In Their Own Right Understanding and Supporting Family Members - - PowerPoint PPT Presentation

In Their Own Right Understanding and Supporting Family Members Affected by Gambling

Jim Orford University of Birmingham, England

Victorian Responsible Gambling Foundation Melbourne, October 23‐24, 2014.

Addiction and the Family International Network

AFINet UK

Akan Ibanga Laura Nice Jim Orford Lorna Templeton Richard Velleman

Formerly The Alcohol, Drugs and the Family Research Group

Affected Family Members: Long recognised but still neglected

• ‘It is the nature of emotional disorders that when one

member of the family is afflicted, the effects are felt by all the others. There are few, however, in which the impact is felt with such severity as in the case of compulsive gambling’ (When Luck Runs Out, Custer & Milt, 1985).

• ‘… we have had a monster living with our family – a

monster in the shape of a fruit‐machine. Practically every penny my husband earned went into that machine’ (a wife cited by Barker & Miller, 1968).

A rough estimate of the numbers of family members affected by their relatives’ problem gambling

Assuming 2 other people seriously affected in each case and problem gambling prevalence 2% in Australia and 1% in the UK: Australia: 920,000 Victoria: 232,000 UK: 1,280,000

Wives of Problem Gamblers

Some of the things they talk about

• Being in the dark about the extent of the gambling
• Finding out about it; suddenly or slowly
• Trying to get back control of family finances
• Feelings of anger and mistrust, but feelings mixed
• Other family members and relations not very helpful
• Doctors and other professionals don’t know what to do

Parents of Young Problem Gamblers

Some of the things they talk about

• Discovering financial irregularities
• Changes in behaviour and personality, education and work
• Crises occur
• Parents’ social life, relationship and health affected
• To be tough or tender?
• Trying to protect others

Children may be particularly vulnerable

In the few studies carried out, children have often reported being caught in the middle of family tensions, taking on the role of peacemaker, often experiencing disappointment due to broken promises, feeling sad, hurt, angry, depressed, confused and ashamed, even taking the blame for family difficulties stemming from the problem gambling.

The Stress‐Strain‐Coping‐Support Model

Addiction FM’s stress Inform‐ ation Coping FM ill‐ health Adults Child‐ ren Social suppor t

Family members are affected in three main areas (McComb et al., 2009)

• Financial: harms ranging from the pilfering of small amounts of money

right through to the whole family being put at serious financial risk due to large losses and debts.

• Relationships: Relationships between family members and their gambling

relatives are often undermined by the secrecy of their relatives’ gambling, and by arguments, and worse, when the seriousness of the gambling becomes apparent. Loss of trust is usually a big factor.

• Health (both emotional and physical): Being highly stressed, family

members are themselves at heightened risk of mental and physical health difficulties, particularly anxiety and depression.

A Wife’s Constant Worry

• I was constantly worrying: he’s going there, he’ll gamble, he’ll

lose, he’ll come back, he’ll be angry – you know it was constant worry – bursts of anger, bursts of upsets. Then I had a child staying at home [and] you didn’t want it to impact him. He had to do homework, he had to go to hockey, you don’t want to hear your mother and father screaming… So, you’re worrying, [thinking] ‘I’m not going to scream, I’m not going to argue, it’ll pass’ it’ll pass’.

• Tepperman, Betting Their Lives, 2009, p 152

A Daughter

• I’d get home from school, I’d watch TV and my Mum would

be upstairs on the computer. She’d just be on the computer like that all the time and then she’d make my tea and then she’d probably go back up again. Then she’d probably watch some TV and then I think before she went to bed she went on

• it. And then it just went like that.
• Valentine and Hughes, Ripples in a pond, 2010, p 282

FAMILY MEMBERS’ WORRIES ABOUT THEIR RELATIVES

• Worry about the relative’s physical health
• Worry that the relative is neglecting himself or herself
• Worry about the relative’s mental health
• Worry that the relative’s education, work or sporting performance is failing
• Worry about the relative’s financial affairs
• Worry about the frequency, quantity or form of the relative’s addictive behaviour
• Worry about the company the relative is keeping

