Motivational Enhancement Therapy Talking About Gambling… It’s simple, but not easy A GRI Gambling Research Conference 2007 New Developments in Treatment NetworkCentre

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

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

Motivational Interviewing Rollnick & 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

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

Principles of MI  Express empathy  Support self efficacy  Develop discrepancy  Explore ambivalence

Interaction Techniques OARS  Open ended questions  Affirmations  Reflective Listening –Simple reflection –Amplified reflection –Double sided reflection  Summaries

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

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?

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

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

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

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

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)

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

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

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

Global Distress

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

Adherence MI Elements MIAC t (18) p Summaries Reflections Self motivation Agree with change

Therapist Effects (N = 81) 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

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

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.

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

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

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?

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.

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

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