that the playing field is level. This information isreadily available in books on gambling.44Guidebook for PG Clinicians, Produced by CGROWTH

Providing women who gamble with accurate information on thegames they play aids in developing and maintaining the therapeuticrelationship and is consistent with her experience and reality. Forexample, it is therapeutically alienating to tell a woman that she willnever win, or deny a woman’s experience that there are streaks ofwinning as this is not true.Education about Gambling HooksGiving women accurate information on gambling hooks can behelpful.For example…• Classical and operant conditioning of players (psychologicalmanipulation) using such terms as ‘near misses’• The highly addictive nature of intermittent reinforcement• Illusion of control created by providing handles on slot machinesKnowing information about gaming can mobilize a self-protectiveresponse and help women move from a place of self-blamingand self-criticism. Negative beliefs and statements of blame andcriticism, common in women who have been victimized, need tobe redirected and reframed to encourage continued growth andchange. Righteous anger can be empowering and serves to enhanceand support women’s motivation to change gambling patterns.Financial Health and Reality CheckWomen who problem gamble will ultimately lose more than theywin. Women often resist suggestions that they total their gamblingexpenditures and losses as thinking about their financial lossesbrings up overwhelming feelings of guilt and depression.Exploring financial losses is difficult for women. Using an empatheticapproach, women can safely talk about money and the financialimpact their gambling has in their life.Discussing finances helps to:• Make plans to deal with financial impacts of gambling.• Encourages financial responsibility to deal with financialconsequences and unanticipated bills.• Make plans to deal with any triggers, urges to gamble, or strongfeelings of being overwhelmed that may come with monthly bills.• Increase women’s motivation to change the gamblingbehaviours.Guidebook for PG Clinicians, Produced by CGROWTH 45

Encouraging women to monitor the financial amounts involved inany subsequent gambling activities can serve as a financial realitycheck and aid in their understanding of urges, gambling triggers andsolutions to change gambling behaviours.Money TriggersEarly interventions are helpful for women to stop the financial impactof their gambling. Focus on money triggers, such as access tomoney and encourage women to find ways to distance themselvesfrom easy access to funding that can trigger impulsive gambling.Creative ways some women have found to do this while retaining asense of control and choice include:Distancing techniques• Cut up credit and bank cards• Leave credit and bank cards at work, home or with a supportperson• Arrange with the bank to limit access to money, e.g., reducewithdrawal limit• Create a time delay in accessing money., e.g., ING bankaccount – which requires a period of time to transfer moneyback to the bank for withdrawal• Operate day to day on a cash only basis• Purchase gift cards rather than carrying cash• Arrange automatic payment of bills and expenses on payday• Never carry enough money to stimulate urges to gamble• Shop with a friend or family member who can hold cash• Plan and budget expenses• Avoid a sense of deprivation and spend money on leisureactivities or self-care46Guidebook for PG Clinicians, Produced by CGROWTH

Women’s Voices:The Issues for Gambling Women of OntarioOver half of the VOICES women selected issues related to gambling,finances, stress levels and social/leisure needs from among a broadmenu of issues that would be helpful to address in treatment.There were differences between the needs identified by players ofBingo and slot machines.Gambling ChangesUrges to gamble 71%Strategies to limit play 68%Triggers 67%Strategies to stop 64%False beliefs 50%Getting support 46%Mathematical odds 43%Social pressure 29%Financial SurvivalIncreasing Income 69%Money management 66%Money values 61%Resolving debts 59%Personal EnrichmentStress 72%Self-esteem 63%Depression 59%Empowerment 57%Anxiety 56%Guilt & shame 53%Spiritual well-being 53%Burn-out 41%Leisure and Social NeedsMeaningful Use Free Time 70%Having Fun 69%Isolation/Loneliness 54%Bingo vs Slot PlayersSignificant differencesSelf-esteem 83 vs 52%Depression 74 vs 54%Empowerment 70 vs 45%Drinking 28 vs 13%Drug use 23 vs 12%Guidebook for PG Clinicians, Produced by CGROWTH 47

