CHAPTER THREE PERSONAL DISPOSITION IN PROBLEM AND PATHOLOGICAL GAMBLING
The purpose of this chapter is to focus on the complex array of biological, psychological and social vulnerabilities in developing problem and pathological gambling in order to explain the aetiology of this disorder. A series of distinct vulnerabilities in different subgroups as potential predisposing risk factors leading to the development of problem and pathological gambling will be described.
PROBLEM GAMBLING AS A MULTIFACETED BEHAVIOUR
Gambling is a multifaceted behaviour, strongly influenced by contextual factors that cannot be encompassed by any single theoretical perspective (Griffiths & Delfabbro, 2001). Blaszczynski and Nower (2002) developed a pathways model that integrates the complex array of biological, personality, developmental, cognitive, learning theory and ecological determinants of problem and pathological gambling – with an emphasis on biochemistry and genetics linked to pathological gambling. He proposed that three distinct subgroups of gamblers manifesting impaired control over their behaviour can be identified. These groups include (a) the psychological vulnerable gambler, (b) the biological vulnerable gambler (including anti-social and impulsivist), and (c) the behaviourally conditioned problem gambler.
It has been known for some time that some people are genetically more vulnerable than others to certain addictions. People with one addiction are also more likely to develop another, and this likelihood needs to be addressed in treatment. However, although I do not dispute some kind of biochemical impairment, the question remains as to whether the biochemistry or brain changes precede the gambling, or occur as a result of gambling. It could be that either or both may occur, depending on the individual. There is also no evidence that all three of Blaszczynski’s pathways have the same genetics or brain chemistry. The behaviourally conditioned problem gambler often presents without any prior experience of addiction. I recall a sixty-year old lady with a perfectly normal, successful life until she encountered electronic gaming machines. One year later, severely depressed and suicidal, she had lost almost everything – part time job, family and life savings. I am almost certain her brain functioning was not the same as it had been the year before. Does this mean that she has gone through the previous sixty years with a genetic vulnerability that never emerged? Somehow I doubt that. Just because some people are more vulnerable than others does not mean that everyone else is risk-free. There are many more contributory factors than just genetics. I believe that there is a shifting, multidimensional range of risks over a person’s lifetime and across individuals which could leave everyone at some level of risk.
In treating problem and pathological gamblers I became aware that motivations vary according to personal characteristics of the gambler and it is therefore important to determine what makes some gamblers more susceptible than others to losing control over gambling, and whether pathological gamblers possess qualities which would predispose them to excessive gambling. While I agree, in principle, with Blaszczynski and Nower’s (2002) three subgroups of gamblers, I do however want to add another pathway dimension – codependency – as an additional predictor of problem gambling which could possibly assist in explaining a person’s vulnerability in developing a gambling problem. Determining the existence of a codependency syndrome in problem gamblers has major implications for treatment matching and long term intervention.
Thus, it is important to acknowledge the existence of specific at risk sub-types of gamblers, each influenced by different factors yet displaying similar phenomenological features. If, and when these specific at risk subtypes come into contact with the structural characteristics of gambling, it is possible that a gambling problem can develop. These specific at risk subtypes will be discussed under the following headings:
Type I – The biological vulnerable gambler
Type II – The emotional vulnerable gambler
Type III – The codependent vulnerable gambler
– Type A: Aggressive type
– Type B: Passive type
Type IV – The psychosocial vulnerable gambler
The above typology can also be used as a basis to present an integrated biopsychosocial vulnerability model of problem gambling as can be seen in Figure 3.5.
TYPE I – THE BIOLOGICAL VULNERABLE GAMBLER
Type I – Biological vulnerability
(Figure 3.1) – adapted from Blaszczynski and Nower (2002).
– Biochemical impairment (dopamine, serotonin and noradrenaline deficiency) can predispose a person to problem gambling.
– Neuropsychological impairment (e.g. ADHD, impulsivity and antisocial personality disorders) can predispose a person to problem gambling.
– A genetic predisposition is also suggested by family histories of addiction.
– However, biological vulnerability is very often linked to some kind of emotional vulnerability (childhood disturbances or substance abuse – in this type without a codependent vulnerability), which necessitates exploration of both the biological and emotional vulnerabilities.
