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Gambling Harm Minimisation

ABACUS Feedback to the Ministry of Health
regarding
Emerging Trends in National & International Literature.

This summary of research has relevance to the clinical workforce,
it forms part of a regular six monthly report provided by ABACUS to the Ministry.

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Literature:

Problem gambling and family violence: family member reports of prevalence, family impacts and family coping Authors: Suomi A, Jackson A, Dowling N, Lavis T, Patford J et al (2013) Asian Journal of Gambling Issues and Public Health, 3:13

Link

Findings:

  • This Australian part of a large international study (Australia, NZ, Hong Kong) focuses upon problem gambling and family violence.
  • In phase 1, n=1030 clients of problem gambling, mental health, domestic violence, family support and substance abuse services were screened for family gambling problems, and n=120 (12%) confirmed gambling problems within their families.
  • Of the 120, over half (52.5%) reported some form of family violence within the last year. Of these, 20% had been the victims of such violence, 10.8% had been violent person, and 21.6% had been both the victim of and the perpetrators of the violence
  • This was a high level of violence when compared with previous findings of family violence in Australia (range 2.1% to 28%)
  • Problem gambling and family violence were related in over 70% of the family members responses, and that the problem gambling precedes the victimisation or perpetration of the violence in most circumstances
  • Violence from family member to gambler may be related to underlying anger and mistrust, and from gambler to family related to financial stress and crisis within the home. However, the relationship is complex with timing and cause often unclear as to direction. Pre-gambling violence appeared to increase with gambling, with multiple negative impacts occurred with families under distress from gambling
  • The authors acknowledge that there were some limitations to their findings of high levels of violence associated with problem gambling, including the relatively small sample size, self reporting and that it was a cross-sectional study. Also, clients were help-seekers and may comprise a different ‘population’ from those families who don’t seek help from gambling or family counselling services (or between these two where numbers were too small to compare)
  • The authors concluded that the negative impacts of problem gambling were unequivocal and that families attending problem gambling services should be routinely screened for violence.
  • The findings, conclude the authors, give support for family-based therapies to be used

Comment:

  • This is an important study that is currently underway also in NZ, with this paper reporting upon Australian early findings.
  • The paper has also been reported on by WAGER (Feb 2014) as part of its focus upon family effects of problem gambling (Special Series on Addiction within Relationships), indicating an new or increased international focus upon violence and problem gambling
  • Violence was identified on the basis of (within the past year) anyone physically hurting, insulted, talked down to, threatened with harm, screamed or cursed the person; also participants were asked if they either received (were victims of) or caused (perpetrated) this violence. The paper did not differentiate each of these forms of violence; however, the consequences of insult or being talked down to may be as harmful as physical harm, and this has been accepted for some time
  • Although some families may have had a culture of violence before gambling became a problem, the paper supports the expectation that such violence is more likely to be exacerbated by the gambling
  • Perhaps the most important finding is the increased likelihood of violence, even when taking into account the wide range of findings (gambling problems may increase family violence from 2 to 25 times) and that this Australian finding may have relevance to NZ, with some cultural similarities.
  • From a treatment perspective, there may be an expectation that unidentified family violence may result in a range of negative treatment outcomes, including resistance to change behaviours, relapse risk, as well as less well-being for the gambler or their family. Gambling is described as a hidden disorder, with difficulty confirming that gambling has stopped or reduced from overt symptoms; this may reduce family support when gamblers are receiving counselling, and in the absence of support, may maintain a culture of perpetration or victimisation within the family
  • Also, relatively few family members seek help for their own issues arising from the problem gambling of a member, and one important harm other than financial stress may be violence; this paper suggests that this may be the majority of gamblers, and family members may be affected by family violence
  • Currently, it is unlikely in NZ problem gambling services that clients (gamblers or their significant others) are screened verbally or otherwise for violence. A possible solution is to use the CHAT screen in a systematic approach for all clients, as three of the 16 screening questions would be appropriate and have been validated for the NZ population. These questions are: “Is there anyone in your life whom you are afraid of or who hurts you in any way?”; “Is there anyone in your life who controls you and prevents you doing what you want?”; and “Is controlling your anger sometimes a problem for you?”
  • The above questions are in addition to the 2 gambling questions and 11 co-existing issue questions that would support a CEP approach currently rolling out in NZ for a mental health and addictions strategy
  • Help-seeking by family members of problem gamblers is an even lower level that the acknowledged low level help-seeking by gamblers (compared with AOD). A family approach recommended by the authors could provide both relevance and enhance help-seeking by family members, as well as addressing what appears to be an important barrier to change and recovery for all affected family members.
  • These findings of high levels of family violence and problem gambling are found in other recent research. In a recent study (Echeburua, Gonzalez-Ortega, Corral, Polo-Lopezn (2013) Spanish J of Psychology, 16 (1)) problem gamblers (n=103) were matched to non-problem gamblers (n=103) with many negative findings for the problem gamblers (more anxious and impulsive; lower education, family history of alcohol abuse, greater CEP by way of DSM Axis 1 disorders, more adjustment difficulties with daily problems, female problem gamblers with more unemployment and lower socio-economic status, male problem gamblers more affected by alcohol problems). The most striking finding was the high level (68.6%) of family violence, with female problem gamblers reporting high levels of intimate partner violence when compared with female non-problem gamblers experiencing such violence (9.8%).
  • Violence in problem gambling has not previously been identified as a topic for inclusion in either screening or treatment, and the growing findings of violence associated with problem gambling suggests the need to move this topic to the forefront of consideration through systematic screening and treatment formulation.

