Motivational Enhancement Motivational Enhancement TherapyTherapy

Talking About Gambling… Talking About Gambling… It’s simple, but not easyIt’s simple, but not easy

AAGRI Gambling Research Conference GRI Gambling Research Conference 20072007

New Developments in TreatmentNew Developments in Treatment

Network Centre

Current Therapeutic Approaches in Current Therapeutic Approaches in Gambling TreatmentGambling Treatment

BibliotherapyBibliotherapy Gambling help linesGambling help lines Self help groupsSelf help groups Brief interventionsBrief interventions Behavioural interventionsBehavioural interventions PsychopharmacologyPsychopharmacology Cognitive behavioural interventionsCognitive behavioural interventions Inpatient treatmentInpatient treatment

Motivational InterviewingMotivational Interviewing Definition Definition

A directive, client-centred method for A directive, client-centred method for enhancing intrinsic motivation to change by enhancing intrinsic motivation to change by exploring and resolving ambivalence exploring and resolving ambivalence (Miller & (Miller & Rollnick, 2002)Rollnick, 2002)

Focused and goal-directedFocused and goal-directed Accepting of ambivalenceAccepting of ambivalence Style versus therapyStyle versus therapy

Motivational InterviewingMotivational InterviewingRollnick & Miller 1995Rollnick & Miller 1995

Readiness to change is not a client trait, but Readiness to change is not a client trait, but a fluctuating product of interpersonal a fluctuating product of interpersonal interactioninteraction

Motivation to change is elicited from the Motivation to change is elicited from the client, not imposed by othersclient, not imposed by others

Direct persuasion is not an effective method Direct persuasion is not an effective method for resolving ambivalencefor resolving ambivalence

Spirit of Motivational InterviewingSpirit of Motivational Interviewing(Miller & Rollnick, 2002)(Miller & Rollnick, 2002)

CollaborationCollaboration– Partner-like relationshipPartner-like relationship

EvocationEvocation– Elicit (draw out) motivation rather than instill itElicit (draw out) motivation rather than instill it

AutonomyAutonomy– Respect for individual autonomy – responsibility Respect for individual autonomy – responsibility

for change is with clientfor change is with client

Principles of MIPrinciples of MI

Express empathyExpress empathy Support self efficacySupport self efficacy Develop discrepancyDevelop discrepancy Explore ambivalenceExplore ambivalence

Interaction TechniquesInteraction TechniquesOARSOARS

OOpen ended questionspen ended questions AAffirmationsffirmations RReflective Listeningeflective Listening

– Simple reflectionSimple reflection– Amplified reflectionAmplified reflection– Double sided reflectionDouble sided reflection

SSummariesummaries

RCT Design and Flow ChartRCT Design and Flow Chart(Diskin & Hodgins)(Diskin & Hodgins)

Initial Telephone Contact and RecruitmentInitial Telephone Contact and RecruitmentUrn Randomization to AC or MI conditionUrn Randomization to AC or MI condition

Face to face interview + self help manual +$20.00 Grocery Face to face interview + self help manual +$20.00 Grocery Gift CertificateGift Certificate

1 month Telephone Interview1 month Telephone Interview3 Month Telephone Interview3 Month Telephone Interview6 Month Telephone Interview6 Month Telephone Interview

6 month – collateral informant interview6 month – collateral informant interview12 Month Telephone Interview 12 Month Telephone Interview

Mail $30.00 Grocery Gift CertificateMail $30.00 Grocery Gift Certificate

Motivational InterventionMotivational Intervention

Good and not so good things about gamblingGood and not so good things about gambling Personalized normative feedbackPersonalized normative feedback GRTQ questions and discussion of stage of GRTQ questions and discussion of stage of

change modelchange model Written decisional balanceWritten decisional balance Self efficacySelf efficacy Values exploration – future with and without Values exploration – future with and without

gamblinggambling Readiness ruler – motivation and confidenceReadiness ruler – motivation and confidence Possible alternatives – what would change look Possible alternatives – what would change look

like?like?

