Embedding a Relational Focus in Gambling Treatment Alberta Gambling Research Institute 14th Annual Conference Critical Issues in Gambling Research March 26-28, 2015 Bonnie Lee, PhD, Associate Professor, Faculty of Health Sciences, University of Lethbridge Overview Relationship factors in mental disorders and GD Integrative systems model Relational gap in research and treatment Synergies in Alberta RELATIONSHIPS & MENTAL DISORDERS Relational Factors Individual factors ◦ Demographic characteristics ◦ Types of gambling ◦ Comorbidities Relational factors --- between two or more individuals ◦ Couple distress ◦ Family and Intimate partner violence ◦ Childhood maltreatment Couple Distress Depression Anxiety (Calvocoressi et al., 1995; Daiuto et al., 1998; Durham et al., (Beach, 2001) 1997) PTSD (Johnson & Williams-Keller, 1998) Substance use disorders (Fals Stewart, Birchler, & O’Farrell, 2003) Depression Meta-analysis of 10 studies (Whisman, 2001): Evidence that marital distress predates onset of major depression Spouses unhappy with marriage 3x more likely than happily married spouses to develop and episode of major depression over a 12-month period (Whisman & Bruce, 1999) mean correlation between marital distress and major depression = 0.66 Depression Relationship dissatisfaction predicts increased risk for a major depressive episode in the subsequent year, even after controlling for history of depression (Whisman & Bruce, 1999) Poor marital adjustment at the end of active individual depression treatment is a risk factor for increases in depression severity during follow-up (Whisman, 2001). Substance Use Disorders Marital functioning predicts likelihood of relapse and time to relapse in alcoholic patients (O’Farrell et al., 1998) 40-60% of married or cohabiting SUD patients report episode of partner aggression a year preceding entry into treatment (Fals-Stewart & Kennedy, 2005) Problematic drinking predicts increases in marital distress and likelihood of divorce or separation a year later (Leonard & Roberts, 1998) Relational Distress Etiology Maintenance Relapse Treatment Outcomes Demonstrated comorbidity between relationship distress and many physical and mental disorders (Heyman, et al., 2009; Snyder & Whisman, 2003; Whisman & Uebelacker) Couple Treatment Significant impact of the relational dissatisfaction on behavioural, cognitive, affective, and neurophsiological systems Attention to relationship problems is essential for the appropriate management of mental health and addiction disorders (Heyman et al., 2009) Chicken or Egg? Bi-directional and Recursive (Snyder & Whisman, 2004; Lee, 2012a) Faultlines (Lee, 2012) Limited range and depth of communication Limited range and depth of communication Overfunctioning or Underfunctioning Separate activities Emotional and physical abuse Life Transition Stress Gambler Transition/Stressor Andy Adolescence Harry Marriage; Father’s death Mita Immigration; Loss of profession; Parenthood Shaun Parenthood Greg Parenthood; Job Loss Fred Retirement Ethel Burnout, Financial Loss Tom Demotion Couple Relationship Before and After Pathological Gambling Five Circuits (Lee 2012) C4 Relapse Relapse C2 Pressure pt. Family of C1 Fault Line PG R1 R2 Origin Congruence C = Circuits Exacerbation R 1 = Distressed relationship R 2 = Congruent relationship C3 C5 REVERSING THE SPIRAL Congruence (Lee, 2009) Awareness Acknowledgment Alignment A House with Four Doors (Lee, 2009) INTRAPSYCHIC: PSYCHOLOGICAL INTERPERSONAL: COMMUNICATION INTERGENERATIONAL: FAMILY OF ORIGIN UNIVERSAL-SPIRITUAL: YEARNINGS, WORTH ESSENCE INTERGENERATIONAL INTERPERSONAL COMMUNICATION ``Water Line`` FEELINGS ------------------------------------ INTRA-PSYCHIC FEELINGS ABOUT FEELINGS PERCEPTIONS & BELIEFS EXPECTATIONS UNIVERSAL -SPIRITUAL YEARNINGS SELF: I AM The Iceberg: Satir et al., 1991; Banmen, 1994; Lee, 2009l., 1991; Banmen, 1994; Lee, 2001, 2009 Sample N=30 Baseline PG score (DSM-IV): 8.7 Retention: 89% at 2 month follow-up High percentage of lifetime traumatic experience: gambler (70%); spouse (55%) Gamblers more mental distress than spouses at baseline and post-treatment Spouses better family systemic functioning than gamblers at baseline and follow-up Participants’ Demographics Gamblers Gender Age (Mean in years) Education completed Employment Household Income Province Years married/together Sexual Orientation Ethnicity Immigration Religion DSM-IV PG score Amount of money lost Co-addiction Spouses Male = 66% Female = 34% 49.3 (range: 35-62) 48.9 (range: 36-70) University =27%; 2-year College=50%; High school = 23% Employed = 87%; Unemployed=6%; Retired=7% $80,000 CAD p.a. Ontario = 6 couples; Alberta = 9 couples Mean = 18 years Heterosexual = 100% Caucasian = 73%; Asian=24% ; Aboriginal=3% 37% landed immigrant Christian=50% ; Atheists=20% ; Jewish=7%; other=14% Mean = 8.7 out of 10 Mean = $87,000; most common gambling type: lottery, slots 57% reported co-addiction; most common: nicotine, alcohol, marijuana Treatment and Control Groups (MANOVA OUTPUT) Instrument GSAS (F(1,14)) BSI DAS (F(1,27)) (F(1,28)) Manova here Number of