Motivational Enhancement Therapy Talking About Gambling… It’s simple, but not easy

1. Addiction Centre Network Motivational Enhancement TherapyTalking About Gambling… It’s simple, but not easy AGRI Gambling Research Conference 2007 New Developments in Treatment

2. Current Therapeutic Approaches in Gambling Treatment • Bibliotherapy • Gambling help lines • Self help groups • Brief interventions • Behavioural interventions • Psychopharmacology • Cognitive behavioural interventions • Inpatient treatment

3. 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

4. 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

5. 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

6. Principles of MI • Express empathy • Support self efficacy • Develop discrepancy • Explore ambivalence

7. Interaction TechniquesOARS • Open ended questions • Affirmations • Reflective Listening • Simple reflection • Amplified reflection • Double sided reflection • Summaries

8. 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

9. 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?

10. 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

11. 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

12. Sample and Recruitment • Inclusion criteria: • Over 17 • Not in treatment • Score of >= 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

13. 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

14. 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)

15. Mean Dollars Gambled/MonthMain Effect of Intervention F (1,76) = 5.55, p = .02

16. Time by Intervention Interaction for Days Gambled/Month F (2,72) = 3.46, p = .04

17. Intervention by Severity for Dollars/MonthF (1,75) = 3.81, p = .055

18. Global Distress

19. 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

20. Adherence

21. 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

22. 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

23. 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.

24. 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

25. 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

26. 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? Future Research

27. 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.

28. 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

29. 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