Clinical report

[This article prints out to about 14 pages.]

Online help for problem gambling:
Why it is and is not being considered

	By Gerry Cooper, EdD Centre for Addiction and Mental Health Sudbury, Ontario, Canada E-mail:
	Guy Doucet, MSW (Candidate) Pinegate Addiction Services, Northeast Mental Health Centre Sudbury, Ontario, Canada

 

Key words: Computer-Mediated-Communication, Internet, Online Assistance, Peer Support, Problem Gambling, Self-Help, Stigma

Abstract

Despite an increasing prevalence of gambling problems, evidence suggests that most people do not receive help for their problems. The issue of stigma has been cited as a contributing factor.

Technological advances have now made it possible for individuals who are concerned about stigma to seek help for their problems without making any personal disclosures. In this way, the inherent advantages of the Internet (privacy, convenience, safety and portability) help to ensure that assistance for problem gamblers is always available and that concerns about stigma are neutralized.

Unfortunately, many who might benefit from Internet-based help are unaware of these possibilities, and treatment specialists and other health-care professionals may not direct problem gamblers to these services.

This paper considers:

1. What is available to problem gamblers through the Internet?
   
   
2. What is known about the efficacy of such services?, and
   
   
3. Possible reasons why problem gamblers have not been referred to the Internet by point-of-entry personnel. Implications for future action will be discussed.

Introduction

Despite the increasing prevalence of gambling problems in today's society, evidence suggests that most people are not receiving help. (National Gambling Impact Study, 1999). Some studies have shown that the issue of stigma is a contributing factor in this regard (for example, see Cooper, 2001a; Hodgins & el-Guebaly, 2000; Marotta, 2000).

New technological advances have now made it feasible for individuals who are concerned about stigma to seek help for their problems without making any personal disclosure (Cooper, 2001a). This makes it possible for people who are initially reluctant to seek help to be more willing to follow through in the future. The inherent advantages of the Internet (privacy, convenience, safety, portability and so on) ensure that help is always available to those with access to the Internet. Seeking help through the Internet does not have to involve others, in this way, stigma can be neutralized.

Unfortunately, many who might benefit from Internet-based assistance appear to be unaware of the possibilities. Unless individuals are lucky enough to find an online support group on their own, they are likely unaware that these Web sites exist. As clinicians and other point-of entry service personnel are quick to suggest the benefits of more traditional approaches such as treatment programs and peer-support groups (e.g., GA), we have observed that online interventions are not nearly as popular as their face-to-face counterparts.

This paper speculates about why treatment specialists prefer in-person resources versus online ones. In addition, we will discuss what might be done to better educate the problem gambling community about the Internet and its resources. We will examine what is available online and what is known about clinical outcomes associated with using Internet resources.

What Internet resources are available to assist problem gamblers?

note 1

There are a growing number of Web sites devoted exclusively to providing information and support to problem gamblers (and those interested in the subject). Most of these sites offer information (for example, signs and symptoms of a problem gambler) and where to go for face-to-face treatment and/or peer support. Most search engines if prompted with key terms such as "problem + gambling" will yield a wide selection of Web sites such as the following (the list is not comprehensive).

• Responsible Gambling Council (Ontario): http://www.responsiblegambling.org/
• The Directory of Organizations and Activities Addressing Problem Gambling in Canada, The Canadian Centre on Substance Abuse (CCSA): http://www.ccsa.ca/gambdir/gambhome.htm
• The Electronic Journal of Gambling Issues: eGambling, The Centre for Addiction and Mental Health (CAMH): http://www.camh.net/egambling/
• GamCare from the United Kingdom: http://www.gamcare.org.uk/
• The Wager, Harvard Medical School: http://www.thewager.org/
• Gamblers Anonymous: http://www.gamblersanonymous.org/
• Problem Gambling: A Canadian Perspective Web site, Gerry Cooper: http://www.problemgambling.ca
• Problem Gambling News Page, CCSA: http://www.ccsa.ca/gambgen.htm
• The National Council of Problem Gambling from the United States: http://www.ncpgambling.org/

It is not always readily apparent if the content of a Web site is primarily educational or therapeutic; indeed, some would argue that both can be quite similar in appearance and effect. With online (or computer-mediated) forms of communication, views about how people interact, learn and change differ. For this reason, distinctions about such therapeutic variables as clinical approach, modality and setting are not as easy to characterize. For example, what might have been a relatively static and directive self-help guidebook ("bibliotherapy") in the pre-Internet years could now be transformed into a fluid interactive tool available 24 hours every day (regardless of weather, or geography and so forth) via the Internet. ^{note 2} Those using an online guidebook could conceivably have instantaneous access to more current feedback from clinicians or coaches, support from others pursuing recovery, links to other supportive materials including audio and/or video-based information (not just print-based). The general hallmark of online help is the Internet's interactivity (immediate or delayed). We qualify using the term "general" because there will always be exceptions to the rule: what some people will find to be therapeutic, others will find educational. Thus beauty — or in this case, therapy — is in the eye of the beholder.

