1. Exploring online problem gamblers' motivation to change
Ayna Johansen, PhD
Håvar Brendryen, Pål Helland
Edmund Henden & Dag Wennesland

2. Disclosures This project has been made possible by
the Norwegian ExtraFoundation for Health and Rehabilitation
Blue Cross Norway (part of International Blue Cross)

3. Online gambling risk
Online gambling is experienced by those who gamble as “more addictive” compared to traditional forms of gambling (Griffiths & Barnes, 2008), in part because it offers convenience, value, variety and anonymity (McCormack & Griffiths, 2012).
The anonymity comes at a price as most at-risk online gamblers go undetected by the treatment system, and puts them at risk for the most serious of negative outcomes including suicide (Wong, Kwok, Tang, Blaszczynski, & Tse, 2014).

4. Online referrals
Due to a proliferation in online gambling opportunities (Gainsbury, 2015) including media and sometimes, aggressive and personally targeted advertising, the online contexts of many at-risk and problem gamblers are currently in strong support of continued gambling.
Effective treatments for problem gambling exist (Cowlishaw et al., 2012), but with multiple routes to choose between to reach at-risk problem gamblers, more needs to be known about how to best gain access to this population.

5. Gambling as psychological addiction
The addictive cycle of gambling begins with the person's negative feelings associated with gambling losses, combined with the positive experience of the gambling activity itself, a shortage of money, and the need to keep the extent of gambling hidden from the view of others (Orford, 2013).

6. Gambling interactions
Affecting around one percent of the general population (Wardle, 2011; Pallesen, Hanss, Mentzoni, Molde, & Morken, 2014) problem gambling can cause:
Financial difficulties (Downs & Woolrych, 2010)
Crime and legal problems (Hodgins, Peden, & Cassidy, 2005)
Increased conflict within relationships (Downs & Woolrych, 2010)
Work-related problems (Holdsworth, Nuske & Hing, 2013)
Psychological distress (Lorains, Cowlishaw & Thomas, 2011)
Substance abuse problems (Welte, Barnes, Wieczorek, Tidwell, & Parker, 2004; Lorains et al., 2011)
Increased risk of suicidality (Ledgerwood & Petry, 2004; Wong et al., 2014).
These factors interact in creating a situation where individuals increase their gambling in an attempt to either escape, or increase their income (Holdsworth et al. (2013)

7. Online problems and referral
Online gambling is attractive to people with psychological problems (Hyun et al., 2015).
As few as 1 out of every 10 individuals with addictive behaviors come into contact with mental health services (Grant et al., 2004).
The majority of individuals who commit suicide due to gambling-related problems have gone undetected by the treatment system
in part because they are married, employed and have no past criminal records (Wong, Cheung, Conner, Conwell, & Yip, 2010).
We need new knowledge on how to capitalize on online and publically available materials to reach and/or motivate individuals with online problem gambling to enter treatment.

8. Broader psychosocial aspects?
While escape is recognized as the prime characteristic of problem gambling (Wood & Griffiths, 2007), the broader psychosocial aspects involved in this negative reinforcement or escape from other life problems are poorly understood (Ladouceur & Dube, 1997).
No studies to date have examined the motivation for change of problem gambling from the users’ perspectives.

9. Gambling specific motivation
The same motivational strategies may not work for every gambler.
Generally people’s motivation to gamble is considered to be “gambling specific”
Behavior driven by knowledge and interest in gambling (Clarke, 2004).
The skill element of gambling is therefore attractive to individuals who enjoy a sense of mastery (Chantal, Vallerand, Vallieres, 1994) – e.g. poker
Put off by traditional treatment approaches (Bjerg, 2010)
gambling viewed as a result of cognitive distortions (Ladouceur, Sylvain, Boutin & Doucet, 2002).
Psychologically heterogenous group, including ”subtypes” of emotionally vulnerable and depressed, or antisocial, impulsive “action seeking” individuals (Blaszczynski & Nower, 2002).

