|
 |
Mary appears to be typical of the women I have
seen
I am interested to learn from others in the field who
work with female gamblers. I apologize that, unfortunately, my response
is to be short and to the point. Presently I am busy writing my final
project to complete master's degree requirements; this area has been
my focus for the last several months, and continues to be so.
I have worked with over 300 female pathological gamblers
to date and Mary appears to be "typical" of the women I have seen. My
first priority with Mary would be to encourage her to "fess up" to her
family physician. Many women are embarrassed and ashamed to admit to
their family doctor that they have been gambling excessively. If Mary
refused, I would encourage her to be assessed by one of the psychiatrists
at the clinic where I work to rule out depression. I would be concerned
as Mary is displaying many of the symptoms of a clinical depression.
I would also be very concerned about the medications she is prescribed.
My second priority would be for Mary to have her spouse,
Steve, accompany her to an appointment with me. I find that most women
resist their husband's knowing, and yet, once the gambling problem has
been revealed, their stress level decreases. I would want to explain
to her husband in plain language, without jargon, how, initially, gambling
may be fun and exciting but can become stressful and lead to financial
loss and escapism. Most spouses I have worked with were unaware of their
wife's dilemma and are understanding when they find out. I would also
stress the importance of communication and refer them for marital counselling
as well as family counselling, since their son has been triangulated
into the "problem" by having to pick sides and keep secrets. I would
also encourage their son to come for counselling at the next session
and encourage the family to talk with each other.
I would also address the importance of limiting access
to money and accountability for the money Mary does access as well as
for her time. Most women are hesitant when it comes to this topic and
are resistant to have their spouses "control their lives." I would encourage
Mary to attend my all-female gamblers group or Gamblers Anonymous (GA).
The non-GA group that I conduct has several members in
long-term recovery. It appears that most women who enter the group will
take direction from a peer rather than from myself (an authority figure).
The group that I facilitate is not a 12-step program but an opportunity
for the women to discuss issues that are of importance to them in a group
setting. We work on self-esteem, confidence building, ways to deal with
urges to gamble, conflict resolution and healthy coping methods. The
issues discussed are important to the women themselves and they have
a choice in what we discuss.
I would also discuss self-banning from the casino for
Mary. Unfortunately, she has experienced the lack of enforcement that
so many others have also encountered with self-exclusion programs. I
would also encourage Mary to take responsibility and to avoid driving
or walking by the venues where she likes to gamble. I would encourage
Mary
to replace
the gambling activity with other activities. Like many others, Mary has
learned to use gambling as a quick fix to her problems and must now learn
to incorporate healthy activities and stress-reducing tactics.
From my experience, eliminating gambling from one's life
takes time and patience. The more support Mary has from family and friends
the easier this daunting task will be. Initially, I would see Mary on
a regular basis and then reduce individual appointments to a less frequent
basis as long as she attended groups. Mary has many issues she needs
to discuss and work through, which will take time.
In short (very short), this is how I would initially
work with Mary. I would appreciate feedback or suggestions from others.
Thanks for the opportunity to participate.
Using Wilber's developmental approach in working with
Mary
Wilber's Spectrum of Development Model
Wilber's (1977, 1986, 1990, 1995, 1997, 2000) spectrum
of consciousness model mapped out nine stages, or levels, in a developmental,
structural, holarchical, systems-oriented format. Wilber synthesized
the initial six stages from the cognitive, ego, moral and object relations
lines of development of conventional psychology, represented by such
theorists as Piaget (1977), Loevinger (1976), and Kohlberg (1981), and
the final three stages from Eastern and Western sources of contemplative
development. Wilber's model is unique in that not only is it a developmental
spectrum of pre-personal, personal and transpersonal consciousness but
also a spectrum of possible pathologies, as there are developmental issues
at each stage. It is a model that allows us to integrate many of the
Western psychologies and interventions. Originally used for mental health
issues (Wilber, 1986), it has now been applied to substance use issues
(Nixon, 2001), and this case study looks at the application of this model
to gambling issues. Here is an outline of the first six stages of the
developmental model as they apply to working with Mary on her gambling
issues.
Pre-personal stages
The first three stages of development, all pre-personal
stages, are sensoriphysical, phantasmic-emotional and rep-mind (Wilber,
1986). The first stage, sensoriphysical, consists of matter, sensation
and perception. Pathologies at this level need to be treated with equally
basic physiological interventions, as the whole point is to stabilize
the person. In addictions treatment, this typically means detox programs;
for gamblers, some form of physical exclusion from the casinos.
The second stage, phantasmic-emotional, is represented
by the development of emotional boundaries to self (Wilber, 1986). Problems
at this stage show up as a lack of cohesive self. The self treats the
world as an extension of the self (narcissistic) or is constantly invaded
by the world (borderline). Typical interventions focus on ego- and structure-building
techniques, such as object relations and psychoanalytic therapy. In addictions
treatment, 12-step programs can provide a structured format and focus
on the selfishness of the person's lifestyle. Chronic cocaine users can
regress to this core narcissistic level; an interesting issue is whether
pathological gamblers regress to this level as well.
