Executive summary

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. Family members (inclusive of partner, parent, child, sibling, other relative or friend) infrequently seek help but when they do, it is most frequently prompted by emotional distress and financial concerns, and worry that the problem will worsen. 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 interventions delivered by a professional variously replicate traditional talk therapy and may involve counselling, support, information or referral. Until recently, the most frequent low-intensity option was telephone counselling but, in Australia, e-therapy has become widely available and accessible. In Australia, the most frequent types of e-therapy accessed by family members are chat and email counselling provided by the national online help service Gambling Help Online. Family members also access self-help information provided on the Gambling Help Online website as well as community peer support forums. Although these low-intensity and self-help options have been offered to family members for more than five years in Australia, there has not as yet been any examination of the specific experiences of family members seeking help online or indeed their treatment and support needs more broadly.

The current study aimed to describe the experiences of family members seeking help online. Quantitative and qualitative analyses were applied to describe the characteristics of family members seeking help, the effect of gambling on the family member and the types of low- and high-intensity services previously accessed. The study also described the types of e-therapy accessed and the reasons for help seeking. Given the limited literature currently available the five aims were exploratory and included:

1. 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.
2. Describe the impact of gambling on family members including their functioning, coping and levels of social support.
3. Describe the types of low- and high-intensity services accessed by family members prior to e-therapy.
4. 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.
5. Explore reasons for seeking help, expectations of treatment and what family members ideally want from services.

Sixty-two family members were recruited from Gambling Help Online. Family members were most often female, younger than 35 years of age and also most often the partner of a person with a gambling problem. Over half of family members had found out about the gambling problem in the past 12 months and over two-thirds currently lived with the person with the problem.

Family members reported a wide range of serious effects to their mental and physical health. Almost 80% reported that they often experienced feelings of sadness, anxiety, stress or anger due to another person's gambling and two-thirds reported that gambling often affected the quality of their relationship with the person with the problem.

Family members reported accessing a wide range of low-intensity (e.g., chat, email, forums, telephone) and high-intensity (e.g., face-to-face) services prior to this contact with e-therapy. Over two-thirds of family and friends had engaged with at least one low-intensity option and viewed website content.

Family members accessed all of the e-therapy options including chat, email, forums and self-help information on the Gambling Help Online website. On average, two different services were accessed, and over half of family members said that the services they accessed were sufficient at that time to meet their needs.

Help was sought for four main reasons: psychoeducation about gambling, approaching the person with the gambling problem, how to encourage help seeking and how to support change. There were also 57 resource needs identified, which were thematically grouped into improving coping skills/self-efficacy and social support.

The findings of this research suggest family members experience a significant range of gambling-related harms and access help for a variety of reasons. The vast majority of family members in this study reported that their experiences of e-therapy were positive and the services that they accessed were sufficient. However, caution should be applied to these findings given the sample size and self-selection into the study. Furthermore, the survey administered was intentionally brief. It included questionnaires that were developed for the current study and also some not previously widely administered. This was because in multiple instances no validated instruments were available.

While the findings from this research are positive, they also 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 ongoing, and while a single session of e-therapy was sufficient for many family members, resources need to be available for family members to access over the longer term and across the multitude of situations they will likely encounter.

For these reasons, programs and services need to be developed that are tailored to the needs of family members. The measures used in the current study suggest these needs are very similar to those described in the Mental Health First Aid Guidelines for gamblers (i.e., information for family members on how to identify gambling problems, approach someone with a problem, encourage help seeking and change, and how family members can help someone that does not recognise that there is a problem) (Bond et al., 2016, Appendix E). These guidelines urgently need to be adapted to a training program for counselling staff working with family members, and also provided to family members via Australian websites or other self-directed modalities. The impact of providing family members with evidence-informed information should then be evaluated.

Background

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:

1. 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.
2. Describe the impact of gambling on family members including their functioning, coping and levels of social support.
3. Describe the types of low- and high-intensity services accessed by family members prior to e-therapy.
4. 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.
5. Explore reasons for seeking help, expectations of treatment and what family members ideally want from services.

Approach

Participants and recruitment

Recruitment of family members occurred between January 2014 and January 2015 from Gambling Help Online. Criteria for participant inclusion was (1) a family member or friend of someone with a gambling problem; (2) completion of an e-therapy option, including chat, email, forum or website information; (3) an interest in taking part in a research project; and (4) a willingness to be contacted following engagement with an e-therapy option.

