The Effects of treatment support for family members on older adult

THE EFFECTS OF TREATMENT SUPPORT FOR FAMILY
MEMBERS ON OLDER ADULT GAMBLERS:
A RAPID EVIDENCE ASSESSMENT
April 2015
Vanessa Hazell1, 2, Jane Leslie3
(1) Gambling Research Exchange Ontario, Guelph, ON, (2) University of Guelph, Guelph, ON, (3) Peel
Addiction Assessment and Referral Centre, Mississauga, ON
Table of Contents
Executive Summary ................................................................................................................... 3
Background and Methodology.................................................................................................... 4
Summary of REA Findings ..................................................................................................... 7
The Effects of Treatment Support of Family Members on Older Adult Gamblers ............. 7
The Effects of Treatment Support of Family Members on Adult Gamblers ....................... 7
Details of Studies ............................................................................................................ 7
Summary ......................................................................................................................... 7
Study Examples .............................................................................................................. 7
The Effects of Treatment Support of Family Members on Older Adult Substance Abusers
........................................................................................................................................ 8
Details of Studies ............................................................................................................ 8
Summary ......................................................................................................................... 8
Study Examples .............................................................................................................. 8
The Effects of Treatment Support of Family Members on Adult Substance Abusers ....... 9
Details of Studies ............................................................................................................ 9
Summary ......................................................................................................................... 9
Study Examples .............................................................................................................. 9
Discussion .............................................................................................................................11
Conclusions & Points for Consideration .................................................................................12
References ...............................................................................................................................13
Appendix A: Detailed Methodology ...........................................................................................21
Appendix B: Illustrative Search strategies .................................................................................22
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Background: Problem gambling (PG) is becoming a significant issue among older adults (age 55+)
(Abbott et al., 2013), with 12-month prevalence rate estimates ranging from 0.3 to10.4% in North America
(Tse et al., 2012). The consequences of PG can be devastating for older adults, as these individuals often
have a fixed, modest monthly income (Lemay et al., 2006) and are thus less capable of replacing the
money they lose (Government of Canada, 2006). In addition, PG has been linked to a variety of
psychological and social concerns among older adults (Ariyabuddhiphongs, 2012). Despite these facts,
the gambling literature largely focuses on younger populations. Currently, little is known about how to
effectively treat PG among older adults. Positive impacts of involving family members in treating PG
issues are well-documented with younger age groups, however surprisingly under-researched among
older adults.
The current study documented the evidence of the impacts of providing treatment support to family
members of older adult gamblers.
Impact Question: “How might treatment support to family members affect recovery in older adult problem
gamblers?”
Methods: A rapid evidence assessment (REA) was undertaken. Due to the dearth of research on older
adult gamblers, the search was expanded to include all adults (18+ years) and older adult substance
abuse and addictions. A total of 5,104 resources and book chapters were screened across three
databases (PsycInfo, Google Scholar, PubMed). After title and abstract screening, 88 papers were
selected as the evidence base for the REA.
Results: The gambling and substance abuse literatures both showed that treatment support to family may
be quite beneficial for older adults. Specifically, family involvement was linked to decreased gambling
frequency, less money spent on gambling, decreased severity of gambling consequences, decreased
gambling urges, increased treatment attendance, and increased abstinence among adult problem
gamblers. It is also suggested that family involvement can strengthen the older adult substance abuser’s
social support network and increase his/her capacity for change.
Recommendations: This study provides a launching point for practitioners, family members and
researchers working with older adult problem gamblers in providing them with best evidence to be
successful in treatment. Recommendations are made for three audiences:
Treatment Providers: Adopt a family-oriented approach in the treatment of older adult problem
gamblers.
Family Members: With the help of a treatment provider, support the older adult’s treatment
initiation, engagement, and adherence; strengthen his/her social support network; increase
capacity for change through simultaneous treatment
Researchers: Further research on older adult problem gamblers is needed. Potential research
areas include efficacy studies of PG treatments, mechanisms of efficacious treatments, and
replication of the effectiveness of substance use treatments (e.g. behavioural couples therapy,
CRAFT, ARISE).
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This rapid evidence assessment (REA) was conducted for the Peel Addiction Assessment and Referral
Centre (PAARC) as part of a program of knowledge translation and exchange being undertaken by the
Gambling Research Exchange Ontario (GREO), whose purpose is to support evidence-informed decision
making about gambling and its potential harm.
Evidence of the beneficial impact of involving family members in psychological treatment is wellestablished in the gambling literature. However, the bulk of these studies have focused on child and
adolescent populations. This review investigates the evidence of family-oriented gambling interventions
and positive outcomes in the older adult population (age 55 years and older).
The research question which the current REA sought to answer was “How might the provision of
treatment support to family members affect recovery in older adult problem gamblers?” Jane Leslie,
Counsellor/ Case Manager of the Older Persons Substance Use and Problem Gambling Program at
PAARC had requested that research be conducted on this topic with the intention of obtaining guidance
on how to involve family members in the treatment of older adult gamblers. Through this process and
knowledge translation and exchange, GREO hoped to draw attention to an underrepresented subset of
the gambling population and demonstrate to practitioners the potential impact of helping older adults
indirectly through the involvement of their loved ones in treatment.
