25 June 2012

Gamcare - Working with Problem Gamblers

"If he does not play to win, he does not play to systematically lose either, rather for those breathtaking moments at which everything - absolute gain, ultimate loss - becomes possible" Marc Valleur

I recently attended a 2 day training event in Brighton entitled "Working with Problem Gambling" with GamCare Clinical Training Officer Trevor David.

My training was funded by GamCare as I have recently become an Associate Counsellor for Steven James Counselling, a counselling agency in Poole, Dorset, who are in turn, a partnership agency of GamCare. [please note that I have taken a break from working via GamCare with effect from June 2015 although am still seeing people with gambling issues privately]

Gamcare was founded in 1997 and is a charity that provides information, advice, support and free counselling for the prevention and treatment of problem gambling. They also engage in ongoing research around the issue of problem gambling and work with gambling companies to develop responsible policies.

So, some facts and statistics we learned were:

  • 73% of adults in Great Britain gamble each year
  • Over 1 billion pounds is staked each week
  • After the National Lottery, scratchcards are the most popular gambling activity
  • 14% of the population used the internet to gamble in the past year

Training focused on problem gambling and pathological gambling. In 2010 approximately 0.9% of the GB population met the DSM IV Pathological Gambling criteria up to around 450,000 people. In the USA the proportion is 3.5% and in Hong Kong it's 5.3%. Canada and New Zealand are at 0.5%.

So with the focus on problem gamblers we learned that:

  • Gambling can be used as emotion management - to dispel difficult or threatening feelings and emotions
  • Problem gamblers often believe that they are an expert in what they do
  • They have distorted beliefs about the likelihood of winning money back
  • There is persistence even when losing, and a tendency to "chase losses"
  • There is  toleration of associated costs (financial, personal, social)

There is a risk of suicide with problem gamblers - 13% reported an attempt, and 26% of pathological gamblers had attempted, so this is an important part of the assessment process and shows the necessity of support.

I was relieved that we weren't told exactly how to run the sessions but given background information about gambling and tools to incorporate in our existing practice, including existing models of problem gambling, tips on how to work with inevitable ambivalence and an introduction to Motivational Interviewing which fits in very well with my person-centred/existential leanings. MI is "a collaborative, person-centred form of guiding to elicit and strengthen motivation for change".

The 2 day course was jam-packed with information - there was so much to learn delivered in a variety of teaching methods. What helped enormously was Trevor David's teaching style which, whilst professional and informative, had a distinct edge of sharp humour, self-disclosure and humanity. Since learning that latest neurology states that when we learn, the recall of new facts is enhanced by the presence of certain degrees of emotion during learning” (Antonio Damasio 2000)I have appreciated being taught in a vivacious way that doesn't reply only upon academic fact being imparted.

I see gambling as a form of addiction, not dissimilar to addiction to substances. In the case of gambling, the person is addicted to the neuropeptides and neurotransmitters (the body's natural chemicals) that are released when gambling, whether they win or lose (see quote at the start of this blog post!). The person suffers withdrawal symptoms when they try to stop this behaviour. The cells of their body are used to receiving certain levels of these chemicals and when they stop, their body's homeostatis is sent out of kilter. The unconscious, survivalist part of the brain sends messages to say "get those chemicals" and highjacks the thinking part of the brain (the frontal lobe) into making decisions that will restore the homeostatis - i.e. we will engage in behaviour to ensure we get those certain chemicals we're used to by partaking in gambling. This model of addiction to our own chemicals can help explain why people may struggle with anger, stay in abusive relationships, or not be able to stop worrying.

I also share some of the ideas of the psychodynamic approach to gambling which says that gambling behaviour is a reenactment of an unresolved conflict. This may make sense to you when you consider that there is often a cycle of low self-worth, followed by gambling until one has nothing left, followed by a further dip in self-worth. Why would somebody carry on doing the very thing they are ashamed of, that is getting them into financial and relationship trouble, if there wasn't some pay off in the wretchedness they suffer after the event? The same applies to people with problems with substances.

The GamCare helpline is open daily from 8am 'til midnight:

0808 8020 133

4 June 2012

Counselling - The Frequency of Therapy and the Question of Client Autonomy

I had a discussion with my partner yesterday morning about whether it is right to ask clients to commit to weekly sessions and/or to specify a duration of therapy. He suggested that it would be a good concept for me to explore and blog about.  I had spent the previous day at Exeter Respect Festival, with the Therapy@GandySt stall. We were tucked away in the Healing Zone – pretty much hidden from most of the park and consequently, we weren’t getting much traffic. So yesterday I decided to stray away from the Healing Zone and present a question to the festival goers.  This seemed like a great opportunity to do some real learning based on what people actually want, rather than basing my stance on personal preferences.

At the agency where I work clients are expected to commit to weekly sessions of 10 weeks, or weekly sessions of an undetermined duration. The “open-ended” contract is to be reviewed periodically but the expectation is that the client will come along at the same time, on the same day on a weekly basis, except for pre-agreed holidays. Allowance is made for emergencies and illness but generally speaking, cancelled sessions are expected to be paid for. One of the justifications for this is that the agency can only charge such low costs for counselling based on regular client attendance. Also, that the clients needs to show commitment to their therapy.

In my private practice, I have tended to leave the duration and regularity of therapy entirely up to the client. This may have something to do with the fact that my therapist, whom I saw throughout my training and beyond, does not bring up the issue of frequency or ever ask if I want to book the next session. I have always liked this lack of pressure and the fact that the decision is left entirely to me. It suits my personality and I had assumed that everybody would share this appreciation.