An email was sent to 407 eligible family members who met the inclusion criteria. A total of 78 family members clicked through to the survey. Consent was sought from 65 family members meeting the inclusion criteria and three declined to participate in the study. The final sample comprised 62 family members. The survey was offered entirely online via Qualtrics survey software.

Ethics approval for this study was received from the Eastern Health Research and Ethics Committee E01/2014.

E-therapy options

Gambling Help Online provides chat, email, website, forums and self-help. Family members accessing any of these services were included in the current report. Gambling Help Online is a nationally funded program that is operated by Turning Point from the state of Victoria.

E-therapy services are offered 24 hours a day, seven days a week. All services are free of charge and without appointment. Professional counsellors with backgrounds in psychology and social work deliver e-therapy. The specific options investigated in the current study:

• Synchronous chat: Chat is offered 24/7 and works similarly to instant messaging, where both the counsellor and client type in a secure environment. A typical counselling session has a 45-minute duration.
• Asynchronous email: Email support is provided via the same secure site as the real time chat. A client is allocated the same counsellor for two to three emails a week for approximately six weeks.
• Website: The website provides information on gambling issues, interactive self-assessments, and strategies for regaining control as well as accessing support and helping others. In total, the site offers over 30,000 words of content across more than 20 separate pages.
• Community forums: Forums are post-moderated by a clinician from Gambling Help Online. Family and friends can read and create a post in the forums in a family specific area or in general topics such as strategies for change and stories of recovery. Critically, this service provides peer support from a supportive community of members.

Measures

The survey included very brief demographics, measures of the impact of gambling and services accessed. Survey items were initially developed by the lead researcher and then subjected to consensus amongst the research team and AGRC. The survey was then pilot-tested with counsellors, gambling researchers and administration staff.

Characteristics of family members

Family members reported their gender, age and an email address. In addition, we asked family members to state the nature of the relationship with the person with the gambling problem (i.e., "What relationship do you have to the person with the gambling problem?"). The response options were partner, parent, sibling, child, friend and other relative. Given this broad range of relationships, family members were advised that when the questionnaire referred to family, it was inclusive of friends and colleagues as part of that family.

Family members were asked to state whether they currently lived with the person with the problem (i.e., "Have you lived with your family member with the gambling problem in the last 12 months?"). To determine the impact of gambling on the family member, we asked family members to provide information on the time since the problem was identified by the family member. Specifically, we asked, "To the best of your knowledge, for how long has your family member (the gambler) had a problem with gambling?", and then, "How long has it been since you first discovered that your family member (the gambler) has a gambling problem?"

Impact of gambling on family members

Gambling impacts and coping were measured with multiple scales. These were:

