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Family Coping Treatment Group for Chinese Help-Seeking Family Members of Problem Gamblers Elda Mei-lo CHAN Tung Wah Group of Hospitals Integrated Centre on Addiction Prevention and Treatment, Hong Kong; University of Melbourne, Australia Daniel Tan-lei SHEK The Hong Kong Polytechnic University, Hong Kong Daphne Nam-ying YEUNG Tung Wah Group of Hospitals Even Centre, Hong Kong Ryan Hing-yan WONG Tung Wah Group of Hospitals Integrated Centre on Addiction Prevention and Treatment, Hong Kong
Literature review – Family impacts Impacts of Pathological Gambling on family • • Financial and debt problems Family conflicts and arguments Neglect of family Development of problem gamblers and other addictions (Kalischuk et al. , 2006)
Literature review – Family impacts Impacts of Pathological Gambling on Spouse • • Separation and divorce Depressive thoughts and suicidal attempts • Increased risk of violence • Dysfunctional coping such as excessive drinking, overspending and gambling (Lorenz & Yaffee, 1988; Abbott, 2001; Crisp, et al. , 2001; Krishnan & Orford, 2002)
Literature review– Family coping Lorenz & Yaffee (1988) • Inadequate coping skills of partner prevent them from coping effectively with compulsive gamblers and their maladaptive behavior Orford et al. (1998) • Suggested 3 broad ways of coping including engaging, tolerating, withdrawing that would have different impacts on the family Rychtarik and Mc. Gillicuddy (2006) • Coping behavior and functioning of partners of PGs had improved after intervention through a coping skills enhancement programme Meyers, Dominguez & Smith (1996) • Decreased in global psychological distress and improved relationship functioning occurred for significant others of alcoholics after family training program
Literature review– Group Therapy Kinney (2003) • • • Learn through interacting with others Get social support and feedback Receive hope for changes. Vannicelli (1995) • • Share the common problem relating to addiction Help stay vigilant about recovery
Literature review - Treatment for family members Involvement of family members in gambling treatment • Adopting Community Reinforcement and Family Training (CRAFT) approach for significant others of gamblers • Family members as active and influential participants in recovery • Assisting family members to manage their own personal distress • By addressing areas of stress in their own lives, they will be equipped to better cope with the problems of gamblers (Hodgins et al. , 2007)
Background – gaps in literature • • • Associations between family violence and family coping styles to problem gambling were found in a previous study in 2012 Recommended to focus on the change in the family members which might impact favorably on the gambler Scientific studies on intervention to improve coping and functioning of family members of problem gamblers amongst Chinese communities are non-exist.
Family Coping Treatment Group Aims • To help family members identify the development of their • • particular coping styles towards gamblers’ gambling problems To strengthen family members’ abilities to adopt more effective coping styles To enhance family members’ awareness to look after their mental and physical health Design • From July 2013 to September 2013 • 10 weekly group sessions • 10 Family members of problem gamblers who sought gambling treatment from TWGHs Even Centre Inclusion criteria • Chinese ethnicity, aged 18 or above • No manifestation of signs of cognitive impairments or imminent suicidal risk
Family Treatment Group Content • • • Psycho-education on pathological gambling problems Awareness of own coping style & distress Interactive cycle of response with gamblers Self-care Effective communication skills Format • • • Exercise of self-exploration, e. g. , drawing, role play Group sharing and support Relaxation, e. g. , muscle relaxation exercise, meditation… Self-care exercise, e. g. , small gift, food and quality time for self Communication skill rehearsal, e. g. , i-message
Aims of Current Study To investigate the effectiveness of preliminary family coping treatment group for family members of problem gamblers
Measures Socio-demographic information Gambling-related information 1. 2. Family coping: 30 -item Coping Questionnaire (CQ; Orford, 1994) covering 3 major ways: 3. • • • Engaged coping (subsuming controlling, assertive, emotional and supportive) Tolerant-inactive coping (subsuming inactive, tolerant and supportive) Withdrawal coping (subsuming independent and avoidance)
Measures Family functioning: 3 subscales of Chinese Family 4. Assessment Instrument to assess family functioning in Chinese culture (CFAI; Shek, 2002) • Mutuality • Communication • Conflict Psychological distress: 21 -item self-report Depression Anxiety Stress Scale to measure negative emotional states (DASS 21; Lovibond & Lovibond, 1995) 5. • • • 6. Depression Anxiety Stress Qualitative analysis of interview reports
Basic demographic information Family Members (N =10) Gender Male 30. 0% Female 70. 0% Age Mean = 49. 9 Marital status Never married 30. 0% Married or cohabited 70. 0% Divorced, separated or widowed 0%
Basic demographic information Family Members (N =10) Educational attainment Primary School 50. 0% Secondary School 50. 0% Economic status Full-time or part-time work 60. 0% Unemployed 0% Homemakers 10. 0% Retired 20. 0% Students 10. 0%