Attention Control InterventionAttention Control Intervention

Discussion of gambling historyDiscussion of gambling history SCID II semi structured interviews for SCID II semi structured interviews for

avoidant, narcissistic, obsessive compulsive avoidant, narcissistic, obsessive compulsive and histrionic personality disorders and histrionic personality disorders – Structured interviews used to maintain Structured interviews used to maintain

consistency – participants encouraged to speak consistency – participants encouraged to speak about their perceptions/concernsabout their perceptions/concerns

Discussion of gambling policyDiscussion of gambling policy

Follow UpFollow Up

One month 97.5%, 3 months 93.8%, 6 One month 97.5%, 3 months 93.8%, 6 months 91.4%, 12 months 85.2%months 91.4%, 12 months 85.2%

12 participants lost to follow up 12 participants lost to follow up – 9 AC, 3 MI 9 AC, 3 MI – 2 females, 10 males2 females, 10 males

Sample and RecruitmentSample and Recruitment

Inclusion criteria: Inclusion criteria: – Over 17Over 17– Not in treatmentNot in treatment– Score of >= 3 on CPGIScore of >= 3 on CPGI– Gambled in previous 2 monthsGambled in previous 2 months– Willing to participate in follow upWilling to participate in follow up– Willing to provide collateral informantWilling to provide collateral informant

136 calls to study136 calls to study97 participants randomized and given appointments97 participants randomized and given appointments83 attended interviews83 attended interviews81 data analyzed81 data analyzed

Sample (Sample (NN = 81) = 81)MI (MI (nn = 42) AC ( = 42) AC (nn =39) =39)

AC and MI groups did not differ significantly on AC and MI groups did not differ significantly on any demographic or gambling related variablesany demographic or gambling related variables– AgeAge– GenderGender– IncomeIncome– Gambling measures (SOGS, NODS, CPGI)Gambling measures (SOGS, NODS, CPGI)– Amount spent gambling, days spent gambling, Amount spent gambling, days spent gambling,

dollars/daydollars/day– GSI, DAST, PHQ alcohol and depressionGSI, DAST, PHQ alcohol and depression

Primary HypothesisPrimary Hypothesis

Participants who received a motivational Participants who received a motivational intervention would gamble less than participants intervention would gamble less than participants who received an attention control interventionwho received an attention control intervention

Primary Outcome Variables – Mean Dollars Primary Outcome Variables – Mean Dollars Gambled/Month, Mean Days Gambled/Month, Gambled/Month, Mean Days Gambled/Month, ( averaged over 3 months)( averaged over 3 months)

Linear Mixed Model Random Regression using Linear Mixed Model Random Regression using data for 2 months preceding intervention as data for 2 months preceding intervention as covariatescovariates

Results for intent to treat sample (Results for intent to treat sample (NN = 81) = 81)

Mean Dollars Gambled/MonthMean Dollars Gambled/MonthMain Effect of Intervention Main Effect of Intervention

FF (1,76) = 5.55, (1,76) = 5.55, pp = .02 = .02

02 0 04 0 06 0 08 0 0

1 0 0 01 2 0 01 4 0 01 6 0 0

2 m o n th sp r i o r

3 m o n th s 6 m o n th s 1 2 m o n th s

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Time by Intervention Interaction for Time by Intervention Interaction for Days Gambled/Month Days Gambled/Month FF (2,72) = 3.46, (2,72) = 3.46, pp = .04 = .04

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2 m o n th sp r i o r

3 m o n th s 6 m o n th s 1 2 m o n th s

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ys

/Mo

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Intervention by Severity for Intervention by Severity for Dollars/MonthDollars/Month

FF (1,75) = 3.81, (1,75) = 3.81, pp = .055 = .055

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Global DistressGlobal Distress

T i m e b y I n t e r v e n t i o n I n t e r a c t i o n f o r B S I s c o r e s

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CollateralsCollaterals

Collaterals were asked to supply estimates of days and Collaterals were asked to supply estimates of days and dollars gambled for the 2 months preceding the 6 month dollars gambled for the 2 months preceding the 6 month interviewinterview

These were compared with gamblers’ self reports for the These were compared with gamblers’ self reports for the same periodsame period

Good correlation for estimates of days gambled Good correlation for estimates of days gambled ICC ICC (34)(34) = = .65, .65, pp=.001, less for dollars gambled =.001, less for dollars gambled ICCICC (33) (33) = .32, = .32, p p = .1)= .1)