• The Problem Gambling Significant Other Impact Scale (PG-SOIS) (Dowling et al., 2014) is a six-item scale that is a brief measure of the impact of problem gambling across six broad domains. These include financial, emotional distress, interpersonal relationship with the gambler, social life, employment and physical health. The PG-SOIS measures the impact in the previous three months using a frequency response format from (0) "Not at all" to (3) "Often", with scores ranging from 0 to 18. This is the first brief scale that seeks to measure the impact of gambling on family members but it has not yet been subject to validation.
• The Problem Gambling Family Impact Measure (PG-FIM) (Dowling et al., 2015) is a 14-item scale that measures three domains of functioning. These include financial, increased responsibility and inter/intrapersonal functioning. Compared with the PG-SOIS, the PG-FIM investigates fewer domains but does so in more depth. The PG-FIM measures the impact over the previous three months using a frequency response of (0) "Never" to (3) "Often", with results in a possible score ranging from 0 to 42. The PG-FIM also has three sub-scales including financial impacts (items 1, 2 and 3), increased responsibility impacts (items 4, 5 and 10) and psychosocial impacts (items 6, 7, 8, 9, 11, 12, 13, 14). The means of the factor scores indicated that the most commonly endorsed factor was psychosocial impacts (M = 2.50, SD = 1.47), followed by financial impacts (M = 2.09, SD = 1.10) and increased responsibility (M = 1.39, SD = 0.81). The PG-FIM (problem gambler version) has displayed good internal consistency: financial impacts (α = 0.87), increased responsibility impacts (α = 0.85), and psychosocial impacts (α = 0.94) but still needs to be validated against other measures of family impact (Dowling et al., 2015).
• The Coping Questionnaire (Orford, Templeton, Velleman, & Copello, 2005) measures strategies family members use to cope with alcohol use problems. Adapted for gambling from a similar screen for family members, the 30-item instrument has been used to measure coping in family members of people with problem gambling (Krishnan & Orford, 2002; Dowling, Suomi, Jackson, & Orford, in preparation). Dowling et al. (in preparation) identified six factors when this instrument was employed to measure the perception of family member coping from the perspective of treatment-seeking gamblers: Engaged-supportive coping (α = 0.88), involving engaging in trying to change a family member's excessive gambling in a variety of supportive and assertive ways; Engaged-emotional coping (α = 0.85), involving engaging in trying to change a family member's excessive gambling in a variety of emotional and controlling ways; Withdrawal coping (α = 0.82), involving withdrawing from the family member or engaging in activities independently of the family member; Tolerant-sacrificing coping (α = 0.74), involving putting up with a family member's gambling in a sacrificing way; Tolerant-emotional coping (α = 0.74), involving putting up with a family member's gambling in an emotional way; and Tolerant-accepting coping (α = 0.47), involving accepting the family member's gambling. The total summed score for all 30 items yielded high internal reliability (α = 0.93). Based on the highest loading item for each of these factors, we adapted the questionnaire so that it could be administered as a brief six-item questionnaire. Participants rated the frequency of use of each action over the past three months. The response format was (0) "Not used" to (3) "Often", with a range of scores between 0 and 18.
• The Oslo 3-item Social Support scale was used to determine the level of social support available to family members (Dalgard, 1996). Questions included (1) "How many people are so close to you that you can count on them if you have serious problems?" (none, 1-2, 3-5, 5+); (2) "How much concern do people show in what you are doing?" (1 = a lot of concern or interest, 5 = no concern or interest); and (3) "How easy is it for you to get practical help from neighbours if you need it?" (1 = very easy, 5 = very difficult; note this item was reversed scored). Higher scores indicate greater social support than lower scores. Previous research has reported the OSLO is related to quality of life (Schmidt, Mühlan, & Power, 2006) and that the items can reliably be combined to measure a global score for social support (Kamenov et al., 2016).

Types of low- and high-intensity services accessed

We sought to identify a range of common services and supports that people commonly used to change or manage a family member's gambling problem. Responses were grouped into three categories: low-intensity, high-intensity and self-directed actions. Low-intensity interventions were defined as those offered as a single session and do not necessarily involve an ongoing commitment. Each of the options identified were provided at a distance and via the Internet (i.e., chat and email) or phone (i.e., helpline). Ongoing interventions (e.g., problem gambling counselling and financial counselling; support groups), as well as treatment from a general practitioner (GP), psychologist or psychiatrist were defined as high-intensity interventions. We also included a category of self-directed interventions (e.g., read information on websites; tried a self-help strategy like budgeting; talked to family members or friends about gambling).

Low-intensity interventions:

• talked to a gambling help counsellor online;
• sent an email to a gambling help counsellor;
• phoned a gambling helpline.

High-intensity interventions:

• talked to a gambling counsellor face-to-face;
• sought financial counselling by phone or face-to-face
• talked to a psychologist, psychiatrist or GP about the gambling;
• attended a family and friends support group for gambling;

Self-directed interventions:

• read or posted in the online forums;
• read information on the Gambling Help Online website;
• talked to family members or friends about the gambling;
• tried a self-help strategy like budgeting to reduce the impact of gambling.

Family members were asked, "How often have you accessed support? Here is a list of services and supports people impacted by gambling can access. They include online options as well as face-to-face and phone services. This time we are checking whether you have ever used the service. How often have you ever tried these support options? If you have never used the service or support check 'never'." Family members responded with "never", "once", "2-5 times" or "more than 5 times".

Types of e-therapy accessed

Participants were asked three questions about their experiences with Gambling Help Online. Questions were based on an evaluation of the Michigan Gambling Helpline (Ledgerwood, Wiedemann, Moore, & Arfken, 2011) and included:

• Thinking back to when you registered for Gambling Help Online yesterday, what service/s did you access? (Response options were "yes" or "no" against each service offered.)
• Thinking back to the services you accessed yesterday, rate the extent to which the service you received was enough (i.e., that you did not need any more services for your concern)? (Response options were from 1 = "definitely not enough" to 5 = "definitely enough" for each e-therapy service accessed.)
• Thinking about the service you accessed yesterday, how likely is it that you will follow-up on the information or referral that you received? (Response options were from 1 = "definitely will not follow up" to 5 = "definitely will follow-up" for each e-therapy service accessed.)

