Reasons for using web-based counselling among family and friends impacted by problem gambling

Abstract

Despite the range of free services available in Australia, few family and friends of people with problem gambling access them. Over recent years, the Australian gambling help service system has expanded to include web-based counselling. Family and friends make up approximately 15% of people accessing this new modality, however little is known of the reasons for choosing this form of assistance over other interventions. This research aimed to understand the reasons family and friends choose to use single-session web-based counselling over other modes (i.e., face-to-face and telephone), as well as why they would recommend it to other affected people. The study involved 63 participants (70% intimate partners, 13% children, 6% friends, 5% parents, 6% other family members) who completed open-ended questions on reasons for using and recommending web-based counselling, with over three-quarters of the sample seeking help for the first time. A descriptive content analysis revealed multiple overlapping themes, including ease of access (41.3% of reasons for choosing), privacy and anonymity (17.5%), and a preference for the characteristics inherent in the therapeutic medium (23.8%). We also found web-based counselling provided a pathway into services (11.1%) and that the intervention provided was viewed as helpful and a reason for recommendation (34.9% of reasons for recommending). This research provides important new information on the help-seeking preferences of family and friends. Future research is required to understand the relationship between reasons for use, help-seeking preferences and the effectiveness of single-session web-based counselling for people affected by problem gambling.

Background

The impact of problem gambling is broader than its effects on the gambler, with estimates suggesting up to seven people close to the gambler are also typically adversely affected (Productivity Commission 2010). Impacts experienced include cash flow problems and debt, poor mental health, lowered quality of life (Kalischuk et al. 2006), increased tension within relationships and interpersonal conflict (Dowling et al. 2009; Hodgins et al. 2007;Kalischuk 2010). In addition, family and friends report confusion over how to manage the problem gambling (on a daily basis as well as long-term), and particularly struggle with putting boundaries around spending (Patford 2007a). These effects have been most frequently studied among the intimate partners and children of problem gamblers, but extended family members and friends are also affected, although probably generally to a lesser extent (Heineman 1989;Kalischuk et al. 2006; Moody 1989; Patford 2007b).

Despite a range of symptoms associated with problem gambling, there is limited research exploring the role of family and friends in the treatment of problem gamblers or the efficacy of treatment for this group. It has been proposed that family and friends may be significant in assisting gamblers seek help (Clarke et al. 2007), and in some cases, reduce harms associated with problem gambling (Hodgins et al. 2007;Ingle et al. 2008). Interventions designed to improve the functioning of the family and friends of problem gamblers have included Community Reinforcement and Family Training (CRAFT), which has been previously found to be effective in reducing alcohol use (Hodgins et al. 2007; Makarchuk et al. 2002), as well as treatments that specifically aim to increase the coping skills and decrease the distress of family and friends (Rychtarik & McGillicuddy 2006).

While structured interventions show some efficacy, most family and friends typically engage in much lower intensity interventions, such as self-help, self-regulation, telephone or online support (Hing et al. 2013). Despite this, family members delay contacting helplines for a range of reasons, some of which relate directly to service characteristics (Hing et al. 2011). These include a lack of awareness that helplines cater for family members, that they are free, as well as issues around shame associated with problem gambling and wanting to manage it within the relationship (i.e., partner, parent, sibling, etc.).

Brief interventions with family and friends are largely unreported, despite them comprising approximately 15-20% of callers to helplines and web-based services internationally (Clifford 2008;Rodda & Lubman 2012b;Wood & Griffiths 2007). For example, over recent years, web-based counselling has been offered to anyone in Australia affected by problem gambling. Gambling Help Online offers 24/7 immediate real-time chat, email support, community forums and self-help information via its website (gamblinghelponline.org.au). This website was visited 60,729 times by 47,333 visitors in 2010–11, and pages for family and friends are viewed frequently, including those that provide information on helping others (n = 10,188 page views) and how to offer practical help (n = 2893 page views). Approximately 15% of web-based clients receiving counselling are family and friends of people with problem gambling.