Issues Identified by Professionals inDesignated Treatment System for GamblingA provincial survey of professionals within the designated treatmentsystem of Ontario was conducted to explore clinical perspectiveson the needs and issues of women who problem gamble in Ontario(Brewster & Boughton, 2002).The key issues named were consistent with those identified by thegamblers themselves. The issues perceived as most frequentlyoccurring were stress, guilt and shame, depression/anxiety, selfesteemand leisure time.Clinical observationsabout the treatmentneeds of womenentering treatment,also noted theimportance ofco-occurring issuessuch as trauma andabuse, alcoholproblems, finances,assertiveness andanger.The collectiveexperience of womenwho gamble andprofessionals whowork with womenwho gamble, revealsthe wisdom of astep-care approachto treatment.Clearly some issuesare primary for allwomen who problemgamble, while otherissues are criticallyimportant to sub-groupsof women renderedmore vulnerable bypsychiatric and/orabuse histories.Clinical Concurrent Issues for FemaleProblem Gamblers Identified byGambling CounsellorsStress 98Guilt or shame 98Self-esteem 96Leisure time 95Depression/Anxiety 95Social relationships 94Intimate relationships 92Finances & budgeting 87Assertiveness 83Coping with loss 79Crisis management 79Credit counselling 78Trauma/Abuse 74Drug & Alcohol problems 68Compulsive spending or shopping 66Anger management 62Panic attacks 59Parenting 57Spirituality 54Employment issues 53Legal issues 51Sexual behaviour 43Eating disorders and body image 42Physical health problems 42Cognitive impairment or memory 36Sexual preference issues 2148Guidebook for PG Clinicians, Produced by CGROWTH

It has been our experience at both Amethyst Women’sAddiction Centre and the Jean Tweed Centre, inworking with both women who gamble and womenwho use substances that there are differencesbetween these two types of clients.A particular difference that we have noticed is thatgambling clients are often less likely, initially, thansubstance use clients to make connections betweenher gambling and her life experiences, including herhistory of trauma. However, we have also noticedthat the longer we work with these women, the betterable they are to recognize these connections and healemotionally.Beth Murray and Gundel Lake, CounsellorsGuidebook for PG Clinicians, Produced by CGROWTH 49

NOTES50Guidebook for PG Clinicians, Produced by CGROWTH

Key Feelings and Issuesfor Women in RecoveryLeisure and Social ChoicesWomen’s leisure choices are shaped by needs for:oooRelationship and ConnectionSocial ComfortPhysical and Emotional SafetyFew activities offer the social network, safety, flexible hours andfriendly environment available in casinos and bingo halls.For many women…• loneliness, isolation and boredomare factors in their gambling(Brown & Coventry, 1997).• gambling is perceived as areward, a time out, or a chanceto get away by themselves afteryears of taking care of others.• limitations created by suchconcerns as physical or mentalhealth, family or work demands,finances, safety andtransportation constrict choices.Attraction ofBingo Halls & Casinos• Hours of operation• Friendly environments• Social networks• Freedom to go alone• SafetyFinding alternative leisure and social options to replace gamblingcan be challenging. Often women have social anxiety or othermental health struggles that can create obstacles. Further, financialissues can also limit social and leisure options. Age or healthrelated changes might also render a return to earlier forms of leisureimpossible. Working with women to identify and resolve social andleisure needs is key in the treatment of problem gambling.The task of filling the holes left by changes to gambling is one ofthe more difficult and challenging tasks of recovery(Boughton, 2003)Guidebook for PG Clinicians, Produced by CGROWTH 51