Much research has been done on the biological vulnerability of the problem gambler as presented in Figure 3.1. Although it is extremely hard to determine whether the biochemistry or brain changes precede the gambling, or occur as a result of the gambling, it still remains important to assess the gambler’s biological vulnerability, as pharmacological treatment becomes necessary in treating any underlying biological vulnerability or condition. The following is a summary of certain biological research findings as cited in Blaszczynski and Nower (2002).
Serotonergic, Noradrenergic and Dopaminergic
According to Rosenthal (2004), as cited in Blaszczynski, (2002), there are a number of studies that point toward the importance of biological and genetic factors tentatively linking receptor genes and neurotransmitter deregulation to reward deficiency, arousal, impulsivity and pathological gambling. Studies of biological markers have suggested deficits in the serotonergic (mood regulation) (serotonin receptor hyposensitivity and hypersensitivity) (Moreno, Saiz-Ruiz & Lopez-Ibor, 1991; Carrasco, Saiz-Ruiz, Hollander, Cesar & Lopez-Ibor, 1994; Blanco, Orensanz-Munoz, Blanco-Jerez & Saiz-Ruiz, 1996; DeCaria, Begaz & Hollander, 1998a), dopaminergic (reward regulation) (increased release of dopamine) (Berg, Eklund, Sodersten & Nordin, 1997) and noradrenergic (mediating arousal) (increased noradrenergic activity) (DeCaria, et al. 1998a) systems, playing a role in impulsivity, mood disorders and impaired control.
A genetic predisposition is also suggested by family histories of problem gambling (Gambino, Fitzgerald, Shaffer, Renner & Courtnage, 1993; Winters, Stinchfield & Fulkerson, 1993; Winters, Bengston, Dorr & Stinchfield, 1998), through twin studies (Eisen, et al. 1998; Slutske, et al. 2000), and genetic research (Comings, et al. 1996, Ibanez, Perez de Castro, Fernandez-Piqueras
& Saiz-Ruiz, 2000; Comings, et al. 2001). EEG (Goldstein, Manowitz, Nora, Swartzburg & Carlton, 1985) and neuro-imaging studies utilizing PET scans and MRI’s (Goyer, Semple, Rugle & McCormick, 1999; Potenza, 2001) show significant differences between pathological gamblers and normal controls. It is also emphasized that pathological gambling is not a single gene disorder, and that mutant genes are not disease-specific but rather associated with a spectrum of interrelated disorders.
In genetic studies of pathological gambling, Comings, et al. (1996) demonstrated that, compared with controls, gamblers were significantly more likely to have the A1 allele for the dopamine D2 receptor gene, which proved a significant risk factor in pathological gambling. The more severe the gambling pathology, the more likely they were to possess the abnormality. This genetic variant has also been found more often in individuals with impulse control disorders and has been associated with reduced D2 receptor density and deficits in dopaminergic reward pathways. Of note, 76.2% of pathological gamblers who were co-morbid alcohol abusers carried the gene compared to 49.1% of males without co-morbid alcohol abuse or dependency. It is hypothesized that a lack of D2 receptors cause individuals to seek pleasure-generating activities, placing them at high risk for multiple addictive, impulsive and compulsive behaviours, including substance abuse, binge eating, sex addiction and pathological gambling. The discovery of a link between the D2A1 allele and impulsive-addictive-compulsive behaviours such as pathological gambling may also have implications for pharmacological treatment. Blum, Sheridan, Wood, Braverman, Chen, Cull and Comings (1996) speculate that pharmacological sensitivity to dopaminergic agonists may be determined in part by DRD2 genotypes and that carriers of the A1 gene would be more responsive to D2 antagonists.
Since serotonin has been implicated in the regulation of impulsivity and compulsivity, noradrenaline in the mediation of arousal and novelty seeking, and dopamine in reward and reward dependency, the above findings, albeit preliminary, are of significance. Rosenthal (2004) believes that all three neurotransmitters are involved in pathological gambling, but at different stages of the gambling cycle. Thus, anticipatory arousal may be linked to the noradrenergic system, the “high” of the actual gambling episode associated with the serotonergic system, and difficulties extinguishing the behaviour under the aegis of the dopaminergic system.
It is important to take note that these deficits could be a consequence of gambling or it could point to a prior dopamine deficiency that would make people vulnerable to a gambling addiction. While prolonged use or exposure to an addictive substance or an activity like gambling may cause depletion of dopamine or other neurotransmitters, it is also possible that the deficiency occurred first and created the vulnerability for addiction. The primary deficiency could be related to genetic factors, early trauma or other environmental conditions, or another disorder such as depression (Rosenthal, 2004).