Previous research suggests web-based interventions are attractive due to their potential for anonymity and convenience (Cook & Doyle 2002;Young 2005), as well as their accessibility and availability (Wood & Wood 2009). While this research has almost exclusively involved clients involved in ongoing treatment or members of forums, there is limited knowledge on those engaged in single session brief interventions. Two studies have sought to identify the reasons why people choose web-based counselling over telephone or face-to-face. The first, involving young people contacting a generalist help online service, found privacy and an emotionally safe environment (e.g., reduced exposure, privacy, control), and issues around time were motivators for using the service (more time to reflect) (King et al. 2006). The second study, involving people with problem gambling, found anonymity and confidentiality, convenience, service system access, therapeutic medium and professional support to be the main motivators (Rodda et al. 2013).

Although studies on barriers to treatment and interventions are important, there are several constraints that may limit their generalisability to family and friends seeking single session brief interventions. There has been a focus on longer term and appointment-based treatment programs for family and friends, with little investigation of their help-seeking preferences. Furthermore, while many studies have identified reasons for seeking help, few have identified reasons for seeking help from a particular type or mode of service, and none involving family and friends.

This study aimed to understand the reasons why family and friends chose to engage in web-based counselling, with a particular emphasis on investigating why they did so over other modalities (i.e., face-to-face and telephone). A qualitative methodology was adopted because of our focus on understanding the perspectives of family and friends, and because it is a valuable approach for exploring such issues in under-researched areas.

Methods

Sample

Between December 2010 and September 2012 there were 366 family and friends who completed a counselling session at Gambling Help Online. This service is a solely web-based program providing assistance to anyone affected by problem gambling. The service provides real-time chat and email in addition to a community forum and a range of self-help materials. Approximately 1500 people each year use the chat and email, which can be accessed from any internet-enabled device following a brief sign-up process. Family and friends choosing the chat option are typically connected to an online counsellor within a few minutes and a session involves a combination of counselling, information and support over a 45-minute period by a professional counsellor with qualifications in psychology or social work (Rodda & Lubman 2012a). Until recently, participants were offered a completely anonymous service (i.e., no email address was required), and as such no follow-up beyond the session was possible.

Of the 366 family members and friends who accessed the service, 63 completed the short survey (two open-ended questions) provided as a link at the end of their web-based counselling session; (1) ‘What made you decide to use online counselling over other types of assistance (e.g., telephone help line, face-to-face counselling)?’ and, (2) ‘Would you recommend online counselling to someone concerned about a gambling issue (yes/no)? Why is that?’ The survey response rate was 17%, which is comparable to other online surveys that do not involve follow-up reminders, pop-ups or other methods to increase participation (Powell et al. 2003;Sheehan 2001).

Data analysis

The open-ended responses pertinent to this study were analysed using descriptive content analysis, as described by Newell and Burnard (2011). This approach allowed the examination of themes emerging from the two pre-set open-ended questions rather than allowing general themes to develop. Two authors (SR, DL) independently read transcripts and developed themes and created open coding headings from a review of the data. To ensure categories were mutually exclusive, a number of categories (or codes) were combined (e.g., privacy and confidentiality) and sub-categories developed. In addition, categories were collapsed into higher order codes (or categories) such as therapeutic medium, which consisted of a range of themes related to the characteristics of the medium (e.g., able to be more honest and expressing oneself) (Newell & Burnard 2011). The Microsoft Excel database was then employed to code the items into categories and higher order codes.

Results

Socio-demographic characteristics of participants

The 63 participants were predominately female (87%), with 30% aged under 30 years, 30% aged between 30 and 39 years, 27% aged between 40 and 49 years, and only 13% aged over 50 years. Participants were most often intimate partners (70%), with smaller numbers of children (13%), friends (6%), parents (5%) and other relatives (6%). Participants represented all states across Australia, and most often identified as Australian ethnicity (78%), followed by Asian (8%), European (6%), Oceania (5%) and African (3%). They most often reported family member engagement in non-strategic forms of gambling (such as electronic gaming machines, lotteries, bingo and Keno; 59%) than strategic forms of gambling (i.e., wagering, casino gambling, sports betting; 41%). Almost 55% of participants stated the gamblers’ preference was to gamble in a venue, and only 5% reported the preferred method was to gamble via the internet. The remaining participants (40%) were unable to identify the preferred method.