The third developmental stage is rep-mind (Wilber, 1986).
This stage represents the birth of the representational self. This is
typified by the development of the id, ego and superego and intrapsychic
structures. Problems at this level are experienced through psyche splits,
such as issues of inhibition, anxiety, obsession, guilt and depression.
Interventions focus on intrapsychic resolution through awareness of cognitive
distortions, stress management, assertiveness training and feeling awareness.
Personal stages
The pre-personal stages are followed by rule/role, formal-reflexive
and vision-logic stages of development and represent the mature ego developmental
phase. The rule/role phase, Wilber's fourth stage of development and
first personal stage, is highlighted by individual development of rules
and roles to belong. A person's stance is becoming less narcissistic
and more sociocentric (Wilber, 1986). Because problems at this level
are experienced as a fear of losing face, losing one's role or breaking
the rules, typical interventions center on script pathology, such as
transactional analysis, family therapy, cognitive therapy and narrative
therapy. At this level, a person with gambling issues may have developed
a whole set of unique roles and rules to support an addictive lifestyle.
The next personal stage and fifth overall, formal-reflexive,
represents the development of the mature ego (Wilber, 1986). A person
at this level has a highly differentiated, reflexive self-structure.
At this stage, identity issues need to be explored and the processes
of philosophical contemplation and introspection need to take place.
At this stage, the underlying identity of a person with an addiction
can be challenged. The next stage of development, the final personal
stage and sixth overall, is the vision-logic or existential stage. Here,
the integrated body-mind confronts the reality of existence (Wilber,
1986). Thus, we see a concern for the overall meaning of life, a grappling
with personal mortality and an effort to find the courage to be. At this
level, a person may be forced to deal with the emptiness of their addictive
lifestyle.
The first six stages culminating in the vision-logic
or existential stage represent conventional Western psychology. To this
conventional scheme of development, Wilber (1986, 2000) also added psychic,
subtle and causal contemplative levels that represent psycho-spiritual
levels of development.
Counselling Mary using a developmental model
Wilber (1986) makes the point that counselors using the
developmental model must start with the basic levels first to avoid an
elevationalist stance. It is evident that Mary is out of control with
her gambling. So, at a basic sensoriphysical level, it is important for
Mary to have strategies to avoid gambling in the casino. Self-exclusion
appears not to have worked for Mary. A referral to Gamblers Anonymous
may be helpful in giving Mary a place to turn to other than the casinos.
A financial management program in co-operation with her husband may be
the best option, but Mary may need a few counselling sessions before
she feels she can disclose her gambling problems to him.
The big win can be a moment in time that any gambler
constantly tries to recreate. At the time of winning her $10,000, Mary
felt she had the answer. In our counselling session, we would recreate
the glory of that moment so Mary could recognize her thoughts and feelings
about that "big win," which she has been trying to recreate ever since.
Mary could be challenged to view this as a counterfeit way to being a
success, just as Grof (1993) observed that substance abuse can be a counterfeit
quest for wholeness.
The real clinical work with Mary, however, would begin
with the intrapsychic work of the representational mind (level three).
At this level, Mary could begin to examine the thought processes that
keep her preoccupied with gambling. A cognitive therapy approach could
be used to teach Mary about the cognitive distortions she embraces when
she is gambling, such as chasing losses and other distortions she uses
to convince herself her luck is about to change. Mary could be asked
to log her distortions.
In addition, Mary is having thoughts of suicide. A split
in the psyche can represent conflict at this level; Mary's super-ego
is overfunctioning with strong critical messages. An empty chair technique
from Gestalt therapy could be used with Mary in which her normal self
and her critical self are split off into two chairs. Therefore, Mary
could see how huge and negative her critical voice is. This awareness
of her critical self could be expanded to deal with the theme of anxiety
that has haunted Mary her whole life. Mary could learn just how much
her critical voice has shut her down in life and begin to reframe her
anxiety as energy when she begins to become more aware of her split off
judging part. We could also work on recognizing that gambling has served
as a sanctuary to escape all of this psychic tension, including, perhaps,
the recent grief of her father dying and her anxiety.
As the counselling work progressed, the process could
now look at the rules and roles Mary has embraced in life (Wilber's fourth
level). As Feinstein and Krippner (1988) asked, what has Mary's mythic
journey been like? Mary could be asked to talk about the family myths
she grew up with. She might describe learning to be a harmonizer to deal
with her dad's drinking. She might have learned to take care of everybody
and adopt the martyr role in her family. Taking care of others and putting
others needs ahead of hers is a myth she might have carried into her
adulthood. We can process what it means to be the mother and how she
has always been there for other people. At this point, it might be important
to consider the feminist perspective in that she has served as a nurturer
and a mother her whole life, yet at a societal level, this role can be
devalued. Mary could be asked if she has ever had any time for herself;
she could be encouraged to start exploring personal passions and interests.
