Some important considerations are specific to working with gamblers in groups:

• Although it is common in all “recovery” groups, group leaders need to pay particular attention to establishing ground rules about financial involvements between group members and other contacts outside the group. Clients are encouraged to refrain from any business relations/activities, or from borrowing/lending money while in the group. Financial relationships with the counsellor or the agency are also discouraged.
• A hierarchy may develop in the gamblers’ groups, for example, Nevada ticket players at the bottom, card players at the top, or slot players at the bottom, craps shooters at the top, and so on. There needs to be a group norm that participants respect each other whatever their past gambling experience has been.

Some gambling clients may feel stigmatized by attending “groups” because of their perception that going to group is a sign of a mental health disorder requiring “therapy.” Treatment programs may want to consider their terminology when referring to this modality. For example, one program has decided to call its groups “workshops” at the suggestion of its gambling clients as a way of responding to this belief. The clients chose this name because the “workshop” is seen as a learning experience, whereas “group” is “for people who are sick.”

Another group norm centres on clients abstaining from mood-altering substances. It makes sense that clients not attend group while under the influence of a mood-altering substance. It is also important not to assume that because a client has a gambling problem, he or she will automatically have or be vulnerable to a substance abuse problem as well, or that he or she will automatically substitute a substance for the gambling, or vice versa. Recent U.S. research indicates that gamblers are six times more likely to have or to have had a co-occurring substance abuse disorder, but it is important to be cautious when generalizing from the literature on this issue, because it is very small and is mostly U.S.-based. Many of the research participants in the U.S. studies are already in residential treatment for substance abuse problems in Veterans’ Administration hospitals. We may only be seeing a small part of the picture. In Canada, as more outpatient programs develop, gambling venues become more accessible, and the laws related to alcohol in gambling establishments change, a different client profile may evolve. Further research is clearly needed in this area.

There is little research on the following issues, but intuitively they seem important to consider:

• whether or not groups should be made up of people with similar gambling behaviours; casino gamblers with casino gamblers, bingo players with bingo players, etc.
• given that gambling is a relatively new social issue and problems with gambling are minimized by the population at large, it may be especially helpful for the gambler to attend groups, as groups tend to help eliminate the stigma associated with gambling, as well as decreasing a client’s isolation.

Typically, clients attend group in person. Recent technological advances using the Internet, particularly “chat rooms,” support the notion that it is possible to hold groups on the Internet. These seem to be working well for substance abuse, and might have a particular appeal for youth, or those in remote or isolated areas of the country. This may be challenging to counsellors who believe that they have to see the person face-to-face in order to do good therapeutic work (see the section on Telephone/Face-to-face), See section “ Cultural Background and Problem Gambling ,” for a consideration of the impact of cultural variables on client preferences for individual and/or group counselling.

Group Counselling

Advantages:

• Clients learn from each other.
• Clients can practise new interpersonal skills in group.
• Clients hear a range of perspectives from the group members.
• Clients learn problem-solving skills.
• Through giving and receiving feedback, clients give and receive peer support.
• Clients can come out of their isolation.
• Clients have an opportunity for validation.

Disadvantages:

• Clients may have needs that are not met by the group.
• Clients may be resistant to participating in group.
• The agency may not have sufficient clients to support a group.

The one-on-one approach seems to be the most acceptable approach to most problem gamblers. Most of them ask for one-on-one when they first present for treatment. This seems puzzling in one sense because many of the gamblers state that what they need is assistance with interpersonal communication, social skills, conflict management, and isolation, all of which suggest that group treatment would be more helpful.

Some clients may prefer to start seeing a counsellor individually because it gives them an opportunity to talk about their problems with a non-judgmental listener, and also to clarify what their issues might be. For many clients, this might be the first time that they have talked about their gambling aloud to anyone. The health-producing principle of sharing with a trusted other is common to all therapeutic approaches, and is also consistent with the fourth step of the GA program.

• Developing a therapeutic alliance between the counsellor and the client accounts for 30% of the positive outcome of treatment (Miller, 1997).
• The downside of choosing one-on-one as your basic program approach is cost. It is clearly more expensive than the group modality.