Almost three-quarters of participants (74%) were speaking with a professional for the first time about the gambling problem, with 16% previously receiving counselling and 10% currently seeking other forms of treatment for the gambling problem. Those who previously sought help for the gambling problem had accessed face-to-face (56%) and telephone (44%) counselling. Most real-time chat sessions occurred outside traditional business hours, including evenings and weekends (68%). Most participants (91%) indicated that they would recommend web-based counselling to someone concerned about a gambling issue.

To determine the representativeness of the current sample, participants’ demographics were compared with the total population of 366 family and friends who completed a real-time chat counselling session with Gambling Help Online between December 2010 and September 2012. Chi-square analysis indicated that there were significantly fewer participants under 30 (χ² (1) = 8.66, P = .004), significantly more participants aged 40 to 50 years (χ² (1) = 8.02, P = .007), and significantly fewer people identifying as Australian compared with the total population (χ² (1) = 6.10, P = .14). In addition, significantly more participants did not know the preferred method of gambling (χ² (1) = 4.55, P = .036). There were no significant differences between groups in terms of gender, type of gambling, treatment seeking status, or time of contact.

Reasons for choosing web-based counselling

Ease of access

The most widely reported reason for using and recommending web-based counselling was ease of access (reported by 41.3% of participants). For family and friends affected by another person’s gambling, easily accessing help that was convenient was important. For others, ease of access that was immediate meant that highly motivated individuals could act immediately without waiting for an appointment.

Because it is so easy to access and so available. Not like face-to-face counselling where you have to make appointments or telephone counselling where they might not be available all hours (partner, 25–29, female).

Indeed, this combination of immediacy and 24-hour access meant that help was available when it was needed. Some participants reported feeling desperate to receive advice on how to manage a gambling problem late at night.

For others, there were issues around the cost of help-seeking. This was either due to not having a telephone landline or being restrained in their mobile phone billing arrangements, such as having pre-paid devices. Indeed, participants noted 1800 helpline calls were not free and were prohibitive to use from a mobile device.

Financial limitations, I only have a prepaid mobile phone, didn’t want my partner to hear me (partner, 40–44, female).

Privacy and anonymity

As described above, there were issues around privacy and anonymity (17.5%). Privacy and confidentiality most often related to not being able to discuss concerns over the phone. Discrete and private conversations were a concern where the participant did not want to be overheard by work colleagues or the person with the gambling problem.

Because I have a very busy work schedule and find it hard to talk without my partner around (partner, 20–24, female).

In addition to some participants being concerned about being overheard, others were concerned about not being identified. Anonymity emerged as a reason for web-based counselling in terms of feeling safe behind a screen with no names exchanged and as a good way to be honest and get honest answers without being personal. Indeed, issues around anonymity were expressed in terms of reducing barriers related to the shame and stigma of problem gambling.

I’m the partner of a problem gambler; it’s hard to realise that you’re not a bad person to also need help. The anonymity of online assists in opening up [talking about the problem] (partner, 20–25, female).

Therapeutic medium

The therapeutic medium appears to assist with self-disclosure and comfort (reported by 23.8% of participants). This was typically around being able to talk openly and honestly without feeling embarrassed. This was expressed as a general difficulty in talking with people and, specifically, around the gambling problem.

First time I’ve done this over the internet; find it hard to talk to people in person, especially when I don’t know them. Guess I needed to vent and share with someone what I was going through (daughter, 20–24, female).

In addition, being able to communicate raw and overwhelming emotion was viewed as easier online. Participants described ease of communication and concern that they would be incomprehensible on the telephone or face-to-face as they were crying and shaking. They also indicated a preference for writing over talking, suggesting it was easier to write concerns down rather than speak them aloud.

I liked the idea of online because I could write out exactly how I felt and all my thoughts at once (partner, 20–24, female).

Underpinning many of these responses was an assumption participants were comfortable with technology. Indeed, one explicitly made a statement regarding the relationship between comfort and technology.

If you are comfortable with online communication, it is less confronting than actually talking to someone (partner, 40–44, male).