Guilt, Shame and Self-EsteemFor women who problem gamble, issues of guilt, shame, and selfesteemreguire special attention. The socialization of women is keyin creating and perpetuating women’s guilt, shame and low selfesteem(Mason, 1991). As a result of living in a “white-male system”with many power imbalances, women can be socialized as less-thanand inferior.The female patient must be helped to establish enoughself-esteem to feel worthy of recovery, and to careenough about the future to expend the necessary effort(Lesieur & Blume, 1991)This may be aggravated insome cultural contexts whereperceptions of women’s rightsand roles are limiting and rigid.Exploring women’s cognitiveschemas of self in relation to theirculture and society is important.Women’s predisposition toshame carries into her treatmentexperience. Women areparticularly vulnerable to feelingshame about gambling and manyhave internalized the social stigmaattached to women who gambleexcessively.Win or lose, gambling touchesupon personal values and moralstandards. The dissonancecreated by the gambling andgambling - related behaviourssuch as lying, criminal activity orspending money intended for otherthings can be extreme. Failing tolive up to internal standards leadsto feelings of guilt and remorse,adding considerably to loss ofself-esteem.Money & Self-ImageMany women take pridein responsible moneymanagement. Even asgamblers they tend totake smaller risks and aremore cautious (Bruce &Johnson, 1994). Losingmoney devastates thisimage.Even winning canchallenge moral standardsbecause of an ethicalconnotation of being selfishor greedy. King (1990)notes that bingo playersoften neutralize guilt overthis by denying that therewas any skill involved inthe win, sharing profitsand rationalizing that theyplayed for charity.(Boughton, 2003)52Guidebook for PG Clinicians, Produced by CGROWTH

Given the intense shame and guilt, many female gamblers havedifficulty with self-forgiveness. It is imperative to help women movefrom self-contempt to self-acceptance and empathy in healing shame(Mason, 1991).Because low self-esteem is such a prevalent issue among womenwho problem gamble, connecting women to additional resources toaddress this issue is often critical. Programs that address self-esteemfor women can be often found through local community health andresource centres or mental health programs.Self –CareEncouraging women to practice self-care is a critical but oftendifficult task in recovery. Women are socialized to put the needs ofothers ahead of their own, often at the expense of their own. Caringfor self therefore is seen by many women as selfish. Further, manywomen also have vicious internal critics, especially women whosechildhoods were shaped by trauma, abuse or parental addiction.These internal critics evolved during childhood as a self-protectivemeasure and allow for nothing less than perfection and relentlessendeavor. Working with women to understand the impact of theseearly experiences in terms of relationship to self is key.Self-NurturingNajavits (2002) suggests that a central issue in treating women whoabuse substances is pleasure. She notes that women’s impulsiveand excessive search for pleasure and simultaneous lack of healthypleasures contributes to their ongoing struggles. This concept is alsoappropriate in understanding women who problem gamble. A majorgoal of therapy therefore, is to decrease destructive pleasures whileincreasing healthy pleasures. This is safe self-nurturing.Self-SoothingTeaching skills of distress tolerance and emotion regulation are coreelements of both trauma work and Dialectical Behaviour Therapy(DBT). Both approaches emphasize the importance of teachingwomen to reduce emotional vulnerability and build positiveexperiences. Self-soothing is primary to developing these skills.Guidebook for PG Clinicians, Produced by CGROWTH 53

Parent, Adult and Child Ego StatesCalling on women’s capacity to care for others, especially children,sometimes helps to circumvent self-hatred. The TransactionalAnalysis model (TA) of the Parent, Adult and Child ego states canbe an effective tool (Stewart & Joines, 1987) as many clients canidentify with the internalized critical parent and the child state.Women generally can relate to the idea that it is the impulsive funlovingchild that is dominant when they are gambling, leaving theadult to pick up the pieces. This approach allows an opportunity tosuggest that women act towards themselves (the inner child) withthe same compassion they would show a child in the external world.It is important to find (other) sources of fun and stimulation while atthe same time, setting healthy limits.AngerMany women have troubled relationships with their anger, eitherunder or over-controlling it. This is very much a part of women’ssocialization (Potter-Efron & Potter-Efron, 1991; Gilligan, 1982;Underhill,1985; Lerner, 1989; Goleman, 1995).Gambling and AngerAnger has many masks but is often active in some guise in thegambling behaviour of women:• Gambling may serve to distract from anger. Distraction isa “highly powerful mood altering device” and way of deescalatingstrong feelings (Goleman, 1995)• Gambling may serve as an indirect and off-target (passiveaggressive)expression of relational anger• Anger may be used to justify the gambling• Anger may participate in maintaining the gambling behaviour;losses often generate a defiant determination to “get mymoney back” leading to escalated play• Anger may be a secondary emotion, a protective responseto cover feelings such as sadness, shame, guilt, hurt or fearrelated to the gambling54Guidebook for PG Clinicians, Produced by CGROWTH