We chose individual counselling as the mainstay of our program. We included an optional LifeSkills group as an adjunct to the individual counselling. The literature at the time suggested that it was difficult to retain gamblers in treatment, and that when they did come, they came for only short periods (usually from one to three sessions.) In order to maximize the counselling encounter, we decided that in one on- one sessions we would be better able to build rapport, define the problem and determine solutions. In this way, the gambler would leave the session with a concrete, practical strategy in hand. We believed this would improve the chances of their returning for further help in the event they decided they needed it. In addition, if it was true that gamblers were only going to come for a short period of time, it didn’t make sense to have a group as the mainstay of the program.

Closed or Open Groups?

For the purposes of this chapter, it is important to consider the potential meanings of closed/open groups. “Closed” can mean time-limited. In some systems, “closed” means that only one category of client can attend (for example, all gamblers in one group, family members in another). “Closed” can also refer to the process of group intake, where all group participants begin at the same time, and no additional members join the group except by exception. By contrast, “open” can mean not time-limited. It can also mean that the groups can be mixed, or it can refer to the process of continuous intake. When making decisions about closed/open groups, it is important to be clear which meaning you are using.

Key decision criteria
When deciding whether to have closed or open groups one key issue is the number of clients in your program. Most of the group literature suggests that in order to run an effective group, you need a viable critical mass of group participants (i.e., six to eight). At the time of writing, problem gambling treatment in Ontario is relatively new. As yet, there are few problem gamblers presenting for treatment, and so, the difficulty of forming groups is evident. This might not be the case in a few years as the number of people coming into treatment increases.

Second, the length of time spent by the majority of clients in a treatment program ranges between one and six sessions. Many problem gambling treatment programs also report anecdotally that they have difficulty retaining clients for a long period of time. In light of this information, the decision to hold a closed group (i.e., group intake) could be challenging, and choosing an open group concept at this point in the history of problem gambling treatment (i.e., continuous intake) might make more sense.

We started with closed groups that were ten weeks in length and open only to gamblers. The groups ran with six core clients. Topics were not predetermined, but evolved as the group members stated their needs. In order to serve family members, specialty groups were introduced consisting of topics such as money management, stress management, nutrition, leisure/recreation. This brought the gamblers and the family members together to deal with mutual concerns affecting the family. Eventually, a set of fixed topics was determined. They are outlined in the section below.

Groups with/without a topic and its impact on task/process
The decision to hold groups with or without a topic will have definite impacts on the process of the group. As with any group, those with a predetermined topic may end up being task-focused and not have much to do with the immediate interpersonal functioning of the group members.

Benefits of Defining a Topic

• Clients know in advance what the topic of discussion will be. This reinforces the principle of informed choice. It could also help increase their comfort level so that they can be prepared for their potential involvement in the group.
• The gambling clients know what they are getting. The topic is concrete, clear, and focused on relevant areas of their problem.

Benefits of Not Having a Topic

• Clients can focus better on the process. The relationship between the interpersonal dynamics and their relationship to triggers for the gambling client may become clearer in a process-driven group. Process behaviours such as expressing an opinion, or sharing personal thoughts, values and beliefs may counter some commonly held beliefs by gamblers: competition, trying to get ahead quickly, “keeping your cards close to your chest,” keeping a straight face, “getting something for nothing,” ownership of “my” (slot) machine, chasing to get “my” money back.
• Other process skills, such as conflict resolution, anger management, assertiveness, saying no, and using I-statements may help gamblers deal more appropriately with related gambling urges that may arise in the context of their lives. Whatever skills they do learn here will be relevant and will emerge out of their particular needs. In this way, the topics that are developed are specifically related to what these gamblers need at this particular moment.

Some possible topics for a problem gambling group:

• identifying needs
• urges, temptations and testing personal control
• dealing with conflicts and negative emotions
• early-warning signs of relapse and rationalizations
• self-care and recreation
• winning/chasing — illusions, skill and control
• self-esteem
• money management
• feelings — identifying, accepting, coping
• trust
• communication
• living on a limited budget
• long-term relapse prevention

Should participants with different goals be in the same group?
There is an ongoing debate about whether clients with a goal of abstinence can be placed in a group with clients who have a goal of moderation. Some research states that clients who have made a clear choice about their treatment goal, whether it is abstinence or moderation, can do well in a mixed group. Clients who are ambivalent about their treatment goal do not do as well in a mixed group. In Prochaska and DiClemente’s model (1998), these are the people who truly are in contemplation, who have not resolved the ambivalence issues related to their desired change. Having a group that focuses on helping them resolve their ambivalence might be more helpful as a starting position.