Reasons for help-seeking

To determine the treatment and support needs of family members, we asked a series of open and closed questions. Open questions were related to why they were seeking help online and expectations of the services provided. These were:

• We are going to ask you a few questions about the reasons you sought help online. Firstly, can you tell me the main reason you recently accessed online help?
• When you contacted the online service yesterday what help did you expect to receive? For example, if you wanted information, what kind did you want? If you wanted someone to talk to, what did you expect them to do or say?

Family members were also asked to provide their views on how families can be better supported when dealing with problem gambling. Specifically we asked:

• Finally, we are interested in your views on how we can help the families of people with problem gambling better. What services, support or information would you like to have over the next month?

To determine improvements to e-therapy and possible service options for the future, family members were asked to rate the importance of multiple reasons for seeking help. These items were informed by the literature and consensus amongst the research team. Each of these items was rated from (0) "not at all important" to (3) "extremely important". Items included:

• Get my family member to reduce their time or money spent gambling.
• Understand more about problem gambling.
• Improve my skills in responding to the problem, like assertiveness skills.
• Get my family member into treatment.
• Increase my knowledge of support and help options.
• Get help to better support my family member.
• Improve the quality of my relationship with my family member.
• Make my relationship with my family member less stressful.
• Get help in managing a crisis situation related to the gambling.
• Improve my skills in managing my emotions or feelings.
• Have someone to listen to my story and needs.
• Read stories of people in a similar situation to me.
• Talk with someone who is in a similar situation to me.

Statistical analysis

Descriptive statistics were used to report on the characteristics of family members, the impact of gambling on family members, types of low- and high-intensity services accessed, types of e-therapy accessed and reasons for help-seeking.

The three open questions: (1) "Can you tell me the main reason you recently accessed help online?", (2) "When you contacted the online service yesterday what help did you expect to receive?", and (3) "What services, support or information would you like to have over the next month?", were analysed in Microsoft Excel using thematic analysis as outlined by Braun and Clarke (2006). This involved (1) familiarisation with data, (2) generating initial codes, (3) searching for phenomena among codes, (4) reviewing phenomena, (5) defining and naming phenomena, and (6) producing the draft results. 

Results

Characteristics of family members

The first aim of this study was to describe the characteristics of family members including gender, age, relationship to the gambler and length of time the gambling has impacted on the family member.

Services users were most often female (89%, n = 55). The average age was 36 years of age (SD = 12.5), with a range between 21 and 67 years of age. As shown below, 59% of family members were younger than 35 years of age.

Notes: n = 58. Percentages may not total exactly 100.0% due to rounding.

Family members were asked to describe their relationship to the person with the gambling problem. Almost two-thirds were the partner of the person with a problem. As shown below, the person with the problem was also a parent, child, sibling or friend.

Note: n = 62.

A high proportion of family members currently lived with a family member with a gambling problem. Over two-thirds of family members lived with a person with a gambling problem in the last 12 months (n = 42, 68%). Seven family members had lived with someone with a gambling problem but did not currently do so (11%). A further 13 family members did not and had not lived with a person with a gambling problem (21.0%).

We asked family members, "To the best of your knowledge, for how long has your family member had a problem with gambling?" The highest percentage was more than 10 years, with a similar number reporting a more recent development of a problem (i.e., 1-2 years).

In addition to the duration of the gambling problem, family members reported the amount of time that had passed since they found out about the problem. Over half the family members found out about the problem within the previous 12 months, with almost 25% finding out in the past month.

Impact of gambling on family members

The second aim was to examine the impact of gambling on family members including their functioning, coping and levels of social support.

The PG-SOIS was employed to measure the impact of problem gambling across six broad areas of functioning including financial, emotional distress, interpersonal relationship with the gambler, social life, employment and physical health. The average score on the PG-SOIS was 13.3 (SD = 4.1) and scores ranged between 3 and 18. Participants were most likely to report being often impacted in terms of their emotions (77%), their relationships (67%) and financially (51%), with smaller proportions reporting being often impacted in terms of social life (40%), physical health (40%), and employment (33%).

Note: n = 57.

Note: n = 58. Percentages may not total exactly 100.0% due to rounding.