Gambling has become an increasingly popular form of recreation and entertainment among older adults
in Canada, with one study reporting that up to 73.5% of older adults in Ontario engaged in some form of
gambling activity over the last year (Wiebe, Single, Falkowski-Ham, & Mun, 2004). This trend is likely due
to older adults’ increased leisure time and disposable income, as well as society’s acceptance of
gambling as a form of recreation (Centre for Addiction and Mental Health (CAMH), 2001; McNeilly &
Burke, 2002). As a result, older adults are frequently targeted with special promotions (e.g. discounted
transportation to the casino, free meals) to encourage them to gamble (CAMH, 2001; McNeilly & Burke,
2002). Older adults primarily report engaging in gambling for social reasons (e.g. excitement, fun,
socialize), as well as to win money (Wiebe et al., 2004). Excessive gambling and increased access to
opportunities to gamble may lead to the development of more severe gambling and mental health issues
(Tse, Hong, Wang, & Cunningham-Williams, 2012), therefore it comes as no surprise that problem
gambling is increasingly becoming a significant issue among the older adult population (Abbott et al.,
2013), with 12-month prevalence rate estimates ranging from 0.3 to 10.4% in North America (Tse et al.,
2012). Single older adults, between the ages of 60 and 65, with lower levels of income, may be
particularly at risk of developing a problem gambling issue (Wiebe et al., 2004).
The consequences of problem gambling can be particularly devastating for older adults, as these
individuals often have a fixed, modest monthly income (Lemay, Bakich, & Fontaine, 2006) and may be
less capable of replacing the money they have spent (Minister of Public Works and Government Services
Canada, 2006). In one review of the literature (Ariyabuddhiphongs, 2012), it was found that problem
gambling among older adults is linked to a variety of psychological and social concerns including
comorbid substance abuse/dependence, depression, anxiety disorders, and family/social difficulties.
Another study indicated that many older adult problem gamblers felt guilty about their gambling, chased
losses, and felt criticized for their gambling behaviours (Wiebe et al., 2004).
The impact of problem gambling is not limited to the problem gambler alone. Researchers have found
that problem gambling can also have negative financial (McComb, Lee, & Sprenkle, 2009), physical
(Lorenz & Yaffee, 1988), emotional (Lorenz & Yaffee, 1988), and interpersonal (Dickson-Swift et al.,
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2005; Lee, 2002; Hodgins, Shead, & Makarchuk, 2007) impacts on family members and concerned
significant others (CSOs) (Kourgiantakis, Saint-Jacques, & Tremblay, 2013; McComb et al., 2009).
Indeed, a large number of people who access problem gambling services are the family members and
CSOs of problem gamblers (McComb et al., 2009).
Perhaps due to the fact that younger adults are more at risk of developing problematic gambling
behaviours than older adults (Alberta Alcohol and Drug Abuse Commission, 2001), the bulk of the
gambling literature has focused on younger populations. Given the potential severity of the
consequences of problem gambling among older adults, it is crucial that researchers study problem
gambling in this age group so that these findings can inform clinicians on best practice in serving this
population. One potential type of intervention, which has been surprisingly understudied among older
adults, is interventions involving family members and CSOs. Previous research with younger samples
have already demonstrated the positive impacts of involving family members in a problem gambler’s
treatment on treatment outcomes, family functioning, and individual functioning (e.g. Kourgiantakis et al.,
2013), however few have examined this in older adult samples. The current REA sought to explore the
effects of treatment of family members and CSOs on older adult problem gamblers.
A question-led approach was used to identify and review evidence of the impact of the provision of
support to family members on older adult gamblers. Specifically, PAARC provided the impact question
which investigated “How might treatment support to family members affect recovery in older adult problem
gamblers?”
Treatment support was defined as “any form of psychological services provided to help family members
address mental health concerns arising from an adult family member’s gambling”. Psychological
treatment refers to, “the provision of any psychological services to family members of an older adult
gambler. The older adult can be a) receiving psychological services individually, with family members
supporting the individual outside of therapy, b) receiving psychological services on a group basis,
alongside family members (e.g. family therapy, couples therapy), or c) not receiving psychological
services although the family members are receiving psychological services to address the issue of the
older adult’s gambling (e.g. ARISE, CRAFT). Older adults were operationalized as “adults over the age
of 55”, while family members were operationalized as “members of the gambler’s immediate and
extended family”. Recovery was defined as “a reduction in gambling frequency”. Problem gambling was
defined as “…any type of repetitive gambling that an individual engages in that leads to (or aggravates)
recurring negative consequences such as significant financial problems, addiction, as well as physical
and mental health issues.” (Abbott et al., 2013, p. 5).
Study Design An REA was conducted instead of a systematic review due to time and resource
constraints. Inclusion criteria were established by GREO. Appendix B details the search strategy
undertaken.
Three databases were searched for literature: PsycInfo, Google Scholar, and PubMed. The electronic
articles and book chapters gathered during the search were reviewed to determine relevance to the study
using pre-defined inclusion/exclusion criteria. Both quantitative and qualitative research studies were
included to capture the full scope of literature. The timeframe of the search parameters was 1990’s
onward. Substance abuse and addictions literatures were included in the search, as the findings of these
literatures are frequently extrapolated onto the gambling literature. Only PsycInfo was used to search the
substance abuse and addictions literatures.
Adult gambler research, age 18 to 55 years, was also included to compensate for the dearth of research
on older adult gamblers. As such, an assumption was made that findings concerning adult gamblers
could be generalized to older adult gamblers. Impact of family support on children or adolescents (18
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years and below) were excluded, as it was reasoned that generalizations could not be applied to older
adult gamblers. Single or both gender study populations were included in the REA.