10. Aim/objective
As gambling becomes less novel, people likely adapt, as indicated by a lack of increase in prevalence despite an increase in gambling opportunities (Hodgins, Stea & Grant, 2011).
Broadly, this means different gambling specific social motivations may need to be addressed in treatment (Toneatto & Millar, 2004).
More flexible services may increase treatment-seeking and decrease treatment dropout, and research should aim to find new ways of connecting knowledge on gambling motivation with clinical programs (Hodgins, Stea & Grant, 2011).
Aim: to identify factors related to online-gamblers’ motivation for change
Objective: explore the process of becoming motivated in a sample of individuals reporting on the motivational effects of the contents showed in an online problem gambling treatment referral website.

11. Method
Qualitative study analyzed using the general inductive approach to data analysis (Van Manen, 1990).
Researchers and participants interact to describe and interpret an experience from the individual's’ point of view (Van Manen, 1990).
To identify individual and contextual circumstances of motivation we used in-depth interviews of individuals seeking treatment, and focus groups of people seeking and not seeking treatment (Lambert & Loiselle, 2008).

12. Sample
In-treatment, treatment seeking, as well as non-treatment seeking online gamblers invited to help evaluate a treatment referral website.
Purposive sample of 19 online gamblers, of which 14 participated in four focus groups, and five provided individual, in-depth interviews.
Treatment-seekers (5)
Non-treatment seekers (11)
Persons who had undergone treatment (3)
Game preferences
poker (online and/or live at underground clubs),
sports betting
online casino games (online slot machines).
Participants were male, ranging in age from years of age, with a median age of 30.5, and a mode education of 2 years of college.
14 lived with either a partner or children
6 were single and lived alone

13. Referral website
We developed a web page (“ to recruit young male gamblers for treatment
self-test
written information on gambling and problem gambling
video interviews with fictional gamblers and significant others, showing 3 men with different gambling experiences and levels of motivation for change, and 1 girlfriend who talked about how it was to live with someone in the borderline landscape of professional poker and problem gambling.
The website had around visitors during the period of the study. Although just 60 persons used the contact page to ask for help, 20 of these persons went on to attend a face to face session with a therapist in the outpatient clinic.
This represented a 30 percent increase from the gambling referrals made from the family doctor/general practitioner in a similar timeframe the year before.

15. Methodology
Focus groups: Website used as stimulus material to stimulate discussion (Punch, 2002).
Individual interviews supplied detailed descriptions of how individuals progressed from a state of low to high motivation.
guides contained open ended questions about the stimulus materials and motivation for change of gambling habits.
Emerging themes from the focus groups were explored within the interviews.
Triangulation:
methods
source
two coders to analyze

16. Analysis
Naturalistic context of producing a problem gambling referral  general inductive method
appropriate for theory building in applied fields (Lynham, 2002) and analyzing qualitative evaluation data (Thomas, 2006).
Produses a model but does not separate descriptions (themes) from explanations (processes)
limits theory building to the presentation and description of the most important categories.
This befits model building based on evaluative data because the identification of unplanned or unanticipated effects are seen as important as evaluating the expected (Thomas, 2006), and the purpose is a “goal-free” description of actual program effects.
Looked for
“change talk” e.g. expressions of desire, ability, reasons and needs for change), as well as defensiveness or ambivalence, which resolution can initiate motivation (Miller & Rollnick, 2013).
events and persons that initiated problem awareness and motivation for change, which we defined as “change talk” (