Service system access

Service system access for the gambler as well as the participant was a commonly reported reason for using web-based counselling (11.1%). Some participants stated that web-based counselling was a way to access the service system for information and guidance on managing the impact of problem gambling. For these participants there was no need for other services: I am the partner of a gambler looking for support; didn’t need face-to-face counselling. For others, information, advice and referral were sought for the gambler. Where referral to services was being sought for the gambler, participants said they would recommend web-based counselling as a good place to start.

Because it opens up the door and lets a problem gambler know that there are people there to help you whenever (parent, over 65 years, male).

Participants also described web-based counselling as not just a place to start but a way to ease gamblers into talking about their problem. Indeed, one participant described the features of web-based counselling as a method to access information on the suite of treatment options.

Because they can quickly, easily and without judgement access all the information they need to move forward (partner, 20–24, female).

Helpfulness

While few family and friends explicitly stated that they initially used web-based counselling because it would be more helpful than telephone or face-to-face (4.7%), having experienced the service they now regarded this as a reason for recommending it to others (34.9%). Helpfulness included being generally helpful in terms of the counsellor providing an empathic non-judgemental approach where the participant felt heard and understood.

Good to be able to have advice and support - non judgemental and available whenever it’s needed (partner, 30–34, female).

In addition, professional advice and guidance included the provision of helpful, valuable expertise and support. Access to knowledge and information in a timely manner also assisted in identifying next steps.

It was helpful to sort out ideas in my head and give me some direction and guidance for the future (partner, 20–25, female).

For a small proportion of participants (n = 5), web-based counselling did not meet their expectations and it was deemed unhelpful. This was typically due to them perceiving they were being provided with insufficient help, not feeling heard, and experiencing language difficulties communicating with counsellors.

Discussions

This exploratory study provides a first look at the reasons why family and friends choose web-based counselling over telephone or face-to-face services, and why they would recommend it to someone else experiencing concerns about a family member’s or friend’s problem gambling. As expected, themes around ease of access and privacy and anonymity emerged as well as characteristics inherent in the therapeutic medium. Similar to previous research involving gamblers seeking help online (Rodda et al. 2013), we also found web-based counselling provided a pathway into services and that the intervention provided was viewed as helpful and a reason for recommendation.

Five themes emerged that describe the reasons family and friends choose and recommend web-based counselling. First, ease of access was the most widely reported reason for using web-based counselling. This included being able to access services immediately and without an appointment at any time of the day or night. Similar to other studies involving affected family and friends (Hodgins et al. 2007), 70% of our sample was the intimate partner of someone experiencing problem gambling. Previous research suggests the proximity of intimate partners to the gambling problem make them particularly vulnerable to interpersonal conflict and increased distress (Hodgins et al. 2007; Patford 2009). Our research suggests family and friends value support at times of high stress and distress, along with advice on how to manage problem gambling. In addition, participants reported financial barriers to accessing other forms of treatment, particularly in relation to telephone contact. Increasingly, mobile phones have replaced landlines, with an associated loss in free-call access. Family members of problem gamblers may be especially vulnerable to any costs associated with help-seeking given the incidence of debt and financial problems (Downs & Woolrych 2010).

Second, web-based counselling was chosen and recommended due to its potential for privacy and anonymity. Privacy was a concern when talking about the impact of the gambling without the gambler or others overhearing the conversation. While previous research has found confidentiality commonly related to privacy in help-seeking (Hing et al. 2011), we found participants were more concerned about being able to talk discreetly. For other participants, there were significant issues associated with the shame and stigma of problem gambling that were alleviated via anonymity. Although shame and stigma has been repeatedly found to be a barrier to treatment for people with problem gambling (Evans & Delfabbro 2005;Hing et al. 2011;Suurvali et al. 2009), there has been little research on the embarrassment felt by family and friends about a loved one’s problem gambling, as well as their role in helping or hindering the problem (Bellringer et al. 2008). However, there is some evidence to suggest family members experience guilt and self-blame (Dickson-Swift et al. 2005), possibly due to the hidden nature of problem gambling (especially in the case of internet gambling which often occurs in the home) (Valentine and Hughes 2010). Family and friends are often the first people from whom gamblers seek advice (McMillen et al. 2004), attesting to the importance of also providing a safe space for families to obtain their own support and advice.

