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Recovering from addiction is all about changing one’s behavior. Anyone who has tried to diet, quit smoking or get off the couch and exercise knows that changing behavior can be very challenging. It is especially true for individuals struggling with an addictive disorder. To assist people with changing their abuse of alcohol and drugs, specialists in addiction have developed motivational interviewing (MI), a widely disseminated clinical approach that uses a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence about changing the addictive behavior (Miller & Rose, 2009). William R. Miller, Ph.D., Emeritus Distinguished Professor of Psychology and Psychiatry at the University of Mexico, led the development and testing of the original concept.

Research has shown successful outcomes when MI is employed by alcohol and drug counselors. But what about disordered gambling?This month’sIssues & Insightswill focus on the origins of motivational interviewing, its principles and how David Hodgins, Ph.D., professor of psychology at the University of Calgary in Canada, is testing this approach with disordered gamblers.

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing.American Psychologist, 64(6), 527-537.

NCRG staffResearch Update

Recovering from addiction is all about changing one’s behavior. Anyone who has tried to diet, quit smoking or get off the couch and exercise knows that changing behavior can be very challenging. It is especially true for individuals struggling with an addictive disorder. To assist people with changing their abuse of alcohol and drugs, specialists in addiction have developed motivational interviewing (MI), a widely disseminated clinical approach that uses a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence about changing the addictive behavior (Miller & Rose, 2009). The development and testing of the original concept was led by William R. Miller, Ph.D., Emeritus Distinguished Professor of Psychology and Psychiatry at the University of Mexico.

Research has shown successful outcomes when MI is employed by alcohol and drug counselors. But what about disordered gambling? This month’sIssues & Insightswill focus on the origins of motivational interviewing, its principles and how David Hodgins, Ph.D., professor of psychology at the University of Calgary in Canada, is testing this approach with disordered gamblers.

The Origins of Motivational Interviewing

The method and research of MI emerged from a series of unexplained outcomes (Miller & Rose, 2009). As with penicillin, the early antidepressants and many other major scientific discoveries, MI was discovered by chance. Its origins illustrate Louis Pasteur’s observation that “chance favors the prepared mind.” In other words, the genius behind accidental discoveries and inventions was that the scientists were prepared and, thus, were able to capitalize on insights derived from mistakes, accidents or coincidence.

In the 1980’s, studies by Dr. Miller yielded a suprising finding: the therapists’ empathy with their clients accounted for successful outcomes in the treatment of alcohol use disorders—regardless of the type of intervention used. Based on these observations, Dr. Miller developed a conceptual framework and clinical guidelines for MI, including a focus on responding to the client’s speech “within a generally empathic person-centered style” and attention to strengthening the client’s own verbalized motivations for change. In contrast to the confrontational style of addiction counseling at the time (a image that persists today in popular culture), the counselor using MI responds empathically to the client’s expression of ambivalence. “Pushing or arguing against resistance seemed particularly counterproductive, in that it evoked further defense of the status quo. A guiding principle of MI was to have the client, rather than the counselor, voice the arguments for change” (Miller & Rose, 2009, p. 2).

Motivational interviewing is guided by five therapeutic guidelines: (a) expression of empathy (acceptance of the individual and recognition that ambivalence about change is normal), (b) development of a discrepancy between the individual’s present behavior and his or her goal and self-image, (c) avoidance of argument and confrontation, (d) rolling with resistance (looking for opportunities to reinforce accurate perceptions versus correcting misperceptions), and (e) support of the self’s ability to change (Miller & Rollnick, 2002).

Since Dr. Miller developed MI, more than 200 clinical trials on this topic have been published. These trials have yielded positive results for an array of health problems that require changes in behavior, such as cardiovascular rehabilitation, diabetes management, dietary change, hypertension, illicit drug use, infection risk reduction and management of chronic mental disorders.