Basic demographic information Family Members (N =10) Relationship with gamblers Spouse/ Partner 40. 0% Parents 20. 0% Siblings 10. 0% Son/ Daughter 30. 0% Others (e. g. other relatives) 0%
Gambling-related information Family Members (N =10) Main Types of gambling Casinos 3 Horseracing betting 2 Soccer betting 1 Mahjong 1 Others (e. g. cards, stock speculation) 1 Length of gambling problems 2 -33 years Severity of Gambling (Reported by the gambler) Pathological gambling (DSM-IV score higher than 5) 5 Probable problem gambling (DSM-IV score = 3 or 4) 0
Family functioning Chinese Family Assessment Instrument (CFAI) Before Treatment After Treatment Mutuality * (0 -42) 2. 33 (. 68) 1. 91 (. 33) Communication * (0 -27) 2. 79 (. 81) 2. 33 (. 78) Conflict (0 -24) 3. 82 (. 80) 4. 05 (. 53) Note ** p<0. 01, *p<0. 05
Emotional distress Depression, Anxiety and Stress Scale (DASS 21) Before Treatment After Treatment Depression * (0 -42) 9. 2 (5. 3) 3. 0 (3. 4) Anxiety * (0 -42) 11. 4 (9. 4) 4. 4 (3. 9) Stress ** (0 -42) 15. 8 (8. 5) 7. 6 (3. 4) Note ** p<0. 01, *p<0. 05
Gambling-related family coping Coping Questionnaire (CQ) Before Treatment After Treatment Engaged Coping * (0 -42) 25. 4 (6. 1) 18. 5 (7. 8) Tolerant-inactive coping * (0 -27) 14. 0 (6. 4) 8. 2 (5. 9) Withdrawal coping (0 -24) 14. 4 (4. 3) 24. 8 (30. 1) Note ** p<0. 01, *p<0. 05
Level of Confidence to Cope with Difficulties caused by Gambling Problems Emotional distress ** (0 -10) Damaged family relationship ** (0 -10) Note ** p<0. 01, *p<0. 05 Before Treatment After Treatment 9. 2 (5. 3) 3. 0 (3. 4) 11. 4 (9. 4) 4. 4 (3. 9)
Areas covered in Focus Group • Ways to cope with gamblers’ gambling problems ◦ Behavioral responses ◦ Emotional responses • Confidence to manage negative consequences caused by gambler’s gambling problems ◦ Psychological distress ◦ Damaged family relationship
Limitations • Small sample size used ◦ Results reported are preliminary and require replication • Lack of control group ◦ Alternative explanation of results cannot be eliminated • Intervention received before the group ◦ Certain amount of coping skills were learnt and emotional support was rendered before group such that mean levels of depression and stress fell within normal and mild range • Partial reliance on family members’ reports ◦ Gambling related information on problem gamblers may not be accurately assessed • Caution to directly compare with previous studies ◦ Differences in terms of: � Targets (intimate partner vs family members) � Treatment goal focus (coping skills training vs family enhancement) � Format (individual session vs group session)
Discussion • Effectiveness of family coping treatment group ◦ Program effective in reducing depression, anxiety and stress level for family members of gamblers ◦ Results supported the contemporary view that distress caused by both gambler’s gambling problems and their ineffective coping strategies ◦ Consistent with results from previous studies (e. g. individuals of alcoholic/gambling partner; Rychtarick & Mc. Gillicuddy, 2005; 2006)
Discussion • Family members reported higher level of family functioning after treatment: ◦ Significant improvement made in the area of mutuality and communication: Family member B: “I try not to push her too much by discussing with her on subjects in common, such as future plan. A relax atmosphere can now be maintained. ” 家人B: “用另一個方法同�溝通囉，同�傾下屋企將來嘅 planning…變�自己心態 都輕鬆一�。 ” Family member C: “ He can better control himself unlike the past. We often have conversation before making any decisions. ” 家人C: “�亦都無咁亂黎，而家開始會同我有商有量�。以前 就唔識點處理，但而家�都可以軟化�咁同我傾 ” Family member D: “ After making more ‘I-message’, I gain more positive response from him. It is effective!” 家人D: “我講多�一� I-message…講多��又會回應多�， 都有效” Ø Increased awareness of self-care, less reactive response towards gamblers and improved coping skills may help improve family functioning
Discussion • Family members reported significant improvement in the aspect of emotional distress after treatment ◦ Promotion of awareness and better coping of own emotional distress Family member A: “ My emotion is stable now. I am able to be more aware of my own emotional condition, for example, if I cannot sleep, I will find ways to relax such as listening to music. ’ 家人A: “情緒好好多，會盡量察覺自己情緒嘅狀況，譬如�唔著，會盡量搵方法解 決，例如聽下碟，令自己唔好困住係個思想裡面。” Family member C: “ Her attitude may sometimes be bad, and even hurting me by saying something bad. Like tsunami, it would be over finally if I can be tolerant at the moment. 家人C: “�可能態度好差，用嘅語言係好傷害你嘅，令你情緒好困擾嘅。但如果 可以抵受到�一刻，其實好似海潚咁，過�之後就無事架 ” Family member E: “I will join activities together with the other group members, shopping with my daughter after work. I am happy!” 家人E: “我會同組員一齊參加活動，放假又同�女行街飲茶，有 90分咁開心
• Adjustment of expectation and promotion of understanding of pathological gambling Family member A: “ Now I understand that gamblers also have burden. They also feel guilty but they cannot control themselves. ” 家人A: “明白了解�賭徒都有擔憂、都有�疚， 不過控制唔到� ” Family member B: “ After attending the treatment group, I am more relieved. It takes time for him to decide whether he will continue to gamble or to quit gambling. ” 家人B: “上完小組後我好似睇得輕鬆�，覺得始終� 要去賭或者要戒都唔係一時三刻嘅事” ◦ Promotion of awareness, adjustment of expectation towards gamblers’ changes and better emotional coping skills help reduce emotional distress in a great extent.
