What gets in the way of going to treatment? Barriers to care and strategies for breaking them downDavid M. Ledgerwood, Ph.D.

Department of Psychiatry and Behavioral NeurosciencesWayne State University dledgerw@med.wayne.edu

OutlineWho goes to treatment?What can we learn from people who make initial contact? Lessons from the helpline.Can we actually reach non-treatment seeking problem gamblers?Outreach

ObjectivesUnderstand specific factors that predict treatment engagement and client-reported barriers to treatmentAware of new research into evidence-based strategies for enhancing outreach for problem gamblersStrategies to enhance engagement

Who Goes to Treatment?

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

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

Lessons from the State of Michigan/NSO Help-lineWhat can we learn from people who do and dont make initial contact?

Study AimsWe 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 AimsWe 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 10how helpful was the counseling you received from the helpline?rate the extent to which the counseling you received was enough (i.e., that you didnt 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 treatment engagementLedgerwood et al., In Press, American Journal on Addictions

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Initiators

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Helpful8.87.8

Enough4.94.6

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Initiators

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Multivariate Logistic RegressionLedgerwood et al., In Press, American Journal on Addictions

What did and didnt predict?Did predictGambling SeverityGambling DebtMotivation to ChangeFinancialPast Treatment for GamblingFinding the Help-line HelpfulIntent to go to TreatmentSpousal Conflict

Did not predictDemographicsAge of gamblingPsychiatricSubstance AbuseFamily/SocialFamily of OriginNon-Gambling TreatmentMost Legal

Barriers to Treatment

Most frequently reported barriers to treatmentAsked 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 DifferencesCallers who do not go to treatment:Dont believe they have a problem or feel they can handle it on their own.Dont want to stop gambling.Report not being ready for treatment.

Most frequently reported reasons for going to treatmentAsked 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 importantParticipants 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 treatmentTelephone 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-complianceAvailability, Cost, Stigma and Uncertainty differ between gamblers who do and dont seek treatmentInterventions can address the ambivalenceIn 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?Determine reasons why people dont seek services. Expand outreach. Expand treatment services.Tailor interventions to fit the needs of the patients who would be most likely to benefit from them.

What can be done?Determine reasons why people dont seek services. Expand outreach. Expand treatment services.Tailor interventions to fit the needs of the patients who would be most likely to benefit from them.

What are the implications?To engage problem gamblers, we need ways to improve motivation and awareness

Possible ways to engage gamblersHelplineAds/Billboards/Newspaper/Radio/TVPrimary CareSubstance Abuse TreatmentMental Health TreatmentBankruptcy Lawyers/Financial AdvisorsWeb-based interventionsWorking with industry

Can we use computer outreach to engage problem gamblers?

Solutions for treatment outreach in primary careCurrent pilot project to use brief screening and video-based intervention to encourage treatment seeking.Reduces the amount of time needed for healthcare professionalsReduces the need to be an expert on PGStandardizes interventions across treatment sites

Intervention Flowchart

Sample Videos

Preliminary DataN = 13 individuals meeting lifetime criteria for pathological gamblingSix women, seven menAll non-treatment seekersAverage age 50 (range 28-66)Average NODS = 5PY, 7LT

Motivation of Viewers during BME

ItemN EndorsingWhat 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 Nothing91073150

Motivation of Viewers during BME

ItemN EndorsingWhat 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

4216711001

Motivation of Viewers during BME

ItemN EndorsingAdvantages 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 gambling72310601210

Readiness to change gamblingTwo ItemsOn 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?

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BME Satisfaction Ratings (/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 lead?Therapist guided and computer guide interventions to encourage treatmentImproved outreach to problem gamblers in primary care who would not seek treatment on their ownSelf-directed outreach e.g., web-based

Where we hope this will lead?Increased motivation and awarenessApplications to other groups of problem gamblers (e.g., self-excluders)Make problem gambling treatment visible

AcknowledgementsWayne State / U WindsorBojana KnezevicCynthia ArfkenKen BatesJoi MooreAshley WeidemannLisa SulkowskyDeb KishJessica ButzinCaren SteinmillerMelissa WilliamsNick RupcichRon Frisch

Neighborhood Services OrganizationDon HolmesLaNiece JonesHelpline StaffTreatment ColleaguesDavid Hodgins University of CalgaryElga Wulfert SUNY AlbanyCarlos Blanco Columbia UniversityMichigan Association on Problem GamblingGrant SupportOntario Problem Gambling Research CentreMichigan Department of Community Health (Deborah Hollis)Contact: David Ledgerwood dledgerw@med.wayne.edu

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