Effectiveness of Problem Gambling Interventions in a Service Setting: Clinical Trial

Katie Palmer du Preez, Lisa Campbell, Laura Hay

National Training Forum For Preventing and Minimising Gambling Harm February 2017

Background and relevance of the study

• Evidence base for our gambling interventions is weak, but MI and CBT show promise.

• What works best and for whom in NZ?

• Opportunities for clinical development and evidence based practice

• Building on learnings from the New Zealand Gambling Helpline Trial (Abbott et al, 2012)• Compared 3 levels of motivational interviewing and ‘treatment as usual’

• Single MI session + booster phone sessions + self help workbook worked the best for Maori, and those with high distress and many coexisting issues.

Research questions

• How effective are two of the most promising forms of face-to-face therapy for problem gambling in New Zealand (CBT and MI)?

• How effective are gambling-related post-treatment text messages in preventing relapse and sustaining treatment gains?

• Do specific population groups (e.g. age, gender, ethnicity and gambling problem severity) respond better to one or more of the interventions?

Introducing our study collaboration…

TSA Oasis

GARC, AUT

Clinical experts

Advisory Board

Research funded by the Ministry of Health.

Methodology of the study

• Pragmatic Randomised Controlled Trial (RCT)

• We will involve 300 Oasis client participants.

• Randomly allocated to one of two treatment conditions:• MI = 6 motivational interviewing sessions (1x face-to-face, 5x via telephone)

supported by a self-instruction workbook.

• CBT = 10 cognitive behaviour therapy sessions including exposure therapy

• Half to receive additional text message support.

• Measure and compare client outcomes: Before treatment, 3m, 12m and 24m after treatment.

Study exclusion criteria

• Under 18

• Actively psychotic

• Require immediate crisis or police intervention

• Unwilling to read a workbook

• Unwilling to participate in counselling/treatment

• Unwilling to have counselling sessions audio-recorded

• Unwilling to provide follow-up data on gambling

• No self-perceived gambling problem.

Ethical approval

• Health and Disability Ethics Committee process• Rationale and study protocols reviewed and approved on 27 August 2015,

reference number 15/CEN/99.

• We seek to protect participant safety and the integrity of the research throughout our study.

• Draw on support from Oasis, clinical experts and our advisory board.

Recruitment, informed consent and randomisation• Oasis ‘first contact’ staff:

• Assess client eligibility and interest in the study. • Gain verbal agreement for contact details to be passed to AUT if interested. • Mail/email a Participant Information Sheet to the client.• Arrange a first appointment time.• Gain written consent when participants attend their first intervention session.

• AUT researchers (before client’s first appointment):• Answer any additional client questions, check their understanding of what

participation involves.• Record verbal consent to participate.• Conduct an initial assessment questionnaire. • Randomize the client into a treatment group• Feed back all results to Oasis through a secure online portal system.

Treatment protocols

• All treatment is delivered by Oasis counsellors: both MI and CBT

• Manualised versions of MI and CBT produced by two world experts in gambling treatment.• MI: Professor David Hodgins at the University of Calgary in Canada.

• CBT: Professor Malcolm Battersby and the team at Flinders University in Australia.

• Training provided by AUT and clinical experts and supervisors.

Post treatment TxtSupport program• Half of MI and half of CBT clients, 2 txts per week for 9m.

• Content tailored to MI and CBT (some generic)

• Informed by an Australian investigation of gambling self-help strategies (Lubman, Rodda et al, 2015).

Example message:

“Kia ora <name>. Welcome to txt support for preventing gambling relapse (TxtSupport). We’ll send you texts twice a week with tips and advice others have found helpful to help you stay on track. Some people find this helpful… distract yourself or do something else until the urge to gamble passes. Txt STOP to opt out of these messages”

Study progress February 2017: Randomisation

• Pilot Nov 2015- May 2016. Main study May 2016 - ongoing

• 312 clients registered nationwide into main study, 207 eligible.

