Compulsive Gambling: Structured Family Intervention Mary Heineman,
MSW, CAC, CGC
South Oaks Hospital, Amityville, N Y
Family intervention has been an effective procedure for getting alcoholics into treatment for more than twenty years. Now this technique is being used with compulsive gamblers. Because the gambling disorder is so easy to hide, the patient seems to be further into the illness by the time the family seeks help. Furthermore, because the gambling offers intermittent rewards, the denial in both the patient and family appears to be stronger than found with most alcoholics. During the intervention it is important to tell the compulsive gambler why the help of a professional was sought; what changes have been observed by family members and friends as a result of his/her gambling; how family relationships have been affected; what is feared will happen if he/she doesn't get help; and what each family member hopes will happen once the gambler is in recovery. Most concerned persons enter family interventions with the sole purpose of getting the gambler into treatment. However, since this is a family disease, ethically the primary goal of family intervention needs to be to get someone into treatment, if not the individual suffering with the disease then one or more of those concerned persons suffering from it.
Family members are confronting compulsive gamblers about the consequences of their gambling all the time. Unfortunately these confrontations are often nothing more than empty threats. When these encounters take place they are usually done on a one on one b a s i s - the concerned person alone with the gambler--and, as a result, the effort is futile. This is because the gambler is a well seasoned manipulator, and able to offer reassurance, put off, or ignore the loved one. Send reprint requests to Mary Heineman, MSW, 41 Surrey Lane, Plainview, NY 11803.
Journal of Gambling Studies Vol. 10(1), Spring 1994 9 1994 Human Sciences Press, Inc.
JOURNAL OF GAMBLING STUDIES
Another shortcoming of self directed interventions is that those intervening are not trained in what to say and how to say it. This type of intervention is often a "hit or miss" operation rather than a process which evolves over time. These ineffective interventions often result in painful negative emotions for the loved ones, leaving them feeling more discouraged, more disappointed and more helpless than before. In addition, the family continues being affected by a disease they do not understand but which they continue to try to control. These families do not know that they too need help and that effective treatment is available. Their belief, "I will be fine as soon as the gambling stops," is erroneous. T o d a y professional preparation for those seeking to confront a compulsive gambler is being made available at mental health/addiction treatment agencies across the US. These professionally conducted interventions are done in such a way that the gambler is not criticized, put down, or lectured; and the family is neither manipulated nor ignored. "[C]aring people can create a crisis, an artificial bottom, sufficient to force the chemically dependent person to seek help" (Bratton, 1987, p. 10). The compulsive gambler is confronted in a loving and supportive manner while hearing, often for the first time, that compulsive gambling is a disease, which therefore cannot be controlled, only arrested. Compulsive gambling is an emotional illness which leads the gambler to believe the answer to all existing problems, financial or emotional, is to "hit it big' one more time. This child-like thinking often keeps the compulsive gambler active in the disease until the very late stages. As a result, the family may be more affected, both emotionally and physically, than the compulsive gambler. Because this disease can be completely hidden for so long, the family too often has no knowledge as to the depth of the illness until the late stages. The goal of most family interventions is to get the identified patient (the compulsive gambler) into treatment. "It's a short term focus (family intervention) . . . . the structure is built around the immediate goal of getting the person (the addict) to accept help." (Johnson, 1987, p. 18). "The goal of the intervention . . . is to have the alcoholic see and accept enough reality so that, however grudgingly, the need for help can be accepted." (Johnson, 1980, p. 57). In reality, the only acceptable, ethical goal of any family intervention is to get s o m e o n e into treatment. In order to help some of the family members and friends who are hurting from this disorder, it is, at times, necessary to "hook" them into treatment through the intervention door. Once these concerned others
get some understanding of this disease, begin to support each other, and have a common goal of refusing any future "bailouts" to the gambler, the progression of the disease is road blocked for the gambler. It can never be emphasized enough that in order to interrupt the progression of any addiction, it is often most advisable to start with the family, as opposed to the compulsive gambler, because they are better able to hear about the nature of the illness and the necessary steps to take in order to arrest it. PROCEDURE
