What gets in the way of going to What gets in the way of going to treatment? Barriers to care and treatment? Barriers to care and

strategies for breaking them strategies for breaking them downdown

David M. Ledgerwood, Ph.D.David M. Ledgerwood, Ph.D.

Department of Psychiatry and Behavioral Department of Psychiatry and Behavioral NeurosciencesNeurosciences

Wayne State University Wayne State University

dledgerw@med.wayne.edudledgerw@med.wayne.edu

OutlineOutline

Who goes to treatment?Who goes to treatment? What can we learn from people who What can we learn from people who

make initial contact? Lessons from make initial contact? Lessons from the helpline.the helpline.

Can we actually reach non-treatment Can we actually reach non-treatment seeking problem gamblers?seeking problem gamblers?– OutreachOutreach

ObjectivesObjectives

Understand specific factors that Understand specific factors that predict treatment engagement and predict treatment engagement and client-reported barriers to treatmentclient-reported barriers to treatment

Aware of new research into Aware of new research into evidence-based strategies for evidence-based strategies for enhancing outreach for problem enhancing outreach for problem gamblersgamblers

Strategies to enhance engagementStrategies to enhance engagement

Who Goes to Who Goes to Treatment?Treatment?

Disordered GamblingDisordered Gambling

Disordered gambling (inclusive of Disordered gambling (inclusive of problem and pathological gambling) problem and pathological gambling) affects 3% to 5% of the general affects 3% to 5% of the general population.population.

Despite the large numbers and adverse Despite the large numbers and adverse consequences of disordered gambling, consequences of disordered gambling, fewer than 10% of pathological fewer than 10% of pathological gamblers ever seek or receive services gamblers ever seek or receive services (Slutske, 2006; National Research (Slutske, 2006; National Research Council, 1999). Council, 1999).

Lessons from the State of Lessons from the State of Michigan/NSO Help-lineMichigan/NSO Help-line

What can we learn What can we learn from people who do from people who do

and don’t make initial and don’t make initial contact?contact?

Study Aims

We sought to understand the characteristics of problem gamblers calling the Michigan Problem Gambling Help-line. Our study aims were:

1) Determine the socio-economic and legal consequences of problem gambling among callers to the Michigan Problem Gambling Help-line;

 2) Document the proportion of people seeking help

from the gambling Help-line who did not enter formal treatment and the perceived and actual barriers they encountered.

 

Study Aims

We sought to understand the characteristics of problem gamblers calling the Michigan Problem Gambling Help-line. Our study aims were:

1) Determine the socio-economic and legal consequences of problem gambling among callers to the Michigan Problem Gambling Help-line;

 2) Document the proportion of people seeking help

from the gambling Help-line who did not enter formal treatment and the perceived and actual barriers they encountered.

 

Demographic and gambling characteristics of helpline callers who did vs. did not attend treatment.

Ledgerwood et al., In Press, American Journal on Addictions

Demographic and gambling characteristics of helpline callers who did vs. did not attend treatment.

Ledgerwood et al., In Press, American Journal on Addictions

What did they think of the helpline call?

Asked 3 Questions, on a scale of 1 to 10– …how helpful was the counseling you

received from the helpline?– …rate the extent to which the counseling

you received was enough (i.e., that you didn’t need any more counseling for your gambling problems).

– …how likely are you to follow up on the treatment referral you received from the helpline?

Experience of help-line callers predicting Experience of help-line callers predicting treatment engagementtreatment engagement

Ledgerwood et al., In Press, American Journal on Addictions

Multivariate Logistic Multivariate Logistic RegressionRegression

Ledgerwood et al., In Press, American Journal on Addictions

What did and didn’t predict?What did and didn’t predict?