Women benefit from understanding how anger relates to theirgambling and learning healthy ways to both honor it as a signalthat there is something wrong and use it effectively as a tool forchange. Assertiveness and skill training in regulating emotions canbe invaluable.GriefLoss is often a significant issue in the lives of women who problemgamble. As with other addictions the losses that women whoproblem gamble sustain extend beyond financial into areas such asrelationships, self-esteem, freedom or employment.The loss of gambling is the loss of asignificant love object(Miller, 1986; Wildman 1997)In some cases, losses have been instrumental in initiating orexacerbating gambling. For instance, women may experience lossthrough death, separation, abortion, miscarriage or loss of children.Further, the high incidence of abuse and violence creates significantpsychological vulnerabilities and losses, often leading women tolook for ways to cope or escape. This loss of safety is a significantfactor in the lives of many women who problem gamble.Pathological gamblersperceive their world asunsafe due to a historyof unresolved lossesand cannot endure thethreat of impending loss.Gambling is a defenseagainst loss, a way todiminish or eliminate thesense of time and forestallthe inevitability of death.(Whitman-Raymond, 1988)Women often grieve the loss of thegambling itself. Gambling meetssome very real needs of women. Theattachment is strong, and women areoften ambivalent about cutting backor stopping (Miller, 1986).It is important to acknowledge theselosses and help facilitate the grievingprocess. Specialized services mayneed to be considered when acomplicated grief reaction or traumais present.Guidebook for PG Clinicians, Produced by CGROWTH 55

RelationshipsAs in the treatment of women for substance use problems (Wilke,1994), relationship concerns can be an issue for women whoproblem gamble (Lesieur & Mark, 1992). Heterosexual marriedwomen often have difficult relationships that are further aggravatedby the problem gambling. The problem gambling may act as botha trigger for relationship tensions and an attempt to escape them.Men are more likely to leave their female partners who problemgamble than women are to leave their male partners who problemgamble (Custer & Milt, 1985: Lesieur & Blume, 1991).Many women have difficulty with some aspects of assertion andrelational-boundary setting which can compound relationshipdifficulties. Women are generally able to be assertive in positiveways (e.g. “I love you”, “I like it when…”) but have more difficultybeing assertive when their needs are unmet or violated.Just as often it is the lack of relationship that is a principal factor ingambling. About half of women who problem gamble are separated,divorced or widowed. High rates of single status or poor relationshipsmeans that many women are less likely to have spousal supportthan are men who problem gamble.Shame leads many women to cloak gambling problems in secrecy,hiding the problems from family and friends who might be able tohelp. Thus support systems for women are often non-existent orlimited which further aggravates isolation, loneliness and shame.VOICES: Relationship IssuesIssues identified by 45% to 50%✓ assertiveness✓ setting healthy boundaries✓ dealing with anger✓ conflict in relationship✓ meeting my needs inrelationship(Boughton & Brewster, 2002)56Guidebook for PG Clinicians, Produced by CGROWTH

Violence and TraumaPower imbalances and violence are part of many women’s lives.For women who problem gamble, the sources of trauma can bemultiple:• Childhood histories of trauma, emotional, physical and/or sexualabuse, abandonment or parental addiction (Lesieur & Blume, 1991;Boughton & Brewster, 2002).• Current and past histories of adult emotional, physical and/orsexual abuse.• Oppression, torture, war and poverty.VOICES women report….. ChildhoodPhysical Abuse 41%Sexual abuse 38%VOICES women report…..AdultPhysical abuse 46%Sexual abuse 28%Abuse In Current Relationships 39%(Boughton & Brewster, 2002)Experiences of violence and trauma are a factor in some women’sgambling. Gambling can function as an escape, or way to cope withsymptoms of simple or complex post-traumatic stress related tocurrent or past abusive situations.It is important to ask women about experiences of violence andtrauma as a part of assessment. If past or current issues of traumaand violence are forming barriers to making changes to the problemgambling, these issues need to take priority and/or be simultaneouslyaddressed. Appropriate referrals to trauma specialists or programsare important.Guidebook for PG Clinicians, Produced by CGROWTH 57