If collaterals were “extremely confident” days gambled If collaterals were “extremely confident” days gambled ICC ICC (22) = .75, (22) = .75, pp = .002, dollars gambled = .002, dollars gambled ICCICC (19) = .58, (19) = .58, pp = .03 = .03

AdherenceAdherence

MI ElementsMI Elements MIMI ACAC t t (18)(18) pp

SummariesSummaries 5.55.5 00 8.48.4 .00.00

ReflectionsReflections 37.137.1 11.711.7 5.75.7 .00.00

Self Self motivationmotivation

27.627.6 3.33.3 10.910.9 .00.00

Agree with Agree with changechange

11.811.8 2.42.4 4.24.2 .00.00

Therapist Effects Therapist Effects ((NN = 81) = 81)

No significant difference on outcome No significant difference on outcome variablesvariables

No difference in drop out ratesNo difference in drop out rates No between group difference on therapist No between group difference on therapist

ratings of warmth, trustworthiness, ratings of warmth, trustworthiness, sympathy, respectfulness and sympathy, respectfulness and understandingunderstanding

Interview Evaluation immediately Interview Evaluation immediately post intervention ( post intervention ( NN = 81) = 81)

MI group rated interview higher than AC MI group rated interview higher than AC group on the following statements group on the following statements

I was able to discuss problemsI was able to discuss problems We worked on them effectively We worked on them effectively The approach made sense The approach made sense The session was helpfulThe session was helpful I was satisfied with the sessionI was satisfied with the session

Exploratory Results Exploratory Results ( ( nn = 69 ) = 69 )

Over the 12 month period MI participants Over the 12 month period MI participants rated themselves higher on motivation to rated themselves higher on motivation to change, confidence they could change, change, confidence they could change, success in changingsuccess in changing

No significant between group differences on No significant between group differences on treatment seekingtreatment seeking

2/3 of MI participants who received 2/3 of MI participants who received feedback remembered it, 1/3 did not. feedback remembered it, 1/3 did not.

Study LimitationsStudy Limitations

Heterogeneous sampleHeterogeneous sample Financial incentiveFinancial incentive Between group difference on time spent on Between group difference on time spent on

AC and MI interviewsAC and MI interviews Use of self reports for gambling behaviourUse of self reports for gambling behaviour All participants received self help manualAll participants received self help manual

ConclusionsConclusions

When compared to a group of gamblers who When compared to a group of gamblers who received an attention control intervention, received an attention control intervention, participants who received a single session participants who received a single session motivational intervention reduced the days and motivational intervention reduced the days and dollars they spent gambling over the following 12 dollars they spent gambling over the following 12 month period.month period.

Participants in the MI condition reported reduced Participants in the MI condition reported reduced levels of distress and more motivation to change levels of distress and more motivation to change their gambling behaviourtheir gambling behaviour

Future ResearchFuture Research

Can MI techniques for the treatment of problem gambling Can MI techniques for the treatment of problem gambling be adopted in non-research environments? be adopted in non-research environments?

Implications regarding severity – how can we find out what Implications regarding severity – how can we find out what was so helpful to participants with more severe problems?was so helpful to participants with more severe problems?

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What is it about MI that helps What is it about MI that helps promote change?promote change?

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

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

Extensive analysis of 20 telephone Extensive analysis of 20 telephone motivational interviews from Hodgins et almotivational interviews from Hodgins et al

Seven categories of language were used: Seven categories of language were used: commitment, reasons, ability, desire, need, commitment, reasons, ability, desire, need, readiness, and actionreadiness, and action

Found that strength and frequency of Found that strength and frequency of commitment language was predictive of commitment language was predictive of gambling outcome at 6 weeksgambling outcome at 6 weeks

AcknowledgementsAcknowledgements

““Effectiveness of a Single Session Motivational Effectiveness of a Single Session Motivational Intervention on Problem Gambling Behaviour” was Intervention on Problem Gambling Behaviour” was funded by the Alberta Gaming Research Institutefunded by the Alberta Gaming Research Institute

Supervisor and Co Investigator – Dr. David Supervisor and Co Investigator – Dr. David HodginsHodgins

Co- therapist – Dr. Maria LizakCo- therapist – Dr. Maria Lizak Research Assistants – Steven Skitch, Erin Research Assistants – Steven Skitch, Erin

Cassiday, Kristen MoultonCassiday, Kristen Moulton 83 research participants83 research participants