17. Results: 1. Empathising with others -
“The guilt is the worst thing about it. No doubt. To disappoint people. To disappoint Grandpa. That was terrible. Grandpa, you know! He’s had some addiction problems as well, in his younger days. And he’ll probably get the feeling that it runs in the family and stuff like that. And I don’t want it to be like that. I want to try to keep it from other people - that it is their fault. Try to put it all on myself, that is all I really want.”
Some of the participants who were not already motivated to change gambling approached the behaviour during the interviews by trying to understand what it might mean in the eyes of their concerned significant others. The process involved in some cases participants’ creating their own story about how a loved one might feel about the participants’ gambling, empathizing with the feelings of the loved one, and using the resulting empathic feeling as motivation for change. When projecting qualities onto others in the context of confronting gambling problems, participants would compare themselves with others. For example, one participant who had been coerced into treatment by his mother became motivated to change during the research interview by gaining access to a memory concerning his grandfather, not fearing loss of support, but envisioning emotionally hurting his grandfather, as well as the contents of the grandfather’s attributions of the behavior:
Unmotivated gambler, 19 years

18. “Close others whom you care about, I think it hits harder than listening to someone who is a bit like yourself... whom it is easy to distance yourself from anyhow. But a [hypothetical] girlfriend stepping on them toes may have more of an effect... if she says any of the same things that my wife complains about at home, and if she makes any other valid points... well, I think that will hit home.”
Empathizing with others for motivation was also generated by unmotivated participants who watched the intervention videos displaying the responses of a gambler’s girlfriend. The video demonstrated a young woman talking about the consequences of the gambling to her, and the video prompted the participants to start identifying her reactions and their meaning. In processing the feelings of others, it appears the gamblers would experience the same feelings as the woman talking, but nonetheless ascribing those feelings to her. In turn, they are able to integrate the girlfriend’s feelings with their own because she is a distant, and not a close other. The following quote illustrates the transitioning from external to internal motivation for change through accepting and processing the fictional girlfriend’s experiences:
Motivated gambler, father in 40s

19. 2. Dissonance
Dissonance between gambling behavior and ideal self image.
“One year ago I gambled away my entire paycheck in just… I even blew off work and just played the entire day. And then I didn’t have any money left for the whole month, so I had to lie to my parents, and it was such a blow, I knew it was a serious problem, because if you are normal, you would have a tiny bit of control and not gamble recklessly. So if you had control... a normal person would not have done such a thing.”
A main motivating factor in the decision to start treatment for the treatment-seeking participants and those already in treatment was awareness of problems related to the gambling. Dissonance would come from comparing financial-, family/relationship- problems, workplace issues, comorbid drug/alcohol-abuse, signs of gambling addiction and consequences to self image to how they felt things ought to be. Dissonance could also come from doing things one normally does not do, such as deceiving others or stealing. The greater the discrepancy between their experience of the current situation and the ideal self-image, the stronger and more unpleasant was also the feeling of guilt. One man reported that the self-image dissonance came from being able to stop once, and then relapsing – thus projecting himself as through time. He explained that while he could excuse his first mishap as “youthful stupidity”, the second one “was on him”, implying that his behavior was now in contrast to his ideal self is one of being someone who acts rationally and learns from their mistakes. Some described the problem awareness as “knowing they were at the end of their rope”, and the respondents highlighted that they did not feel normal. Oftentimes participants would experience several indicators of dissonance at the same time, as one young man who came to recognize his loss of control when he lost financial independence:
Young gambler, motivated

20. dissonance. cont.
“So I put the cards on the table and told my sister “Yes I am gambling-addicted!”. It was extremely difficult... because people talk about you... like you are stupid. And I insist -- I’m not stupid! I had to defend myself. I told her; I’m not stupid! And she said she realizes this. ‘It’s a disease.’ So she was understanding... of it being a disease, and that it’s not something I can... that I wouldn’t have done this in a clear state of mind. And it meant a lot to me, that I wasn’t judged to be stupid”
Participants could in turn respond to the emotional pain/dissonance due to the loss of control. Similar to how the same young man did; by telling another person that he had become ill, it was possible to take responsibility by acknowledging the illness, and changing his behavior:
Young gambler, motivated

