Pathological Gambling: Etiology and Treatment

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The Basics of Motivational Interviewing

• David C. Hodgins
• University of Calgary
• www.addiction.ucalgary.ca

Missouri, 2008
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All Problem/Pathological Gamblers
Ready to Change
Not Ready to Change
MATCHING FACTORS Severity? Other mental
health disorders? Social Support?
Public Awareness, Family Support, Opportunistic
interventions
Self-Change
Brief Intervention
Outpatient Intervention
Public Health Stepped Care Model
Intensive Intervention
From Hodgins, 2004
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Problem Gambling Self-recovery Program
Hodgins, Currie el-Guebaly, 2004
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• Motivational Interview Motivational Nudge
• 1. Elicit client concerns
• 2. Explore ambivalence
• 3. Promote self-efficacy
• 4. Suggest strategies

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Minimal Treatment - 24 Month
Outcome
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Clinical Classification of Outcome of
Participants at 12 and 24 Months

• 12 months 24
  months
• 
  Motivational Workbook Motivational
  Workbook
• Interview Only
  Interview Only
• Abstinent () 30 21
  36 38
• Improved () 59 57
  54 25
• Not significantly 11 21
  11 38
• improved ()
• Total N 27 28
  28 24

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Minimal Treatment Conclusions

• Results promising. Gamblers report reading the
  manual and following the strategies.
• Media recruitment is an effective way to attract
  problem gamblers not seeking treatment
  particularly women.
• Significant reduction in gambling at 24 months.
• Support for Stepped Care Model.
• Motivational enhancement helpful.

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Objectives

• Describe the spirit and principles of MI
• Develop MI strategies
• Discuss application to your work

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Case Study - Chris

• Age 25
• Self-employed sales
• Internet poker gambling
• Major debts
• Phase of life issues anxiety, depression
• Alcohol problem
• escape gambler
• Cognitive errors gambling is a solution belief

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• Plus many cognitive justifications
• I will only play a few hands
• I will limit myself to 30.
• Treatment Process Seven sessions
• Motivational enhancement
• Monitoring Success and Failures
• Functional Analyses

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Cognitive Analysis
Discussion with Dad about money 11am
Few Drinks at lunch
Ill only play 30. maybe Ill win enough to
make a payment
5 hours of play- 400.
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Motivational Interviewing Definition

• A directive, client-centred method for enhancing
  intrinsic motivation to change by exploring and
  resolving ambivalence (Miller Rollnick, 2002)
• Style versus therapy
• Client centred listening reflecting
• Focused on ambivalence
• Focused and goal-directed

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Motivational InterviewingRollnick 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

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The Hammer Metaphor

• When have only been trained to use hammers
  (direct and advise), we tend to see every risk
  behavior as a nail.
• from Mark Twain

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The Nut and Bolt Metaphor

• Hammers do not work very well with a nut (risk
  behavior) rusted to a bolt (client). Hammering
  away at patients may make things worst, and even
  damage the threads of the bolt so the nut never
  comes off.

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Coercion is not an effective strategy
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It is all about active listening
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The MI Spirit(Miller Rollnick, 2002)

• Collaborative
• Partner-like relationship
• Evocative
• Elicit (draw out) motivation rather than instill
  it
• The counselling style is quiet and eliciting
• Respectful
• Respect for individual autonomy responsibility
  for change is with client
• Client needs to be able to choose
• Client has the resources

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It is all about active listeningandResolving
ambivalence about change
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Bad habits are like a comfortable bed easy to
get into but hard to get out of.

• Anonymous

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Ambivalence Mixed feelings

• Ambivalence is regarded as a normal aspect of
  human nature common to us all
• I want to, but I dont want to
• I would feel better if I quit smoking but I might
  gain weight and feel gross.
• I want to lose weight but I hate dieting
• I want to spend time with my wife, but I am so
  busy
• Getting stuck in ambivalence can make change
  difficult

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Areas to explore to help resolve ambivalence

• Reasons for and against change
• What does the person perceive to be the outcome
  of different courses of action?
• What would happen if you.

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Ambivalence (cont)

• what does the person want? how does changing
  help them achieve or preserve what they do want?

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Components of MI
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Basic Principles of MI

• Express Empathy
• Listening versus telling
• Reflective listening
• Understanding where the client is at within the
  change process (stage)
• Develop Discrepancy

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Basic Principles (cont)

• Roll with the Resistance
• Opposite of challenge
• Goal is to evoke clients solutions
• Resistance is
• under pressure

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Basic Principles (cont)

• Support self-efficacy
• Help client believe that they can change

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Components of MI
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Phases of MI

• 1. Building Motivation to Change
• Elicit change talk
• Explore ambivalence
• 2. Strengthen the Commitment to Change
• begin planning for change

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Interaction Techniques(used throughout process
of MI)

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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Open-Ended Questions (continued)
Example 1 Would you like to quit the
slots? A more open-ended question?
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Open-Ended Questions (continued)
Example 1 Would you like to quit the
slots? How do you feelabout your slot play?
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Open-Ended Questions (continued)
Example 2 How much pot do you smoke? A more
open-ended question?
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Open-Ended Questions (continued)
Example 2 How much pot do you smoke? Would
you please tell me more about your pot smoking?
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Interaction Techniques(used throughout process
of MI)

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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Affirmations

• Support the patient/client
• Convey respect
• Convey understanding
• Encourage more progress
• Help clients/patients reveal less positive
  aspects of themselves

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Affirmations (continued)

• Examples?

