What gets in the way of going to treatment? Barriers to care and strategies for breaking them down

1. What gets in the way of going to treatment? Barriers to care and strategies for breaking them down David M. Ledgerwood, Ph.D. Department of Psychiatry and Behavioral Neurosciences Wayne State University dledgerw@med.wayne.edu

2. Outline • Who 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

3. Objectives • Understand specific factors that predict treatment engagement and client-reported barriers to treatment • Aware of new research into evidence-based strategies for enhancing outreach for problem gamblers • Strategies to enhance engagement

4. Who Goes to Treatment?

5. Disordered Gambling Disordered 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).

6. What can we learn from people who do and don’t make initial contact? Lessons from the State of Michigan/NSO Help-line

7. 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.

8. 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.

10. Demographic and gambling characteristics of helpline callers who did vs. did not attend treatment. Ledgerwood et al., In Press, American Journal on Addictions

11. Demographic and gambling characteristics of helpline callers who did vs. did not attend treatment. Ledgerwood et al., In Press, American Journal on Addictions

12. 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?

13. Experience of help-line callers predicting treatment engagement Ledgerwood et al., In Press, American Journal on Addictions

14. Multivariate Logistic Regression Ledgerwood et al., In Press, American Journal on Addictions

15. What did and didn’t predict? • Did predict • Gambling Severity • Gambling Debt • Motivation to Change • Financial • Past Treatment for Gambling • Finding the Help-line Helpful • Intent to go to Treatment • Spousal Conflict • Did not predict • Demographics • Age of gambling • Psychiatric • Substance Abuse • Family/Social • Family of Origin • Non-Gambling Treatment • Most Legal

16. Barriers to Treatment

17. 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)

20. 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.

21. 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)

24. 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

25. 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

26. 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

27. What can be done? • Determine reasons why people don’t 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.

28. What can be done? • Determine reasons why people don’t 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.

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

30. Possible ways to engage gamblers… • Helpline • Ads/Billboards/Newspaper/Radio/TV • Primary Care • Substance Abuse Treatment • Mental Health Treatment • Bankruptcy Lawyers/Financial Advisors • Web-based interventions • Working with industry

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

32. Solutions for treatment outreach in primary care • Current pilot project to use brief screening and video-based intervention to encourage treatment seeking. • Reduces the amount of time needed for healthcare professionals • Reduces the need to be an expert on PG • Standardizes interventions across treatment sites

33. Intervention Flowchart

34. Sample Videos

35. Preliminary Data • N = 13 individuals meeting lifetime criteria for pathological gambling • Six women, seven men • All non-treatment seekers • Average age 50 (range 28-66) • Average NODS = 5PY, 7LT

36. Motivation of Viewers during BME

37. Motivation of Viewers during BME

38. Motivation of Viewers during BME

39. Readiness to change gambling • Two 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?

40. BME Satisfaction Ratings (/5)

41. Where we hope this will lead? • Therapist guided and computer guide interventions to encourage treatment • Improved outreach to problem gamblers in primary care who would not seek treatment on their own • Self-directed outreach – e.g., web-based

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

43. 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