The PG-FIM was employed to measure the impact of problem gambling on family members across three broad domains (financial, increased responsibility and inter/intrapersonal functioning). The average score on the PG-FIM was 29.2 (SD = 11.0), with a range of between 0 and 42. The three sub-scales were calculated with the highest mean reported for the psychosocial sub-scale (M = 16.6, SD = 6.7). Sub-scales for financial (M = 6.2, SD = 2.7) and increased responsibility due to gambling were similar (M = 6.4, SD = 3.0). Family members were most likely to report often being impacted by an inability to trust the gambler (67%), feelings of anxiety (64%) and anger towards the gambler (62%). The least commonly endorsed impact was related to family violence or conflict (19%). Even though family violence or conflict were less frequently endorsed, it was still endorsed by almost one in five family members across the sample.

The Coping Questionnaire measured family members attempts to cope with problem gambling. The average score was 8.8 (SD = 4.8) with a range of 0 to 18. The median score was 9 and the mode was 11. The most commonly endorsed coping strategies involved encouraging your family member to take an oath or promise not to gamble (79%), starting an argument about the gambling (78%), making excuses, covering up for the gambler, or taking the blame for the gambler (71%).

Notes: n = 58.

Family members were asked to describe their levels of social support. Specifically, they were asked how many people are so close to you that you can count on them if you have serious problems. Thirty family members reported that they had one or two close friends (52%) and 14 reported 3-5 people (24%). Six family members stated that they had six or seven close friends. Eight family members said that they did not have any close friends that they could count on (14%).

In terms of social connectedness, most family members stated that other people showed concern or interest in what the family member was doing. Thirty-eight family members stated that people had a lot of concern or some concern and interest (66%). Fifteen family members were uncertain of the amount of concern others displayed (26%) and a further five family members stated that others showed little or no concern in what they were doing (9%).

For the most part, family members reported that it would be difficult for them to get practical help from neighbours if they needed it. As shown below, over two-thirds of family members stated that it would be difficult or very difficult to get help if needed.

Types of low- and high-intensity services accessed

The third aim was to describe the types of low- and high-intensity services accessed by family members prior to e-therapy. Almost all family members had attempted some kind of intervention prior to accessing e-therapy (93%). Only four family members had not accessed any help prior to accessing one of the e-therapy options.

As indicated in Table 6, over two-thirds of family members had engaged with at least one low-intensity service prior to accessing one of the e-therapy options (n = 41, 68%). Twenty-six family members had accessed one low-intensity service and 13 had accessed two low-intensity services. Just two family members had accessed three low-intensity services.

Notes: n = 60.

Prior to accessing e-therapy, 25 family members (42%) had accessed a high-intensity service. Twelve had accessed one service and nine family members had accessed two high-intensity services. Four family members had accessed three or more high-intensity options.

Fifty-three family members had attempted at least one self-directed option prior to accessing e-therapy (88%). Five family members had tried one option and 13 had tried two high-intensity options. The highest proportion of self-directed options accessed was three (n = 20, 33%), and 15 family members had attempted four different self-directed options.

Family members were also asked if there were any services or treatment options that they had accessed that were not represented in the questionnaire. For the most part, family members stated they had not accessed any other types of treatment. Three family members identified a school counsellor and relationship counselling that is not specific to finances or gambling. One family member identified the use of interactive tools to calculate financial goals, saying that this was a way to demonstrate what could be achieved if gambling spending were to change.

Types of e-therapy accessed

The fourth aim was to examine the types of e-therapy accessed (i.e., what was accessed and in which combinations) and the degree to which the intervention was enough. Family members were asked to indicate the types of services that they had accessed at Gambling Help Online. There were 36 family members that interacted with a professional counsellor (58%) and 26 that accessed a forum or website content and did not interact with a counsellor (42%).

As shown on the table below, the most frequent service accessed was information on the website followed by reading or contributing to online forums.

Notes: n = 62

As shown below, there were 10 possible combinations of service access. Of the four service options being investigated, family members accessed an average of 1.9 services (SD = 0.85, mode = 2). Reading information on the website was one of the activities undertaken in three of the top five combinations. The most frequent combination of service options was for family members to talk to a counsellor via chat and read information on the website. The second most frequent combination was to email a counsellor and read or post in the forum.

There were 22 family members who accessed one service only (36%). The most frequent single service option was information on the website, followed by chat. No family members reported accessing email without also accessing one of the other service options.

There were 26 family members (42%) who accessed two services, with the highest combination being chat and the website. Ten family members sent an email to a counsellor and read or posted in the forum.