Studies which focused exclusively on the harmful effects of gambling, substance abuse and/or addiction
were excluded. Studies which examined the psychological and social outcomes of family treatment
support on the gambler/substance abuser/addict were included, however literature which examined these
outcomes on other family members were excluded, as it was beyond the scope of the current review.
Inclusion and exclusion criteria for specific psychological and social outcomes were not developed in
order to be inclusive of the full range of potential outcomes documented in the literature.
All geographic, national, and social settings were included in the REA, however non-English language
resources were excluded to accommodate the reviewer’s language proficiencies.
The inclusion and exclusion criteria were applied to each study based on the abstract. When over 100
hits were returned in a literature search, only the first 100 articles were reviewed due to decreasing
relevance. Open access articles and book chapters that met the criteria were included in the REA, while
those which were not readily accessible were excluded.
A total of 5,104 resources were screened across three databases. After title and abstract screening, 88
papers were used as the evidence base for the current REA. Twenty-six of the 88 studies pertained to
problem gambling, with one of these resources focusing exclusively on gambling among older adults.
Three resources concerning addictions among older adults were also included, with two of these studies
examining prescription drug use and one article examining alcohol use. The remaining 59 resources
looked at substance abuse, with 16 focusing on alcohol abuse, 9 focusing on drug abuse, and 36
focusing on substance abuse in general. Additional details about the included studies are provided in later
sections. Appendix A shows the total of selected records once scanned through inclusion and exclusion
criteria.
One limitation of the evidence base is that the majority of resources used to answer the research question
pertain to substance abuse, rather than problem gambling. Although it was possible to only include
problem gambling literature, the sample of studies would be too small to draw general conclusions from.
Therefore substance abuse and addictions literatures were used to generalize findings to the problem
gambling realm, as has been done by other researchers. Consequently, the evidence informing the
research question comes at a risk of misinforming best practices in working with older adult problem
gamblers.
Similarly, an additional limitation is the lack of evidence pertaining to older adults. It appears that relatively
few studies have been conducted with this population in the areas of gambling, substance abuse, and
addiction compared to other age groups, and as a result there are even fewer studies examining the
impact of family treatment support on this population. The conclusions drawn from adult studies must be
interpreted with caution, as older adulthood is a life stage distinct from adulthood, and these conclusions
may be less applicable to older adults.
The findings of the REA are organized by the literatures that were searched. Findings of the effects of
family members’ treatment on problem gamblers are presented first, followed by its impact on substance
abusers and other addictions. Conclusions from both sets of literature will then be presented, including
how findings from the substance abuse and addictions literatures can be generalized to the gambling
literature.
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The Effects of Treatment Support of Family Members on Older Adult Gamblers
Only one article (Lucke & Wallace, 2006) provided suggestions of how to include family members in the
treatment of older adult gamblers. Lucke and Wallace conceptualized problem and pathological gambling
from a nursing perspective as dysfunctional family processes and outlined that the goal of intervention is
to increase the family’s ability to manage the older adult’s gambling and increase family members’
abilities to cope with this stressor. Although most of the intervention techniques proposed in their
treatment plan involve providing treatment to the older adult gambler through psycho-education,
accessing community resources, and counselling services, it includes a family component as well.
Specifically, the family aspect of the treatment plan entails encouraging family members’ involvement in
treatment and encouraging family members to support the older adult’s adherence to treatment. It is
important to note that the researchers acknowledge that little information exists which supports the use of
specific interventions for this population; therefore these clinical recommendations should be interpreted
with some caution.
The Effects of Treatment Support of Family Members on Adult Gamblers
Details of Studies
Twenty-three studies discussed the treatment of family members and its impact on adult gamblers.
Fourteen of these resources focused on the treatment of concerned significant others (CSOs), while six
focused on family members in general (including CSOs). Three of the articles were excluded because
they did not directly examine the impact of family treatment on adult gamblers (i.e., using self-report to
assess the impact of social support and family involvement on treatment outcomes; no specific treatment
modalities discussed). A total of 20 resources were included.
Summary
The majority of these studies indicated that the involvement of family members in the treatment of
problem gamblers showed positive outcomes for problem gamblers, including decreased gambling
frequency and severity of gambling consequences. Two studies did not support this finding; however this
may have been due to methodological issues.
Study Examples
Kourgiantakis, Saint-Jacques, and Tremblay (2013)’s review of 30 studies from 1998 to 2013 found that
treatment support of family members is associated with better treatment outcomes and improved
functioning for the problem gambler. Specifically, three of the reviewed studies (Hodgins, Shead, &
Makarchuk, 2007; Hodgins, Toneatto, et al., 2007; Peden, 2011) examined the effects of improving
CSOs’ coping skills by using the Community Reinforcement and Family Training (CRAFT) approach. This
training showed changes in the gambling behaviour of a family member, including decreases in gambling
frequency, amount of money spent on gambling, and severity of gambling consequences. Two studies in
the review (Lee, 2002; Lee & Rovers, 2008) found that participating in congruence couples therapy led to
a decrease in the number of gambling urges and an increase in maintaining abstinence. Finally, one
cohort study in the review (Ingle, Marotta, McMillan, & Wisdom, 2008) found that the participation of a
significant other in treatment increased the chances of a successful treatment outcome for the problem
gambler. Further, problem gamblers with a significant other in treatment attended 30% more treatment
sessions than problem gamblers whose significant other did not participate in treatment.