Did predictDid predict– Gambling SeverityGambling Severity– Gambling DebtGambling Debt– Motivation to ChangeMotivation to Change– FinancialFinancial– Past Treatment for Past Treatment for

GamblingGambling– Finding the Help-line Finding the Help-line

HelpfulHelpful– Intent to go to Intent to go to

TreatmentTreatment– Spousal ConflictSpousal Conflict

Did not predictDid not predict– DemographicsDemographics– Age of gamblingAge of gambling– PsychiatricPsychiatric– Substance AbuseSubstance Abuse– Family/SocialFamily/Social– Family of OriginFamily of Origin– Non-Gambling Non-Gambling

TreatmentTreatment– Most LegalMost Legal

Barriers to TreatmentBarriers to Treatment

Most frequently reported barriers to treatment

Asked participants to answer the following question:– Whether or not you followed up on your

treatment referral, what factors made it less likely that you would seek treatment for your gambling problems? (e.g., factors that made it difficult or that turned you off of treatment)

Most Prominent Differences

Callers who do not go to treatment:– Don’t believe they have a problem or

feel they can handle it on their own.– Don’t want to stop gambling.– Report not being ready for treatment.

Most frequently reported reasons for going to treatment

Asked participants to answer the following question:– What factors made it more likely that

you would seek treatment for your gambling problems? (e.g., factors that made seeking treatment easier or that made treatment more appealing)

What are the implications?

Motivation for changing problem gambling behaviors is very important

Participants mostly knew that they were unlikely to follow through on their referral – Interventions that address motivation (e.g.,

Motivational Interviewing) can be used to improve the chances a problem gambler will attend treatment

– Telephone counselors at the helpline can be trained to do these interviews

What are the implications?

Treatment barriers are also very important in understanding treatment non-compliance– Availability, Cost, Stigma and Uncertainty

differ between gamblers who do and don’t seek treatment

– Interventions can address the ambivalence

– In some cases, treatment providers may be a distance away

What are the implications?

Those who went to treatment saw treatment as believe that they had a significant gambling problem, saw treatment as a potentially effective alternative, believed therapy to be a supportive/non-judgmental environment, and appreciated the opportunity to discuss their problems with others

What can be done?What can be done?

Determine reasons why people don’t seek Determine reasons why people don’t seek services. services.

Expand outreach. Expand outreach. Expand treatment services.Expand treatment services. Tailor interventions to fit the needs of the Tailor interventions to fit the needs of the

patients who would be most likely to patients who would be most likely to benefit from them.benefit from them.

What can be done?What can be done?

Determine reasons why people don’t seek Determine reasons why people don’t seek services. services.

Expand outreachExpand outreach. . Expand treatment services.Expand treatment services. Tailor interventions to fit the needs of the Tailor interventions to fit the needs of the

patients who would be most likely to patients who would be most likely to benefit from them.benefit from them.

What are the implications?

To engage problem gamblers, we need ways to improve motivation and awareness

Possible ways to engage Possible ways to engage gamblers…gamblers…

HelplineHelpline Ads/Billboards/Newspaper/Radio/TVAds/Billboards/Newspaper/Radio/TV Primary CarePrimary Care Substance Abuse TreatmentSubstance Abuse Treatment Mental Health TreatmentMental Health Treatment Bankruptcy Lawyers/Financial AdvisorsBankruptcy Lawyers/Financial Advisors Web-based interventionsWeb-based interventions Working with industryWorking with industry

Can we use computer Can we use computer outreach to engage outreach to engage problem gamblers?problem gamblers?

Solutions for treatment Solutions for treatment outreach in primary careoutreach in primary care

Current pilot project to use brief Current pilot project to use brief screening and video-based intervention screening and video-based intervention to encourage treatment seeking.to encourage treatment seeking.

