Online support needs and experiences of family members affected by problem gambling
Family members accessing e-therapy in the current study were most often female, aged younger than 35 years of age and also the partner of a person with a gambling problem. These findings are similar to our earlier research involving 366 family members accessing Gambling Help Online (Dowling et al., 2014). Almost three-quarters of family members were currently cohabiting with the person with a gambling problem and that problem ranged between less than a year to more than 10 years. Despite this, over half of family members had only become aware of the problem in the previous 12 months. Indeed, around 20% of family members had just found out about the problem, and a further 30% had known about it for between six and 12 months. Over two-thirds of family members reported that they had been affected by the gambling problem for more than two years.
Family members reported a range of impacts. The highest endorsed impact was associated with feelings of sadness, anxiety, stress or anger followed by a negative impact on the relationship. Again, these findings were similar to our previous study of family members seeking help online (Dowling et al., 2014). A more in-depth assessment of the three domains of functioning (financial, increased responsibility and inter/intrapersonal functioning) revealed family members most highly endorsed psychosocial impacts including relationship and emotional difficulties, which is consistent with previous research of the perceived family impacts reported by gamblers seeking help at face-to-face services (Dowling et al., 2015). Although the rates of endorsement of impacts by family members are much higher than those provided by gamblers themselves (Dowling et al., 2015), the most and least commonly endorsed items are similar. Dowling et al. (2015) found that gamblers reported the most frequent impacts on others as loss of trust, anger, depression, anxiety, distress due to gambling-related absences and reduced quality of time together. These were reported by between half to two-thirds of gamblers. In contrast, almost all family members in the current study reported loss of quality time, feelings of anxiety and anger and loss of trust or depression. The difference is due in part to 41% of the Dowling et al. (2015) sample being single (no information on contact with other family or friends), but also because the family members in the current study all identified as being affected by another person's gambling. It is likely that people with gambling problems under-report the impacts of their gambling on their family members (Dowling et al., 2015).
A consistent theme across this study was supporting family members to improve their levels of coping. Problem gambling has serious negative impacts on family members and, as demonstrated in the current study, is associated with poor mood, relationships and financial difficulties. Family members report becoming entwined with the gambling problem (e.g., focused on getting the gambler to change) and this approach was often associated with ineffective communication strategies (e.g., arguments, ultimatums, demands and threats). Unfortunately, these strategies might actually make it more difficult for family members to cope. Previous research involving people with alcohol and drug issues suggests trying to change the person or the problem is associated with poorer outcomes for family members (Orford et al., 2001). Orford et al. (2010) suggests a more helpful approach is to assist family members to increase their social and emotional support, as well as provide good information and material help.
Family members engaged in a wide range of low- and high-intensity treatments as well as self-directed options. Prior to accessing Gambling Help Online, two-thirds had accessed another low-intensity option, with almost all family members attempting a self-directed option including self-help or talking to someone else. In terms of high-intensity services, family members most often consulted a health professional who was not a specialist gambling counsellor. Future research might investigate whether help from GPs or other allied or mental health professionals was specific to helping the person with the gambling problem, or in managing the impact of gambling on the family member.
Family members accessed e-therapy in a variety of different ways. Almost 60% accessed one of the professionally delivered options (chat or email), with 40% accessing community forums or self-help information. Less than one-third of family members accessed just one e-therapy option with most family members accessing 2 options. Self-help information on the Gambling Help Online website was highly accessed, and almost half the family members said that this was sufficient for them.
Across the sample, a high proportion of family members stated that the e-therapy service that they had accessed was sufficient. This was highest for those accessing chat counselling and lowest for those accessing email or forums. Chat counselling was also associated with the highest proportion of family members stating that they were likely to follow-up on information received. These findings from family members are broadly similar to previous research involving gamblers contacting the Michigan Problem Gambling Helpline (Ledgerwood et al., 2011). However, in the current study, chat clients more frequently reported that what they received in the session was enough. This is consistent with our previous research involving family members as well as gamblers (Rodda, Lubman, Dowling, & McCann, 2013; Rodda, Lubman, Dowling, Bough, & Jackson, 2013). These studies reported that for some family members online treatments were preferred over telephone or face-to-face treatments and that for some they did not want to access their treatment or support in any other way.
In contrast, email support and forums were associated with lower ratings of being considered to be enough than chat or website information. However, family members who used these services frequently reported that they would follow-up information that was provided. This difference in the rate of endorsement is perhaps related to the service expectations and treatment options provided to family members. Compared with chat, email requires identifying information (i.e., email address), engages in an ongoing relationship with a counsellor, and is delayed (i.e., not an immediate response). Similar to face-to-face services in terms of ongoing therapist contact, it is possible that some family members used email as a way of accessing face-to-face or other one-on-one services and hence they rated email as less frequently sufficient for their current needs.
Our final aim was to describe the reasons for seeking help, expectations of treatment and what family members ideally wanted from services. Family members indicated psychoeducation and advice or support in approaching the person, encouraging help and supporting change as being important. When provided with a list of possible goals of help-seeking, the most frequently endorsed was changing the gambling behaviour (i.e., get the person with the gambling problem to spend less time or money) and to support change (i.e., get help to better support the person with the gambling problem). This speaks to the importance of making available materials to support family members in talking to the person with the gambling problem. Recent research involving the development of Mental Health First Aid Guidelines (Bond et al., 2016, Appendix E) describes an evidence-informed approach to helping a person with a gambling problem, and this includes how to help someone that does not acknowledge that they have a problem and also how to communicate concerns about gambling behaviours. Future research should consider making these guidelines available to family members as well as problem gambling and other interested clinicians. For family members this could include self-directed programs offered via smart phone applications, the integration of this information into websites and printed information for family members, and broader public health campaigns.