In 2002, Web sites that offer direct help to problem gamblers beyond simple information are not common, but can be found. In other words, Web sites that provide visitors with an opportunity to interact with others (either through temporal sequenced "asynchronous" communication as in the case of bulletin boards, or instantaneous "synchronous" formats like chat rooms) are less common than Web sites that primarily provide information (even if they are instructive). Here are some examples of Web sites that go beyond mere information dissemination:

• Compulsive Gamblers Hub (a peer-support Web site): http://cghub.homestead.com/pst.html

• Self-help materials written by psychologist Geoffrey P. Jones: http://www.gamblingtoomuch.com/
• New Zealand's Gambling Problem Helpline (providing among other things e-mail counselling): http://www.gamblingproblem.co.nz/
• The South African Resource for Compulsive & Problem Gamblers: http://www.cghub.co.za/

What is known about the effectiveness of online help for problem gamblers

Unfortunately, little is known about the effectiveness of online resources for problem gamblers. Online assistance is a recent phenomenon, generally speaking. For a variety of other health or social problems, some sources have reported favourable outcomes when the results of online help are compared to the results of face-to-face help (Ferguson, 1996b; Zimmerman, 1987).

Research has yet to empirically address many of the relevant questions. (For example, how well do problem gamblers respond to online help? Do some individuals have better outcomes than others, and if so, why?) A recent exploratory study by Cooper (2001a), one of the few studies in this area, showed that about 70 per cent of the individuals who expressed an opinion felt that GAweb (a peer-support group, which was available from 1986 to 2001 ^{note 3} had made a difference to their gambling behaviour. There are key methodological challenges, however, with a study such as this: its participants were self-selected and all recruited from one Web site. Therefore, it is difficult to generalize about other problem gamblers who seek help online.

On the other hand, it is clear that increasingly people are using the Internet. For example, it has been estimated that as of August 2001, there were about 513 million people worldwide who were connected to the Internet, including roughly 181 million North Americans (NUA Internet Surveys, 2001). As many as 53 per cent of Canadians were connected to the Internet in 2000 compared to just 18 per cent in 1994 (Brethour, 2001).

For those who do utilize online resources, they often report their fondness for the

• readily accessible services ("24/7")

• availability, regardless of geography, weather conditions, lack of public transportation, and the amount of time they have at their disposal
• safety in knowing they are truly anonymous, and therefore, they have the ability to be more honest with others without fear of reprisals
• opportunity to "test drive" the service without declaring their presence (known as "lurking")
• equal distribution of power in online environments — consumers are truly in the "driver's seat," with the ability to carefully select information at leisure rather than having it pushed at them
• "democratic ideals" of the Internet where information or advice is considered for its value without being unduly influenced by the author's characteristics (qualifications, gender, race and so forth), and
• ability to overcome what might ordinarily be obstacles (physical and/or emotional) to their participation, and hence, they feel connected with like-minded people from around the world (Ferguson & Madara, 1998).

There is some evidence to suggest that those who benefit the most are those who experience the negative effects of social stigma. For example, Davison, Pennebaker & Dickerson (2000) found that the highest online participation levels in support groups were correlated with the most stigmatizing health and social conditions — conditions that were not well served by the more traditional helping community.

In smaller communities where peer-support groups like Gamblers Anonymous are not always available or if low membership necessitates infrequent meetings, the opportunity to connect with a supportive network through the Internet is important. Moreover, there is less pressure on the individual to attend every meeting, unlike small group participation where a missed meeting may result in feelings of guilt.

Lastly, because geography is neutralized in cyberspace, individuals have a much greater choice of support groups with different ideologies to choose from. Arguably, this might even create a closer relationship between professional therapists and the peer-support community. For example, clients can use online help as an adjunct to their professional treatment, and therapists can have a better understanding of the kind of support available online. There, therapists too can observe firsthand the kind of help and advice their clients are exposed to at the support group.

