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 and Relapse Prevention
Chapter 8: Abstinence Control
146
ST
(l)
ar\
L-7
lde
Pulse'" the urges' negative emo-
i\:'3) Controlling the impulse bV managmg
tlonr' -aiognitive expectations that lead to gambling'

next two
are discussed in this chapter; the
The first two parts of the process

to interruPt the sequence'

TheorY
Stimulus Control and Self-Regulation
Managing the environment via
sti
Self-regulation the
lation theory.
the first steP in stimulus contr
Functional analYsis is a form of
multiPle factors involved in
gamtting from a runawaY i
functional analYsis suggests
str
implement self-regulation theory
Gambling is linked to choices
in the chain' This Permits them t

for autonomY'
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148 Chapter 8: Abstinence Control and Relapse Prevention

detail. Gambling is never an occasion for scolding or disappointment but an

opporhrnity to leam more about the dynamics of gambling for the patient. If
patients can absorb this mentality from the therapist, they can look at their slips
as a learning experience-a topic discussed under relapse prevention.
Over time, keeping a record of the antecedents and consequences of gambling
results in identifying pattems. Those patterns will indicate external environ-
mental situations and intemal feeling states that correlate with gambling. Simi-
larly, noting what happens to the person afier garnbling can indicate the function
gambling plays for the person as a solution to emotional or cognitive needs.
When clients are unable or fail to keep track between sessions, therapists invite
them to complete it in session. Doing it together often reveals new information
as well as helps gain understanding into the client's lack of motivation. All
motivational defrcits, including failure to complete homework assignments,
should be treated in the manner discussed in the chapter on motivational
enhancement. Using the principle of "successive approximations" or "shaping,"
the therapist can describe "success" as having the client think about the task
between sessions, while gradually increasing the level of task difFrculty in
keeping the record.
Bill, a triply addicted person (gambling, cocaine, and alcohol) described a
typical sequence leading to gambling. Until this analysis, Bill saw his gambling
behavior only as a reaction to "feeling bad." He broke down the gambling
antecedents into smaller units that encompassed his thoughts as well. The
sequence started with financial concerns, which led to believing he could not
adequately support his pregnant fiancee and their child. These concerns led to
thoughts about suicide, which in turn led to gambling. For Bill the racetrack
served as a distraction to drown out suicidal ideation.
Francesca's gambling triggers were more straightforward. She succumbed
whenever the state lottery reached a critical mass atound a million dollars. She
became aware of this from the billboard in her inner-city neighborhood and at
night when they selected the lottery winning numbers during intermission of
her television game shows. Inevitably, this led her to the nearest convenience
store to buy tickets. Therapists need to be aware that a functional analysis
uncovers the idiosyncratic and specific triggers to gambling that lead /his person
to garnble under these circumstances.
Worksheet 8.2 moves the analysis of slips from the level of motor acts toward
understanding intention and choice. Here the therapist guides the patient from
seeing the slip as an irresistible impulse to an act composed of mini-decision
points (Marlatt & Gordon, 1985). This worksheet, in conjunction with the
triggers exercise, should provide patient and therapist with a multilevel look at
each gambling episode. If the therapist remains consistent with this process,
patients become much more attentive to their triggers for no other reason than
dealing with the mandatory therapeutic debriefing.
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 Prevention
150 Chapter 8: Abstinence Control and Relapse

owedmanypeoplehugeamounts.TheonlysolutioninhermindwastoprevailShe
like murder instead of suicide'
on a friend to assist inlanng her death look
directly to her creditors and die
could thereby i"qr*tr, her ilnsurance benefits
creditors, good detective work
with her debts resolved. Unfortunately for her
she had killed herself'
uncovered the plan but not, sadly' before
Illegal acts to obtain money iarse the issue of determining a differential diag-
nosisforantisocialpersonalitydisorder.Althoughitishelpfultomaintainsome
indexofsuspicionaboutthisearlyintheassessmentprocess,themajorityof
pathological gamblers committin
criteria for antisocial personality
present in early adolescence' Seco
ii*"a to gambling behavior rather
in the diagnosis'
Often the very inJptness of the crime assists
Apoliceofficer,whosewifewasahomemakerwiththreesmallchildren,was
debts' He held up a bank teller at a
about to iose tris house due to gambling
drive-throughwindow.Whenhehandedthetelleranoteaskingforasum
the gun sitting next to him on
equal to his mortgage debt he alerted her to
thepasserrger,"o]t.'ri"wasapprehendedinlessthan3houisbecausehis
seat easily in range of the security
uaoge and iolice number sat on the same
camera and the teller's alert vision'
the
Inthe erson' the therapist queries the patient about
manySourcesofincomeaSiSreasonable.Afewindi-
vidual uld give the therapist a sense of how honest the
client is likelY to be'

RelationshiP Principles
Thegoalofthesupportperson,spresenceintherapyistoassisttheclientin
developing stimulus c^<introi skills. In order
to achieve that goal, a collaborative
relationshipisessentialbetweenthesupportpersonandthepatient,particularly
partner'
when the support person is a spouse or intimate
as tools for building a
rhe ttrerafii ,irigt, explain the following guidelines
persons in intimate relationships who use
fence around itre teriptation to gamble.
that no doubt was
these tools have the uaA"a Uono' of increasin-g-9-oqsulfation
dormant or nonexistent

dynamic in
1. Flood the partner with information' The presenting
the pathological gambler's
the relationship is usually one in which
primary goal is to keep the partner in the dark' As a result' com-
purposely deceptive'
,n rni"utl"on is not only minimal, it is often
the operatrve strategy ls
Breaking that pattern is no small task' so
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152 Chapter 8: Abstinence Control and Relapse Prevention