Reduces the amount of time needed for Reduces the amount of time needed for healthcare professionalshealthcare professionals

Reduces the need to be an expert on PGReduces the need to be an expert on PG Standardizes interventions across Standardizes interventions across

treatment sitestreatment sites

Intervention FlowchartIntervention Flowchart

Sample VideosSample Videos

Preliminary DataPreliminary Data

N = 13 individuals meeting lifetime N = 13 individuals meeting lifetime criteria for pathological gamblingcriteria for pathological gambling

Six women, seven menSix women, seven men All non-treatment seekersAll non-treatment seekers Average age 50 (range 28-66)Average age 50 (range 28-66) Average NODS = 5PY, 7LTAverage NODS = 5PY, 7LT

Motivation of Viewers during Motivation of Viewers during BMEBME

Item N Endorsin

gWhat do you like about your gambling?

I like the excitement or rush of gambling I like having the chance to win Gambling relaxes me/takes my mind off things I get to be with my friends I like how it makes me feel like a winner I like the casino atmosphere  Nothing

  9

 10731 5 0

Motivation of Viewers during Motivation of Viewers during BMEBME

Item N Endorsing

What worries or concerns do you have about your gambling?

My gambling is hurting my family   My gambling is hurting my health My gambling is putting my job in jeopardy My gambling is causing me a great deal of stress My gambling is making me depressed/anxious I am using drugs/alcohol too much because of gambling My gambling is causing serious financial problems My gambling is resulting in legal problems  I have no worries about my gambling

  

421671

 100 1

Motivation of Viewers during Motivation of Viewers during BMEBME

Item N Endorsing

Advantages of making changes in your gambling?   My family life would improve My work life would improve My health would improve I would have less stress in my life My mental health issues would improve I would drink less and/or use drugs less My financial problems would improve  My legal problems would improve There would be no advantages to changing my gambling

   723106 0121 0 

Readiness to change Readiness to change gamblinggambling

Two ItemsTwo Items– On a scale from 1 to

10, how important is it for you to make changes in your gambling?

– On a scale from 1 to 10, how confident are you that you can change your gambling behavior?

BME Satisfaction Ratings BME Satisfaction Ratings (/5)(/5)

Item * Mean(SD)

1. How much did you like this component? 4.2(0.8)2. How interesting was it? 4.1(1.0)3. Was it respectful to you? 4.5(0.5)4. How much did some parts of this component bother you?

2.5(1.2)

5. How helpful was it for you? 3.5(1.4)6. Are you more likely to change your gambling because of this component?

3.2(1.5)

7. Do you feel excited about the possibility of changing?

3.6(1.1)

8. Do you think problem gamblers would be helped by this component?

4.2(1.0)

9. Did this component get your thinking about your gambling?

3.9(1.2)

Where we hope this will Where we hope this will lead?lead?

Therapist guided and computer guide Therapist guided and computer guide interventions to encourage treatmentinterventions to encourage treatment

Improved outreach to problem Improved outreach to problem gamblers in primary care who would gamblers in primary care who would not seek treatment on their ownnot seek treatment on their own

Self-directed outreach – e.g., web-Self-directed outreach – e.g., web-basedbased

Where we hope this will Where we hope this will lead?lead?

Increased motivation and awarenessIncreased motivation and awareness Applications to other groups of Applications to other groups of

problem gamblers (e.g., self-problem gamblers (e.g., self-excluders)excluders)

Make problem gambling treatment Make problem gambling treatment visiblevisible

Acknowledgements

Wayne State / U Windsor– Bojana Knezevic– Cynthia Arfken– Ken Bates– Joi Moore– Ashley Weidemann– Lisa Sulkowsky– Deb Kish– Jessica Butzin– Caren Steinmiller– Melissa Williams– Nick Rupcich– Ron Frisch

Neighborhood Services Organization– Don Holmes– LaNiece Jones– Helpline Staff

Treatment Colleagues– David Hodgins – University of

Calgary– Elga Wulfert – SUNY Albany– Carlos Blanco – Columbia

University Michigan Association on Problem

Gambling Grant Support

– Ontario Problem Gambling Research Centre

– Michigan Department of Community Health (Deborah Hollis)

Contact: David Ledgerwood – dledgerw@med.wayne.edu