Eleven family members (18%) accessed three services. The most frequent combination was chat, the forum and website content (11%). Just three people accessed all four e-therapy options.

As shown in Table 8, over half of the family members who talked to a counsellor via chat rated this as enough or definitely enough (54%). Almost half of family members rated information sourced from the Gambling Help Online website as enough or definitely enough (49%).

Note: Percentages are calculated on the number of family members who had accessed that service option.

Family members who accessed these services were then asked how likely it was that they would follow up on the information or referral that they received. As shown in Table 9, the highest likelihood of follow up was reported by those who had sent an email to a counsellor (83%) and those who had talked to a counsellor via immediate chat (73%).

Note: Percentages are calculated on the number of family members who had accessed that service option.

Reasons for help-seeking

The fifth aim was to describe reasons for seeking help, expectations of treatment and what family members ideally want from services.

Given the similarity in the reasons for seeking help, expectations of treatment and what family members ideally want from services, we have grouped these responses together. The three open questions related to help seeking elicited 155 responses from 55 family members.

In total there were 53 reported reasons for help seeking, which were thematically grouped into psychoeducation (seeking information), approaching the person, encouraging help, and supporting change. There were also 57 resource needs identified, which were thematically grouped into improving coping skills/self-efficacy and social support.

Psychoeducation of gambling behaviours

Fifteen family members sought psychoeducation (or information) to understand problem gambling. This included understanding why people gamble in order to understand the problem better. One family member stated that they wanted to understand how problem gambling developed so that they could determine how severe the problem was and whether their family member was ready to change (i.e., specifically, to understand the severity of the problem).

Two family members reported that they expected to source information on the thinking associated with problem gambling in terms of what their family member could be thinking or feeling. Understanding the nature of problem gambling was seen as a way of gaining insight into the family member's current situation, including the severity of the problem. Information was also a way the family member could be reassured that their response to the gambling problem was a normal reaction to a difficult situation:

I wanted information. Facts and figures and the impact of those. I'm not the best at saving money either so had nothing to compare it too. (Female, 26, partner)

I wanted information about gambling. What I was experiencing was a normal reaction to the situation? (Female, 29, partner)

Four family members stated that they sought help in the expectation that they would feel more hopeful following the contact. For three family members who accessed the online forum, reading other people's stories gave a sense of hope that there could be a good outcome. They said:

I thought it might be helpful to access the blogs and hear about other people's stories, to give perspective on the situation and hope that there is a future. (Female, 32, partner)

I hope that I'm not alone and that this can be managed and my relationship isn't doomed. (Female, 36, partner)

I also needed hope that the problem can be fixed. (Female, 21, partner)

Three family members stated that information on gambling would be helpful. One family member stated that it would be helpful to explain that problem gambling can happen to anyone.

You don't need to have lost huge sums of money for it to be a recognised problem. (Female, 40, partner)

Another family member stated that they wanted to understand the cycle of gambling better, saying:

I want to get a better understanding of why he does these things. (Female, 44, partner)

Similarly, another family member requested more specific information on the harms of gambling specifically around life stage. They suggested:

Continued facts and figures about different age groups and what you miss out on at different stages in life. (Female, 26, partner)

Approaching the subject of problem gambling

Eight family members wanted help in how to approach the subject of problem gambling. The most frequent reason for contact was because of a family member's excessive gambling or because of their gambling problem, compulsion or addiction. Often the gambling had recently changed, which had prompted contact. For example, one family member stated:

My partner has recently started excessively gambling and has clocked up thousands of dollars of debt in just a few short weeks. (Female, 36, partner)

Two family members wanted help in how to begin responding after a gambling problem was disclosed.

Similarly another family member reported they accessed the site in search of information and resources that were available to family members impacted by problem gambling:

My husband admitted to a gambling problem. I didn't know where to begin helping him. (Female, 28, partner)

I accessed the site in search of information and to see what resources are available to the families of problem gamblers. (Female, 32, partner)

Communication was an issue for three family members. This included how to talk to the person and also their family about the gambling problem:

I am concerned about a family member and wanted more specific information that would help the family to talk about it with her. (Male, 33, other relative)

Two family members made contact specifically because of a relapse. One family member reported that their partner had started gambling again. Another family member stated that they knew that their partner had experienced problems in the past, but was shocked that they were still gambling. One said:

I recently found out my husband had been gambling playing the pokies. I wasn't aware of his return to gambling. He previously had an addiction that he had told me about and told me he hadn't gambled since meeting me, which has been over 16 months. We have recently married, so it has upset me dearly. (Female, 49, partner)

To encourage help-seeking

Thirteen family members wanted information on how to encourage help seeking inclusive of seven family members that wanted advice on how to help someone that did not want help. There were five family members that explicitly said that they made contact because the person with the problem did not want help. For one family member, her partner had agreed to seek help but had not carried through with the decision.