In the interim….Trauma experts suggest that the first stage of trauma treatment is toteach women the skills to manage their responses effectively. Morein-depth exploration of the trauma or violence needs to wait untilwomen have learned to manage symptoms such as flashbacks, reexperiencing,dissociation and persistent arousal (hyper vigilance).It is also critical to help women establish both physical and emotionalsafety in the present. Emotional safety can encompass regulation ofemotional responses, self-soothing and grounding.GroundingGrounding is the most important therapeutic approach fordealing with any form of dissociation or flashback. The goal ofgrounding techniques is to help:• Reconnect the person to the present• Orient the person to the here and now• Connect her to her body and personal control• Connect her to the therapist and the safe context of the therapyroom(Haskell, 2003)Excellent resources: Trauma TreatmentCopeland, Mary Ellen and Maxine Harris (2000). Healing theTrauma of Abuse: A Woman’s Workbook. Oakland: New HarbingerPublications.Haskell, Lori (2001). Bridging Responses: a Front-line Worker’sGuide tp Supporting Women who have Post-Traumatic Stress.Toronto: Centre for Addiction and Mental Health.Haskell, Lori (2003). First Stage Trauma Treatment: A Guide forMental Health Professionals Working with Women. Toronto:Centre for Addiction and Mental Health.Linehan, M (1993). Lineham, M. (1993a). Skill Training ManualFor Treating Borderline Personality Disorder. Toronto: Centre forAddiction and Mental Health.Linehan, Marsha (1993b). Cognitive Behavioral Treatment ofBorderline Personality Disorder. New York: The Guilford Press.Included in the Appendix is a handout on grounding techniques.58Guidebook for PG Clinicians, Produced by CGROWTH

Thank YouThank you for your time and attention to the concerns of women whogamble. Feel free to copy and distribute the information but pleasecite us as a reference. We welcome any questions or feedback;please refer to the contact information at the front of this booklet.Guidebook for PG Clinicians, Produced by CGROWTH 59

NOTES60Guidebook for PG Clinicians, Produced by CGROWTH

Appendix• Brief Psychiatric Rating Scale• PTSD Screen• Financial Check-Up• Assessment and Screening Questions• Gambling Specific Questions• Grounding TechniquesGuidebook for PG Clinicians, Produced by CGROWTH 61

Brief Psychiatric Rating Scale (BPRS)Individual’s name:Rater’s Name:Date:INSTRUCTIONS: This form consists of 24 symptom constructs, eachto be rated on a 7-point scale of severity ranging from ‘not present’to ‘extremely severe.’ If a specific symptom is not rated, mark ‘NA’(not assessed). Circle the number headed by the term that bestdescribes the patients present condition.1 2 3 4 5 6 7NotPresentVeryMildMild Moderate Moderately Severe ExtremelySevereSevere1.2.3.4.5.6.7.8.9.10.11.12.13.14.15.16.17.18.19.20.21.22.23.24.Somatic concern N/A 1 2 3 4 5 6 7Anxiety N/A 1 2 3 4 5 6 7Depression N/A 1 2 3 4 5 6 7Suicidality N/A 1 2 3 4 5 6 7Guilt N/A 1 2 3 4 5 6 7Hostility N/A 1 2 3 4 5 6 7Elated Mood N/A 1 2 3 4 5 6 7Grandiosity N/A 1 2 3 4 5 6 7Suspiciousness N/A 1 2 3 4 5 6 7Hallucinations N/A 1 2 3 4 5 6 7Unusual Thought Content N/A 1 2 3 4 5 6 7Bizarre Behaviour N/A 1 2 3 4 5 6 7Self-Neglect N/A 1 2 3 4 5 6 7Disorientation N/A 1 2 3 4 5 6 7Conceptual Disorganization N/A 1 2 3 4 5 6 7Blunted Affect N/A 1 2 3 4 5 6 7Emotional Withdrawal N/A 1 2 3 4 5 6 7Motor Retardation N/A 1 2 3 4 5 6 7Tension N/A 1 2 3 4 5 6 7Uncooperativeness N/A 1 2 3 4 5 6 7Excitement N/A 1 2 3 4 5 6 7Distractibility N/A 1 2 3 4 5 6 7Motor Hyperactivity N/A 1 2 3 4 5 6 7Mannerisms and Posturing N/A 1 2 3 4 5 6 7Reference1 This version was adapted by Ventura, M.A., Green, M.F., Shaner, A.& Liberman, R.P. (1993). Training and quality assurance with the briefrating scale: “The drift buster”. International Journal of Methods inPsychiatric Research, 3, 221-244.62Guidebook for PG Clinicians, Produced by CGROWTH