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Heineman (1994) argues that the best way to make an impact on problem gambling is to intervene with
family members because they are more receptive to intervention than the gambling family member.
Heineman outlines a framework for a structured family intervention, which includes psychoeducational
and disclosure components, as well as GamAnon (a support group for family members of gamblers)
attendance. This article did not describe measured outcomes.
Two studies did not report a positive impact of family involvement in treatment. Zion, Tracy, and Abell
(1991) found that whether a spouse participated in GamAnon did not impact gamblers’ relapse rates,
while Rychtarik and McGillicuddy (2006) found no differences in gambling frequency between partners
who participated in coping skills training (CST) and those who did not. However, the researchers
acknowledge that their lack of findings may be due to methodological limitations. Specifically, Zion and
colleagues measured total abstinence as an outcome, which they acknowledge as potentially problematic
due to relapse being a part of the recovery process. Rychtarik and McGillicuddy measured gambling
behaviours before the partners had mastered CST, meaning mastering these skills may have had a
different impact.
The Effects of Treatment Support of Family Members on Older Adult Substance Abusers
Details of Studies
Ten studies discussed the impact of family and couples treatments on older adults who abuse alcohol
and/or drugs. Three of these studies were excluded from the REA: One study discussed the impact of
involving family members on CSOs, but not on older adults; another study did not discuss treatment
support provided to family members; and the third study did not examine specific treatment modalities
involving family members, but the interactions between relationship quality, psychological well-being, and
drug use. Seven studies were included.
Summary
The literature in this area is mainly prescriptive in nature, stressing the importance of family member
involvement in treatment of older adults dealing with substance abuse. However, none of these studies
evaluated the effectiveness of involving family members in treatment.
Study Examples
Based on their review of the literature and key expert testimonies, Health Canada (2002) identifies as
best practice that family members should be involved in older adults’ substance abuse treatment. This
recommendation is supported by other researchers referenced in this REA (e.g. Morgan & Brosi, 2007;
Perkins & Tice, 1999; Stelle & Scott, 2007; Stoddard & Thompson, 1996). Perkins and Tice state that it is
important to involve family members in order to strengthen the older adult’s support network and, in this
way, increase their capacity for change. Stelle and Scott’s review suggests that involving family members
in older adults’ substance abuse treatment may be beneficial for both family members and the older
adults; however, they indicate that there is mixed evidence of family therapy’s effectiveness in addressing
this issue among the older adult population.
Sorocco and Ferrell (2006) outline how family members can become involved in an older adult’s
substance abuse treatment. Specifically, the authors assert that family members should be taught
effective communication skills so that they can effectively express their concerns to the older adult in an
intervention.
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The Effects of Treatment Support of Family Members on Adult Substance Abusers
Details of Studies
Forty-nine studies examined the role of family member treatment on adult substance abuse. Eleven of
these studies were excluded from the REA. Reasons for exclusion included a lack of discussion of
psychological treatment (2 studies); failing to discuss the impact of a family intervention on the affected
individual (10 studies); and examining the impact of treatment on comorbid psychiatric symptoms (1
study). A total of 37 resources were included.
Summary
The studies in this area of research documented a number of family-oriented treatments for adult
substance abusers which are associated with a variety of positive outcomes. A large number of studies (n
= 19) examined the treatment outcomes of behavioural couples therapy and found that undertaking this
form of therapy leads to increased readiness for change; decreased frequency of substance abuse; lower
relapse rates; and increased relationship satisfaction. A large number of studies (n = 10) examined the
impact of interventions designed to engage substance abusers in treatment (i.e. CRAFT, A Relational
Intervention Sequence for Engagement (ARISE)), and found that these interventions were effective in
increasing treatment engagement and retention and decreasing substance use. The remaining studies
discussed multiple family-oriented treatments.
Study Examples
O’Farrell and Clements (2012) reviewed the alcoholism literature from 2002-2010 for outcome research
on marital and family therapy, also referencing the findings of one of the author’s review of the literature
prior to 2002 (O’Farrell & Fals-Stewart, 2003). The researchers found that CRAFT may be particularly
beneficial for alcoholics who were unwilling to enter treatment. This form of treatment entails providing
CSOs with behavioural skills training for the purpose of altering the alcoholic’s substance use and helping
this individual enter treatment (Meyers, Apodaca, Flicker, Slesnick, 2002). In their review, O’Farrell and
Clements found that CRAFT demonstrated the highest treatment engagement rates (59-86%) of all the
other interventions reviewed including: Johnson Institute Intervention (25-30%), Pressure to Change
approach (31%), and Unilateral Family Therapy. Meyers, Apodaca, Flicker, and Slesnick (2002) also
found evidence of CRAFT’s effectiveness in fostering treatment engagement over other treatment
modalities (i.e. Al-Anon (13%), Johnson Institute Intervention (30%); as referenced in Miller et al., 1999).
According to Rowe’s (2012) review, CRAFT has also demonstrated similar outcomes among drug
abusers, with higher rates of treatment engagement and retention compared to other approaches (e.g.
Kirby, Marlowe, Festinger, Garvey, & LaMonaca, 1999). Further, CRAFT has been linked to high followup rates in illicit drug users, both as an individual format (59%) and with the inclusion of group sessions
(76.7%; Meyers, Miller, Smith, & Tonigan, 2002).