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Affirmations (continued)

• You are very courageous to be so revealing about
  this.
• Youve accomplished a lot in a short time.
• I can understand why video poker feels so good
  to you.

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Interaction Techniques(used throughout process
of MI)

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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Reflective Listening

• questions phrased as statements
• Reflective listening says
• I hear you
• Im not judging you.
• This is important
• Please tell me more
• Dr. Miller with John

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Reflective Listening (continued)
Example 1 My girlfriend gets really angry when
I drink and pass out. Reflective response?
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Reflective Listening (continued)
Example 1 My girlfriend gets really angry when
I get drunk and pass out. She gets mad when
youdrink and fall asleep.
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Reflective Listening (continued)
Example 2 Im not a pleasant drunk.Ive
beaten people up badly. Reflective response?
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Reflective Listening (continued)
Example 2 Im not a pleasant drunk.Ive
beaten people up badly. Youve hurt people
whenyouve been drunk.
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Reflective Listening (continued)
Example 3 I know I shouldbe gambling
less. Reflective response?
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Reflective Listening (continued)
Example 3 I know I shouldbe gambling
less. You feel that gambling lesswould be a
good idea.
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Reflective Listening

• questions phrased as statements
• Simple Reflection
• Repeat
• Rephrase
• Paraphrase
• Reflection of feeling
• Double-sided Reflection
• Amplified Reflection

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Interaction Techniques(used throughout process
of MI)

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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Summaries

• What youve said is important.
• I value what you say.
• Here are the salient points.
• Did I hear you correctly?
• We covered that well. Now let's talk about ...

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Putting it together

• Speaker return to work or to school?
• Listener goal is understand completely
• Open-ended questions
• Affirmations
• Reflections
• Summaries

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Components of MI
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Methods in Stage One

• ELICIT CHANGE TALK
• Recognize disadvantages of status quo
• Recognize advantages of change
• Express optimism about change
• Expressing intention to change
• Change talk predicts actual change
• We talk ourselves into change We believe what we
  say - cognitive dissonance, self-perception theory

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Nine Strategies for Evoking Change Talk

• Asking open questions
• Ask for elaboration
• Ask for examples
• Looking back before the problem
• Looking forward
• Query extremes
• Decisional balance - Good Things and Less Good
  Things

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Decisional Balance Pros and Cons
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More Strategies

• Use Change rulers
• Explore goals and values
• What do you want in life?

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Importance Confidence Rulers

• How important is it to.. on a scale of 1 to 10?
• How confident are you that..?
• What would it take to be a 10?
• How come you are not at zero?

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Responding to change talk

• Just dont sit there
• Reflect it
• Ask for elaboration
• Ask for more
• Affirm
• Summarize
• Respond to even weak talk

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Phase two Committing to a Change Plan

• Dont rush into it. Listen to clients language,
  let client take the lead but provide direction.
• Set goals, discuss options, develop plan
• T So from what you have said, you are thinking
  that you need to quit gambling. That makes a lot
  of sense. Do you feel committed to do this?
  (commends abstinence and confirms readiness)

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Phase 2 Tasks

• Discussing a plan
• Draw from client
• Communicate free choice
• Consequences of action and inaction
• Information and advice
• Playing hard to get
• Ask permission
• Dealing with resistance

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What is Resistance?

• People with 2 wills meeting
• Prochaska client is in precontemplation and
  your are in action
• Feeling of irritation for the therapist
• Absence of a collaborative relationship

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How do you recognize Resistance?

• Arguing / Bickering
• Ignoring / tuning out / not paying attention
• Overt opposition

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Rolling With Resistance

• Do not meet it head on. I dont want to quit
• Simple reflection So you dont want to quit
• Reflection with amplification In fact, you may
  not be able to quit
• Double-sided reflection On the one hand,

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Rolling With Resistance

• Do not meet it head on. I dont want to quit
• Shifting focus I think you are jumping the gun
  to say you have to quit. Lets talk about
• Emphasizing personal control
• Gentle paradox What I hear you saying is that
  even though there are some negatives, the
  positives still outweigh them.

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Gambling Example

• Group A Identify Examples of Elicting Change
  Talk
• Group B- Identify OARS
• Every one Areas for improvement

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Checklists

• Change Talk
• Asking open questions
• Ask for elaboration
• Ask for examples
• Looking back
• Looking forward
• Query extremes
• Decisional balance
• Use Change rulers
• Explore goals and values

• Open ended questions
• Affirmations
• Reflective Listening
• Simple reflection
• Amplified reflection
• Double sided reflection
• Summaries

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But skill development requires practice and
feedback