Primary Care PTSD Screen______________________________________________________________In your life, have you ever had any experience that was so frightening,horrible, or upsetting that, in the past month, you*1. Have had nightmares about it or thought about it when you didnot want to?YESNO2. Tried hard not to think about it or went out of your way to avoidsituations that reminded you of it?YESNO3. Were constantly on guard, watchful, or easily startled?YESNO4. Felt numb or detached from others, activities, or yoursurroundings?YESNO______________________________________________________________Current research suggests that the results of the PC-PTSD should beconsidered “positive” if a patient answers “yes” to any three items.Guidebook for PG Clinicians, Produced by CGROWTH 63

A Financial Check‐upThe first step towards financial success is recognizing problemareas.Think of your financial situation in the past 12 months and answerthe following questions:v Are you near, at, or over the limit on your credit cards?v Have you missed monthly credit payments?v Are you using one credit card to pay off another?v Are you borrowing from friends or relatives just to get by?v Have you cancelled auto, medical or life insurance just to makeends meet?v Are you living on your bank overdraft?v Have you been denied further credit because of your creditrating?v Do you have sleepless nights because you worry about moneyand your debts?v Have you been avoiding opening your mail because you arescared your creditor has sued you and is going to garnishee yourwages?v Do you have a reasonably stable job with good income but thetake home pay is just not enough to pay everyone?If you have answered “yes” to any of these questions, you may wantto consider meeting with a certified Credit Counsellor.This screen was created by Family Services Thunder Bay,Credit Counselling Program.64Guidebook for PG Clinicians, Produced by CGROWTH

Assessment and ScreeningSecondary Issues . . . Ask About . . .Sexual/Physical/EmotionalHealthDisordered EatingSubstance AbusePrescription MedicationsMental HealthMoney ManagementCare-TakingLeisureGambling Specific QuestionsConsider asking the following questions around gambling in yourassessment:• Do they have access to a computer at work?• How much time to they spend gambling at once?• What are their eating/medication taking habits while gambling?• What part does their cultural background and/or sexual orientationplay in their gambling?• Any legal charges associated with gambling?Family Violence (current/past)Other Abuse (current/past)Sleep HabitsExercise HabitsMenopauseBinging, Purging, (current/past)Alcohol or Drugs (current/past)Family HistoryTake as prescribedAre meds px but not filled dueto financial problems?Suicidal IdeationSelf HarmDiagnosisPast Trauma(s)Spending Problems (shopping)Budgeting KnowledgeGainfully EmployedDependant/Special NeedsChildren/Spouse/ParentsLeisure Interests (current/past)Guidebook for PG Clinicians, Produced by CGROWTH 65

Grounding TechniquesGrounding is a set of strategies that will help you stay in the presentand manage if you are overwhelmed by emotional pain or disturbingthoughts or images. Grounding works by encouraging you to focuson the external world, rather than inward toward the self. Groundingcan be done any time, any place and anywhere, and no one has toknow. There are 2 main types of grounding:Cognitive Grounding:• Describe the environment in detail, using all of the senses; describeobjects, sounds, textures, colours, smells, shapes and numbers.• Visualize a safe place in your mind, describe it in detail and imagineyourself there.• Say a safety statement. “ My name is____; I am safe right now.Today’s date is ___. I am located ____.”• Begin counting either slowly forward or backward.• Play a “categories” game with self. Try to think of types of “singers,”“animals,” “cities,” “TV shows,” or “sports.”• Do an age progression. If you have regressed to a younger age (e.g.8 years old), you can slowly work your way back up (e.g., I’m now 9,I’m now 10, etc.) until you are back to your current age.• Think of favourites such as colours, foods, animals, TV shows• Say a coping statement: “I can manage this,” “this feeling willpass.”• Remember the words to an inspiring song, quotation or poem.• Repeat a pleasant word to yourself (e.g. “safe”, “calm”).Physical Grounding:• Focus on your breathing, noticing each inhale and exhale.• Place feet firmly on the ground, keeping eyes open. Stamping yourfeet may also be helpful.• Grab tightly onto a chair.• Rub your palms; clap your hands. Listen to the sound. Feel thesensation.• Touch various objects around the room.• Run cool or warm water over your hands.• Carry an object meaningful and tangible in your pocket, such as astone that you can touch whenever you feel triggered.• Hold something that you find comforting.• Drink a glass of water.• Clench and release your fists. Hold onto a stress ball.• Listen to soothing music or familiar music you can sing along to.Dance to it.Adapted from Seeking Safety by Lisa Najavits and First Stage TraumaTreatment by Lori Haskell66Guidebook for PG Clinicians, Produced by CGROWTH

