Online support needs and experiences of family members affected by problem gambling
The harms associated with problem gambling are significant, and not only affect the person with problem gambling, but also their family and friends. Recent research suggests gambling harms occur at the individual, family and community level across seven broad domains (Langham et al., 2016). These domains cover the financial, relationships, emotional or psychological, health, cultural, work or study and criminal activity. The Productivity Commission estimated that problem gambling affects about seven people around the gambler (Productivity Commission, 1999), and in some jurisdictions the impact of gambling on others is estimated to be as high as 18-20% of the population (Salonen, Castrén, Alho, & Lahti, 2014; Svensson, Romild, & Shepherdson, 2013). While the most severe impact of problem gambling appears to be financial, research has found family members are affected by problem gambling in terms of their relationships and higher levels of interpersonal conflict (e.g., anger, arguments, interpersonal violence) as well as a lowered quality of life, intimate and family relationship dysfunction, poorer social support and poorer physical health (Dowling, Smith, & Thomas, 2009; Kalischuk, Nowatzki, Cardwell, Klein, & Solowoniuk, 2006; Dowling et al., 2016).
These issues appear to be frequently experienced by those who seek help. A study of family and friends seeking help online showed almost all clients reported high rates of emotional distress (98%) and effects arising from the relationship with the gambler (96%) (Dowling, Rodda, Lubman, & Jackson, 2014). Research suggests family members attending face-to-face services frequently report a loss of trust and feelings of anger towards the person with the gambling problem (Dowling, Suomi, Jackson, & Lavis, 2015). They also report negative mood states, including sadness, depression, anxiety and distress. Although most help-seekers are partners of people with problem gambling, the impacts on children, siblings, parents and others appear similar (Dowling et al., 2015).
Help-seeking by family and friends
Given these serious impacts, it is not surprising that family and friends seek help. In Australia, family and friends have access to the same free and confidential services as people with problem gambling. These options comprise multiple independently operated services, providing face-to-face counselling (including problem gambling and financial), and peer support as well as the statewide gambling helplines and a national online counselling service (known as Gambling Help Online). Family and friends comprise up to one third of clients in Australian telephone, online and face-to-face help and support services (Productivity Commission, 2010; Rodda, Lubman, Dowling, & McCann, 2013; Crisp, Thomas, Jackson, & Thomason, 2001).
Family and friends seek help for a number of reasons. These include worry that the gambling could become a major problem, negative emotions (such as sadness or anxiety) and because they are having problems maintaining everyday activities (Hing, Tiyce, Holdsworth, & Nuske, 2013). Research has also reported that financial problems are a key reason family members seek help (Bellringer, Pulford, Abbott, DeSouza, & Clarke, 2008). However, family and friends appear to delay help-seeking for similar reasons as those reported by people with problem gambling (Gainsbury, Hing, & Suhonen, 2013). These include wanting to solve the problem themselves and feelings of shame or embarrassment. There is some evidence that family members seek low-intensity interventions (telephone, online) more frequently than high-intensity options (i.e., face-to-face counselling). For example, Hing et al. (2013), in their study of 46 family and friends contacting Australian gambling helplines, reported that telephone and online support were the most often accessed services. This study involved one of the largest samples of help-seeking family members affected by problem gambling. However, as noted by the authors, the representativeness of the sample of broader helpline callers was not known. This is due in part to a limited literature reporting the characteristics or experiences of family members seeking help via helplines, as well as other services more broadly, such as online or face-to-face services.
Initial research suggests family members are an important source of support when a person with a gambling problem has entered treatment (Ingle, Marotta, McMillan, & Wisdom, 2008; Kourgiantakis, Saint-Jacques, & Tremblay, 2013). Over the years, there have also been multiple attempts to develop effective treatment programs for the family and friends of people with gambling problems. The aim of these programs include improving the personal and relationship functioning of family members, engaging gamblers in treatment to decrease their gambling (Hodgins, Toneatto, Makarchuk, Skinner, & Vincent, 2007), and increasing family members' coping skills and decreasing distress (Rychtarik & McGillicuddy, 2006). These initial studies have provided mixed findings in terms of the efficacy of these programs targeted towards family members. For example, research involving a Community Reinforcement and Family Therapy (CRAFT) program aimed at reducing alcohol consumption and increasing rates of treatment-seeking did not produce similar positive results when adapted for problem gambling (Hodgins et al., 2007). In contrast, a coping skills training program produced a large improvement in coping skills that appeared to mediate a corresponding significant reduction in depression and anxiety relative to a delayed treatment control condition (Rychtarik & McGillicuddy, 2006). These findings support a contemporary stress-coping perspective.
Dowling et al. (2014) partially applied the stress-strain-coping-support model previously developed for alcohol and other drugs (Orford, Copello, Velleman, & Templeton, 2010) to problem gambling. This model is built on the presumption that the impacts of problem gambling are stressful. How family members cope and the amount of social support they can draw upon affects the levels of stress and the degree of emotional and physical health problems. Coping and social support, however, have not yet been examined in terms of online help-seeking by family members for problem gambling. This is important because they may, in part, indicate the types of services or resources that should be made available.