ANALOGOUS FORMS OF STRESSFUL LIFE CIRCUMSTANCES

• Relative’s mental illness
• Relative’s chronic illness
• Relative’s dementia
• Relative’s HIV/AIDS
• Partner’s combat stress
• Partner’s infidelity
• Family unemployment
• Work overload
• Bullying at work
• Disaster
• In a war zone
• Persecution

The Stress‐Strain‐Coping‐Support Model

Addiction FM’s stress Inform‐ ation Coping FM ill‐ health Adults Child‐ ren Social suppor t

Two Partners’ Struggles to Understand

• I’ve racked my brains trying to figure out what’s in it for him.

I’ve tried to get him away from it, try to get him to think about other things, tried to get him interested in something

• ther than that. I even suggested we play board games. ‘No’.
• Once [my partner] starts gambling, I don’t feel a part of this

relationship anymore. I find it’s very selfish behaviour. Then I try to analyze it and then I [wonder], is it an addiction.

• Tepperman, Betting Their Lives, 2009, pp 218 & 226

The Stress‐Strain‐Coping‐Support Model

Addiction FM’s stress Inform‐ ation Coping FM ill‐ health Adults Child‐ ren Social suppor t

Addiction Dilemmas

Main Coping options for affected family members

• Withdrawing from it, being

independent of it

• Engaging in trying to change it,

standing up to it

• Accepting it, putting up with it

Family Members’ Ways of Coping

STANDING UP TO IT PUTTING UP WITH IT WITHRAWING AND GAINING INDEPENDENCE Resigned, accepting Sacrificing, compromising Supporting the relative Controlling, protecting the family Confronting, talking rough Refusing, resisting, being assertive Avoiding, escaping Not worrying, getting a new life

A Sister’s Coping Dilemma

• She said she’d had some debts; she was very sorry she’d gone on

the gambling again. She needed so much to bail herself out… would I be willing to do it?… So I spoke to my mother. I spoke to my husband and we all came to the conclusion that she needed a loan. I’d get her the loan but it had to be, you know, there had to be certain regulations or conditions to getting the loan. And I made her wait for a week before I told her. And then another condition was she had to tell her husband because her husband had no idea what she had been doing… I took the loan out from my bank and made sure it was a secured loan for £5,000… I’m not best pleased… I took the loan out because I thought it’s not fair on her daughter to have to suffer and go without.

• Valentine and Hughes, 2010, p 280

A Partner’s Coping Dilemma

• I am not being strict enough with him… I want to help him but

I don’t want to treat him like a child either. I don’t want him to feel like I am being like his mother either. I don’t want him to cause a big fight and have him be like, ‘Oh, you’re just trying to be my mother.’ I don’t want him to feel like that.

• Tepperman, Betting Their Lives, 2009, p 247

A Father’s Attempts to be Supportive

• I’ve tried to tell my son that the only winner is the machine. I

had on a TV programme about gambling and I wanted him to see it and had kept him there for as long as I could. I think the nicking has now stopped. At one time I discovered he’d been taking money from the till over a period of several months. I had to sack him from working with me over it. I think he was upset about that. I am working very hard now to try and be with him as much as possible, to do things with him.

• Orford, Addiction Dilemmas, 2012, p 82

The Stress‐Strain‐Coping‐Support Model

Addiction FM’s stress Inform‐ ation Coping FM ill‐ health Adults Child‐ ren Social suppor t

A Mother’s Network Diagram

Mother

• Mother-

in-law

• Husband

+

Two sisters

• Daughter's

ex- boyfriend

• Daughter's

coffee-bar friends

• Other

parents

• Daughter's

schoolfriend and family

+

Policeman

+

Daughter's social worker

• Another

social worker

• Criminal

justice system

+

A close friend

+

Friend in casualty

• Other

close friends

+

Work colleagues

• Step-

father

The Stress‐Strain‐Coping‐Support Model

Addiction FM’s stress Inform‐ ation Coping FM ill‐ health Adults Child‐ ren Social suppor t