O’Farrell and Clements acknowledge that ARISE is another promising option; however, no controlled
studies have been conducted on this approach. This three-stage approach entails mobilizing the
substance abuser’s social supports in order to motivate this individual to initiate treatment (Fernandez,
Begley, & Marlatt, 2006; Landau et al., 2004). During the first stage, a family member or CSO contacts a
clinician to get help for a substance abusing individual. An initial meeting is set up between the CSO and
clinician, and the CSO invites the substance abuser, as well as the substance abuser’s social support
network, to attend the meeting (Fernandez et al., 2006; Landau et al., 2004). If the substance abuser
does not initiate treatment after this stage, the substance abuser’s family members meet with the clinician
for up to five sessions to situate the issue within the family context and negotiate treatment for the
substance abuser, whether or not this individual attends the meetings (Fernandez et al., 2006; Landau et
al., 2004). If the substance abuser still does not initiate treatment, a variation of the Johnson Intervention
is implemented, where family members write letters to the substance abuser, select treatment options,
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and determine consequences for not complying with treatment (Fernandez et al., 2006; Landau et al.,
2004).
Landau and colleagues (2004) found that the ARISE intervention had an 83% success rate among
substance abusers, with 55% entering treatment by the end of Stage I of the intervention. Indeed, 50% of
substance abusers entered treatment within one week of initial contact with a clinician, and 84% entered
treatment within three weeks of the intervention. The researchers argue that these high engagement
rates are due to the intervention’s immediacy, sharing the responsibility for the situation with the support
network, fostering confidence in the CSO, and respecting the substance abuser’s involvement.
O’Farrell and Clements (2012), as well as Meyers and colleagues (2002), have also found that involving
family members in an alcoholic’s treatment can be quite effective in fostering their recovery from
alcoholism. Family therapy approaches argue that familial attitudes and behaviours can support
substance use, and altering these factors can lead to decreased substance abuse (Meyers et al., 2002;
Rowe, 2012). Therefore, the goals of this form of therapy is to mobilize family members to help the
substance abuser decrease their substance use and engage in lifestyle changes, while, simultaneously,
altering maladaptive features of the family environment in order to ensure the maintenance of positive
behaviours and promotion of recovery in the long-term (Rowe, 2012).
Meyers and colleagues (2002) found that marital/family therapy demonstrates greater efficacy than
individual therapy in addressing alcohol issues, and involving family members in treatment can increase
alcoholics’ treatment engagement (73% with family member involvement versus 12% without family
member involvement); as well as decrease alcohol consumption (58% with family member involvement
versus 12% without family member involvement) (Edwards & Steinglass, 1995).
Behavioural couples therapy (BCT), in particular, has been found to be an effective treatment modality for
individuals dealing with alcoholism (O’Farrell & Clements, 2012) and drug abuse (Rowe, 2012). This
treatment consists of interventions which involve building familial supports for abstaining from
alcohol/drugs, and relationship-focused interventions, which entail increasing constructive
communication, positive emotions, and shared activities among family members. It is believed that if
family communication is improved, relapse rates will be lower (O’Farrell & Clements, 2012). Outcomes
linked to BCT include an increase in days of abstinence (McCrady, Epstein, Cook, Jensen, & Hildebrandt,
2009), a decrease in days engaging in heavy drinking (McCrady et al., 2009), and decreased
interpersonal violence (Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009). These outcomes were also
found at the 1-year follow-up (O’Farrell & Clements, 2012). BCT also demonstrated better drinking
outcomes and perceived relationship quality than individual therapy. In terms of drug abuse, Rowe’s
(2012) review found evidence that BCT was superior to individual therapy in terms of drug use outcomes,
arrests, interpersonal violence, and family outcomes (e.g. Fals-Stewart, Birchler, & O’Farrell, 1996).
O’Farrell and Clements also noted a handful of studies which do not support BCT as more effective than
other treatment methods, however these studies demonstrated a number of methodological issues.
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This rapid evidence assessment of the gambling and substance abuse literatures has identified numerous
benefits for problem gamblers and substance abusers as a result of the inclusion of family members in
interventions. Examining evidence from research conducted over a period of 20 years, it is suggested that
practitioners of PAARC and other problem gambling treatment providers utilize the following findings of
the REA:
o
o
o
o
o
Encouraging family members to participate in an older adult problem gambler’s treatment and
supporting his/her treatment adherence may prove beneficial.
Involving family members in the treatment of adult problem gamblers has been linked to positive
outcomes such as decreased gambling frequency, less money spent on gambling, decreased
severity of gambling consequences, decreased gambling urges, and increased treatment
attendance and abstinence.
Involving family members in an older adult’s substance abuse treatment is considered best
practice, as this involvement can strengthen the older adult’s social support network and increase
capacity for change. However, some researchers report mixed evidence for the effectiveness of
family therapy in addressing substance abuse issues among older adults.
Participating in behavioural couples therapy can increase readiness for change, decrease
frequency of substance abuse, lower relapse rates, and increase relationship satisfaction among
adult substance abusers.
Participating in engagement-oriented treatments (e.g., CRAFT, ARISE) can increase treatment
engagement and treatment retention, and decrease substance use among treatment-resistant
adult substance abusers.