Financial Control Strategies

R"1!g!rrg,?gg"-$lgJggqeJ is the frst m t in abstinence
fnut 6mp6-""t goes hand in glove with developing an
financial plan (see Chapter 13). But financial control cannot wait until e

asptct6FTu-ageting i s comPl ete.

phase one evolves out of the overall clinical assessment of the
method of operating as well as the behavioral chain assessment described abo
Once high-risk situations are identified, the next step is to limit access
financial resources to gamble with. To illustrate the challenge involved rn
alco
step, consider the nature of substance abuse. People do not need to have
or heroin in their possession to manage the activities of daily life. Money'
the other hand, is essential, but money is intricately linked to the
compulsion.
The first phase involves planning which financial resources the patient
control on a daily basis and what system for accountability will be used.
require severe restrictions; perhaps enough money for lunch or transpol
Strict accountability may also be essential, for example, keeping receipts
expenditures.
controlling access to funds is also critical, that is, writing checks,
loans, using credit cards for cash advances, and so on' Families may
prevent access to certain accounts, write letters to the bank stopping all
post (
applications, change automatic teller machine passwords, and set up a
box number to ensure that bills, credit card applications, and the like go
to the support person. Chapter 13 offers further suggestions for support
to proteci themselves financially and legally from the gambler's il
irresponsible use of money.
Individualized assessment is essential in taking any of these steps.
most severe cases, patients should cafiy a limited amount of money and
strict accountability, with no access to other income. other patients may
minimal monitoring. A good rule of thumb is to start with minimal
minimat amounts but to gradually increase both as recovery progresses
develops. Naturally, monitoting and renegotiating these guidelines are
a

gr
describes feeling either scared about what kind of financial damage the
will do or guilty for acting like a parent who is infantalizing the patietr
discussion usually resolves these issues by reassuring everyone that
temporary phase in the recovery process that helps both parties
eoals.
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154 Chapter 8: Abstinence Control and Relapse Prevention

SUMMARY

This chapter has reviewed two major aspects of stimulus control or ways for
gamblers to manage their environments to reduce risk of gambling. These strate-
eies included:

l. A functional analysis of thinking, feeling, and behaving that leads

to gambling.
Assessing the methods the gambler used to obtain money to gam-
ble or cover it up.
3. Developing methods to restrict access to money through the help
of support persons and thus prevent impulsive gambling.
Developing strategies to cope with the physical situations that
increase the probability of gambling.

The next chapter describes how patients in their attempt to cope with gambling
urges inadvertently increase their intensity, duration, and frequency through the
process of misregulation. To cope effectively with these urges the chapter extends
the therapeutic strategy of acceptance into the realm of gambling treatment.

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 Worksheet 8.2
Coping with Relapse
Lapse/Slip Analysis Worksheet

1. When a slip/lapse occurs, people often feel blindsided by the event. Yet they fail to see how they may have Warning I

put the blinders on themselves. Slips usually occur when people take a step early in the slip process that makes
resistance extremely difficult. Problem gamblers who were admitted to the addiction treatment hospital where
I worked would sometimes decide to drive through Atlantic City. It was actually 200 miles out of the way, but 1.

they wanted to take "the scenic route." Did they consciously intend to gamble? Some didn't. Was it sensible?
What do you think?
2.
2. The purpose of this worksheet is to dissect a recent slip/lapse to see whether you did things early in the
process that made the slip more difficult to resist.
J.

3. Use your Triggers Worksheet to analyze a recent slip/lapse.

4.
4. Break down the event roughly into these stages:

Preparatory: 5.

Middle: 6.

Ending: 7.

8.

What choice(s) did you make in the preparatory stage that you can now see set the stage for the slipAapse?
9.
a. How did this/these choice(s) contribute to the slip/lapse?

b. How aware were you at the time that this choice could be closely linked to a slip?

c. How aware now?

d. What do you need to do differently to keep the blinders off?

156
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 Worksheet 8.4
Coping with Relapse
Containing a Slip by Stopping Snowballing

1. Describe your slip/lapse.

2. Negative Thoughts about the Slip/lapse.

A. Thoughts related to: I messed up, might as well go all the way and do it right.

B. Thoughts related to: It's no use, what's the point, I'm not strong enough anyway.

3. Consequences of Negative Thoughts

A. Negative Feelings.

B. Effect on My Self-Esteem

C. What I feel like doing right now.

4. Challenging the Negative Thoughts.

A. Yes, I messed up-but, how worse will a binge make my situation?

What resources do I have to get back on my feet?

Who will support me even now if I sincerely try?

Even though I made a mistake what personal qualities do I still have that are worthwhile?

What evidence do I have that I still have some personal control?

B. How can I use the slip as a leaming experience?

What would I do differently?

5. New Way of Thinking and Feeling

6. Plan for my Next Step.

Who do I contact and share?

What do I do next to get back in recovery?

158