21. dissonance. cont.
“I started thinking of my son... and I how much I love him. And it is no fun, having thoughts like that. So then I put all my cards on the table, for my family and my bosses. This was a very difficult acknowledgment to make. But I guess it was the easiest thing for me to do. So I’m dealing with the problem and I’ve come this far: I have told all the people who mean the most to me.”
The dissonance appeared emotionally painful, sometimes excruciating, including feelings of guilt, and a strong awareness of being personally responsible for the consequences related to the gambling. This process of non-defensive awareness included an attitude of putting one’s own comfort aside to care for the other and risking the loss of others’ regard for the sake of righting their wrongs, planning how to manage future temptations. For one man, problem acknowledgment had led him to the brink of suicide, having made an attempt less than three weeks before the interview. Undeniable consequences had made him consider the harms inflicted on his son due to his gambling behavior, and this had brought him into a depressive state, or a disillusioning, “empathic shock” that left him wanting to stay alive for his son’s sake. This also became the only honorable way out of a hopeless situation:
Motivated, father

22. dissonance. cont.
“ I am happy and stably so, when I don’t gamble. Like now, I am happy with myself. I feel like I’m a “good kid”... who controls his finances, pays bills... works out. That is the first motivation. To be quite “normal”.
Resolving dissonance and moving towards a more positive self-image was an outcome of taking responsibility for the problem, as well as a constant source of motivation. For some participants a positive identity was defined as “a person taking responsibility for having a disorder”, meaning, it was okay to admit to being gambling addicted if you were trying to change your behaviors. Maintaining a positive self-image was independent of the participants’ source of psychological pain, be it loss of money, social status, or empathy with negative implications of one's behaviour on others, and motivational stage. For the participants who had recently sought treatment, the goal was to feel good about the self by taking responsibility and experiencing a sense of mastery:
Treatment seeker, motivated

23. 2.1. Dissonance due to sports and athletics.
“It’s not easy. Some of the guys I play (soccer) with also gamble. But I have a family now. I don’t say that, but I think it’s implied, or something. I’ve signaled sufficiently that I can play with them, I just can’t gamble.”
For three of the five that had sought treatment, their motivation to change gambling included a desire to resume sports-related activities or being a sports-fan, which were behaviors that had become personally stigmatized due their associations to gambling. This desire went along with planning leisure time and social activities as part of one's recovery. For example, one man had played soccer as young, and then started betting on soccer games, beating problem gambling meant needing to find ways to partake in sports without betting:
Treatment seeker, motivated

24. 2.2. Dissonance due to gambling among family
“I have a dad with the same problem. He’s gambling addicted. There’s no doubt. And he’s a really old man now. And always, ever since I was a child I’ve thought I wasn’t going to end up like dad, because it destroys so many families, so many relationships. He’s got it hard, we have it hard. And that doesn’t feel good. But I have to admit I’ve been going down the same track. And I’m actually going down it much quicker than him… [because of internet] …. Exactly, and with my access to capital, being a broker… my dad may not be as educated or smart, so he can’t abuse it the way I do, but I work with these things, I know how to get a loan. I know what to do to get most out of the different places. So it shows I’m clever, but what an unfortunate thing that I knew how”
Gambling and problem gambling among family and concerned significant others also added to the perception of dissonance in a way that entangled their own motivations for changing with thoughts and feelings about these relationships. To proceed with their own problems, the participants also had to process the problems of their parents. Specifically, by comparing their parents’ gambling problems to their own, participants could feel they were comparing themselves “downward”. Furthermore, this could reinforce both feelings of being special and feeling hopeless. A quote from one participant, a stock-broker and the son of an immigrant who had his own gambling problems, shows how the mental image of the dad’s problems could boost his ego but simultaneously make him feel stuck:
Son of immigrant, motivated