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With increasing rates of problem gambling among older adults, researchers are attempting to better
understand the issue among this population. Much of the research assessed primarily examines the
factors which may contribute towards the development of a gambling issue, and to a lesser extent, the
outcomes of problematic gambling. Studies examining treatment options and their efficacy for this
population are much less widespread. Indeed, the current review found that studies examining the
outcomes of family involvement in the problem gambling and substance abuse treatment of older adults
are particularly scarce. Information is needed on how to effectively treat older adults with problem
gambling issues. Treatments developed for adult problem gamblers can serve as a starting point for
treating older adult gamblers; however, researchers need to determine the customizations particular to
older adults which may increase the efficacy of these treatments.
The current REA sought to achieve three goals: 1) draw attention to an underrepresented subset of the
gambling population; 2) demonstrate the potential impact of helping older adults indirectly through the
involvement of their loved ones in treatment; and 3) provide guidance on how to involve family members
in the treatment of older adult gamblers that PAARC and other practitioners could use with its clients. This
REA provides a unique examination of problem gambling issues among older adults and provides a
launching point for researchers and practitioners working with this population. These findings suggest that
family involvement in treatment may prove beneficial for older adults’ treatment engagement, adherence,
and outcomes. Further, the findings of the REA suggest that family members can become involved in an
older adult problem gambler’s treatment in a number of ways. They can motivate and support the older
adult problem gambler to initiate and adhere to treatment, and/or acquire the knowledge and skills they
need to help the problem gambler maintain positive behaviours through family therapy or engagementbased therapies. The findings from this REA suggest that practitioners should actively involve family
members in treatment of older adult problem gamblers in order to improve gambling treatment outcomes.
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* indicates studies cited in the report text
Abbott, M., Binde, P., Hodgins, D., Korn, D., Pereira, A., Volberg, R., Williams, R. (2013). Conceptual
Framework of Harmful Gambling: An International Collaboration. The Gambling Research Exchange
Ontario (GREO), Guelph, Ontario, Canada.
*Alberta Alcohol and Drug Abuse Commission. Seniors and gambling. AADAC Profile Oct. 2001.
Available from: http://corp.aadac.com/content/corporate/ research/seniors_gambling_profile.pdf
Allard, J., Allaire, D., Leclerc, G., Langlois, S.P., (1994). The influence of family and social relationships
on the consumption of psychotropic drugs by the elderly. Archives of Gerontology and Geriatrics, 20,
193-204.
Arcidiacono, C., Sarnacchiaro, P., & Velleman, R. (2008). Testing fidelity to a new psychological
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5,104 electronic articles and book
chapters from specific searches of
3 databases screened
PsycInfo (n = 4243)
Google Scholar (n = 700)
PubMed (n = 161)
5,019 resources excluded
after abstract sifting
88 electronic articles and book
chapters assessed for full eligibility
23 resources excluded due to
not meeting inclusion criteria
64 electronic articles and book
chapters that met inclusion criteria
21 PG resources
(1 older adult sample, 20
adult samples)
43 Substance Abuse resources
(7 older adult samples,
36 adult samples)
RAPID EVIDENCE ASSESSMENT |
Gambling + “older adult”
Gambling + older adult*
Gambling + family + older adult*
Gambling + family + category: age group (65 and older)
Gambling + family treatment + category: age group (65 and older)
Gambling + older adult* + couples
Gambling + older adult* + spouse
Gambling + older adult* + CRAFT
Gambling + older adult* + community reinforcement and family training
GamAnon
Gambling + older adult* + couples therapy
Gambling + older adult* + couples counseling
Gambling + older adult* + couples counselling
Gambling + older adult* + couples intervention
Gambling + older adult* + couples treatment
Gambling + older adult* + family therapy
Gambling + older adult* + family intervention
Gambling + older adult* + family treatment
Gambling + “system* model”
Gambling + “system* approach”
Gambling + marital and family therapy
Gambling + seniors OR elderly OR retired + treatment
Gambling + seniors OR elderly OR retired + intervention
Gambling + seniors OR elderly OR retired + family
Gambling + seniors OR elderly OR retired + couples
Gambling + seniors OR elderly OR retired + spouse
Gambling + seniors OR elderly OR retired + CRAFT
Gambling + seniors OR elderly OR retired + community reinforcement model
Gambling + seniors OR elderly OR retired + couples therapy
Gambling + seniors OR elderly OR retired + couples counseling
Gambling + seniors OR elderly OR retired + couples counselling
Gambling + seniors OR elderly OR retired + couples intervention
Gambling + seniors OR elderly OR retired + couples treatment
Gambling + seniors OR elderly OR retired + family intervention
Gambling + seniors OR elderly OR retired + family treatment
Gambling + seniors OR elderly OR retired + family therapy
Gambling + concerned significant others
Gambling partner
Gambling + “adult children”
30
4827