MI for Gambling Problems

We are just now learning about the effectiveness of MI for gambling problems. As with other addictive disorders, individuals with gambling problems struggle with the idea of changing their gambling behavior, even when facing the dire consequences of their excessive gambling. One of Dr. Hodgins’s studies examined the language of problem gamblers in treatment with counselors using MI (Hodgins, Ching, & McEwen, 2009). He and his colleagues hypothesized that participants who expressed stronger commitment to change their gambling behavior during the MI would exhibit better gambling outcomes over 12 months than those who expressed weaker commitment or no commitment to change their gambling behavior during the MI.

The authors explained, “Client speech is the focus of the MI because verbalizing an intention to change and developing a plan to produce change lead to public and personal obligations to modify one’s behavior” (Hodgins, Ching, & McEwen, 2009, p. 122). They measured outcomes by looking at participants’ change in days gambled, dollars lost to gambling, self-confidence in their ability to change their gambling behavior, and success at meeting their treatment goals.

Dr. Hodgins and co-authors reported that the results of their analysis show good support for the initial hypothesis in that the strength of commitment expressed during the MI was predictive of a participant’s gambling outcome over the next year. But what are the practical implications?

Understanding what trends in language are related to positive outcomes allows practitioners to have an accurate perception of the progress of the MI session. Evaluating a client’s likelihood of success on the basis of the MI session allows practitioners to incorporate more or less stringent therapeutic techniques to aid a client in modifying his or her behavior. It also allows the practitioner to modify the interview protocol according to each individual client’s level of resistance and motivation while conducting the MI (Hodgins, Ching, & McEwen, 2009, p.129).

In an interview for this article, Dr. Hodgins further elaborated on the importance of MI for treating gambling problems:

Gambling problems, similar to other addictions, are essentially motivational challenges—individuals are pulled towards something that they are pushing against. There is a good side and a bad side to their gambling- motivational interviewing addresses this head on, helping the person to find the resolve to move ahead (personal communication, November 9, 2010).

MI Training for Clinicians

As Dr. Miller discovered, intensive training of clinicians is the key to the success of MI. Two early studies found that although clinicians perceived themselves to be proficient in MI, tape-recorded work samples before and after training reflected only modest changes in practice and no difference in clients’ in-session response. Extensive continuing education opportunities now exist for clinicians interested in MI. Visithttp://www.motivationalinterview.org/for more information.

The NCRG has provided new MI training programs for health care providers focused on gambling disorders. In 2009, Dr. Hodgins led a live NCRG Webinar, “Treating Pathological Gambling with Motivational Interviewing and CBT: A Webinar for Addiction Professionals.” The archived version is available on theNCRG website.

A new addition to NCRG’s continuing education offerings is a pre-conference workshop on “Motivational Interviewing for Clients with Gambling Problems,” before the start of 2010 NCRG Conference on Gambling and Addiction held on Nov. 14, 2010. For some participants it was the beginning of a long process of learning this approach and for others it contributed a new dimension to their ongoing study of MI.

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In recognition of his pioneering research on MI, brief interventions and relapse, Dr. David Hodgins was namedrecipient of the 2010 NCRG Scientific Achievement Award, presented on Nov. 15 during the NCRG Conference on Gambling and Addiction.

References

Hodgins, D.C., Ching, L.E., & McEwen, J. (2009). Strength of commitment language in Motivational Interviewing and gambling outcomes.Psychology of Addictive Behaviors, 23, 122-130.

Miller, W.R.., & Rollnick, S. (2002).Motivational interviewing: Preparing people for change(2nd ed.). New York: Guilford Press.

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing.American Psychologist, 64(6), 527-537.

Christine ReillyIssues & Insights

The11^thannual NCRG Conference on Gambling and Addictionmoved to the Las Vegas Convention Center yesterday whereGlobal Gaming Expo (G2E), the premier trade show and conference event for the international gaming entertainment industry, is currently taking place. During a session yesterday morning, a panel made up of industry operators and manufactures and a state association representative discussed ways to make the most of responsible gaming awareness weeks.

Holly Wetzel, communications director at theAmerican Gaming Association (AGA), opened the session with an overview the AGA’sResponsible Gaming Education Week (RGEW), which is held each year during the first week of August. RGEW is designed to heighten awareness of responsible gaming and disordered gambling among employees, patrons and the general public. Each year, the AGA creates materials for casinos across the country to help educate their employees and promote RGEW, and individual display promotional materials and provide both employees and customers with copies of important responsible gaming education materials.