ReferencesAbbot, M. (2002). Problem gambling in prisons. How common? What canbe done to help?. Presentation at the 16th Annual National Conference onProblem Gambling. (National Council on Problem Gambling). Dallas: TexasJune 13-15, 2002.Allen, Colleen (2003). Conference Presentation. Best Practices Programmingfor Women. 2003 Conference, Women’s Substance Use Treatment:Celebrating and Moving Forward. Vancouver. Canada. September 26,2003, p 23.ARF (1996). The Hidden Majority: A guidebook on alcohol and otherdrug issues for counsellors who work with women. Addiction ResearchFoundation: Toronto. ISBN 0-88868-256-5.Barbara, A., Chaim, G., & Doctor, F. (2002). Asking the Right Questions:Talking About Sexual Orientation and Gender Identity During Assessmentsfor Drug and Alcohol Concerns. Toronto: Centre for Addiction and MentalHealth.Baron-Cohen, Simon (2003). The Essential Difference. Basic Books: NewYork.Blaszczynski, A (2000). Pathways to Pathological Gambling: IdentifyingTypologies. eGambling feature article: 6/8/2000. (ww.camh.net/egambling)Blaszczynski, A & Steel, Z (1998). Personality disorders among pathologicalgamblers. Journal of Gambling Studies Vol 14 (1). Spring 1998, p 51-71).Blaszczynski, A. & Silove, D. (1995). Pathological Gambling: Forensic Issues.Australian and New Zealand Journal of Psychiatry 1996; 30:358-369.Brown, S., & Coventry, L. (1997). Queen of Hearts: The Needs of Womenwith Gambling Problems. Australia: Financial and Consumers Rights Councilhttp://home.vicnet.net.au/~fcrc/research/queen.htmBoughton, R (1992). Research and Program Development : Grief andChemical Dependence. Unpublished Masters Thesis.Boughton, R, & Brewster, J. (2002). Voices of Women Who Gamble in Ontario:A Survey Of Women’s Gambling: Barriers To Treatment And TreatmentService Needs. Report To the Ontario Ministry of Health And Long TermCare, July 2002. Toronto: Ministry of Health and Long Term Care.Boughton, R. (2003). Women who play bingo in Ontario: A supplementaryAnalysis. NCPG 17th National Conference on Problem Gambling. Louisville,Kentucky: June 19-21, 2003Boughton, R.(2003). A feminist slant on counselling the female gambler.e_gambling: The Electronic Journal of Gambling Issues, May 2003.Guidebook for PG Clinicians, Produced by CGROWTH 67