Symptoms of Ill Health Symptoms of Ill Health

2 1

5 10 15 20 25 30 35

UK Mexico Wives P.Care P.Care Psych Control

Family members, psychiatric outpatients and community controls

Family members

The 5‐STEP Method

for helping affected family members

1. Listen non‐judgementally 2. Provide information 3. Discuss ways of coping 4. Explore sources of support 5. Arrange further help as needed (including the possible involvement of the addicted relative)

The 5‐STEP Method

Features of the method

 Applicable whatever the relationship of family

member to addicted relative

 Applicable in a wide variety of settings, including

primary and specialist healthcare

 Flexible in its application e.g. number of meetings;

number of family members; self‐help handbook; group format

 Can be extended to include joint work with family

member(s) and addicted relative

The Short Questionnaire for Family Members Affected by Addiction – The SQFM(AA)

• Impact on the family member/family

– Worrying behaviour – Active disturbance

• Ways of coping

– Engaged emotional – Engaged assertive – Tolerant – Independent

• Social support

– Informal helpful – Informal unhelpful – Formal helpful

• Symptoms of strain

– Psychological – Physical

Total Family Pressure: Impact + Coping + Symptoms

Family members attending the NPGC compared with family members of relatives attending alcohol/drug services

Gambling Alcohol/drugs N 197 202

Total Family Pressure

26.28 (9.39) 27.72 (10.28)

Items separating gambling clinic and alcohol/drug service family members

Gambling Clinic

• Have the family finances been

affected?

• Watched his/her every move or

checked up on him/her or kept a close eye on him/her? Alcohol/drug service

• Are you worried that your

relative has neglected his/her appearance or self‐care?

• Has your relative threatened

you?

• Started an argument with

him/her about his/her drinking/drug use?

• Given him/her money even

when you thought it would be spent on drinking/drug use?

Total family pressure varies with circumstances

Total Family Pressure before and after intervention (NPGC N=70)

Initial assessment Follow‐up t test Total Family Pressure 26.11 (9.54) 19.87 (9.88) ‐6.22***

Helpful Formal Support before and after intervention (NPGC N=66)

Initial assessment Follow‐up t test Helpful Formal Support 0.92 (1.78) 3.42 (3.12) 6.27***

TRANSFORMATIONS DESCRIBED BY FAMILY MEMBERS RECEIVING 5‐STEPS

• Increased focus on own life and needs (gaining

independence)

• Increased assertiveness over the misuse (resisting

and being assertive)

• Taking a calmer approach towards the misusing

relative (reduced emotional confronting)

• Increased awareness of the relative’s misuse

problem and its effects on family members (cognitive change)

• Feeling better supported

Talking about the problem and how the gambling is affecting the family member

• ‘it was about the first time I felt somebody had listened to

me, someone was interested in how I was feeling’

• ‘I’ve never really had anyone to talk to you about how I was

feeling through all this’

Increased focus on self and own needs

• ‘I thought I was strong and could cope with most things,

but this is something I couldn’t cope with’

• ‘all these years I’ve been through all this and what have I

been left with; now I’ve got to get on with things, I’ve got to build a life’

• ‘I’m looking after myself better, going to exercise classes

and eating less convenience food’

Changes in ways of coping

• ‘I will no longer lie for my husband or cover up for him’
• ‘I’ve stopped shouting and arguing about it’

Building better social support

• ‘My wife and I now sit down and talk about our son’s

problem and work out a way to support each other in what we are doing’

• ‘I don’t keep it a secret any more from friends and

relations and as a result I feel less tense about it and people are supportive’

Does it Work?

• Alcohol/drugs, specialist, primary care and

community settings, several countries: pre‐post changes, maintained at follow‐up

• Alcohol/drugs, primary care, controlled trial

comparing handbook and brief professional contact with more intensive professional contact

• Gambling, specialist treatment setting, England: pre‐

post changes in ways of coping and symptoms

If So, How Does it Work?

• By specifically helping family members with

information, coping and support ?