According to Blaszczynski (2002), this subgroup of pathological gamblers describes highly disturbed individuals with substantial psychosocial interference from gambling and is characterized by signs suggestive of neurological or neurochemical dysfunction. This subgroup also possesses both psychosocial and biologically based vulnerabilities. However, this group is distinguished by disorders of impulsivity and antisocial personality (Steel & Blaszczynski, 1996; Blaszczynski, et al. 1997) and attention deficit (Rugle & Melamed, 1993), manifesting in severe multiple maladaptive behaviours and impulsivity affecting many aspects of the gambler’s general level of psychosocial functioning.
Attention Deficit Hyperactivity Disorder
The hyperactive subtype of Attention Deficit Hyperactivity Disorder (ADHD) is a developmental disorder characterized by impulsivity that commences in childhood and is often found in conduct disorder and anti-social personality behaviours. Researchers have argued that there are similarities between problem gambling and children with Attention Deficit Disorder (ADD) (Goldstein, Manowitz, Nora, Swartzburg & Carlton, 1985) in that both are characterized by limited attentions spans, impulsive behaviour, inability to delay gratification and insensitivity to punishment. Petry (2001) also found a significant association between impulsivity, substance abuse and pathological gambling. Rugle and Melamed (1993) concluded that childhood differences in behaviours related to over-activity, destructibility and difficulty inhibiting conflicting behavious are of primary importance in differentiating gamblers from controls. They suggested that at least attention deficit-related symptoms reflecting traits of impulsivity are present at childhood and predate the onset of pathological gambling behaviour. This biological vulnerability weakens behavioural control not only in the domain of gambling but also in other areas of life. This gives rise to the hypothesis that impulsivity proceeds and is independent of gambling and functions as a good predictive factor for severity of involvement in at least a subgroup of gamblers. Recent psychobiological evidence suggests that such traits can be directly linked to deficiencies in the production of certain neurotransmitters thought to be associated with impulse control. One of these substances is serotonin (5-hydrotryptamine: 5-HT), which has an inhibitory effect upon the cortex and is associated with more controlled behaviour (McGurrin, 1992).
It is possible that biologically based traits of impulsivity may create a subset of gamblers who manifest differential responses to reward and punishment, characterized by a marked propensity to seek out rewarding activities, an inability to delay gratification, a dampened response to punishment and failure to modify behaviours because of adverse consequences (Blaszczynski, 2002). Kruedelbach and Rugle (1994) found gamblers to be more impulsive than cocaine addicts or alcoholics, and also found that, at least for a subgroup of pathological gamblers, high impulsivity preceded the history of gambling problems. Potenza (2001) found that the gambling urges of the problem gambler activate the same regions of the brain (e.g. the anterior cingulated) as the cocaine cravings of people with chemical dependence.
Anti-social personality disorder
According to Blaszczynski and Nower (2002), gamblers with a background history of impulsivity engage in a wider array of behavioural problems independent of their gambling, including substance abuse, suicidality, irritability, low tolerance for boredom and criminal behaviours. In an interactive process, the effect of impulsivity is aggravated under pressure and in the presence of negative emotions. These people view the world as a competitive place, they are self-confident and do not depend on others. They dislike authority and being controlled. They are impulsive and mistrustful, tend to avoid emotional engagement, lack empathy and use people for their own purpose. Poor interpersonal relationships, excessive alcohol and drug experimentation, non-gambling-related criminality and a family history of antisocial and alcohol problems are characteristics of this group. Gambling commences at an early age, rapidly escalates in intensity and severity, may occur in binge episodes and is associated with early entry into gambling-related criminal behaviour. These gamblers are less motivated to seek treatment in the first instance, have poor compliance rates and respond poorly to any form of intervention. Blaszczynski and Nower (2002) have labeled these gamblers the “antisocial impulsivist subtype”.
Thus, there are a number of studies that point toward the importance of biological factors in gambling addiction. Determining the biological vulnerability has implications for pharmacological treatment as medication can help to achieve abstinence and can help provide the much-needed structure and support necessary to maintain some patients in treatment.