It was in discussing this with a colleague, who takes a different stance, that I first started to really question this assumption. My colleague told me that when he embarks on private practice he intends to ask clients to commit to weekly sessions of a particular duration. I asked him what his therapist’s stance had been and, low and behold, his therapist had had the same requirements. My colleague said that this was what he needed, that he had benefited from this contract and wanted to give his clients the same.

What also came up was the fact that clients committing to coming along weekly for a set duration is much more handy for the therapist than sporadic attendance. This issue of convenience is something that jars with me and I firmly believe that this is not a good enough reason to insist on weekly sessions.

So, I wanted to find out more about what people actually want out of their therapist with regards to pushing for regular attendance.

I have never done any market research before, or anything that involves approaching strangers and asking them questions. So the first thing I did to make life easier on myself to was to make sure that I only had one question to ask. It seemed much more likely to get a result if I asked “Please could I ask you just one question?”. Of course I had to think of the question and I was conscious that the power of semantics in the choices I was posing to people could heavily influence the outcome. I settled on:

Asking verbally: If you were to choose to have some counselling or psychotherapy which would be your preference?

Then showing the two possible choices on a sheet whilst simultaneously reading them out:

A: The therapist requires you to commit to weekly sessions of a particular duration e.g. 6 or 10 weeks


B: The frequency of therapy is your choice

I did make some prior assumptions as to how the results would turn out, but I was genuinely open-minded and curious as to what they would be.

Do you have an assumption as to what they might be?

So, I asked 119 people in all. Only one person declined to answer – he said it would never be relevant to him, but did point out that his companion had had counselling so he could answer! (he did). On the whole, I was surprised at how forthcoming some people were about their therapy history and I very much valued the time people took to really consider this issue.

I did not keep a tally of ages or gender but I consciously alternated men with women and targeted differing age groups, going from a-level students up to elderly folk  in their 70’s or 80’s. They were mainly white British but with some ethnic variation of around 10% (a rough estimate).

9 of the people I asked are therapists.

It took about 4 hours in total. the majority of people were happy to just give their answer and move on, others wanted to ponder for a while. Some gave a few words by way of explanation of their choice and there were some individuals and groups that I approached that were intrigued and asked more questions and contributed to a discussion about the topic of client autonomy and other counselling related issues.  It was a wonderful experience and I really felt that there was real learning potential for me in this, and hopefully others who may read this blog.

On to the results. Of the 119 people I asked the question:

  •  51 people chose A (42.9%)
  • 60 people chose B ( 50.4%)
  •  1 person declined to answer (0.8%)
  •   1 person said that they had no preference (0.8%)
  •    2 people said that it would depend on the situation (1.7%)
  •    4 people said they would like a mixture of the two i.e. be given the option of structure but given the choice of whether to adhere to it or not, or to start with A and progress to B (3.4%)

From these 119,  the 9 therapists I asked:

  • 6 chose B
  • 1 chose A (but reckoned that clients would choose B)
  • 2 chose a mixture of the two

Some people commented on their choice.

People that chose A said (comments from those that are therapists marked T):

  1. As a client I would want the commitment (T)
  2. I trust their (the therapist’s) judgment
  3. I wish I had had more guidance. Therapy can open you up and leave you raw and without the agreement it could leave people floundering. You can’t sort your head out in one hour.
  4. I would go by what they said
  5. I can’t be trusted
  6. Better being disciplined – it suits my personality
  7. It would be structure and I’m not structured
  8. If you’re going to go on a journey you need to stick to it
  9. I’d like a bit of order
  10. I would have thought that if you needed therapy you would need A
  11. If it wasn’t A I probably wouldn’t bother
  12. Commitment is important – it gives the incentive to keep going even when the going gets tough
  13. If you were told that you had to do it weekly you would be more likely to go
  14. It would be easier for me, I like routine
  15. I would know that that time with the therapist was safe
  16. I would want it weekly, but not for a particular length of time
  17. Would need A to be effective
  18. We assume the therapist knows better than we do.
  19. My judgment may be impaired
  20. A – otherwise I wouldn’t go
  21. I need structure
  22. People need structure, particularly those with addictions

People that chose B said:

  1. It would feel restrictive going weekly
  2. Some clients only want one session (T)
  3. Definitely B – you can’t tell how long it’s going to take somebody to clear (T)
  4. B, but with organised contact e.g. weekly telephone call
  5. I can’t tell what mood I’m going to be in
  6. People are busy, and you might get better
  7. B, but endings are important (T)

Given that these are all the comments made in relation to their choices, it is clear that those that chose A were much more likely to choose to justify their stance (43%) than those that chose B (12%).

What I learned from this is that I have potentially been doing a disservice to some clients based on my assumptions that people would, like me, prefer choice on the frequency of sessions. I intend to use this information during the initial consultation with clients to ascertain what their preference is with regards to this issue, and to make provision for those that want or need the structure of committing to scheduled counselling sessions, or that would like guidance from me. That is an issue in itself – why the client needs guidance from me – which could lead to important work.

I am hoping that this offering will promote discussion and debate on this topic and I appreciate all comments and contributions, regardless of compatibility with my way of thinking.

UPDATE April 2016 - I now only take on clients who can commit to weekly sessions as I have come to learn that the client's commitment to therapy is one of the most important factors in having a successful outcome. I believe that infrequent sessions are not cost effective as the disjointed nature means that the therapy can be inefficient. I have also now had the experience of a couple of years of weekly therapy (with breaks) and found it to be much more effective at getting to core issues.

Amanda Williamson is a professional counsellor working privately in central Exeter, Devon.

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