Third, the characteristics of the therapeutic medium were a reason for using and recommending web-based counselling. Participants described increased openness and honesty, where the interaction was devoid of any visual or aural cues and entirely text based. For many family members, this was their first time speaking with someone about the gambling problem and they were overwhelmed with emotion, but were able to express these thoughts and feelings online. This is consistent with previous work indicating users of web-based services feel more comfortable expressing themselves online compared with on the telephone (King et al. 2006). Previous research has also found that the characteristics of the online environment are likely to lead to greater self-disclosure due to anonymity, particularly when sharing difficult information (Beattie 2006; Leibert et al. 2006).

Fourth, we found being able to easily access the service system was a reason for choosing web-based counselling. Family and friends described a preference for web-based counselling as their only means of obtaining professional support and advice, with over three-quarters of the sample seeking help for the first time. Our sample did not differ to the wider population of family and friends accessing web-based counselling, and they were more often first time help-seekers compared with gamblers accessing the same service (Rodda & Lubman 2012a, b). The value of web-based services to this population is apparent given reasons for access associated with discreteness, anonymity, convenience and ease of access. Previous research suggests that family and friends are not a homogenous group and a range of interventions need to be developed (McMillen et al. 2004). This suggests the best approach may be one that addresses a range of issues from financial to relational, involving different types of interventions (e.g., self-help, professional support). Whether family and friends prefer these types of interventions to be available online warrants further investigation and indeed has implications for the configuration of treatment and services.

Finally, helpfulness of web-based counselling was a reason for recommending the service to other people affected by problem gambling. Helpfulness was expressed in terms of the counsellor listening and providing empathic and non-judgemental support, as well as providing expert advice and information. Helpfulness in the current web-based setting is possibly influenced by the immediacy of the intervention, delivered at a time and place that is accessible (i.e., not embarrassing, discrete and comfortable). As described by Stiles et al. (2002), evaluations necessarily involve a relationship between the evaluator and the event or object being evaluated, and that relationship necessarily changes over time. For example, those finding strategies helpful were possibly in a different place in their help-seeking journey than those who valued information or being able to tell their story. Indeed, previous research has shown that 73% of helpline calls had a preference for information and that 84% of callers were satisfied with this assistance (Hing et al. 2011). Understanding what factors predict helpfulness in a counselling session would be useful information for counsellors.

This study is the first to explore the reasons family and friends access and recommend web-based counselling. However, there are several limitations that need to be considered. Participants were older than the population from which they were drawn; as such, they may not be representative of younger people who use the service. Nevertheless, the age of most participants was under 40 years, which is younger than reported elsewhere (Hing et al. 2011; Hodgins et al. 2007). Second, while this descriptive study sought to represent the reasons for choosing web-based counselling, the data were collected at the conclusion of a counselling session and may have been influenced by the experience of the online session by participants. These findings could be enhanced via the development of a service preferences screening tool offered to all clients prior to a counselling session commencing.

Conclusion

Few family and friends access Australian counselling and support services, despite their availability. Indeed, an inquiry into problem gambling by the Australian Productivity Commission (2010) suggests governments need to develop education campaigns that encourage family and friends to seek help earlier. Our findings have a number of key implications for family and friends, support services and funding bodies. First, given families’ and friends’ preference for services that are easy to access, private and anonymous, as well as the reported benefits of accessing support online, the web-based counselling platform could be expanded to provide a broader range of interventions to assist family members and friends affected by problem gambling. However, to do this effectively, research is needed to examine the benefits of current service delivery across all modalities (i.e., online, telephone, face-to-face), so as to determine what is working for whom and where there are opportunities to better target service provision. Integral to this process is the development of a navigation tool to assist family and friends, as well as clinicians, in determining the most appropriate treatment options. As the service system continues to expand, providing practical advice on how to navigate its breadth and depth becomes increasingly important. Ultimately, this relies on the development of greater knowledge of the fit between service and client characteristics. Finally, the utility of providing time-sensitive emotional support needs to be better understood. Whether interventions provided during a time of crisis empower family and friends to better manage the impacts of problem gambling needs to be further examined.