The client’s stages of change
In terms of the Stages of Change model of Prochaska and DiClemente (1999), the techniques described here are appropriate for clients in the action stage, who have already decided to make changes and are starting to do so. Clients in the contemplation stage can benefit from learning new skills such as decision-making or the development of motivation. This might help them move along the continuum toward action. However, it is counterproductive to encourage contemplative clients to use most of the techniques that follow, since they are not ready, and will likely resist, avoid, and/or drop out of treatment.
On the other hand, gamblers in the action stage do not need the kind of motivational work that is appropriate for contemplators. They are already convinced of the need for change. Too much emphasis in this area will tend to put them off treatment, or waste valuable time needed for the specifics of how they are to make the changes. In the maintenance stage, of course, people can benefit from the plans and preparations, to which the term “relapse prevention” most obviously applies.
What follows is a cognitive-behavioural approach to change and change maintenance, a learning-based model that owes a good deal to Marlatt and Gordon’s (1985) work. It is based on the assumption that people can and do learn new behaviours and cognitions and develop different skills when they have the opportunity to engage in different experiences. It focuses on developing specific skills to cope with specifically identified triggers, an approach that is positive and non judgmental for clients who hear, not that they are defective human beings, but that there are some skills needed to tackle the problem, which they can acquire with practice.
It is clear that, according to Blaszczynski’s (1998) pathways model, the later-onset, non-psychopathologically disturbed problem gamblers will benefit most readily from the kinds of techniques described here. They are likely to be the most competent and highest-functioning of our clients, and can often use, and expand on, their already considerable coping skills to solve the problems confronting them. However, even the second pathway, “vulnerable” clients, and those whose gambling may be biologically based, can benefit from focusing on skill development, such as acquiring skills to cope with mood changes or to block impulsivity.
Motivational and personality issues
Some clients have difficulties with a skills-based approach. When a counsellor emphasizes the need to enhance coping strategies, some clients insist that their motivation is all they need to succeed; they may wish to avoid specific planning. This could be a sign that they are still in the contemplation stage or it may simply be a preference for spontaneity or impulsivity — not an unusual trait in problem gamblers. Some people find the freedom of living moment by moment to be worth any uncertainty or disorganization. Of course, they are likely to be very vulnerable to relapse. It is important to understand their dilemma, and to give them many options so they can compromise between their preferred lifestyle and the need for forethought to avoid relapse. As a change agent, motivation has limitations. Clients may see motivation, or an apparent lack of choice, as automatically leading to change.
Motivation is only half the battle. The other half is technique and strategy. Say someone tried to climb a mountain on sheer determination. If this person took a good run at it, he or she would probably make it quite a long way up using only fingers and toes. But he or she is likely to get stuck, or fall, unless he or she gets equipment, boots, pylons and fellow climbers, and maps out a safe route. Change strategies are about finding a route for each person that is safer, easier and sometimes gives some enjoyment along with the challenge.
The tools described here are not the only ones that should be available to practitioners. A client-centred approach will make use of many techniques, in response to individual clients’ needs. For instance, repeated crises, mood or personality disorders may demand supportive counselling or case management, and may leave little room for an orderly discussion of triggers and coping strategies. Some clients need, or are interested in, a psychotherapeutic model. However, without attending to the practicalities of behaviour change and change maintenance, any treatment may fail.
The Relapse Process
It is important to have a clear picture of the relapse process, and how to catch it early. We need to help our clients anticipate what such a process might be in their own cases, so that they can prepare for it. The process could start with altered family circumstances, a new job, a casino opening up, a change in debt load, distorted thinking, or a thousand other circumstances, internal or external to the client. An example is a client who relapsed when he had to have his truck fixed, and he handled his Visa card again. When a habit is overlearned to the point of addiction — in other words, when the conditioning is strong — it seems likely that when any neuron on the path fires, the whole behavioural complex becomes reactivated. It is essential to help the client become aware of what might start the rollercoaster process, and how to identify and stop it, before it’s too late to get off.
Marlatt and Gordon’s model
Marlatt and Gordon’s model suggests that deficient coping skills will increase the likelihood of relapse, whereas a successful coping response to a high-risk situation will increase an individual’s self-efficacy and reduce the chance of a return to the problem behaviour. The addictive behaviour itself may provide rewards that enhance the perceived sense of control, or the individual may attribute his or her ability to cope with the problem behaviour. Persons attempting abstinence who return to the addictive behaviour, may experience the “abstinence violation effect,” a sense that once they have slipped, they may as well commit themselves to the behaviour entirely. These factors result in a circular process by which dependency on the problem behaviour is increased (Marlatt, 1985). Clearly, the relapse processes described by Marlatt and Gordon, originally with reference to substance addictions, are also relevant when discussing problem gamblers.