Family members also identified a range of personal resources that were perceived as helpful, including the development of skills and strategies, improvement in coping skills and increased self-efficacy or social support. Again this was supported with the quantitative data where almost three-quarters of family members indicated that improving the quality of their relationship with the person with the gambling problem was important. This suggests that services need to address the family member's needs both in terms of their role in supporting change in the gambler as well as supporting the family member in developing their own personal skills and resources.
Implications and recommendations from this study
Based on the findings of the current study, the following are recommended:
- Online, phone and face-to-face services continue to provide brief and minimal interventions, counselling and psychotherapy to family members impacted by problem gambling. Although the evidence base underpinning the development of interventions for the family members of problem gamblers is significantly underdeveloped, the findings of this study suggest that interventions for family members should attempt to increase effective coping, improve social support, and reduce impacts of problem gambling on family members and friends, particularly in relation to emotional distress, interpersonal relationships and finances. Further research, however, is required to develop and evaluate interventions specifically designed for family members delivered across these modalities.
- Based on family members' needs for psychoeducation and information and advice on how to approach and support people with gambling problems, resources such as Mental Health First Aid Guidelines (Bond, et al., 2016) should be made accessible through all problem gambling websites. Furthermore, a training package should be established for counsellors working with family members, which would develop on the basis of these guidelines.
- Family members making contact for support and advice for a person with a gambling problem may also benefit from an increase in the types of services and resources that can be undertaken together (e.g., as a couple, parent-child, etc). For example, one family member noted that there were very limited options for both the family member and gambler to engage in together.
- While the findings from this research are positive, they do highlight multiple areas where gambling service systems could be enhanced to better support family members. As indicated above, family members make contact most frequently for help managing a specific issue (i.e., recent awareness of a gambling problem). This means family issues are likely to be ongoing and while a single session of e-therapy was sufficient for many participants, resources need to be available for family members to access over the longer term and across the multitude of situations they will likely encounter.
- The range of resources available for family members needs to be increased. This should include more targeted resources for increasing their confidence in managing or coping with a stressful situation (i.e., gambling) as well as self-care options.
- Multiple family members reported help was sought because they either had few people that they could trust or confide in or were socially isolated. Perhaps online community forums could be promoted more widely to family members and, indeed, be moderated by people with lived experience of being a family member of someone with a gambling problem.
Limitations and future research
This study is the first to examine experiences and preferences of family members accessing four types of e-therapy. However, there are issues, which need to be considered, associated with the representativeness of the sample, the survey and the measures. First, this study involved a small sample size, albeit comparable with other studies involving family members. Second, the findings are not necessarily generalisable to family members in other settings (i.e., those not seeking help through an online service). Third, family members were recruited from Gambling Help Online via a three-step process that included advertising the study and then emailing further information to those interested in participating in research. This meant that the sample was highly self-selective and not the entire sample of family members accessing e-therapy. However, demographics were similar to the wider population of family members accessing e-therapy (Dowling et al., 2014).
In an attempt to increase recruitment to the project, we rendered the survey as brief as possible with no measures of behaviour beyond self-report. Because of limited previous research investigating the experiences and needs of family members, we included multiple open-ended questions. The open-ended questions provided a great deal of data on the experiences and needs of family members but it is limited in that it does not provide a proportion of family members that might endorse each item. In addition, the current research did not seek to measure or investigate the family members' gambling and so it is difficult to draw conclusions on the relationship between gambling impact on family members and the actual gambling severity or time or money spent. Nevertheless, family members consistently reported a wide range of impacts and these were broadly consistent with other studies involving family members affected by problem gambling (Dowling et al., 2014). Further research is required to develop and validate brief scales that are suitable for use in e-health settings to measure the coping and effects on family members of people with gambling problems.
Family members experience a significant range of gambling-related harms. Those who seek treatment, support and information online consistently reported harms to mental and physical health, finances and relationships as well as difficulty in coping with the often devastating consequences of someone else's gambling. The current study found family members access a wide range of e-therapy services and that they access resources and support from a range of sources before seeking help online.
Family members sought help for the gambler as well as themselves but reported that they wanted more information, more support and strategies to manage the problem. Ideally, low- and high-intensity as well as self-directed options could be developed specifically for the family members' expectations of what they need. This would include programs that target the harms associated with problem gambling (i.e., financial, relationships, emotional or psychological, health, cultural, work or study, and criminal activity).
This research is one of only a few studies investigating the needs of family members. It provides a cross-sectional snapshot of the needs of family members accessing low-intensity and self-directed online support. However, the current study is just a first step in this area. Given that family members affected by problem gambling are in the many thousands, just in Australia, it is perhaps surprising that we know so little about their needs. Compared with the growing body of research investigating the experiences and recovery from problem gambling, the same research involving family and friends is extremely low. To address this issue, multiple programs of work need to be undertaken, including longitudinal work that monitors the harms associated with problem gambling on family members as well as their help-seeking behaviours.