I want to get my partner help but don't know how to go about it. He has had meetings scheduled with someone who would help him financially with gambling but he has either forgotten to attend, couldn't get a proper time or they have cancelled. Since then he hasn't done anything about it and I feel like I need to do something to get him help. (Female, 22, partner)

Similarly, two family members described a situation where the family member would not continue to help themselves:

My partner has been struggling with a gambling addiction for over 10 years (we have been together for five years) and while he identifies as being in recovery, he will not attend meetings or counselling and his refusal to do anything to help himself is affecting our relationship. (Female, 32, partner)

My husband does not have a permanent job and when he gets any work, the money he earns goes straight to gambling and he has been doing it for years and he knows he has a problem but won't seek help. (Female, no age reported, partner)

Three family members stated that they sought help because their family members did not recognise that they had a problem. One family member sought help because they wanted advice on how to help their parent who was having difficulty changing their gambling:

My mum has been affected for many years with gambling issues. As a dependent on her, I cannot help her to change unless I devote enormous time and energy to control her habits. Most significantly, she does not have a will to change and justifies her actions. I contacted this website for some advice although I was sceptical that it could help. (Male, 21, child)

Another family member acknowledged that their partner did not see the gambling as a problem but decided that they needed to seek help for themselves. They stated:

My husband is a compulsive gambler. I need to seek help, he doesn't see it as a big problem, and I know it is only going to end badly. (Female, 52, partner)

Family members also expected assistance in sourcing or obtaining further help. Nine family members requested information on counselling services, support services, support groups and non-specific further help. For these family members the focus was on sourcing information including phone numbers or service details rather than making an appointment. This was often because information was being sought for someone else but also because information was being sought for a later time:

I wanted to understand the support services available. (Female, 30, partner)

I was expecting an email with information on support groups and counselling for my partner and I. (Female, 28, partner)

I want to be able to offer him links or phone numbers, etc., where he can receive professional help. (Female, 52, partner)

Five family members requested specific referral details and assistance with making appointments. This included facilitating contact with local services or making an appointment through an online booking system. Immediate help was also expected. This included immediate access to a counsellor via chat or email because they were feeling distressed:

I wanted someone to talk to online as I was feeling distressed. (Female, 46, partner)

How to support change

Fifteen family members sought strategies and expert advice on how to support change. Family members expected help specifically for the person with the gambling problem as well as strategies and expert advice for their own reaction to the problem. In terms of help for the gambler, family members expected information and advice on how to help a person with a gambling problem. This was most often related to specific steps, strategies and practical solutions:

Any better tips or suggestions to help, other than the basic info on the website. (Male, 33, other relative)

Expectations were also in relation to information on how to help someone who would not recognise that they had a problem and also how to help someone who lies about gambling:

I wanted to try and find the best way to deal with my partner, knowing that he is lying about playing the gaming machines. (Female, 25, partner)

Help with interpersonal communication was related to how to talk about the problem without making it worse. One family member expected general tips on how to communicate and another stated that they needed advice on what they could do to help the person with the gambling problem without causing the other to become distressed. Another family member wanted advice on communication also, but for this person it was so the family member would listen to them:

I wanted advice on how to communicate with my partner as he doesn't seem to hear what I say to him. (Female, 32, partner)

Just two family members expected specific information related to limiting gambling. One family member wanted to know if a small amount of gambling was okay for a person with history of problem gambling.

Resource needs

Improve coping skills and self-efficacy

Eleven family members made contact to improve their coping skills and a further eight family members wanted to improve their self-efficacy or confidence that they were responding to the problem appropriately.