• 97/207 accepted the offer to take part.

• Of those 97 who accepted the offer, 87 have been assessed and randomised.

Number of sessions completed by treatment group

Number of session completed by allocation group

The Salvation Army Oasis – Service Dynamics• Advanced clinical training in gambling treatment for all clinical staff

• Opportunity to review and reflect on clinical practice – improving client care, lead to new model of care?

• Challenges around logistics of 7 days of clinical training, 3 blocks, plus one day study administration training provided regionally

• Changes to our systems / practice (e.g. client bookings, time before first appt, AUT portal use for randomisation and screen information before first session, longer first sessions, following two manualised treatment protocols, recording client sessions, feedback on sessions from clinical supervisors, follow ups).

The Salvation Army Oasis - Cont’d • Large amount of consultation between AUT, Oasis management,

Auckland clinical staff and consumer advisor, as well as briefer consultation with each service centre across country

• Finding the balance between robust research practice and meeting the needs of our clients

• Pilot in Auckland service Nov 15 to May16 – ironing out the details

• Significant change for all our clinical staff and administrators – a big thank you to our staff for their openness and huge effort

• Early client feedback is great – utilising aspects of the treatment approaches with clients that are not in the study as well – especially cue exposure where appropriate

Case Worker View - MI

• Generally one face-to-face session, followed by 5 phone sessions

• MI workbook very well received

• Varied levels of engagement with phone sessions

• Flexible and allows for good client/therapist relationship

• Case study = SC

Case Worker View - CBT

• 10 face-to-face sessions

• Includes cue exposure therapy

• More intense therapy

• More preparation for sessions

• Workbook well set out

• Wide range of resources

• Works well for pokies

• Results & feedback so far = positive

• Case study = TC

Case Worker View - Feedback

• All-in-all fairly positive

• Provides structured sessions

• Restraints due to protocols – non-gambling related issues

• Allows flexibility

• Some case workers finding less engagement with MI clients

• When case workers are enthusiastic about process, so are clients

• Follow-up

References and further readingAbbott, M., Bellringer, M., Vandal, A., Hodgins, D., Palmer Du Preez, K., Landon, J., Sullivan, S., & Feigin, V. (2012). Effectiveness of problem gambling brief telephone interventions: A randomised controlled trial. Auckland: Auckland University of Technology, Gambling and Addictions Research Centre.

Battersby, M.W., Smith, D., Harvey, P.W., & Pols, R. (2013), Cognitive versus exposure therapy for problem gambling: A pilot randomized controlled trial. Adelaide: Flinders Centre for Gambling Research.

Hodgins, D.C., Currie, S.R., & el-Guebaly. N. (2001). Motivational enhancement and self-help treatments for problem gambling. Journal of Consulting and Clinical Psychology, 69(1), 50-57.

Hodgins, D.C., Currie, S., el-Guebaly, N., & Peden, N. (2004). Brief motivational treatment for problem gambling: a 24-month follow-up. Psychology of Addictive Behaviors, 18(3), 293-296.

Hodgins, D., Currie, S., Currie, G., & Fick, G. (2009). Randomized trial of brief motivational treatments for pathological gamblers: More is not necessarily better. Journal of Consulting and Clinical Psychology, 77(5), 950-960.

Lubman, D., Rodda, S., Hing, N., Cheetham, A., Cartmill, T., Nuske, E., ... & Cunningham, J. (2015). Gambler self-help strategies: A comprehensive assessment of strategies and actions. Melbourne: Gambling Research Australia.

Questions?

Our contact details:

Katie Palmer du Preez

Katie.palmerdupreez@aut.ac.nz

09 921 9999 ext 7640.

Lisa Campbell

Lisa_Campbell@nzf.salvationarmy.org

09 639 1134.

Laura Hay

Laura_Hay@nzf.salvationarmy.org

03 365 9659.