388
71
27
13
41
4
3
6
6
3
2
Error
6
52
32
155
3
7
11
54
30
8
1
2
Error
Error
1
Error
Error
Error
Error
8
2
1
8
53
4
16
65
6
--------41
0
0
0
0
0
0
0
0
0
0
0
2
0
1
0
17
2
4
0
0
0
0
0
1
1
0
0
0
3
2
G.Scholar
Search Terms (Gambling)
PubMed
PsycInfo
P a g e | 22
1850
1850
1560
---------
410
0
628
2120
133
RAPID EVIDENCE ASSESSMENT |
P a g e | 23
PsycInfo
Search Terms (Substance Abuse)
Substance abuse + “older adult”
Substance abuse + older adult*
Substance abuse + family + older adult*
Substance abuse + family + category: age group (65 and older)
Substance abuse + family treatment + category: age group (65 and older)
Substance abuse + older adult* + couples
Substance abuse + older adult* + spouse
“Substance abuse” + older adult* + spouse
Substance abuse + older adult* + CRAFT
Substance abuse + older adult* + community reinforcement and family training
Al-Anon
Nar-Anon
Substance abuse + older adult* + couples therapy
Substance abuse + older adult* + couples counseling
Substance abuse + older adult* + couples counselling
Substance abuse + older adult* + couples intervention
Substance abuse + older adult* + couples treatment
Substance abuse + older adult* + family therapy
Substance abuse + older adult* + family intervention
Substance abuse + older adult* + family intervention – adolescent* - child*
Substance abuse + older adult* + family treatment
Substance abuse + older adult* + family treatment – adolescent* - child*
Substance abuse + “system* model”
Substance abuse + “system* approach”
Substance abuse + marital and family therapy
Substance abuse + seniors OR elderly OR retired + treatment
Substance abuse + seniors OR elderly OR retired + intervention
Substance abuse + seniors OR elderly OR retired + family
Substance abuse + seniors OR elderly OR retired + couples
Substance abuse + seniors OR elderly OR retired + spouse
Substance abuse + seniors OR elderly OR retired + CRAFT
Substance abuse + seniors OR elderly OR retired + community reinforcement model
Substance abuse + seniors OR elderly OR retired + couples therapy
Substance abuse + seniors OR elderly OR retired + couples counseling
Substance abuse + seniors OR elderly OR retired + couples counselling
Substance abuse + seniors OR elderly OR retired + couples intervention
Substance abuse + seniors OR elderly OR retired + couples treatment
Substance abuse + seniors OR elderly OR retired + family intervention
Substance abuse + seniors OR elderly OR retired + family treatment
Substance abuse + seniors OR elderly OR retired + family therapy
Substance abuse + concerned significant others
Substance abuse + “adult children”
132
32,896
4,738
416
9
321
207
184
16
11
106
104
42
1
38
137
848
950
369
3031
1698
59
153
190
419
102
127
6
4
0
0
3
2
0
0
3
19
60
18
34
RAPID EVIDENCE ASSESSMENT |
P a g e | 24
PsycInfo
Search Terms (Addiction)
Addiction* + “older adult*”
Addiction* + older adult*
Addiction* + “older adult*” + family treatment
Addiction* + “older adult*” + “family treatment”
Addiction* + “older adult*” + family therapy
Substance abuse + older adult* + family intervention
Substance abuse + “older adult*” + couples therapy
Substance abuse + “older adult*” + couples counseling
Substance abuse + “older adult*” + couples counselling
Substance abuse + “older adult*” + couples intervention
Substance abuse + “older adult*” + couples treatment
Addiction* + “older adult*” + marital and family therapy
Addiction* + seniors OR elderly OR retired + CRAFT
Addiction* + seniors OR elderly OR retired + community reinforcement model
Addiction* + seniors OR elderly OR retired + couples therapy
Addiction* + seniors OR elderly OR retired + couples counseling
Addiction* + seniors OR elderly OR retired + couples counselling
Addiction* + seniors OR elderly OR retired + couples intervention
Addiction* + seniors OR elderly OR retired + couples treatment
Addiction* + seniors OR elderly OR retired + family intervention
Addiction* + seniors OR elderly OR retired + family treatment
Addiction* + seniors OR elderly OR retired + family therapy
543
49,019
53
2
10
6
0
0
0
0
0
0
0
0
1
2
0
0
1
14
37
16
RAPID EVIDENCE ASSESSMENT |
Search Terms (Gambling + Substance Abuse + Addiction/Comorbid)
Gambling + Substance abuse +“older adult”
Gambling + Addiction +“older adult”
Gambling + comorbid* + “older adult”
Gambling + Substance abuse + older adult*
Gambling + Addiction + older adult*
Gambling + comorbid* + older adult*
Gambling + Substance abuse + family + older adult*
Gambling + Addiction + family + older adult*
Gambling + comorbid* + family + older adult*
Gambling + Substance abuse + family + category: age group (65 and older)
Gambling + Addiction + family + category: age group (65 and older)
Gambling + family treatment + category: age group (65 and older)
Gambling + Addiction + family treatment + category: age group (65 and older)
Gambling + Substance abuse + older adult* + couples
Gambling + Addiction + older adult* + couples
Gambling + comorbid* + older adult* + couples
Gambling + Substance abuse + older adult* + spouse
Gambling + Addiction + older adult* + spouse
Gambling + comorbid* + older adult* + spouse
Gambling + Substance abuse + older adult* + CRAFT
Gambling + Addiction + older adult* + CRAFT
Gambling + comorbid* + older adult* + CRAFT
Gambling + Substance abuse + older adult* + community reinforcement and family training
PsycInfo
P a g e | 25
7
11
4
676
1247
309
73
145
25
14
22
8
9
0
3
1
1
2
1
0
2
0
0
Gambling + Addiction + older adult* + community reinforcement and family training
Gambling + comorbid* + older adult* + community reinforcement and family training