TYPE II – THE EMOTIONAL VULNERABLE GAMBLER Type II – Emotional vulnerability (Figure 3.2)
– Emotional vulnerability (e.g. recent life transition event, poor self-esteem, social isolation, unproductive coping skills, life stressors, negative emotions, lack of social support) can precipitate a gambling problem. Gambling becomes a reactive method of unproductive coping with the negative emotions by producing stress relief and emotional escape through the effect of dissociation on mood alteration and narrowed attention.
– Certain personality traits (and not disorders) (e.g. impulsivity, excitement seeking, competitiveness, depressive, avoidant) can predispose a person to problem gambling.
– Emotional vulnerability (e.g. childhood disturbances, addiction) might lead to more chronic psychological disorders (e.g. depression, anti-social, impulsivity, ADHD) which can result in neurobiological impairment (without a codependent vulnerability).
According to Blaszczynski and Nower (2002, p.493), the emotional vulnerable gambler as presented in Figure 3.2 presents with pre-morbid anxiety and/or depression, poor coping and problem-solving skills and negative family background experiences, developmental variables and life events. These factors each contribute in a cumulative fashion to produce an “emotionally vulnerable gambler”, whose participation in gambling is motivated by a desire to modulate affective states and/or meet specific psychological needs.
From what I have experienced in practice with this sub-group is that gambling becomes a reactive method of distraction from everyday problems, a way of avoiding dysphoric states such as loneliness, boredom, anxiety, depression and stress. As more problems arise from gambling, dysphoric moods increase, leading to a cycle of “escaping” through gambling, with resulting financial loss and family problems and dysphoric mood. Psychological dysfunction in this subgroup of gamblers necessitates treatment that addresses the underlying vulnerabilities as well as the gambling behaviour. I would however like to add that the psychological vulnerable gambler can present with or without a codependent style. Initially these two groups might present with a similar history and symptoms which makes it hard to differentiate between these two subgroups. It might then necessitate some kind of formal measurement to establish the existence of codependency traits. It is important to differentiate between these two subgroups as it has implications for long term treatment and relapse prevention. The following is a description of the emotional vulnerable gambler without a codependent style.
Personal vulnerability and experiential factors
Jacobs (1988), in his general theory of addiction, postulated that certain personality characteristics and life events, interacting with physiological states of arousal, are instrumental in influencing the development of gambling problems. He states that excessive gambling is produced by the interaction of two sets of predisposing factors: abnormal physiological resting states of hyper- or hypo-arousal states, and a history of negative childhood experiences.
Personal vulnerability is linked to childhood experiences of inadequacy, inferiority and low self-esteem (McCormick, Taber & Kruedelbach, 1989). Research reveals disturbances during childhood related to problem gambling, such as loss of a close family member due to divorce, separation or death (Whitman-Raymond, 1988). Experiences of abandonment, rejection, emotional neglect and physical abuse have also been reported in qualitative studies (Rich, 1998; Whitman-Raymond, 1988). These findings are consistent with psychodynamic theories of gambling (Rosenthal & Rugle, 1994) and the Walters lifestyle model of gambling (Walters, 1994). Specifically, early parental deprivation and neglect while growing up and an ambivalent relationship with one’s father are frequently noted in the psychoanalytic literature as significant aspects of problem gamblers’ childhoods (Rosenthal & Rugle, 1994).
In addition to the genetic link, a child growing up in an environment where both, or one of the parents suffer from a gambling problem, there are other emotional aspects – besides codependency – which need to be taken into consideration. For example, a child’s attitude towards money begins early in life. Children of problem gamblers experience the rush of the big win when the parents come home laden with presents and good cheer. Life is good! The message is twofold: Money is to be spent and money is love. There is also little internal value placed on how money is attained. Money is, in and of itself, the goal. Money enhances our self-esteem. Money gives us satisfaction. Money is success. We know that early life experiences have a profound effect on the way that the brain constructs itself, and furthermore, that the associations between emotional states and certain experiences are deeply ingrained in the brain pathways. This leads the child to associate, often unconsciously, the experience of gambling with emotional happiness.