Most family interventions begin with a phone call to a treatment agency from a family member or friend of the compulsive gambler. The gathering of information about the gambler and the effects the gambling has had on the family begins with this call. There are specific questions to ask over the phone. It is important to know: the age and sex of the compulsive gambler; with whom the gambler is living; the ages and sexes of the gambler's children; with whom they are living; and whether or not the gambler has ever gone for help (Gamblers Anonymous and/or professional counseling). It is important to ask the caller: what her/his relationship is with the gambler; how long the caller feels the gambling has been a problem; and finally: "Exactly what precipitated this call?" Because the gambling has most likely been a problem for some time, it can be expected that the disease has progressed, and that the latest incident has resulted in additional fear and anxiety on the part of the caller. After the counselor collects the information needed over the phone, the focus becomes the emotional state of the caller. The caller may be feeling very guilty for having "betrayed" a loved one. The caller may have been told by the compulsive gambler that s/he is the cause of the out-of-control gambling. The professional can expect the caller to be filled with many painful feelings, especially guilt for having made the call in the first place. It is important to listen to the caller's feelings and concerns and support their decision to intervene. Once the preliminary information is collected and the caller has been heard and supported, an appointment is made for a consultation. The caller is asked to bring one other concerned person to the consultation session. The purpose of inviting a second party to the consultation is twofold; first, as a support for the initiator of the intervention and second, because the additional party will confirm (or deny) the infor-
JOURNAL OF GAMBLING STUDIES
mation given by the caller. "The ultimate goal of the intervention process is to get the person (the addict) into treatment." (Johnson, 1986, p. 74). THE CONSULTATION This session is a continuation of the conversation between the caller and the counselor. The counselor will continue to collect information from the caller and the accompanying individual in order to determine whether or not the family is appropriate for family intervention. The counselor will need additional information about the identified patient (the compulsive gambler). It is important to ask about the I.P.'s (the identified patient) physical and mental health; whether or not the I.P. has a history of mental illness; whether or not the I.P. is under the care of a medical doctor or a therapist. If the I.P. is under such care, it is recommended that the family contact this primary caretaker to reveal the plan to carry out an intervention and to ask whether the primary caretaker would, for reasons of their own, advise against it. A most important question to ask the two persons attending the consultation is whether or not the I.P. has ever attempted suicide. Should the answer be in the affirmative, it is necessary for the family to request input from the attending physician regarding the I.P.'s mental status before carrying out the intervention. Some agencies will refuse to facilitate a structured family intervention if the attending physician believes the I.P. is at the present, too fragile to be confronted. W h e n this situation exists the professional shall impress upon the concerned the need for them to continue to be educated about this disease and to get support for themselves. Once all the meaningful data about the I.P. has been obtained, the consultation will focus on helping the concerned persons determine exactly who will be attending the preparation sessions. The family will be directed to invite anyone who knows about the I.P.'s problem gambling, who has been affected by it, and who is sincerely concerned about how the gambling is affecting the I.P.'s life. The family is not to go home and inform others about the gambling problem in order to illicit their support at the intervention. T h e y are to approach only those who are already aware of the seriousness of the I.P.'s gambling. Should some concerned persons live out of town, they too can be included in the intervention by being informed as to what is taking place
at each preparation session and, if possible, by being in attendance on the day of the intervention. If this is not possible they can still write down how they are being affected by the gambling and forward it to the professional or to a family member, so that it can be read to the I.P. at the intervention. Children and/or elderly family members who have been affected by the gambling shall also be invited to attend the preparation sessions. The final issue addressed at the consultation is to have each of the individuals in attendance express just how they have been affected by the gambling. By so doing, they have a chance to: get in touch with their pain, verbalize their feelings and be supported by the counselor and their companion. At the same time the counselor will direct each of them to G a m A n o n (a self help program for family members of compulsive gamblers) where they can be further educated and supported. "The goal of an intervention is abstinence from chemicals for the abuser and the beginning of some care." (Wegscheider, 1982, p. 13).