The other panel members, Jim Baldacci, deputy chief compliance offer for Penn National Gaming, Inc.; Wes Ehrecke, CAE, president and CEO of the Iowa Gaming Association; Connie Jones, director of responsible gaming for International Game Technology; and Kelly Skindzelewski, public affairs manager for Potawatomi Bingo Casino; discussed creative, fun and cost-effective ways to participate in responsible gaming awareness weeks. Some ideas discussed during the session include:

• Form committees to develop RGEW programs so the work doesn’t fall to one person
• Get employees involved – they are the ambassadors to get the responsible gaming message out
• Create a contest – employees are more likely to get involved if they have a chance at winning a prize
• Involve a company or property’s general manager
• Work with state and local governments to getproclamationsthat emphasize a commitment to responsible gaming
• Distribute press releases about RGEW efforts
• Engage key stakeholders, including team members, community leaders, patrons, the media and the general public

Jones offered one important piece of advice: ‘Don’t just make gambling fun; keep Responsible Gaming Education Week fun!’

For more information on RGEW, visit theAGA website.

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Click below for the NCRG Blog Team interview with Sarah Nelson, Ph.D., an associate director for research at the Division on Addictions at Cambridge Health Alliance, a teaching affiliate of Harvard Medical School, and an instructor in psychiatry at Harvard Medical School. Dr. Nelson discusses internet gambling and self-exclusion.

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The11^thannual NCRG Conference on Gambling and Addictionheld a plenary session today that looked at problem gambling among diverse populations, as problem and pathological gambling prevalence rates vary between racial/ethnic groups. One of the presenters, Renee Cunningham-Williams, Ph.D., M.P.E, LCSW, associate professor at the Brown School of Social Work at Washington University in St. Louis, applauded the NCRG and the Institute for holding a session on problem gambling and diverse populations, as it isn’t a topic that is frequently presented at conferences.

Carlos Blanco, M.D., Ph.D., associate professor of clinical psychiatry at Columbia University College of Physicians & Surgeons, began the session by discussing a study titled “Disordered Gambling Among Racial and Ethnic Groups in the US: Results from the National Epidemiologic Survey on Alcohol and Related Conditions,” which was published inCNS Spectrums. This study was the first national study to focus on racial/ethnic differences in gambling disorders. Researchers investigated the prevalence and conditional prevalence of gambling disorders and compared sociodemographic and clinical characteristics among disordered gamblers from racial/ethnic groups.

The study concluded:

• Prevalence of disordered gambling differs across racial/ethnic groups.
• African-Americans and Hispanics face increased levels of socioeconomic adversity than non-Hispanic Whites.
• Despite social adversity, African-Americans and Hispanics are less likely to present substance use disorders.
• Similarities in symptom patterns, course and treatment seeking rates suggest no racial or cultural impact on the presentation of pathological gambling.

Following Dr. Blanco, Dr. Cunningham-Williams discussed the effectiveness of screening and diagnosis methods of gambling disorders for minority populations. She presented a study titled, “Racial/Ethnic Variation in the Reliability of DSM-IV Pathological Gambling Disorder,” which was published in theJournal of Nervous and Mental Disease.

The study aimed to assess racial/ethnic variation in the reliability of self-reported lifetime pathological gambling disorder. The researchers recruited 15- to 85-year-old Caucasians and African (American/other minorities) who had gambled more than five times in their lifetimes. The study participants were interviewed two times, with interview sessions held one week apart. Dr. Cunningham-Williams found that prevalence symptoms of gambling disorders tend to decrease during the second interview, and African-Americans/other minorities of mid-age or over 65 provided less reliable answers than Caucasians. When asked why there was a discrepancy, study participants stated that they misunderstood the question during the first interview, did not pay attention to the question or the interviewer miscoded the answer.

Dr. Blanco’s studyandDr. Cunningham-Williams’ studyare available online.

Continue to visitGambling Disorders 360°for daily updates, on-site reporting about the sessions and audio interviews from leading researchers and industry representatives.

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