Discussion • Family member reported adopting better coping strategies after treatment: ◦ Greater awareness of emotional distress, more focus on self-care, shift focus from gambler to self & less reactive response towards gambler Family member B: “I’ve become less rigid as I won’t be too sensitive to what he has done, where he has gone, …etc. 家人B: “我變得無再咁強硬，因為我無再計較�去�邊，做�乜。其實�一 如以往無變過，但我就無咁容易被� trigger到，要好緊要先會影響到我。” Family member D: “I’ve changed my perspectives, I’ve no longer chased where he has been and gambled or not… I’m less disturbed. I will listen to music or do some exercise…I would be nervous before but now, I am able to calm myself and take better care of myself, no longer disturbed by him. 家人D: “我改變�自己嘅睇法，無咁著眼係�去邊呀，又去賭馬呀 …低落嘅 情況就無之前咁犀利。咁又再次搵返�碟出黎聽，又再做運動 …自己本來都 比較緊張，比�纏擾多�，個人都失哂方寸，唔知點呀。而家就唔會啦，由 �啦，讓自己平靜�，善待自己先，唔好比�牽引住 ” Ø Family members with better coping strategies may enable them to calmly set down clear limitations in terms of what they would and would not tolerate.
Discussion • Increased level of confidence to cope with difficulties caused by gambling problems ◦ Significant changes in confidence level to cope with the difficulties Family member C: “Have more confidence to deal with problems caused by gambling after I have joined and learnt from the group. ” 家人C “覺得而家嘅信心都幾大，尤其係小組學��招數，處理就好�。 ” Family member D: “After attending the group, I have stronger will. I will not easily give up but to find ways to resolve the problem, such as , looking for help. ” 家人D: “信心係強�� …如果黎緊再有�咁嘅情形，我都會堅 持�，去搵幫手 ” Family member E: “I believe that I am able to deal with most of the problems now. ” 家人E: “有9成信心可以處理” ◦ Family members with better coping skills & decreased level of emotional distress may promote their level of confidence in coping with further difficulties caused by gambling problems.
Discussion • Change of family members lead to gamblers’ changes ◦ Change of gambling behavior and debt management Family member A: “Unlike before, we can now discuss on issues related to money. ” 家人A: “財務處理就唔似以前咁，無得傾、無得講，一定要跟�嘅方向 ” Family member E: “He is no longer gambling as much as before. He does not watch horse-racing anymore although he may still bet. He works for part-time job to pay his debt and no longer asks money from me. ” 家人E: “�無再好瘋狂咁去賭，雖然我諗�都仲有賭，但可能好少啦，連賭馬都無睇。 �又自己做兼職，自己找返�數，無問我攞錢 ” ◦ Change of communication ways Family member A: “Before, he had bad temper and no patience at all. His threatening behavior drove me crazy. But now we can talk to each other often. 家人A: “以前�就好威嚇性，又好急，令我情緒好差，唔知點好，而家�就可以同 我傾到” ◦ Less reactive responses and better coping strategies of family members may divert the vicious cycle in the relationship that promote positive changes of gamblers.
Recommendations � Involving family members in treatment � Advocating and encouraging help-seeking behavior of family members � Future study ◦ Larger controlled trials are required to evaluate the family coping treatment group ◦ Parallel treatment group for both problem gamblers and family members ◦ Study on paired samples between problem gamblers and their family members in order to obtain a more precise picture on the family as well as to better understand the discrepancy between their coping styles. ◦ Long-term study on influence of trained participants to gambler’s gambling behavior
Significance of the study Provides valuable information regarding family coping among problem gamblers in the Chinese communities and fills a significant knowledge gap • Helps family members adopt more effective ways to cope with gambler’s gambling problems and in turn reducing psychological distress • Helps clinicians develop appropriate preventive and treatment strategies for family members of gamblers •
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