Roger Horbay

Following is a case study designed to illustrate solution-focused brief therapy applied within the framework of the pathways and processes of change models. Motivational interviewing, cognitive-behavioural techniques and relapse prevention skills will also be touched upon.

Sam, a man in his mid-forties, is a husband and father of two children. Sam started playing cards in his teens, became involved in betting on horses and has ended up gambling at the casino. Although Sam has at times found himself in financially tight situations, such as having lost the money he was to have used to pay his bills, these occasions have been few and far between. Sam’s gambling was basically okay until the last couple of years, when a casino opened up near his home. Increased access provided Sam with more opportunity to sharpen his blackjack skills, an opportunity he seldom avoids.

Sam’s gambling annoys Jen, Sam’s wife, and the children. Jen’s frustration peaked the day she told him to get some help or leave the family. Sam’s employer is also concerned about Sam’s gambling and its possible effect on work performance. Sam enters gambling counselling services not knowing if he belongs there and reluctant to quit gambling.Given his happy-go-lucky nature, he doesn’t really see it as a problem.

Sam’s initial counselling session is critically important for setting the tone and expectations for counselling and motivating him to accept help. If at all possible, a counsellor should be the problem gambler’s first contact, so that the counselling process can begin right away. It is essential to begin establishing an understanding of Sam’s gambling history, why he has come to counselling, his views, his specific gambling behaviours and his difficulties. Blaszczynski’s (1998) pathway model is a useful framework for making meaning of the gambling development in the client’s life and helps direct the counsellor to appropriate strategies. Due to Sam’s ambivalence, expressed in his uncertainty about “belonging” at this clinic, motivational interviewing will be an encompassing element to initial contact.

Due to the nature of gambling disorders, it is particularly important to engage people affected by problem gambling as quickly as possible. Unlike clients with other addictive disorders, people affected by problem gambling may not have followed a straightforward progression from positive reinforcement (the high, no noticeable consequences) to negative consequences (psychosocial problems). The nature of gambling provides players with unpredictable, variable reinforcement. The gambler may have experienced numerous cycles of positive reinforcement (winning money, the high, temporary relief problems) followed by extreme negative consequences (large losses, which result in other problems such as relationship difficulties). The gambler may also have “solved” these problems by having a big win (positive reinforcement) and so may now believe that by persisting in gambling, he or she can solve the current problems.

As the initial session proceeds, the counsellor learns more about Sam and his gambling. Like many people affected by problem gambling, Sam exhibits a pathway 1 development of gambling behaviours. He has led a relatively normal life, coping with average stressors such as raising children in a home of two working parents. However, financial stresses that at one time he could control, have increasingly burdened him and now the “normally-not-so-easily-stressed” Sam is easily stressed. Commonly found in pathway 1 developments are touches of pathway 3 patterns. Sam’s pathway 3 characteristics are exhibited in his favouring of games, risk and challenge. Sam tends to live in the present and it isn’t natural for him to make long-term plans. Disliking how Sam manages money, Sam’s wife, Jen, has taken the responsibility of budgeting and paying the bills for the family. This hasn’t tended to lead to any major problems — Jen can deal with their occasional financial crises. However, Jen hit her breaking point when the hidden credit cards and loans eventually surfaced.

At the beginning of the treatment process it is impossible to predict how motivated an individual will be to change, or what problems he will present with. However, over-engaging by confronting or moving into action plans with ambivalent gamblers will result in the potential client disengaging from seeking further help. It is important, right from the beginning, to use skills that will effectively engage gamblers and motivate them toward further treatment. Validating the client’s feelings is also very important in the rapport- building process. A simple reflective statement that lets the client know his struggles, frustrations and challenges have been understood, will go a long way to keeping him engaged.

Clarifying and reflecting back in a non-judgmental way as information is collected, the counsellor summarizes Sam’s situation for him, noting, “Your wife is on your case, you have a $20,000 debt that is larger than you’ve ever had before, your employer is concerned about you so your job may be at risk and you can’t make your next mortgage payment.” Sam says these things are not caused by his gambling but by a number of other factors. The counsellor reflects back and moves on to learning about his beliefs about gambling and winning, such as whether or not his wins are due purely to skill. Reflecting back, the counsellor comments, “So you feel your technique can help you win at blackjack but you’re in debt $20,000. How do you deal with that?” Through discussion, another remark, “You say your wife is even-tempered but she sounds overly tense, especially around money issues. What do you think about that?” Throughout their dialogue, the counsellor has been applying the practical principles of solution-focused brief therapy: expressing empathy, developing discrepancy, avoiding argumentation and rolling with resistance.

People affected by problem gambling usually seek help to alleviate the negative consequences of their gambling (e.g., financial problems, relationship difficulties, guilt or shame). They also often report that they are seldom heard or understood by others. Therefore it is helpful to simply listen to clients to ascertain their reasons for seeking treatment. Avoid the trap of assuming that the client is seeking help primarily for gambling problems. He or she may, in fact, still be ambivalent about changing gambling behaviours but actively willing to deal with other problems that are direct consequences of his or her gambling. Dealing first with what the client believes to be most important will help to keep the client engaged and builds counsellor-client rapport.