Literature:

The concerned significant others of people with gambling problems in a national representative sample in Sweden – a one year follow-up study. Authors: Jessika Svensson, Ulla Romild , Emma Shepherdson (2013) BMC Public Health, 13:1087 doi:10.1186/1471-2458-13-1087

Link

Findings:

  • This paper examined the health, social support and financial circumstances of concerned significant others (CSOs) of problem gamblers in a Swedish sample. CSOs were those who acknowledged that someone close to them currently or previously, had problems with gambling. A longitudinal population study in Sweden (Swelogs) identified 18.2% (n=1,472) were positive for this CSO question; this compared to just over 2% of the Swedish population identified as problem gamblers (moderate to severe risk; 3+ on the PGSI) and close to 4% of the population lived in the same household as a problem gambler, with one third including children in the household
  • The study looked at 2 waves one year apart in the ongoing longitudinal study and compared CSOs and non-CSOs for health, social support and financial situations
  • Approximately half of the CSOs were male, against the expectation that women would comprise the strong majority
  • CSOs were significantly more likely to be exposed to violence (women moreso than men); CSOs generally had more difficulties in paying bills and had significantly poorer mental health than the general population, were associated with alcohol consumption, and reported more arguments and separations.
  • In the 2nd wave, 47.4% of the wave 1 CSOs now reported that they no longer had anyone close to them who had or previously had gambling problems. These previous CSOs reported improved mental health and fewer arguments with others compared with a year previously. They were also more likely to have divorced during the year between the waves
  • Just 10% of the CSOs had sought help for themselves around gambling impacts (although females comprised 80% of callers to gambling helplines), while the authors noted several studies that identified that involvement of CSOs in treatment is helpful for the gambler, and increased effectiveness of treatment for the problem gambler
  • Both male and female CSOs experienced more violence that the general population
  • Limitations the authors identified in the study were: the time of the gambling problems when the word ‘previously’ was included in the CSO question (may have been some time previously), and the finding of a PGSI category of 3+ is not the same as being a problem gambler (3-7 moderate risk), while causation of the problems were not confirmed
  • The authors note that gambling problems affect not only the family unit but also the wider social network. This supports the availability of support for CSOs as well as gender treatment differences found (male CSOs were more likely to also be problem gamblers, and more likely to fear losing employment – female CSOs were less likely to have someone to support them with practical issues, and less likely to have someone who they could share their feelings with)

Comment:

  • The study identified that CSOs are affected by serious and long-term mental health, social support, and financial problems. Gender differences were that male CFOs were also more likely to be problem gambling as well as having more work, debt, and legal problems than their female counterparts.
  • Both male and female CSOs were more likely than the general population to have poorer mental health, abuse alcohol, have greater problems financially, and more likely to have experienced violence within the previous 12 months
  • This research, although with a population that may not be as similar to the NZ population as the population in the above study (Australians) still supported increased risk for violence in families affected by problem gambling, while also expanding the range of problems affecting family units
  • Low help-seeking was noted by CSOs despite these increased needs
  • As does the above research, there is further support for provision of assistance for CSOs; these may require proactive strategies to help them access treatment. However, as supported by their literature review, involvement of CSOs in treatment increases positive outcomes for gamblers in treatment – in addition, the needs of the CSO are able to be addressed with benefits for the children in the family unit. Many families appear to separate in this study and as there is little research into this topic in NZ or elsewhere, this may be an expected outcome with mixed results.
  • In a further recent study (Kourgiantakis, Saint-Jacques, Temblay (2013) Problem gambling and families: a systematic review, J Social Work Practice in Addictions 13(4), 353-372), 30 empirical studies were reviewed, including the impact of family involvement in treatment, and concluded that problem gambling has a number of adverse effects on families and their functioning, while involvement of families in problem gambling treatment is linked with ‘better treatment outcomes and improved individual and family functioning’
  • Again, the screening for family violence (gamblers and CSOs), identifying alcohol misuse (CSOs as well), and the development of supports post-therapy (e.g. GamAnon) may be valid goals for CSOs, who may be in higher need than previously identified. In addition, proactive engagement of families in treatment appears to ensure better outcomes for the gambler and their families. Family therapies have become a less used approach in NZ treatment settings and these recent finding may suggest the need to reaffirm the benefits of this approach.

Literature:

Health behaviour and body mass index among problem gamblers: results of a nationwide survey Authors: Algren M, Ekholm O, Davidson M, Larsen C, Juel K (2014) J of Gambling Studies DOI 10.1007-s10899-013-9437-y

Findings:

  • In this recent Danish study almost 20,000 citizens completed a national health survey which included the Lie/Bet Questionnaire, with almost 1% answering yes (in the previous 12 months) to either one or both questions (‘Have you ever lied to people important to you about how much you gambled?’ -and ‘Have you ever felt the need to bet more and more money?’ (Johnson et al 1997))
  • A number of unhealthy behaviours were listed and responded to – they included heavy smoking (15 or more cigarettes per day compared with not smoking), smoking daily, exceeding WHO alcohol use guidelines, using illegal drugs, lack of exercise (i.e. sedentary activities), and obesity (body mass 30+) – and problem gamblers were compared with non-problem gamblers
  • The authors identified that (past year or ‘current’) problem gamblers were significantly more likely than non-problem gamblers to engage in unhealthy behaviours
  • Problem gamblers were 2.7 times more likely to be heavy smokers, 2.2 times more likely to exceed WHO alcohol use guidelines (males maximum of 21 units of alcohol per week, females 14 per week), and 2 times more likely to engage in sedentary leisure activities
  • Although these findings were clear, the authors note that the Lie/Bet test does not distinguish between pathological and problem gambling and a more subtle test may result in different findings, and causal conclusions may not be drawn – for example gambling is sedentary and may cause obesity, or alternatively environmental and genetic factors may cause or contribute to obesity through poor eating habits
  • The authors concluded however that many unhealthy behaviours are linked with problem gambling which may contribute to the persistence of the gambling. In treatment therefore, problem gamblers may require a mix of treatments to address these co-existing issues, such as weight management, healthy eating strategies, smoking interventions, alcohol use advice, and exercise.

Comment:

  • Although it is known that problem gambling can have financial, legal, inter-personal costs that affect socially and emotionally, health behaviours are less well researched
  • These findings support the CEP approach adopted in NZ for problem gambling interventions, and also support (as do the above papers) the benefits of broad screening of those who seek help for gambling issues.
  • The CHAT screen addresses smoking, alcohol consumption, lifestyle drug use, and exercise; this paper therefore adds to the support for systematic screening of all clients seeking help for gambling issues, and the incorporation of these coexisting issues in a treatment plan

Literature:

Psychiatric co-morbidity in problem and pathological gamblers: investigating the confounding influence of alcohol use disorder. Authors: Abdollahnejad R, Delfabbro P, Denson L (2014) Addictive Behaviours, 39(3), 566-572 DOI: 10.1016-j.addbeh.2013.11.004

Findings:

