Motivational Enhancement Therapy Talking About Gambling Its simple, but not easy

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Motivational Enhancement TherapyTalking About
Gambling Its simple, but not easy

• AGRI Gambling Research Conference 2007
• New Developments in Treatment

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Current Therapeutic Approaches in Gambling
Treatment

• Bibliotherapy
• Gambling help lines
• Self help groups
• Brief interventions
• Behavioural interventions
• Psychopharmacology
• Cognitive behavioural interventions
• Inpatient treatment

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Motivational Interviewing Definition

• A directive, client-centred method for enhancing
  intrinsic motivation to change by exploring and
  resolving ambivalence (Miller Rollnick, 2002)
• Focused and goal-directed
• Accepting of ambivalence
• Style versus therapy

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Motivational InterviewingRollnick Miller 1995

• Readiness to change is not a client trait, but a
  fluctuating product of interpersonal interaction
• Motivation to change is elicited from the client,
  not imposed by others
• Direct persuasion is not an effective method for
  resolving ambivalence

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Spirit of Motivational Interviewing(Miller
Rollnick, 2002)

• Collaboration
• Partner-like relationship
• Evocation
• Elicit (draw out) motivation rather than instill
  it
• Autonomy
• Respect for individual autonomy responsibility
  for change is with client

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Principles of MI

• Express empathy
• Support self efficacy
• Develop discrepancy
• Explore ambivalence

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Interaction TechniquesOARS

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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RCT Design and Flow Chart(Diskin Hodgins)

• Initial Telephone Contact and Recruitment
• Urn Randomization to AC or MI condition
• Face to face interview self help manual 20.00
  Grocery Gift Certificate
• 1 month Telephone Interview
• 3 Month Telephone Interview
• 6 Month Telephone Interview
• 6 month collateral informant interview
• 12 Month Telephone Interview
• Mail 30.00 Grocery Gift Certificate

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Motivational Intervention

• Good and not so good things about gambling
• Personalized normative feedback
• GRTQ questions and discussion of stage of change
  model
• Written decisional balance
• Self efficacy
• Values exploration future with and without
  gambling
• Readiness ruler motivation and confidence
• Possible alternatives what would change look
  like?

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Attention Control Intervention

• Discussion of gambling history
• SCID II semi structured interviews for avoidant,
  narcissistic, obsessive compulsive and histrionic
  personality disorders
• Structured interviews used to maintain
  consistency participants encouraged to speak
  about their perceptions/concerns
• Discussion of gambling policy

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Follow Up

• One month 97.5, 3 months 93.8, 6 months 91.4,
  12 months 85.2
• 12 participants lost to follow up
• 9 AC, 3 MI
• 2 females, 10 males

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Sample and Recruitment

• Inclusion criteria
• Over 17
• Not in treatment
• Score of gt 3 on CPGI
• Gambled in previous 2 months
• Willing to participate in follow up
• Willing to provide collateral informant
• 136 calls to study
• 97 participants randomized and given
  appointments
• 83 attended interviews
• 81 data analyzed

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Sample (N 81)MI (n 42) AC (n 39)

• AC and MI groups did not differ significantly on
  any demographic or gambling related variables
• Age
• Gender
• Income
• Gambling measures (SOGS, NODS, CPGI)
• Amount spent gambling, days spent gambling,
  dollars/day
• GSI, DAST, PHQ alcohol and depression

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Primary Hypothesis

• Participants who received a motivational
  intervention would gamble less than participants
  who received an attention control intervention
• Primary Outcome Variables Mean Dollars
  Gambled/Month, Mean Days Gambled/Month, (
  averaged over 3 months)
• Linear Mixed Model Random Regression using data
  for 2 months preceding intervention as covariates
• Results for intent to treat sample (N 81)

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Mean Dollars Gambled/MonthMain Effect of
Intervention F (1,76) 5.55, p .02
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Time by Intervention Interaction for Days
Gambled/Month F (2,72) 3.46, p .04
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Intervention by Severity for Dollars/MonthF
(1,75) 3.81, p .055
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Global Distress
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Collaterals

• Collaterals were asked to supply estimates of
  days and dollars gambled for the 2 months
  preceding the 6 month interview
• These were compared with gamblers self reports
  for the same period
• Good correlation for estimates of days gambled
  ICC (34) .65, p.001, less for dollars gambled
  ICC (33) .32, p .1)
• If collaterals were extremely confident days
  gambled ICC (22) .75, p .002, dollars gambled
  ICC (19) .58, p .03

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Adherence
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Therapist Effects (N 81)

• No significant difference on outcome variables
• No difference in drop out rates
• No between group difference on therapist ratings
  of warmth, trustworthiness, sympathy,
  respectfulness and understanding

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Interview Evaluation immediately post
intervention ( N 81)

• MI group rated interview higher than AC group on
  the following statements
• I was able to discuss problems
• We worked on them effectively
• The approach made sense
• The session was helpful
• I was satisfied with the session

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Exploratory Results ( n 69 )

• Over the 12 month period MI participants rated
  themselves higher on motivation to change,
  confidence they could change, success in changing
• No significant between group differences on
  treatment seeking
• 2/3 of MI participants who received feedback
  remembered it, 1/3 did not.

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Study Limitations

• Heterogeneous sample
• Financial incentive
• Between group difference on time spent on AC and
  MI interviews
• Use of self reports for gambling behaviour
• All participants received self help manual

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Conclusions

• When compared to a group of gamblers who received
  an attention control intervention, participants
  who received a single session motivational
  intervention reduced the days and dollars they
  spent gambling over the following 12 month
  period.
• Participants in the MI condition reported reduced
  levels of distress and more motivation to change
  their gambling behaviour

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Future Research

• Can MI techniques for the treatment of problem
  gambling be adopted in non-research environments?
  
• Implications regarding severity how can we find
  out what was so helpful to participants with more
  severe problems?

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What is it about MI that helps promote change?

• Amrhein et al. (2003) The elements involved in
  generating commitment strength included
  expressions of a desire for change, ability to
  change, need for change, and reasons to change.
  the researchers found that it was only the actual
  strength of commitment language that was
  predictive of a reduction in drug use.

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Client change language in telephone MI for
problem gambling (Ching Hodgins)

• Extensive analysis of 20 telephone motivational
  interviews from Hodgins et al
• Seven categories of language were used
  commitment, reasons, ability, desire, need,
  readiness, and action
• Found that strength and frequency of commitment
  language was predictive of gambling outcome at 6
  weeks

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Acknowledgements

• Effectiveness of a Single Session Motivational
  Intervention on Problem Gambling Behaviour was
  funded by the Alberta Gaming Research Institute
• Supervisor and Co Investigator Dr. David
  Hodgins
• Co- therapist Dr. Maria Lizak
• Research Assistants Steven Skitch, Erin
  Cassiday, Kristen Moulton
• 83 research participants