As is found in the lives of people with mood disorders life stress plays a contributing factor. According to Jacobs (1888) problem gambling develops out of the need to obtain relief from a stressed state, be it noxious feelings of inferiority, guilt, rejection, and/or inadequacy, recurring dysphoria/depression and chronic under stimulation, or a combination thereof. Depressed pathological gamblers experienced a significantly greater number of negative life events before the onset of their gambling compared to control subjects (Blaszczynski and Nower, 2002). Individuals who suffer from such negative affective states may turn to gambling in a reactive attempt to regulate their experiences. The intense focus and concentration on gambling may serve to push unpleasant aspects of life out of awareness so the activity allows gamblers to “self-medicate” or “dissociate” from the condition of stress. Gambling becomes a conscious reactive attempt to avoid distressing feelings. In addition, everyday life stress is an issue that both men and women have to deal with – we live extremely stressful lives. Especially here, it is important to take into consideration the changing role of women in our society. The demand to be “Superwomen”, juggling family and career, has created a whole new set of problems for women who feel that they should, but do not, measure up – resulting in exhaustion, frustration and depression. Stress is increasing for women at a rate that places stress levels above those of men (Grant, 2002) and the greater burden on women to provide care, affects the health of women rather than men. If female problem gamblers, in particular, are deliberately choosing to gamble to escape dysphoric emotions their gambling could fundamentally be seen as a form of coping, albeit a maladaptive form. The Folkman and Lazarus (1988) model of stress proposes that individuals appraise potential stressors and search for a coping strategy to reduce the threat. These strategies can range from active attempts to “solve the problem”, through to emotional responses, help-seeking or attempts to escape from the situation, either physically or mentally. Therefore, coping resources are theorized to mediate the impact of stressors (Billings & Moos, 1984), although it is clear that some strategies will be more effective than others. Avoidance or escapist coping refers to activities or cognitions used by people to divert attention away from a source of distress (Folkman & Lazarus, 1988). This method of coping is very common and can range from culturally acceptable activities such as jogging to destructive behaviours such as taking drugs or alcohol (Folkman & Lazarus, 1988). It is possible that gambling could be used in a similar way to divert attention away from a distressing issue. In this context, gambling is viewed as a reactive means of producing stress relief and emotional escape through the effect of dissociation on mood alteration and narrowed attention (Anderson & Brown, 1984).
General dissatisfaction is one of the primary ingredients of both depressive states and boredom, two important risk factors for the development of problem gambling. Therefore, it could be that those who feel that their daily life is unrewarding, troublesome, or lacking in complex and novel stimuli – that is, individuals who feel dissatisfied with their lives – are at higher risk for excessive gambling. According to a study conducted by Dickerson, Haw and Shepard (2003), with regard to psychological predictors, increased levels of harmful gambling are shown to be related to increased levels of negative emotions, such as depression, anxiety and stress. Research suggests that mood and gambling problems appear to be inextricably linked. These findings were similar to a study conducted by Bulwer (2003). Short term negative emotions correlated significantly with impaired control over gambling. Quantitative research into problem gambling interestingly revealed evidence of elevated dysphoric states, such as depression, anxiety, stress, isolation, worries, boredom and loneliness in both male and female gamblers (Blaszczynski & McConaghy, 1988; Trevorrow & Moore, 1998). There is also strong empirical evidence to suggest that social support plays an important role in alleviating personal problems and problem gambling (Dickerson, et al. 2003; Bulwer, 2003). The conclusion made is that the effect of emotional stressors on problem gambling may be moderated by certain coping tendencies.
Dickerson (2003) found that those who maintain control over their gambling use significantly less of the type of coping strategies traditionally thought of in the literature as maladaptive, than those players who do not maintain control over their gambling. People who have high levels of control over their gambling activities prefer coping strategies that deal with the problem they are facing, for example, developing a plan of action, rather than non-productive coping strategies such as self blame, abuse, escape, confrontation or avoidance. In other words, the way people deal with life events and stressors is related to the way they deal with their gambling. People who maintain control over their gambling are able to set realistic time and monetary budgets and stick to them, and also staying away from gambling venues when it is felt that time/money spent is escalating. At the other end of the control scale, those people who are unsuccessful in their attempts to stick to time limits and monetary budgets experience feelings of anger and self blame. Also, the manner in which people cope with a recent distressing or disruptive life event such as relationship problems, divorce, retirement, death or career setback, do relate to harmful gambling. Gambling may legitimize the time spent in the company of others and provide a sense of belonging, social support and group solidarity through engagement in a parallel activity with other players. Unlike committed interpersonal relations, however, this camaraderie makes no claims for intimacy, which might cause discomfort in gamblers with underdeveloped coping skills in seeking social and emotional support.