Gambling + Substance abuse + older adult* + couples therapy
Gambling + Addiction + older adult* + couples therapy
Gambling + comorbid* + older adult* + couples therapy
Gambling + substance abuse + older adult* + couples counseling
Gambling + Addiction + older adult* + couples counseling
Gambling + comorbid* + older adult* + couples counseling
Gambling + substance abuse + older adult* + couples counselling
Gambling + Addiction + older adult* + couples counselling
Gambling + comorbid* + older adult* + couples counselling
Gambling + substance abuse + older adult* + couples intervention
Gambling + addiction + older adult* + couples intervention
Gambling + comorbid* + older adult* + couples intervention
Gambling + substance abuse + older adult* + couples treatment
Gambling + addiction + older adult* + couples treatment
Gambling + comorbid* + older adult* + couples treatment
Gambling + Substance abuse + older adult* + family therapy
Gambling + Addiction + older adult* + family therapy
Gambling + comorbid* + older adult* + family therapy
Gambling + Substance abuse + older adult* + family intervention
Gambling + Addiction + older adult* + family intervention
Gambling + comorbid* + older adult* + family intervention
Gambling + Substance abuse + older adult* + family treatment
RAPID EVIDENCE ASSESSMENT |
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
5
11
4
3
14
1
36
P a g e | 26
Gambling + Addiction + older adult* + family treatment
Gambling + comorbid* + older adult* + family treatment
Gambling + Substance abuse + “system* model”
Gambling + Addiction + “system* model”
Gambling + comorbid* + “system* model”
Gambling + Substance abuse + “system* approach”
Gambling + Addiction + “system* approach”
Gambling + comorbid* + “system* approach”
Gambling + Substance abuse + marital and family therapy
Gambling + Addiction + marital and family therapy
Gambling + comorbid* + marital and family therapy
Gambling + Substance abuse + seniors OR elderly OR retired + treatment
Gambling + Addiction + seniors OR elderly OR retired + treatment
Gambling + comorbid* + seniors OR elderly OR retired + treatment
Gambling + Substance abuse + seniors OR elderly OR retired + intervention
Gambling + Addiction + seniors OR elderly OR retired + intervention
Gambling + comorbid* + seniors OR elderly OR retired + intervention
Gambling + Substance abuse + seniors OR elderly OR retired + family
Gambling + addiction + seniors OR elderly OR retired + family
Gambling + comorbid* + seniors OR elderly OR retired + family
Gambling + Substance abuse + seniors OR elderly OR retired + couples
Gambling + Addiction + seniors OR elderly OR retired + couples
Gambling + comorbid* + seniors OR elderly OR retired + couples
Gambling + Substance abuse + seniors OR elderly OR retired + spouse
Gambling + Addiction + seniors OR elderly OR retired + spouse
Gambling + comorbid* + seniors OR elderly OR retired + spouse
Gambling + seniors OR elderly OR retired + CRAFT
Gambling + addiction + seniors OR elderly OR retired + CRAFT
Gambling + comorbid* + seniors OR elderly OR retired + CRAFT
Gambling + comorbid* + seniors OR elderly OR retired + community reinforcement model
Gambling + seniors OR elderly OR retired + community reinforcement model
Gambling + addiction + seniors OR elderly OR retired + community reinforcement model
Gambling + substance abuse + seniors OR elderly OR retired + couples therapy
Gambling + addiction + seniors OR elderly OR retired + couples therapy
Gambling + comorbid* + seniors OR elderly OR retired + couples therapy
Gambling + substance abuse + seniors OR elderly OR retired + couples counseling
Gambling +addiction + seniors OR elderly OR retired + couples counseling
Gambling + comorbid* + seniors OR elderly OR retired + couples counseling
Gambling + substance abuse + seniors OR elderly OR retired + couples counselling
Gambling +addiction + seniors OR elderly OR retired + couples counselling
Gambling + comorbid* + seniors OR elderly OR retired + couples counselling
Gambling + substance abuse + seniors OR elderly OR retired + couples intervention
Gambling + addiction + seniors OR elderly OR retired + couples intervention
Gambling + comorbid* + seniors OR elderly OR retired + couples intervention
Gambling + substance abuse + seniors OR elderly OR retired + couples treatment
Gambling + addiction + seniors OR elderly OR retired + couples treatment
Gambling + comorbid* + seniors OR elderly OR retired + couples treatment
Gambling + substance abuse + seniors OR elderly OR retired + family intervention
Gambling + addiction + seniors OR elderly OR retired + family intervention
Gambling + comorbid* + seniors OR elderly OR retired + family intervention
Gambling + substance abuse + seniors OR elderly OR retired + family treatment
Gambling + addiction + seniors OR elderly OR retired + family treatment
Gambling + comorbid* + seniors OR elderly OR retired + family treatment
RAPID EVIDENCE ASSESSMENT |
56
14
0
1
0
2
6
0
0
1
0
4
8
4
2
1
0
2
5
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
P a g e | 27
Gambling + substance abuse + seniors OR elderly OR retired + family therapy
Gambling + addiction + seniors OR elderly OR retired + family therapy
Gambling + comorbid* + seniors OR elderly OR retired + family therapy
Gambling + Substance abuse + concerned significant others
Gambling + Addiction + concerned significant others
Gambling + comorbid* + concerned significant others
Gambling + substance abuse + “adult children”
Gambling + addiction + “adult children”
Gambling + comorbid* + “adult children”
RAPID EVIDENCE ASSESSMENT |
0
0
0
3
0
0
2
3
0