Subtyping based on readiness and confidence: the identification of help-seeking profiles for gamblers accessing web-based counselling

BACKGROUND AND AIMS: Problem gamblers are not a homogeneous group and recent data suggest that subtyping can improve treatment outcomes. This study administered three readiness rulers and aimed to identify subtypes of gamblers accessing a national web-based counselling service based on these rulers. METHODS: Participants were 1204 gamblers (99.4% problem gamblers) who accessed a single session of web-based counselling in Australia. Measures included three readiness rulers (importance, readiness and confidence to resist an urge to gamble), demographics and the Problem Gambling Severity Index (PGSI). RESULTS: Gamblers reported high importance of change [mean = 9.2, standard deviation (SD) = 1.51] and readiness to change (mean = 8.86, SD = 1.84), but lower confidence to resist an urge to gamble (mean = 3.93, SD = 2.44) compared with importance and readiness. The statistical fit indices of a latent class analysis identified a four-class model. Subtype 1 was characterized by a very high readiness to change and very low confidence to resist an urge to gamble (n = 662, 55.0%) and subtype 2 reported high readiness and low confidence (n = 358, 29.7%). Subtype 3 reported moderate ratings on all three rulers (n = 139, 11.6%) and subtype 4 reported high importance of change but low readiness and confidence (n = 45, 3.7%). A multinomial logistic regression indicated that subtypes differed by gender (P < 0.001), age (P = 0.01), gambling activity (P < 0.05), preferred mode of gambling (P < 0.001) and PGSI score (P < 0.001). CONCLUSIONS: Problem gamblers in Australia who seek web-based counselling comprise four distinct subgroups based on self-reported levels of readiness to change, confidence to resist the urge to gamble and importance of change.

Clinical reasoning sessions: back to the patient

BACKGROUND: Problem-based learning (PBL) was developed as a facilitated small group learning process based around a clinical problem. Originally designed for pre-clinical years of medical education, its application across all years poses a number of difficulties, including the risk of reducing patient contact, providing a learning process that is skewed towards an understanding of pathophysiological processes, which may not be well understood in all areas of medicine, and failing to provide exposure to clinically relevant reasoning skills. CONTEXT: Curriculum review identified dissatisfaction with PBLs in the clinical years of the Sydney Medical School's Graduate Medical Program, from both staff and students. A new model was designed and implemented in the Psychiatry and Addiction Medicine rotation, and is currently being evaluated. INNOVATION: We describe an innovative model of small-group, student-generated, case-based learning in psychiatry - clinical reasoning sessions (CRS) - led by expert facilitators. IMPLICATIONS: The CRS format returns the student to the patient, emphasises clinical assessment skills and considers treatment in the real-world context of the patient. Students practise a more sophisticated reasoning process with real patients modelled upon that of their expert tutor. This has increased student engagement compared with the previous PBL programme.

Sober assessment of the link between substance abuse and crime-eliminating drug and alcohol use from the sentencing calculus

The relevance of drug and alcohol involvement to sentencing law and practice is one of the most perplexing and unsettled areas of sentencing law and practice.1 It is also one of the most important issues in the criminal justice system. Most crimes are committed by offenders who are substance involved, and nearly half of all crimes that are committed are done so by offenders who are intoxicated at the time of the offense. Substance involved individuals are grossly over-represented in the criminal courts. Addiction and intoxication impair sound judgment, and hence, it intuitively appears that intoxicated offenders are less culpable for their crimes. Moreover, there is often a sense that addiction and intoxication causes aberrant behavior and that curing the substance involvement will lead to more prudent (law-abiding) conduct.