  • This recent Australian study addressed the high co-existence between problem gambling, alcohol use disorder, and co-existing mental health disorders
  • The authors describe findings that pathological gambling has been consistently found to exist with a range of coexisting mental health disorders, the most common being depression, anxiety, suicidality, and either borderline or antisocial personality disorders (PDs). In the latter, ‘high levels of impulsivity, reduced delay of gratification and tolerance of punishment’ in those affected by antisocial PD may predispose them to developing problems when gambling
  • Alcohol use disorder (AUD) is high amongst those affected by problem gambling, with one cited Australian study of 73% of a treatment seeking sample of problem gamblers affected by AUD
  • The relevance of this to this study is that alcohol may increase risk-taking and persistence of gambling sessions amongst other factors. The study sought to ascertain whether ‘it is problem gambling, substance abuse, or a combination of these conditions (dual diagnosis) that is most strongly associated with the range of (psychiatric conditions)’
  • N=140 participants who gambled at least fortnightly with continuous forms of gambling were recruited from the general public and categorised from assessments into problem gambling (included pathological gambling), plus alcohol use disorder, or those with neither. Participants were also assessed for a wide range of mental health disorders
  • There was a clear finding that problem gamblers (with or without AUD) were more likely to also be affected by coexisting mental health disorders than non-problem gamblers; those problem gamblers with AUD had the highest prevalence of personality disorder. This was not affected by the gender of the problem gambler, and was particularly likely to include a cluster B personality disorder (dramatic, emotional or erratic: antisocial, borderline, histrionic, narcissistic personality disorders)
  • The authors concluded that the coexisting presence of AUD may explain why there is such a high prevalence of coexisting mental health disorders with problem gamblers. They describe three possible explanations: 1) alcohol may contribute to problem gambling in that when under the influence of alcohol, people are less inhibited, take more risks, and persist despite losses or exceeding the amount they had intended to spend 2) alcohol may cause problem gambling in that gambling often coexists with alcohol availability, and gambling stress may encourage excessive drinking in order to cope with this stress 3) there may be some underlying factors that may make the coexistence of AUD and problem gambling more likely, e.g. they may share similar underlying biological mechanisms, such as parts of the brain associated with urges/cravings, such as the VTA, through neurotransmitter imbalances. Also, early trauma suggests added risk for addictions, as are pre-existing psychiatric problems. These issues may predate the gambling problems, and make the person vulnerable to not just problem gambling but also to other addictive disorders, through common genetic, neurological, and psychosocial factors that pre-date these problems
  • The authors found that although depression, anxiety and suicidality were common in problem gamblers both with or without AUD, those with only problem gambling displayed less likelihood of other disorders.
  • The authors did note factors that may limit their conclusions, such as, the self-report measures used may not accord with their actual behaviour, and also that community participants (as opposed to participants attending treatment services) may have greater coexisting mental health problems because they were still gambling, and may elect to volunteer to address their coexisting problems. They also raise the problem of the relatively small sample that prevented them from creating an important 4th category of regular gamblers who were not problem gamblers, but were affected by AUD. This group may have confounded the findings (e.g. the increased coexisting mental health problems may have been due to the AUD)

Comment:

  • The importance of this study lies in the CEP approach in NZ, as well as the importance of ensuring that alcohol, and presumably other drug misuse, may be a major factor in the existence of additional problems required to be addressed in treatment
  • The higher levels of mental health issues found with alcohol use problems raises the importance of screening for substance abuse and other coexisting problems. Positive findings for AUD should take into account the likelihood of pre-existing underlying issues that may be required to be addressed in treatment, including the approach to be taken in the management plan. For example, if the use of gambling and alcohol is a dysfunctional coping mechanism, and suicidality is high (a common finding), then removal of even a problematic coping mechanism may raise risk in the absence of establishment of other coping mechanisms. This may also suggest more regular sessions at the commencement of therapy, or strategies to establish coping mechanisms between sessions (e.g. CBT), as well as designing programmes to address the higher likelihood of personality disorders that may otherwise act as barriers to change, when AUD coexists.
  • The use of a community sample does address the possibility that treatment seeking problem gamblers have different needs (are a subgroup of all problem gamblers that may have important differences), and although the sample is relatively small, the findings are significant and are supported by a range of other studies.
  • The study does describe most problem gamblers as having complex problems, with those affected also by AUD as being even more complex again. It reinforces the need to screen, and to design a management programme tailored to the findings, rather than providing a ‘standard approach’ to treatment.
  • Clients who present with coexisting addictions to a problem gambling service may not be motivated to address a coexisting alcohol issue; however, if the ‘underlying issues finding’ which this paper supports is correct, then there is a likelihood that if it is not addressed, then the risk of resistance to treatment change, relapse risk, and cross-over intensification of the alcohol use (as a dysfunctional coping mechanism) may have a poorer outcome for the client.
  • This is an important study of a similar gambling culture (Australia), that has relevance for NZ treatment approaches.