Boughton, R. (2003). Literature Review: Treatment of the Female ProblemGambler. Presentation at OISE January 25, 2003. Toronto.Boughton, R. (2004). Older Women of Ontario and Problem Gambling:Voices Contribution. NCPG 18th National Conference on Prevention,Research and Treatment of Problem Gambling. Phoenix, Arizona, June 17-19, 2004.Boughton, R. (2006). Secondary analysis of Voices data. Personalcorrespondence.Brewster, J. & Boughton, R. (2002). Helping Women who Gamble: Views ofOntario Service Providers. Report to Ontario Ministry of Health and LongTerm Care July 2002. Toronto: Ministry of Health and Long Term CareBrown, S., & Coventry, L. (1997). Queen of Hearts: The Needs of Womenwith Gambling Problems. Australia: Financial and Consumers RightsCouncil. http://home.vicnet.net.au/~fcrc/research/queen.htmBruce & Johnson, 1994. Male and female betting behaviour: newperspectives. Journal of Gambling Studies. Vol. 10(2). Summer 1994.183-198. Human Science Press Inc.CBC Newsworld, Ontario (1999). Video: BINGO: Faith, Hope and CharityProduced by Prisma Light Ltd. in association with CBC Newsworld, Ontario,1999Canadian Mental Health Association (CMHA) Ontario Division Mental HealthStatistical Sourcebook Volume 1 Zoutris, O. Feb 1999.Crisp, B., Thomas, S., Jackson, A., Thomason, N., Smith, S., Borrell, J., Ho,W. and Holt, T. (2000). Sex differences in the treatment needs and outcomesof problem gamblers. Research on Social Work Practice, Vol 10 No2. March2000 229-242. Sage Publications.Currie J. (2001). Best Practices Treatment and Rehabilitation of Womenwith Substance Abuse Problems, Health Canada.Custer, R & Milt, H. (1985). When Luck Runs Out. New York: Facts on File.Dixey, Rachael (1987). It’s a great feeling when you win. Leisure Studies 6(1987) 199-214. E & F.N. Spon Ltd.Dow-Schull, Natasha (2002). Escape Mechanism: Women, Caretaking, andCompulsive Machine Gambling. Working Paper No 41. April, 2002. Centrefor Working Families, University of California, Berkeley.Gambling in Canada. Report by the National Council of Welfare(1996)Gilligan, C. (1993). In a Different Voice: Psychological Theory and Women’sDevelopment. Cambridge: Harvard University Press.68Guidebook for PG Clinicians, Produced by CGROWTH

Goleman, D. (1995). Emotional Intelligence: Why it can Matter More thanIQ. Bantam Books: New York.Govoni, R., Frisch, R., & Johnson, D. (2001). A community effort: Ideas toaction. Understanding and preventing problem gambling in seniors: A finalreport. University of Windsor. Problem Gambling Research Group. http://www.gamblingresearch.orgGrant, K. (2002). GBA: Beyond the Red Queen Syndrome. Ottawa:Presentation at the GBA Fair, Ottawa Congress Centre, January 31, 2002.Greenspan, M. (1983). A New Approach to Women & Therapy. New York:McGraw-Hill.Haskell, Lori (2001). Bridging responses: a Front-line worker’s guide tosupporting women who have post-traumatic stress. Centre for Addictionand Mental health: Toronto.Haskell, Lori (2003). First stage trauma treatment: A guide for mental healthprofessionals working with women. Centre for Addiction and MentalHealth: Toronto.Hill, J. (1997). Video Vice: The Economic and Social Consequences ofLegalizing Video Gambling in Alabama. http://alabamafamily.org/pubs/vidvice.htmHodgins, David (2000). Promoting the Natural recovery Process throughBrief Intervention. 11th International Conference on Gambling and RiskTaking, June 2000, Las Vegas (University of Calgary)Jain, M. & Turner, N. (2002) Special Problems in Gambling: Attention DeficitHyperactivity Disorder (ADHD) and Pathways to Problem Gambling. May2002, Centre for Addiction and Mental Health. Available through OPGRC@ gamblingresearch.org.Jackson, Thomas, Blaszczynski (2003). Best Practices in Problem GamblingServices: An international literature review and an examination of theVictorian Gambler’s Help program. Prepared for the Gambling ResearchPanel (GRP) by Melbourne Enterprise International. June 2003. ISBN 09751191 0 9.Jacobs, D. (1986). A general theory of addictions: a new theoretical model.Journal of Gambling Behavior, Vol. 2(1) Spring/Summer. 15-31.Jacobs, D. (1993). Evidence Supporting a General Theory of Addictions. InEadington, W.R. & Cornelius, J.A. (Eds). Gambling Behavior and ProblemGambling. 287-294.Kim Berg, Insoo & Briggs, John (2002). Treating the person with a gamblingproblem. EGambling: The Electronic Journal of Gambling Issues. Issue6. CAMH: Toronto. http://www.camh.net/egambling/issue6/feature/index.htmlGuidebook for PG Clinicians, Produced by CGROWTH 69

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