Many agencies and their counsellors design their programs for clients who are in the action phase of change by insisting that their clients become abstinent, whether they have resolved their ambivalence about that decision or not. Then, when clients “fail” in their attempts to be abstinent, they are blamed and often “discharged” from the program. Perhaps if counsellors spent more time helping clients resolve their ambivalence issues, clients would be more successful with their treatment goal, whether it is abstinence or moderation.

If abstinence-oriented clients are mixed with moderation-oriented clients, clients need to be made aware before they enter the group that not all group members may be at the same stage regarding their change process or their treatment goals. As well, some of the clients may have stopped their problematic form of gambling, but may be continuing with other non-problematic forms of gambling. Each treatment program will need to make decisions about “total” abstinence (discussed earlier) and the implications of this decision on the group norms. These decisions might exclude some gamblers from choosing to participate in such groups.

Anyone can attend the groups as long as he or she wants to do something about his or her gambling. His or her goal may be either moderation or abstinence. The Problem Gambling Service has not made a programmatic decision to separate the clients by goal. Most of the clients who come to the Problem Gambling Service are in the Preparation or Action stage. Some may still be gambling, not because their goal is moderation, but because they haven’t yet decided on their ultimate goal. Some may have already resolved their ambivalence. Periodically, there are conflicts that arise within the group. However, counsellors work with the clients to help them resolve their differences, and to honour and respect the choices that each individual has made with respect to his or her life.

Should the client’s family be involved?
We have not found any word or expression to replace “family member.” For the purposes of this chapter, “family member” means anyone who has a significant emotional connection to the gambler, including blood relatives, friends, or partners who could also be termed “intimate others.”

The issue of family member involvement in the treatment of problem gambling is quite contentious. Sometimes it is the family member who initiates the contact of the gambler with the treatment program, or initiates the contact by coming to the program for help dealing with the gambler, in the hope that the gambler will follow him or her to treatment. Sometimes the family member wants help determining how to get the gambler into treatment and this is why he or she is coming to the program. Some programs do not allow the family member to receive help unless the gambler enters the program. Some programs do not allow the gambler to receive help unless the family member enters the program.

Some programs consider the family member to be the primary client, since it is this person who has sought help. Others believe that the family member needs to be excluded, unless the family member wants to adopt a support role for the recovering gambler. Some programs include the family members as corroborators of the gambler, telling the truth or lying about his or her gambling involvement.

This section will not focus on how to help the family member. (Refer to Section “ Helping the Family ,” for further discussion of problem gambling within the family). However, we will focus on the rationale for family member involvement in the treatment program, and how that involvement could have a positive effect on the treatment outcome.

One of our assumptions is that people behave the way they do for a reason, and that that reason usually has a positive intent. In their eagerness to help the gambler, family members might inadvertently do something that might actually be counter-productive to the gambler’s attempts to make positive changes. As a result, the family member might benefit from being educated about how their behaviours could be impacting their relationships, even the entire context of their lives.

Benefits of Involving the Family

• As the family member changes his or her behaviours, there can be a domino effect on the behaviour of others.
• The family member can learn more about problem gambling and therefore have a better understanding of what the gambler is experiencing. As a result, the family member might be better able to support the gambler in making positive life changes, thus decreasing the amount of stress the family is going through.
• The family member could learn new behaviours that could be helpful to the gambler and to him- or herself, such as conflict management, interpersonal communication skills, anger management, relaxation, etc.
• The family member can regain control of his or her life, and re-establish mature, appropriate, adult responses in all of his or her life domains.

Deciding to involve the family member in the program is an issue that needs to be thoughtfully resolved within the policy framework of the treatment agency, while paying attention to the underlying philosophical underpinnings of the program.

We began by seeing gamblers only. However, we found that many family members called us looking for help. We wanted to find a way to respond to them that was also in keeping with our developing mission statement that described our program as a “publicly supported client-centred program dedicated to reducing the harm to individuals, families and communities affected by problem gambling.” Family members were welcomed as primary clients whether the gambler was a client of the program or not. We also provided choice to the gamblers. They could be seen with or without their family member attending the program. We continue to see family members and offer workshops for family members and gamblers. We are now contemplating a monthly workshop for family members only and offering more comprehensive services, while developing a series of family-focused public information materials.

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