T H E FIRST P R E P A R A T I O N S E S S I O N
The session begins with introductions and with each member present sharing their perception of the I.P.'s gambling. As each speaks, the professional listens attentively for evidence of denial in any member of the group. When it is heard, the professional does not confront it until each member has had a chance to speak. Then the counselor will return to the individual exhibiting denial and feed back some of the views offered by other family members, which clearly depict the extent of the I.P.'s gambling and its seriousness. The counselor will then address the concept of compulsive gambling as a family disease. Based on what each has shared in the group, the recommendation for each of them getting involved in a self-help program is best introduced at this time. A few minutes is spent explaining the fellowship of GamAnon, and dispensing schedules of meetings. Next the counselor will direct each participant to write down how the I.P.'s gambling has been affecting him/her. This will be read directly to the I.P. at the intervention. The counselor will explain that the importance of writing down what they want to say is so that they will not be thrown off course should the I.P. try to stop them. In addition, should the concerned person or the I.P. become emotional
JOURNAL OF GAMBLING STUDIES
and need to pause for a moment, the reading can continue without losing the thought or feeling being expressed. In other words, nothing important or significant will be left unsaid. It is advisable that these letters follow a particular format. Each letter needs to cover the following: why they sought the help of a professional; what changes they have seen over the last few months/ years; an incident or two involving the I.P.'s gambling and how they were affected by it; how their relationship has changed because of the gambling; what they fear will happen if help is not sought; and what they hope for once the gambling stops. W h e n writing their letters, each participant will speak from a personal position. They will use the pronoun 'T' and not "we," i.e., "I am concerned about you." "I love you." These letters are to be written as though the gambler and the family member are the only two people involved. No other person is to be mentioned in any one letter. The letter is to focus on the writer's feelings in direct relationship to the I.P.'s gambling. They are not to include any criticisms of the gambler, no put downs, nor are the letters to be in the form of a lecture. Each letter is to end with the writer asking the gambler to accept help so that the gambling can be arrested. Should the gambler refuse to accept help, then and only then will the writer tell the I.P. how their relationship will change because the gambling is more important to the I.P. than the relationship between the two of them. Participants are then instructed to return home and begin to write down exactly what they intend to say to the I.P. They are also instructed to return with any questions that might arise. Any out-of-town family members who have also been affected by the gambling are to be contacted and asked to write their own letter to the I.P. The procedure is explained to them by the contact person and in addition they are asked to call the counselor some time during the week so that any questions they have may be answered.
SECOND PREPARATION SESSION Any new participants are introduced and a summary of the proceedings covered in session one are repeated. Then the reading of the letters commences. As each person reads what they have written, all other group members are asked to close their eyes, listen attentively
and pretend they are the I.Po These concerned persons know the I.P. better than the counselor, therefore they are the ones most appropriate to determine what the I.P. will hear, and what reactions to expect. The professional listens to each reading while making notes to remove anything condescending or of a lecturing nature. In addition, the counselor helps each to identify feelings which surface as they read how the I.P.'s gambling has affected them. Following each reading, the group will share how they felt as they listened and how they believe the I.P. will react to what was read. Because the letters are focused on the writer's emotions there is less likelihood of the I.P. becoming defensive. The bottom line is: "Your gambling is causing you to distance from me and I miss you. I want you back in my life." After each letter is critiqued, the group is directed to return home to edit and revise what they have written, remembering to focus on their feelings and nothing else. Before the group leaves the office, the counselor again spends time reinforcing the family disease concept which the group can now better understand after listening to all the pain expressed in the letters. The professional again directs each concerned person to start attending G a m A n o n if they have not already begun to do so. "Nothing works one hundred percent of the time . . . . However, if your intervention is properly p r e p a r e d . . , the chances of it being successful are over ninety percent, with success defined as having your loved one enter treatment." (Picard, 1989, p. 85).
THE THIRD PREPARATION SESSION All new questions are answered. Then the counselor asks the group how m a n y attended a GamAnon meeting during the week. Again the professional encourages and supports each family member. It is important to reinforce their need for support to survive this disease whether or not the I.P. accepts treatment. At this point, the family is usually cohesive and supportive of each other and feels bonded and united for the first time in many years or perhaps ever. Next, each letter is re-read using the same procedure that was carried out in session two. Should any letter still be on an intellectual level, the counselor will give further guidance by helping the writer identify the feelings behind the incidents described. By so doing, the
JOURNAL OF GAMBLING STUDIES
professional is helping each family member to share the pain they have been carrying. Although family members have bailed the gambler out time and time again, the incidents involving money are minimized. By so doing the concerned persons can focus on the amount of time the gambler spends feeding the addiction, how much the gambler is missed, and how hurt they are that the gambler is not there for them emotionally. The latter part of the third session is spent discussing how the group will get the I.P. to attend the following session. Truth is the most important factor in arranging the I.P.'s presence at that session. The counselor will suggest one member of the group tell the I.P. that he/she has been going for counseling to deal with the affects of the gambling. This family m e m b e r will then ask the I.P. to attend the next session. Should the I.P. refuse to attend an alternate plan will be put into affect. The alternate plan consists of the intervention taking place in the home Of one of the concerned persons who attended each of the preparation sessions. Should the intervention take place anywhere but the counselor's office, a spokesperson shall be chosen by the intervention group to see to it that the confrontation is carried out as planned. The spokesperson is rarely the spouse or the I.P.'s enabling parent. In the case of parents, it is common that one parent has become enmeshed with the I.P. while the other parent has distanced. The distant parent has long since made the decision to cease giving the I.P. money, to pay bills or to cover gambling debts. This "hard" parent makes a good spokesperson because this is the parent who, because of the gambling disorder, has recently had the least interaction with the I.P. Because there has been silence between them, the I.P. is likely to listen when this parent speaks. It is most preferable to have the intervention take place in the counselor's office. However, if that is not possible, it can be conducted successfully in another setting. Once the spokesperson is chosen the group begins rehearsing the intervention. Decisions are made as to where each person will sit, who will read their letter first and what part the professional will play throughout the intervention session. The last part of this session is spent once again pointing out to the family how strongly they have been affected by the I.P.'s compulsive gambling; and how important it is for each of them to become part of a self-help group so they can continue to learn, gain strength, and feel supported as well as hopeful.