Literature:

Characteristics of gamblers using a national online counselling service for problem gambling Authors: Rodda S, Lubman D (2014) J of Gambling Studies, 30 (2), 277-289

Findings:

  • This paper described characteristics of clients accessing the Australian email and real-time chat room for problem gambling (Gambling Help Online)
  • For the two year period ended September 2011, over 85,000 visits occurred to the website, with 1,722 clients then engaging in real-time chat with problem gambling treatment counsellors and 299 accessing an email support programme
  • The authors identified that 70% of the clients were accessing treatment for their gambling issues for the first time, especially those clients accessing the email programme
  • 78% of email clients were first time help-seekers for their gambling issues, compared with 68% of those accessing the chat programme
  • Clients in the chat programme were more likely to be male and aged under 40 years, while email clients were more likely to be female and over 40 years
  • The authors concluded that the online service was an important alternative to phone helpline counselling, or face to face counselling, and is particularly attractive to first time help- seekers
  • The authors acknowledged that in the absence of outcome research, the efficacy and impact of the service over time was yet to be confirmed.

Comment:

  • With the recent expansion of online gambling and the difficulties that problem gamblers and their families encounter in accessing face to face treatment, alternative options need to be explored
  • In particular young people are comfortable in using distance counselling services, yet may be less likely to access face to face counselling
  • Problem gamblers and their families are often constrained through finances in travelling to treatment, may have tenuous employment as a result of unreliability associated with their gambling, and are unable to take time off during week days, while few counsellors would be available weekends
  • Distance and online options offer earlier opportunities to access low intensity help (self help, information, screening and automatic feedback, 24 hour accessibility, repeated access free of concerns), and can provide encouragement to step-up access to more intensive (but less than direct telephone conversations or face-to-face) therapies
  • These two online options offered in this programme (chat room and email) provide an alternative to telephone or face to face counselling, and could be regarded as a second tier access, after self-directed interventions
  • For many problem gamblers, where shame and guilt are high and confidentiality is important, talking directly to a counsellor may be a difficult first step and may be a barrier against help-seeking (which is low amongst these clients)
  • Although these services are not new to NZ, with the goal of removing barriers and use of technology to enhance intervention availability, the Australian experience supports these aims. For the majority of contacts to the two programmes, these were the first steps taken by these problem gamblers, suggesting that the needs of younger clients were being met, while the first time contacts, many over 40 years of age, had not previously sought help for gambling issues and may not have otherwise, in the absence of these services
  • Strategies to provide online interventions, especially with the growth of smart-phone use and technology, such as chat and email/twitter and other strategies, including client prompts used in other addictions (e.g. smoking) are options yet to be developed.

Literature:

The impacts of problem gambling on concerned significant others accessing web-based counselling Authors: Dowling N, Rodda S, Lubman D, Jackson A (2014) Addictive Behaviors 39(8), 1253-7 (in press)

Findings:

  • In this paper currently in press, the authors note that research on the effects of problem gambling on significant others is surprisingly low, as is information on their help-seeking behaviours and whether web-based options were desirable
  • The characteristics of significant others of problem gamblers who accessed real time chat rooms and service on an Australian web-based option was described
  • The authors used a new brief scale, the Problem Gambling Significant Other Impact Scale: PG-SOIS, which identified the different factors that aligned with negative impacts of the gambling
  • N=366 significant others were assessed using the scale, over a 21 month period. In most cases, the significant other was the intimate partner of the gambler and most often a female under 30 years of age
  • Significant others provided a similar profile of impact: 97.5% displayed emotional distress, with most impacts (96%) directed at their relationships, followed by impact on their social lives (92%), finances (91%), employment (84%), and physical health (77%)
  • There was little difference between the different significant other types (children, partners, parents, siblings) however, friends were least likely to be impacted by the gambler’s behaviour
  • Higher impact scores on the scale were only associated with the significant other attending previous counselling, or their having an Asian cultural background
  • The authors concluded that these findings may assist with the development of web-based interventions that specifically targeted these issues

Comment:

  • As with the above paper, this research reports upon use of a chat service, and this paper addresses the impacts on those affected by another’s gambling
  • Most significant others were under 30 years of age and reported high levels of a wide range of impacts
  • The different impacts can provide a pathway of issues to be addressed in an intervention, with the chat service providing feedback on each. Alternatively, the online options can be expanded to provide advice, support, and other resources (including direct counselling) for each of these impacts
  • The use by younger clients supports the acceptability of online interventions for these significant others and may provide an alternative for many clients who may not otherwise seek help for the impact of another’s problem gambling on their lives.