25. Discussion: 1. Empathizing with others
Shifts in motivation for change occur in context of exploring negative effects on concerned significant close, and/or distant others. The gamblers’ were likely able to deny having these feelings until faced with either the feelings of a close or distant significant other.
Indicated by identifying projections.
Projections are primarily known as defense mechanisms (Baumeister, Dale & Sommer, 1998), where unconscious fantasies, in this case being participants negative feelings about their gambling habits, are attributed to an external object, so to get rid of aspects of one's own psyche.
Projections include the act of perceiving in other people's characteristics that you do not like in yourself (Newman, Duff & Baumeister, 1997).
Emotional core of anger, shame and guilt may be transferred to another person so that he or she starts recognizing the feelings as their own.
Defense mechanisms obstacles to treatment or facilitator of self-exploration?

26. 2. Dissonance
In the process of transitioning from external to internal motivation, we observed that motivation for change arises from negative consequences, producing a basic motivation to restore psychosocial and financial equilibrium to obtain a positive self-feeling. The dissonance between the perception of ideal and actual behaviors produced a recognition of the impulse to gamble as something bad, involving feelings of guilt and shame, as well as assessment of “not being normal”. Self-discrepancy theory is relevant to understand this process of gambling specific motivation for change, as it relates to exploring dissonance (Higgins, 1998). The theory posits that the perceived difference between actual and ideal selves produces feelings of shame, internalization, and depression, while difference between actual and ought selves, or the idea of what one should be to another person relates with feelings of guilt and agitation.

27. Subthemes: 2.1. sports and athletics
Previous positive social identities, connected to sports and athletics, were described as tarnished due to their associations with gambling problems.
problem gambling is more commonly developed in individuals who strongly identify with playing sports.
Gambling activities are commonly promoted within athletic cultures, even among fans (Nelson et al., 2007), and college athletes are about twice as likely to be problem gamblers (Rockey, Beason & Gilbert, 2002).
Although none of our participants had ever played sports professionally or in college, a majority (n=11) had been actively involved with athletics throughout high-school and later. This association to athletics means they may have had a higher exposure to gambling.
Peer exposure is generally known as an important influence on motivation to gamble (McComb & Sabiston, 2010).

28. 2.2. Intergenerational gambling
Participants described difficulties in coming to terms with their own gambling due to the fear of also stigmatizing or letting down another family member. Knowing that older family members, with whom the participants could relate and empathize, also have gambling problems, was seen as a challenge to esteem, causing dissonance.
Gambling is commonly spread within families (McComb & Sabiston, 2010), often through direct parental support.
Up to 77% of youth generally may receive scratch tickets from their parents (Felsher, Derevensky & Gupta, 2003). Likewise, the majority of problem gamblers have parents who gamble too much (Clarke, 2004).
The parental behavior suggests approval (McComb & Sabiston, 2010) and increases the chances that adolescents becoming problem gamblers (Felsher, et al., 2003).

29. Treatment implications
Most current interventions focus on eliciting the user’s thoughts and feelings regarding negative consequences due to gambling:
utilize projections for motivational purposes, for example, by soliciting users’ imagining significant others’ thoughts and feelings about their gambling habits.
Trained therapists may become aware of, and use induced projections to help patients recognize, act on, and re-attach meanings to their feelings (Johansen, Tavakoli, Bjelland & Lumley, 2015).

30. Online treatment implications
Program features displaying representations of possible mental images of interaction with “like” strangers, such as the distant, yet close girlfriend character used as exposure material in the current study, such as other gamblers who have mastered a significant gambling issue may thus offer greatest benefit when users perceive their identity as threatened.
In contrast, when its close significant others at home who are being critical, there may be an advantage of utilizing fictional characters less like themselves and more like those at home to prompt projections about problem gambling.
Build hope by providing people with stories of users’ successful disentanglement of their passion for sports and gambling.
Based on the current findings, we would expect that efforts to normalize the commonalities of inherited and intergenerational gambling problems is motivating when framed as intended to relieve psychological pain.
Future studies into the use of empathizing with others’ feelings to motivate change in eHealth behavior change programs for problem gambling need to attend to the psychosocial dimensions of helping vs. being helped, and perceived safety and social distance, so not to have a detrimental effect on outcomes (Morrison, 2015).