At this point in time, it may be important to involve
Mary's husband in the counselling process. Hopefully, she would now have
the strength to disclose her gambling history and be able to process
any shock and anger her husband might feel about the lost money as well
as the strength to get him on board in both her recovery plan and money
management issues.
While the family therapy work could take up a number
of sessions, it would be important for Mary to continue her individual
counselling work. She would need to continue to monitor her work so far,
including the cognitive therapy work around her distortions and watching
her critical voice. Mary might be ready to do the introspective work
of level five: asking who she really is. She has been a wife and mother,
a good money saver all her life, and recently, she has fallen into the
gambling track. Who does she really want to be? The pull of gambling
can be about so many unmet needs in Mary's life. Can she have the courage
to look at those unmet needs of her own journey? Mary could be encouraged
to look at herself beyond the mother and nurturer archetype.
This would naturally lead to the existential level (level
six) in which Mary could look at what gives meaning in her life. It is
clear that she loves her husband, and her family gives her tremendous
meaning in life. But using a Frankl logotherapy approach (Frankl, 1985),
maybe Mary could look at what steps she can take to increase the meaning
in her life beyond these roles. She may have passions, hobbies or career
interests that she has put on hold for a long time. She may have psycho-spiritual
needs that she wants to investigate. Obviously, this would be a time
to look at terminating the counselling process, as Mary would now be
into her life journey herself and doing much exploring beyond the counselling
process.
A concluding note
This clinical case study response is designed to show
how using a developmental approach allows for an integration of multiple
perspectives, in that one technique or approach does not work for all
issues of the client. In this response, cognitive, gestalt, family, Jungian
and logotherapy perspectives are combined to deal with a person with
a multitude of gambling-related issues.
Mary is at a crisis point
Mary appears to be a high-functioning woman who, up until
three years ago, had strong relationships with family and friends and
has always had steady employment. She was responsible and took good care
of herself, her family and her finances. However, her family of origin
was not so positive; it included alcoholism and depression in her two
parents, which left her in a position as eldest of having to care for
her family at an early age without getting the support she needed herself.
Mary developed an anxiety disorder around this time. Positive times with
her mother were associated with gambling.
Mary's increased gambling appears to have been precipitated
by the introduction of a gambling venue near her home, her father's illness
and death, and perhaps fewer demands for her at home: her children were
growing up and moving out and her husband was around less due to changed
hours. An early big win probably helped tip her into problem levels of
gambling.
Mary is at a crisis point with regard to her gambling
for several reasons: her son is showing the effects of holding this secret
for her; her debts are becoming too pressing to conceal; she is afraid
her husband will reject her if he finds out about her problem; her self-esteem
is suffering severely; and she feels out of control of her life. However,
she has not yet reached the point of deciding to change her gambling
behaviour.
If I were seeing Mary, I would be addressing this decision
point. This is a time for motivational interviewing. I would encourage
her to explain her concerns about her gambling and the effects it was
having on her life and those around her. I would ask her about the consequences
of either continuing to gamble or quitting. We might do a decision matrix.
Although I would gather information on the anxiety disorder and family
history, I would not spend a lot of time on them initially. As a gambling
counsellor my role would be to explore the immediate gambling problem
first, and try to move toward getting it under control before tackling
other issues. With someone as articulate and high functioning as this,
the other problems are unlikely to be so disabling as to block practical
strategies for change.
Assuming that Mary did move from contemplation into preparation,
we would contract for some period of abstinence at the beginning, and
then, plan together the best means of avoiding gambling. Barriers would
be discussed. It might be helpful to find some way to reinforce self-exclusion
so that the casino could be counted on to recognize and bar Mary in the
future. During this time, I would encourage her to spend time with at
least one friend, despite her discomfort. I would also engage Mary in
looking at non-harmful ways to escape her troubles for a brief time.
I would suggest bringing in her family, and would try
to help her through the decision-making process around "if" and "when" to
tell her husband. This might take some time, but concern for her son
would be a good lever. If her father and/or her children came in, my
role would probably include education around problem gambling and help
in processing their anger, hurt, disappointment, grief and loss of trust.
Since the relationships have been positive, I would support the family
in returning to previous good levels of communication.
The issue of Mary's medication would need to be addressed;
I would refer her back to her doctor, or to a specialist in anxiety.
I would address other issues arising out of her family of origin as they
emerged; I suspect that over-responsibility would be an important issue.
Mary might have difficulties accepting any weakness in herself and might
be reluctant to allow others to support her because of parentification
early on.
|
 |