CHAPTER ONE INTRODUCTION
1.2 PERSONAL BACKGROUND
1.3 RESEARCH FINDINGS
1.4 UNDERSTANDING PROBLEM GAMBLING
1.5 OBJECTIVES OF THIS STUDY
CHAPTER TWO RESEARCH METHODOLOGY
2.1 RESEARCH METHODS
2.2 METHODOLOGICAL UNFOLDING OF THE STUDY
CHAPTER THREE PERSONAL DISPOSITION IN PROBLEM AND PATHOLOGICAL GAMBLING
3.1 PROBLEM GAMBLING AS A MULTIFACETED BEHAVIOUR
3.2 TYPE I – THE BIOLOGICAL VULNERABLE GAMBLER
3.3 TYPE II – THE EMOTIONAL VULNERABLE GAMBLER
3.4 TYPE III – THE CODEPENDENT VULNERABLE GAMBLER
3.5 TYPE IV – THE PSYCHOSOCIAL VULNERABLE GAMBLER
CHAPTER FOUR SITUATIONAL AND STRUCTURAL DETERMINANTS OF GAMBLING
4.1 SITUATIONAL DETERMINANTS OF GAMBLING
4.2 STRUCTURAL DETERMINANTS OF GAMBLING
4.3 PSYCHO-STRUCTURAL INTERACTION IN GAMBLING
CHAPTER FIVE THE CYCLE OF PROBLEM GAMBLING
5.1 THE CYCLE OF PROBLEM GAMBLING
5.2 THE WINNING/INTRODUCTORY PHASE (apparent/impaired control)
5.3 THE LOSING PHASE (poor control – problem gambling developing)
5.4 THE CHASING PHASE (loss of control – gambling problem
5.5 THE ADDICTIVE PHASE (absence of control (compulsion) –pathological gambling)
5.6 DISTORTED SENSE OF SELF
5.7 THE ESCAPE PHASE
5.8 THE DEVELOPMENT OF A DISTORTED REALITY WITH CHARACTER AND COPING
CHAPTER SIX TREATMENT CONSIDERATIONS
6.2 BIOPSYCHOSOCIAL ASSESSMENT IN TREATMENT
6.3 STAGE-CHANGE MATCHING IN THE TREATMENT OF GAMBLING ADDICTION
6.4 COMPONENTS OF TREATMENT IN PROBLEM AND PATHALOGICAL GAMBLING
CHAPTER SEVEN HENRY: A BIOLOGICAL VULNERABLE GAMBLER
7.2 HENRY’S STORY
7.3 ASSESSING HENRY’S GAMBLING PROBLEM
7.4 ANALYSIS OF HENRY’S GAMBLING PROBLEM
7.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS
7.6 MY RELATIONSHIP WITH HENRY AND ROLE AS HIS THERAPIST
CHAPTER EIGHT TINA: A PSYCHOLOGICALLY VULNERABLE GAMBLER
8.2 TINA’S STORY
8.3 ASSESSING TINA’S GAMBLING PROBLEM
8.4 ANALYSIS OF TINA’S GAMBLING ADDICTION
8.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS
8.6 TINA’S OTHER COMPULSIONS
8.7 TINA’S GAMBLING ADDICTION AS SUBSTANTIAL AND COMPELLING CIRCUMSTANCES IN HER COURT CASE
8.8 MY RELATIONSHIP WITH TINA
CHAPTER NINE SANTJIE: A PSYCHOSOCIAL VULNERABLE GAMBLER 285
9.2 SANTJIE’S STORY
9.3 ASSESSING SANTJIE’S GAMBLING PROBLEM
9.4 ANALYSIS OF SANTJIES GAMBLING ADDICTION
9.5 CLINICAL EVALUATION AND LONG TERM TREATMENT CONSIDERATIONS
9.6 MY RELATIONSHIP WITH SANTJIE AND ROLE AS HER THERAPIST
CHAPTER TEN CONCLUSION AND IMPLICATIONS
10.1 GENERAL DISCUSSION OF THE STUDY
10.2 EMERGING HYPOTHESES
10.3 STRENGHTS OF THE STUDY
10.4 LIMITATIONS OF THIS STUDY
10.5 CONCLUSION AND IMPLICATIONS FOR BEST PRACTICE
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