Family members also made contact because of the impact of gambling on the family member. This included effects on the relationship, finances, mental health and coping. When mentioned, relationship problems were entwined with financial concerns. For example, one family member said their husband had both been untruthful and spent all of the family savings. Another stated:

I am in a long-term relationship with somebody with a gambling problem. We are having financial problems and also problems with our relationship as a result of his gambling. (Female, 22, partner)

Financial issues were the primary reason for contact for three family members. These family members reported that the problem gambler had gambled all of their money or had stolen their money. One family member described a combination of secrecy and the accumulation of debt in saying:

My husband has secretly been over-gambling and used up thousands of dollars ... [we are] now in huge debt. (Female, no age reported, partner)

Family members also made contact in response to their own mental health and coping concerns. They reported feeling distressed and hopeless about the gambling. For example, one family member said they felt hopeless and did not know how to recover from the depression that had developed because of the gambling problem. Similarly, another family member made contact because of feelings of hopelessness:

I feel hopeless when trying to help my son who is a gambling addict. He makes a fool of me and is nasty towards me, not realising the impact that his problem has had on me. (Female, 57, parent)

Worry was also an issue for adult children affected by a parent's gambling. Children of gamblers also made contact seeking ways to cope with the gambling situation:

My father is addicted to gambling and I am starting to worry about how it is affecting my mother. (Female, 32, child)

My dad has a gambling problem and I sought ways to help cope with the situation and to help him. (Female, 26, child)

Social support

Expert advice specifically for the family member was also expected. Twelve family members stated that they expected someone to listen and offer support. For the most part, responses were versions of "wanted to talk to someone and have someone to talk to, someone to listen". Others reported that it was a comfort to talk to someone about the issue and feel that there was someone that cared:

Just comfort words and allows me to feel that there would be someone there for me without me having to reveal my identity. (Female, 25, child)

Family members wanted guidance in terms of how to respond to problem gambling. Five family members stated that they wanted to know where to start or to check they were on the right track.

I was hoping someone could point me in the right direction: Where to start really. (Female, 28, partner)

I just needed advice on the best steps to take and I was expecting to speak to someone about what I should do next. The counsellor was really understanding, knowledgeable and sincere to my emotions. She gave me some good advice and made me feel as if I have done the right thing contacting the helpline. (Female, 49, partner)

For others who had already attempted to manage problem gambling, guidance and advice was related to reassurance.

I mostly wanted someone to talk to and someone to reassure me I am taking the right steps. (Female, 23, partner)

There was an expectation that the service could also help the family member in strategies to cope, communicate and either maintain or end their relationship. Coping was related to the situation as well as the possible outcomes if the gambling problem was not resolved. One family member stated that they expected information on how to help manage the situation and deal with the outcome of the gambling problem:

Advice on the mind of an addicted gambler. How to help manage the situation, how to deal with the outcome. How to encourage help. How to recognise how deep he is into his addiction, and hope that I'm not alone and that this can be managed and my relationship isn't doomed. (Female, 36, partner)

Three family members mentioned emotional upheaval, desperation and stress and wanted to know how to handle these experiences. Similarly, another family member reflected on the ups and downs associated with winning and losing from gambling and how this impacted on them:

I didn't know what to expect. I was desperate and was trying anything to help me out. (Female, 31, partner)

How do I handle the stress from having to listen to stuff about how to they lost the race, missed the quadrella, got beaten by a nose, are shattered by their loss. (Female, 42, friend)

Two family members specifically mentioned maintaining the relationship and two expected information on how to make a decision to end the relationship. In terms of maintaining the relationship, one family member said that they expected advice on how to balance managing the money and maintaining the relationship:

I was hoping for some strategies to help our relationship function despite me taking control of his and our finances. (Female, 22, partner)

I want to have an honest relationship and not stress about leaving $20 in my wallet or money in the access bank account. (Female, 25, partner)

Two family members also wanted to end the relationship. One stated that they expected to discuss whether to stay or leave the relationship. Another family member expected advice on how to terminate the relationship without harm or threats of retaliation:

I would like to know how to break up with the one with such problem smoothly, without any threats. (Female, 26, partner)

Reasons for help-seeking ranked by importance

In addition to the three qualitative questions, family members rated the importance of 11 reasons for seeking help across six different domains (gambling behaviour, approach to talking about gambling, encourage help-seeking, support change and identify resources).

Almost 80% reported a focus on the gambling behaviour and getting the gambler to reduce their time or money spent gambling as extremely important. The second most frequently endorsed item was associated with supporting change (i.e., getting help to support the gambler) followed by improving personal resources and coping skills. Encouraging help-seeking was endorsed by almost two-thirds of family members as extremely important.

Note: Percentages may not total exactly 100.0% due to rounding.

Discussion

Main findings

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.

Conclusions

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.

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