Unfortunately, rates of help-seeking for family and friends are low (around 20%), which is a similar rate to people with problem gambling. Low-intensity and self-help interventions may be especially attractive for family members because they overcome common barriers to help-seeking including shame and stigma and limited access to face-to-face services. Low-intensity interventions delivered via telephone or online settings are usually provided at a distance (by phone or online), which can mean easier access, greater convenience and more anonymity.
E-therapy for family and friends
In an attempt to increase rates of help-seeking more broadly, a number of low-intensity and self-directed treatment options have been developed in Australia and internationally. Low-intensity options are those that can be accessed once or twice, and do not necessarily involve an ongoing relationship or a therapeutic intervention. Low-intensity interventions are offered in Australia by phone via a gambling helpline, or in an online setting (Rodda & Lubman, 2014; Rodda, Hing, & Lubman, 2014). Online options in Australia have grown over recent years and, in 2009, a national online counselling service that provides online counselling and email support (known as Gambling Help Online) was established. The Gambling Help Online program also includes self-directed content specific for family and friends that is available on its website. This content has been accessed by thousands of people. The program also includes access to peer support for family and friends via an online community forum.
Low-intensity interventions delivered by a professional variously replicate traditional talk therapy and may involve counselling, support, information or referral. Chat and email are the two most common types of low-intensity interventions that are professionally delivered. Chat is synchronous, meaning that counsellor and client are in the virtual room at the same time. It is typically offered as a single session, without the need for an appointment, but may also be ongoing. Email is asynchronous, meaning that counsellor and client are not usually online at the same time. Research from other fields suggests that chat and email counselling are associated with ratings of rapport similar to those reported in face-to-face services (Sucala et al., 2012)
Email is the most frequently offered type of professional interaction in e-therapy across a range of health conditions (Chester & Glass, 2006). However, data from Gambling Help Online indicate that family and friends access email support less frequently than chat. The higher rate of chat over email is consistent with other services offering anonymous, brief interventions internationally for a range of addictive and mental health disorders (e.g., Kids Help Online, Lifeline, Counselling Online, GamCare (UK)). These findings suggest that addictive populations may prefer the immediacy of chat instead of the delayed contact afforded by email when both types of low-intensity interventions are offered.
Rodda, Lubman, Dowling, & McCann (2013) reported some family and friends of people with gambling problems choose online over face-to-face modalities because of its ease and convenience (41%) and privacy and anonymity (18%), and that this modality is preferred for a significant proportion of family and friends (24%). In addition, this study found that online e-therapy is an important entry point into the service system for 11% of family and friends. A review of Gambling Help Online family member characteristics reported 81% of family members accessing these programs were seeking treatment for the first time (Dowling et al., 2014).
Family and friends also have access to self-directed resources, materials and tools via websites. Community forums have been operating for almost 10 years in the UK for people with gambling problems. Online community forums were one of the first internet-based options for family and friends to access help. Research involving two UK forums revealed that members felt they could cope better with their own or another person's problem gambling after they accessed the forums and that forums were most popular with people who gambled online (Wood & Wood, 2009). That study included gamblers, family and friends, but the data presented was not differentiated by whether the participant was a gambler or a family member affected by gambling.
Aims of the current study
More than 10 years ago, McMillen, Marshall, Murphy, Lorenzen, & Waugh (2004), in a study involving family members (as well as gamblers), came to the conclusion that self-help could be successful to varying degrees and that formal ongoing face-to-face treatment was not going to meet the needs of all who attempt to change their gambling. For highly stigmatised disorders, such as problem gambling, low-intensity and self-directed interventions have the potential to help reduce the impact of problem gambling by overcoming barriers to treatment.
To inform the development of services for family members affected by problem gambling, more needs to be known of the needs of this group. Low-intensity interventions may be especially attractive to this group because they overcome common barriers to help-seeking. This includes shame and stigma and also limited access to face-to-face services. Low-intensity interventions, such as those provided by the Australian national service, are provided at a distance (online) and this can mean easier access, greater convenience and more anonymity. Family members may therefore display a greater willingness to reach out for help via these services.
Although the national service has been operating since 2009, there has not been an examination of how family members have accessed the service. Over the past four years, around 4000 people have engaged in one or more of the e-therapy options that involve one-on-one contact with a specialist gambling clinician (chat or email). Around 20% of people who have accessed the service are family and friends affected by problem gambling (Rodda & Lubman, 2014). Furthermore, Gambling Help Online offers family members access to email support, community support forums, as well as information via its website, but there has not been an examination of the experiences of family members across these low-intensity service options.
The current study aims to investigate the use of low-intensity and self-directed options utilised by family members and friends affected by problem gambling who accessed the Australia-wide Gambling Help Online website over a 12-month period. In this study, we refer to family as inclusive of friends and colleagues as part of that family. Given the absence of research in this area, our aims are for the most part explorative and descriptive of the sample and their help-seeking experiences. Specifically, the aims are to:
- Describe the characteristics of family members, including age, gender, relationship to the gambler and length of time the gambling has impacted on the family member.
- Describe the impact of gambling on family members including their functioning, coping and levels of social support.
- Describe the types of low- and high-intensity services accessed by family members prior to e-therapy.
- Describe the types of e-therapy accessed (i.e., what was accessed and in which combinations) and the degree to which the intervention was perceived to be sufficient.
- Explore reasons for seeking help, expectations of treatment and what family members ideally want from services.