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
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
.00
11.8
2.4
4.2
.00
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?
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