Participants Dependent Variable Tx(n)=8 Control(n)=8 Pre Post Followup Tx(n)=16 Control(n)=13 Tx(n)=16 Control(n)=14 STIC (IPS+ FOO+ Tx(n)=14 RWP) (F(1,24)) Control(n)=12 F Sig. Partial Eta Squared Observed Power 3.373 0.088 0.194 .402 9.442 0.008** 0.403 .815 Pre 5.048 1.287 0.041* 0.267 0.265 0.045 .552 .194 Post 13.371 0.001*** 0.331 .941 Followup 4.949 0.035* 0.155 .573 Post 1.078 0.168 0.308 0.685 0.037 0.006 .171 .068 Followup 0.101 0.753 0.004 .061 Post 1.178 5.855 0.289 0.023* 0.047 0.196 .181 .641 Followup 4.093 0.054 0.146 .493 Pre Pre FRIEDMAN TEST Instrument Treatment Friedman here Pre/Post/FU P-Val Control Pre/Post/FU P-Val GSAS .131 .657 BSI .000*** .353 DAS .002** .504 STIC .000*** .076 Acceptance • Favourably accepted by counsellors and couples O2: Gamblers’ satisfaction: M=6.44 out of 7 (n = 8) Spouses’ satisfaction: M=6.55 out of 7 (n=8) O3: Gamblers’ satisfaction: M=7 out of 7 (n = 4) Spouses’ satisfaction: M=6.75 out of 7 (n = 4) RESEARCH GAP Meta-analysis of Systemic Therapies (2014) Systemic ◦ ◦ ◦ ◦ Theoretical lens Reciprocity Interactive; types of questioning Changing the conditions of the social system May 2014 6681 records identified on systemic therapies 45 articles fit 8 criteria of definition, approach and RCT quality 8 on SUD/addiction SERVICE GAP From the Field “Family Program” 12-step tradition Lack of training Mapping the Mind-Swamps (Lee et al., 2013) Two Calgary Addiction Treatment Agencies Years of experience in addiction and mental health: 57% have over 6-10 years Missing: link to childhood adverse experience; individual symptoms; minimal mention of relationships and communication; coping but unclear. Fragmented, piecemeal, lack coherence GAP-MAP (Wild et al, 2014) 20% of adult Albertans (614,861 people) experienced an addiction and mental health problem in 2012 48.7% reported unmet needs for one or more services Unmet needs for counselling Services based on reactive, acute-care model Unmet needs for information Technologies are under-utilized Inadequate tracking of client outcomes (78% said they needed additional support to document program effectiveness) Underserved Populations (p. 96) Children & Youth “Participants indicated that services and supports are needed for children and youth impacted by parental addiction and mental health problems, early psychosis, substance abuse and addiction” Family (p. 96) Lack of services and supports available to families in Alberta. To address mental health and addiction problems rooted in individuals’ relationships with their family members. Specifically, respondents identified a need for mental health and addictions counseling that adopts a family system perspective, rather than simply focusing on the individual as separate from the family.” Dual Diagnosis and Complex Needs (p.97) Services for complex needs clients: Concurrent Disorders; PTSD System Needs Training ◦ Families ◦ Children and youth ◦ Concurrent disorders (cross-training, specialized training) EMBEDDING A RELATIONAL FOCUS IN TREATMENT SYSTEM STEP 1: Identifying the Need Informal -- conversations with the field, listening to clients and service providers Formal – provincial systematic survey NETWORKING AND RELATIONSHIP BUIDLING STEP 2: Alberta Family Wellness Initiative Translate scientific research into policy and practice Provide resources and symposia to bring key stakeholders together Create a common framework of understanding RECOVERY FROM ADDICTION – 3-YEAR SYMPOSIA Cuts across sectors Experts Conversation & Discussion Relationship Trust Team work AHS ADDICTION AND MENTAL HEALTH STRATEGIC CLINICAL NETWORK Identified priorities: Depression Addiction: prevention through treatment, priority alcohol misuse Child & Youth Mental Health Complex High Needs Users Campus Alberta researchers STEP 3: PLANNING MEETING CIHR Partnerships for Health System Improvement Planning Grant – March 13-14, 2014 20 participants Clear focus on relational counselling Mix of participants: AHS directors, managers, supervisors, evaluators, university researchers, endusers, interprovincial representation Multi-modal – research evidence, end-users testimonials, agencies, role-play demonstration, interactive activities – cognitive and experiential Priorities Teams STEP 4: MOMENTUM INTO GRANT APPLICATION (JUNE 2014) AGRI Major Grant (2015-2017) • Gambling Disorder vs Alcohol Use Disorder: Comparing Treatment Outcomes with Congruence Couple Therapy Researchers: Bonnie Lee, Darren Christensen, Andy Greenshaw, Kathy Aitchison, Olu Awosoga Partner: Alberta Health Services (4 zones) CANADIAN DEPRESSION RESEARCH AND INTERVENTION NETWORK (CDRIN) INNOVATION + COLLABORATION = TRANSFORMATION CIHR Canadian Research Initiative in Substance Abuse – Regional Node CRISM (Wild, Aubrey, Dell, Hodgins et al., 2014- 19) Build teams Academic researchers and service providers Common projects in substance misuse Efficacious, tailored, feasible, applicable interventions easily accepted by service providers A Rising Tide Research as Social Construction of Knowledge Questions? Thank you!
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