• By more generally helping family members feel

acknowledged and to become more resilient and empowered?

• By helping family members help their gambling

relatives change?

Main Modifiers of the Core Family Member Experience

THE CORE EXPERIENCE

Relationship to gambling relative Culture: individual, familial or communal Legal or illegal: traditional or recently introduced Gambling pattern Traditional vs Modern family roles Is modified by FM female

• r male

Family Material circumstances

‘PUTTING UP’ with relatives’ substance problems by WIVES in THREE CULTURAL GROUPS

2 4 6 8 10 12 14 16 SW Eng Mex Sikh 'Putting up'

Wider Theoretical Development

• The ‘capabilities’ approach. Martha Nussbaum , Women and

Human Development (2000).

• Stressful life events and chronic life difficulties and
• depression. ‘Humiliation’ and ‘entrapment’. Brown and

Harris, The Social Origins of Depression (1978).

• Empowerment (or resilience). Orford, Power, Powerlessness

and Addiction (2013).

A Disempowered Group

• Difficult to identify
• Not associated with any one priority health problem
• Do not create a problem of public disorder
• Have no collective voice or identity
• Have no name
• Neglected
• Often blamed
• Feel ashamed

Training and Accrediting Practitioners in the 5‐Step Method

• 1. Train practitioners in the 5‐Step Method
• 2. They practice it
• 3. When they are ready, they submit audio‐recordings of

sessions covering all 5 Steps

• 4. These are assessed against criteria for delivery of the Method
• 5. Once they meet the required level, they are accredited as 5‐

Step Method practitioners

Summary of the Competence Criteria for Step 1

• Allow family member to describe situation and tell his/her story
• Identify relevant stresses and how the FM has been affected
• Identify relevant stresses and how others have been affected
• Normalise the experience of FMs, giving the FM an indication that

(s)he is not alone with the experiences

• Cover appropriately the beginning and ending of the session (e.g.

introduction and purpose of 5‐Step, confidentiality, use of handbook)

The Development of Self‐Sufficiency in Training and Accreditation in the 5‐Step Method for a country (or large organisation)

• Train and accredit practitioners in the 5‐Step Method
• Train these Accredited 5‐Step Practitioners to deliver training

to other practitioners in the 5‐Step Method, and accredit them as trainers

• Train them to become Accredited Assessors

Once a place has Accredited Trainers and Accredited Assessors, that place is self‐sufficient.

A programme of family treatment research and development at several levels

• At the level of individual families or family

members

• At the level of service units
• At the level of whole service organisations
• At the national level
• At the international level

Addiction and the Family International Network (AFINet)

• Mexico
• England
• Australia (NT)
• Italy
• Northern Ireland
• Irish Republic
• Nigeria
• India
• Brazil
• South Africa
• Iran
• Canada
• Hong Kong
• Australia (NSW)
• Germany
• Other countries

Reaching Affected Family Members

• Changing personnel in specialist organisations

to be more family focused (increased awareness and confidence)

• Raising awareness in non‐specialist
• rganisations (social work, debt advice etc.)
• Using new modes of communication, e‐health
• Helping family members campaign for policy

change

• ???

Most up‐to‐date references

Velleman, Cousins and Orford (2014), The effects of problem gambling on family members, in: S. George and H. Bowden‐Jones (eds.). A Clinician’s Guide to Working with Problem Gamblers, London: the Royal College of Psychiatrists. The Alcohol, Drugs and the Family Research Group (2010), The 5‐Step Method: A research based programme of work to help family members affected by a relative’s alcohol or drug misuse, Drugs: Education, Prevention and Policy, Volume 17, Supplement No. 1, December Orford et al. (2013). Addiction in the family is a major but neglected contributor to the global burden of adult ill‐health, Social Science and Medicine, 78, 70‐77 Orford (2012). Addiction Dilemmas: Family Experiences in Literature and Research and their Lessons for Practice, Chichester: Wiley‐Blackwell.

AFINet

Addiction and the Family International Network www.afinetwork.info

Gambling Watch UK

www.gamblingwatchuk.org