Guided by Prochaska and DiClemente’s stages of change model (1998), the counsellor takes note that when Sam came into the office, he was in a contemplative stage about gambling. Thus, he is ambivalent about his need for help and even about having a gambling problem. However, the counsellor has discovered that Sam is in the action stage on the issue of gambling and work when he notes that he will not let his gambling affect his work (a clear goal) and that he plans to do this by not staying at the casino late. Similarly, a counsellor may choose to understand Sam and his gambling within the levels of therapeutic relationship model (Berg & Miller, 1992), by noting that Sam entered the office largely a complainant, although he is a customer for changing particular things in his life. These “customer aspects” are to be used to help Sam move into an overall customer relationship with his counsellor.

It is important to follow the client’s action stages because over sessions, the counsellor can use this action component to lead into issues Sam is contemplative about. For example, the counsellor can say, “You’ve planned not to come home late. What stopped you before?” In response, Sam speaks of reasons why he gets stuck in the casino. Together Sam and his counsellor can plan what to do in particular situations (such as having a big win during the later part of the evening) to encourage leaving on time. Eventually, Sam may come to the conclusion that he cannot go to the casino without leaving late unless he takes someone whom he’s contracted to leave together with or to abstain altogether — decisions that bring Sam into action about gambling. The key to a counsellor’s interactions throughout this process is to take Sam’s concerns seriously and to encourage change in a non-argumentative manner.

Given Sam’s hesitance in acknowledging and understanding that his gambling has become a problem, the use of a decisional balance sheet will be a helpful tool for the counsellor to use as a means of increasing insight into his situation. Gamblers know they can win. The nature of gambling assures that if you play long enough you will win something.Most people affected by problem gambling only focus on the possible short-term, positive outcome — the possibility of winning. However, they fail to realize the long-term negative consequences of gambling — that they will lose more than they will win. The use of a decisional balance sheet brings to light both the short-term and long-term, positive and negative consequences of gambling or not gambling. Decisional balance sheets can be used for any problem where the client is ambivalent about change. Through the use of the decisional balance sheet, Sam comes to realize that he does have a problem with his gambling behaviours.

Once Sam and his counsellor have defined the problem together, the counsellor allows Sam himself to define it and to determine how eager he is to do something about it. A useful technique to use for Sam’s ambiguity is the motivational scaling question. “On a scale of 1 to 10, where 10 means ‘I’ll do anything’ and 1 means ‘I couldn’t care less,’ how willing are you to solve your problem?” The following questions will work from the information Sam has given and may be similar to, “What small step can you take to increase your willingness?” If Sam indicates a 6 or 7, he still has a significant amount of ambivalence. An 8 would indicate a favourable level of motivation. It should be noted that an individual noting a 10 may still experience fear or ambivalence at some point in his or her process of change. The counsellor needs to normalize the client’s ambivalence in order to affirm and encourage change, noting that Sam will need to struggle through until he feels more motivated again.

From the initial interview to the maintenance of relapse prevention strategies, it is very important for the counsellor to have identified Sam’s strengths and resourcefulness in order to motivate, build confidence and uphold Sam as the primary actor in his process of change. By doing so, the counsellor strongly supports Sam’s self-efficacy, the final principle of solution- focused brief therapy.When Sam decides that he “has to do something” about his gambling behaviours, he has moved into an action stage. This signifies to the counsellor that Sam is ready to work on relapse prevention strategies. Together, Sam and his counsellor come up with motivational strategies, such as pinning a Visa bill on the inside cover of his briefcase or remembering how Sam felt driving home after spending 10 hours in the casino. Discovering what actions help keep the client’s goals in mind is an essential task. Sam decides to plan a vacation for Jen and himself and sets the date for a year ahead. He decides to get his vacation brochures out and look through them rather than going to the casino. This motivates him by reminding him of his financial priorities and is also a means of practising to plan for long-term goals. Throughout the action stage, Sam may relapse once in a while or not at all. Social supports and his sense of competence are important to maintain throughout this period — a period that may last the rest of his life.

References

Blaszczynski, A. (1998). Overcoming Compulsive Gambling: A Self-Help Guide Using Cognitive Behavioural Techniques. London: Robinson.

Berg, I.K. (1995). Solution-focused brief therapy with substance abusers. In A. Washton (Ed.), Psychotherapy and Substance Abuse: A Practitioner’s Handbook. New York: The Guilford Press.

Berg, I.K. & Miller, S.D. (1992).Working with the Problem Drinker: A Solution-Focused Approach. New York:W.W. Norton & Company.

Prochaska, J. & DiClemente, C. (1998). Toward a comprehensive, transtheoretical model of change: Stages of change and addictive behaviours. In V. Lopez (Ed.), Treating Addictive Behaviours (2nd ed.). New York: Plenum Press.

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