Transcript Diskin.ppt

Motivational Enhancement
Therapy
Talking About Gambling…
It’s simple, but not easy
AGRI Gambling Research Conference
2007
New Developments in Treatment
Centre
Network
Current Therapeutic Approaches in
Gambling Treatment
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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:
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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
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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
Dollars/Month
Main Effect of Intervention
F (1,76) = 5.55, p = .02
1600
1400
1200
1000
800
600
400
200
0
AC
MI
2 months
prior
3 months
6 months 12 months
Time
Time by Intervention Interaction for
Days Gambled/Month
Days/Month
F (2,72) = 3.46, p = .04
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8
7
6
5
4
3
2
1
0
AC
MI
2 months
prior
3 months
6 months
Time
12 months
Intervention by Severity for
Dollars/Month
Mean Dollars Gambled
F (1,75) = 3.81, p = .055
1000
800
600
High Severity
Low Severity
400
200
0
AC
MI
Condition
Global Distress
BSI Score
Time by Intervention Interaction for
BSI scores
1
0.8
0.6
0.4
0.2
0
AC
MI
Pre intervention
Time
12 Months
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
MI
AC
t (18)
p
Summaries
5.5
0
8.4
.00
Reflections
37.1
11.7
5.7
.00
Self
motivation
Agree with
change
27.6
3.3
10.9
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11.8
2.4
4.2
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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
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
Mean Dollars Gambled
 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?
1000
800
600
High Severity
Low Severity
400
200
0
AC
MI
Condition
What is it about MI that helps
promote change?
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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