31. Implication: use of projections in ehealth
Research into health communication message tactics that has shown focusing on consequences directed at significant others may be more effective in motivating for change than focusing on the individual (Keller & Lehmann, 2008).
eHealth social support features likely produce greatest health benefits when users face stigma (Morrison, 2015), as is the case with problem gambling (Horch & Hodgins, 2008).
User support needs are also time sensitive (Hupcey, 1998), meaning it is possible that not all users of eHealth programs utilizing projective motivational features will benefit from the inclusion of these features.
Projections may be best placed at either at treatment onset (the “contemplation” stage of change) where one considers the pros and cons of changing (Petry, 2005).
Alternatively, used after a lapse, and/or relapse from cessation of gambling (Ledgerwood & Petry, 2006) to explore the positive motivations of sports interests and/or the desire to stay connected with significant others who also gamble, as reported by participants in our study as potential triggers of the relapse.

32. Framing: downward vs. upward comparison
Negative outcomes ensue when people are prompted to make upward” comparisons (Collins, 2002).
The direction of comparison may be less important to the individual than the underlying motivation for the comparison, however (Neighbors & Knee, 2003).
Upward comparisons can be motivating or demotivating depending on whether they are construed by the communicator of the message as contrasts or assimilations, to them.
Thus, it makes a difference whether the individual feels that the comparison with a significant other is made to criticize or help them. It is possible that shame and guilt experienced by the gambler after gaining insights into their behaviors may reduce ongoing help seeking behaviors (Gainsbury, Hing & Suhonen, 2014).
Consider if the significant other used to solicit the projection is perceived as supportive, or potentially critical of the user.
Employ support and relapse prevention strategies necessary considerations when using this technique.
The universal, human motivations including needs for independence and mastery (Deci & Ryan, 1985) make providing social support more motivating and beneficial to recovery for users, than receiving it (Pagano, Friend, Tonigan & Stout, 2004; Johansen, Brendryen, Darnell & Wennesland, 2013).
Accumulate a database of users’ elicited projections describing and thereby also normalizing difficult aspects of recovery.

33. Limitations
Small sample, using cross-sectional, qualitative interviewing as the main method. Findings may tnot generalize to individuals who gamble in all settings.
Further research into motivation for change of problem gambling furthermore needs to explore the narratives of populations not represented in this study, including females and ethnic and cultural minorities.

34. Conclusion
Personal motivations toward sports and athletics, and the potential effects of inherited gambling problems including the guilt of concerned significant others that have their own concerns about gambling or addiction may add value to current conceptualizations of motivation in problem gambling.
For assessment using surveys of readiness for change.
Current likely load onto the same construct, generating only a single dimension of motivation, where intercorrelations between the variables are moderate.
While we were unable to obtain a general review of readiness for change instruments, which are generally based on the transtheoretical change model, which is criticised as a motivational model due to its categorical nature (Wilson & Schlam, 2004).
In the alcohol motivation area one study on readiness for change instruments has already shown that surveys for alcohol change specific motivation may benefit from having added a confidence variable (Harris, Walters & Leahy, 2008).
Also, the authors of a review of eating disorder readiness for change surveys conclude that these instruments need to develop dimensional approaches in measuring motivation to change so to facilitate measurement of motivation on a continuum that has psychological relevance in order to compare these constructs with existing tools, especially in terms of their validity (Hoetzel, von Brachel, Schlossmacher & Vocks, 2013).
In a multidimensional scale, in contrast, the construct will have multiple factors and lower intercorrelations between the variables, indicating processes such as empathizing with others, and/or dissonance due to sports/athletics, which can indicate areas of growing motivation..

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