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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!