Time Frames
Relapses occur in different time frames. Most typically, clients allow circumstances to be set up that allow them to return to previous gambling behaviour, with about a week or two between the beginning of the process and the actual gambling. These lapses are often experienced as impulsive. On examination, they could have been avoided with some planning. For instance, clients may know that they are more vulnerable when they have money that is not immediately needed. If they do not plan ahead to use such money wisely, old habits will tend to overcome the new ones. When they know such planning is needed, and don’t do it, they may well be covertly planning to gamble.
Genuinely impulsive lapses, triggered by unexpected circumstances, are less common. One client was overmedicated for pain and found himself at the track, in a fog, after two months’ abstinence. To prepare for this kind of situation, the client needs to have emergency procedures, like telephone numbers of support people, on hand, just in case.
Last, there are longer-term relapse processes, in which people slowly slip back into old ways of thinking or behaving, long before their harmful gambling behaviour reoccurs. An example is the client who tries to pay off gambling debts too quickly, leaving nothing for recreation or enjoyment of life. He thus increases his stress load to intolerable levels. Such clients may eventually succumb to the idea that they can end the pain by winning. Or, consider the client who relapsed when he handled his Visa card again: he had known for months that he should cut up his card. He allowed himself not to think too carefully about why he was choosing not to do so.
Conceptualizing the process
Though Marlatt’s model is useful for clinicians, and for some clients, gamblers seem to relate very quickly to the simple chart below. The author finds it a useful tool in helping clients conceptualize the process of relapse and its prevention.
The top part of the curve represents the positive path that the client may be on initially — abstaining or limiting successfully, working on his or her goals, taking good care of him- or herself and those around him or her, etc. The downturn represents the change in circumstances, thoughts, feelings or behaviour that tends for this person to lead to relapse. For instance, boredom might be setting in. If the boredom is addressed — say, the person develops some leisure activities — the path has been reshaped into one of the upward curves, and he or she moves back on track again. If the boredom is not addressed quickly, it may lead to depression, resentment, restlessness or a sense of entitlement, all of which have perhaps been triggers in the past. The client may begin to experience a sense of struggle with urges, which become more frequent and/or intense. By about the middle of the curve, a sense of permission creeps in: often covertly, the individual decides to gamble (or says “maybe”), once circumstances allow. Once he or she has given him- or herself permission, it is very hard to turn back, even if his or her better judgment protests. The curve of the path gets steeper. The behaviours around this time represent the “seemingly irrelevant decisions” (Marlatt & Gordon, 1985): actions that set the person up for relapse, without him or her acknowledging that this is taking place. It is not until the bottom of the curve that gambling actually takes place. The time represented by the curve varies, generally from a few days to a week or two. It is rarely less than several hours. Sometimes, as mentioned earlier, it is possible to identify that the process has been going on for a much longer period.
This chart clarifies for clients the need to catch the relapse process early. Many gamblers experience their lapses as completely impulsive and therefore uncontrollable. In fact, once they are in the steep part of the curve, they have great difficulty stopping themselves; this does not mean that they could not have turned back earlier in the process. Often clients experience more sense of hope and empowerment once they absorb these ideas, because they feel more sense of control over the problem.
It is important to emphasize that it is the point where the client makes the decision to gamble, rather than the gambling itself, that is the issue. If the client and counsellor can identify the decision-point, what led up to it, and how to (metaphorically or literally) turn left instead of right at the decisive moment, the client will be in a good position to change the behaviour and keep it changed.
A balanced approach to relapse
One very important point about relapse is that it happens. It’s unlikely that people are going to do this difficult work of changing so much about their lives, without ever making mistakes. It doesn’t mean someone is hopeless, or unmotivated, or has a character flaw. As far as this model is concerned, it means that person didn’t have all his or her bases covered. Of course, it may also lead to serious consequences, which is a good reason to help clients minimize relapses.
When a relapse occurs, it is important neither to overreact nor to under react. For example, one client knew that if she allowed herself to feel too guilty after a relapse, she would just precipitate another one. Forgiving herself was a good strategy. However, she did not use the information from the relapse to avoid falling into the same errors again. Clients need to take the relapse seriously, look at the details, figure out what went wrong, reorganize, hone their skills and try again.
Back to Relapse Prevention