T H E F O U R T H P R E P A R A T I O N SESSION It is to be expected that the I.P. will be present at this session. If it is c o n d u c t e d in the counselor's office, the counselor will guide and orchestrate the confrontation so that it is carried out with dignity and s u p p o r t for the family as well as for the I.P. After each m e m b e r has read their p r e p a r e d statement, the counselor will s u m m a r i z e what has been said and ask the I.P. to accept t r e a t m e n t for the gambling problem. T h e definition of t r e a t m e n t is explained to the I.P. and options are offered so that the I.P. can take part in the decision as to which road to travel to recovery. " T h e intervention did not go well . . . after an h o u r the m a n left. Some time later . . . the m a n was seen sitting in a chair (at a t r e a t m e n t f a c i l i t y ) . . , waiting for g r o u p counseling to start . . . . the goal was met." ( M e a g h e r , 1987, p. 70). 9Should the I.P. agree to t r e a t m e n t , a d e t e r m i n a t i o n is m a d e as to which course of action to take and exactly what constitutes t r e a t m e n t . It is possible the I.P. will agree to start a t t e n d i n g G a m b l e r s A n o n y m o u s meetings and arrest the disease. Some m a y agree to include professional counseling in addition to self-help. In some cases, if the I.P. is obviously very depressed, a psychiatric evaluation m a y be in o r d e r and t r e a t m e n t at an inpatient facility m a y be r e c o m m e n d e d . W h e t h e r or not the I.P. accepts t r e a t m e n t , the family is asked to r e t u r n the following week.
T H E F I F T H SESSION At this session the family will have an o p p o r t u n i t y to deal with the o u t c o m e of the intervention. Each m e m b e r of the group will be able to process the feelings they experienced d u r i n g the c o n f r o n t a t i o n and to share those feelings with the other participants. W h e t h e r the I.P. has accepted t r e a t m e n t or refused it, it is at this session that the family begins their own recovery from the effects of this disease. CONCLUSION Because this is a family disease and because family m e m b e r s are often in m o r e pain than the gambler, ethically, the p r i m a r y purpose of a n y professionally led family intervention should be to get s o m e o n e into
JOURNAL OF GAMBLING STUDIES
treatment. Even if only one member of the intervention group gets into treatment, the intervention is successful. M a n y compulsive gamblers enter treatment following the ongoing recovery of one of their loved ones. When one family member begins to recover, the whole family is affected just as when one m e m b e r of a family begins to gamble compulsively, the ripple effects touch everyone who cares.
B E N E F I T S OF F A M I L Y I N T E R V E N T I O N The benefits of family intervention are such that they cannot be ignored. At the preparation sessions the family breaks the chains of silence for the first time; they begin to speak out openly and honestly; they support one another; they decide as a group to stop bailing out the gambler; they stop blaming themselves and each other once they understand they are dealing with a disease; and most important it is in the preparation sessions that family members begin to realize how badly the disease has affected them. With this revelation, more often than not, one or more of the concerned persons agrees to continue in treatment so they can recover.
REFERENCES Bratton, M. (1987). Guide tofamily intervention. Pompano Beach, Fh Health Communications, Inc. Johnson, V. (1980). I'll quit tomorrow. New York: Harper & Row. Johnson, V. (1986). Intervention. Minneapolis: Johnson Institute Books. Johnson, V. (1987). How to use intervention in your professional practice. Minneapolis: Johnson Institute Books. Meagher, M.D. (1987). Beginning of a miracle. Pompano Beach, Fh Health Communications, Inc. Pieard, F.L. (1989). Family interventions. HiUshoro, OR: Beyond Words Publishing, Inc. Wegscheider, S. & Becker, M. (1982). The intervention. (Self-published). Minneapolis, MN.