Clearly, there are many advantages associated with online forms of help. Equally clear, however, is the fact that the Internet will not be helpful for everybody. For example, even though many more people now have access to computers and the Internet, many do not, particularly senior citizens and those from lower socio-economic circumstances. While it is true that access to the Internet is increasingly available from public locations, such as libraries, it isn't quite the same as connecting from home. More importantly though are issues of literacy; for the most part, taking advantage of online content requires both a certain degree of comfort with computers and an ability to read. Perhaps these barriers will soon be overcome as computer and software manufacturers make their products easier to use; however, it is important to acknowledge the current limitations to this form of assistance.

Why problem gamblers have not been referred to the Internet by point-of-entry personnel

To begin with, it is important to note that we are not reporting new data nor have we found any research to substantiate our claim that individuals seeking help for gambling problems from traditional point-of-entry personnel (i.e. toll-free help lines, local assessment and treatment agencies, family physicians and other caregivers) are not being informed of what is available to them online. At this stage, it is important to be clear that our premise is based on anecdotal observation and wide-ranging discussions we have had with numerous colleagues in the field. Fortunately, we have heard that clients are increasingly being advised of Internet resources at some locations, but this is only a recent development and not necessarily typical of the field at this stage.

That said, we postulate four principal reasons why individuals are not being referred to Internet resources for assistance. These include the following:

1. There are too few online clinical resources specific to problem gambling and they are difficult to locate.
   
   

2. Until recently, problem gambling training programs for clinicians didn't pay much attention to the benefits of online assistance.
   
   

3. Many clinicians are concerned about consumers' safety and well-being when consumers are pursuing online help.
   
   

4. Many clinicians may be concerned, when referring clients to online resources, for themselves either because of legal liability or because they fear being accused of promoting what some might consider to be competition.
   
   This is a valid point since most of what is available to problem gamblers seeking help from the Internet (in early 2002) might best be described as information dissemination (as opposed to being more clinically relevant or oriented; Griffiths & Cooper, in press). That is, much of what is available on the Web either speaks to the etiology of problem gambling, the recognition of signs and symptoms and/or the prevalence of such problems in communities. It seems that not much Web site content is directed towards action a problem gambler might take to address problem(s) (for example, how to adjust cognitions, how to inventory high-risk cues, how to establish alternative coping strategies and so forth). In addition, there are relatively few online peer-support resources where one can obtain quick advice from others who happen to be connected to the same Web site. In short, the majority of our collective online efforts seem to be going towards influencing pre-contemplators and contemplators versus helping those already in the action stage of the Prochaska & DiClemente Model (1982). To be sure, if point-of-entry personnel are to be more prolific with their recommendations about online resources, more sites will need to be established that focus primarily on the action-oriented stages of clinical issues
   
   Web sites specializing in clinical issues will also need to promote their presence to others more vigilantly in the future. To illustrate this point, we were unable to locate one of the busiest online peer-support groups for problem gamblers through repeated and differential use of a variety of the most popular search engines. In addition, we found few Web sites that had content specific to problem gambling that linked to CG Hub. This suggests that many problem gamblers and their significant others who might be looking for this kind of help will fail to find it online.
   
   In part, this speaks to the lack of resources available for the development and maintenance of Web sites specializing in clinical issues for problem gamblers. As it now stands, proprietors of sites like CG Hub may be unable to devote much time to promotion because so much time is taken up with maintenance. Indeed, if they had the resources to further promote their site, they could easily receive more traffic (to an already busy site), which, of course, means more maintenance work for an overextended Webmaster.
   
   

5. Until recently, problem gambling training programs for clinicians paid little attention to the benefits of online assistance
   
   Again, it has been our experience that training programs, training guides and professional conferences oriented towards problem gambling have paid little attention to how the Internet might help problem gamblers. This is likely related to the above point, but many who do know about online sources have been slow to incorporate them into their standard packages of references to others in the field. If professional training resources are not educating clinicians about the existence of online assistance for problem gamblers, then many might not know of them, and without that knowledge, clinicians and point-of-entry personnel are unable to notify their clients.
   
   Fortunately, this is beginning to change as the word spreads about the potential benefits of Internet-facilitated recovery. One might expect that as new training resources and conferences include discussions on how the Internet might help problem gamblers that it will stimulate and encourage others to take up the discussion as well. Respectively, the Centre for Addiction and Mental Health's Helping the Problem Gambler resource guide (Murray, 2001), which includes a related chapter (Cooper, 2001b), and sessions at events such as the Canadian Foundation on Compulsive Gambling's Innovation 2001 conference and the National Council on Problem Gambling's 2001 Building Partnerships for the Future conference exemplify the growing emphasis on this subject.
   
   

6. Many clinicians have concerns about consumers' safety and well-being
   
   Clinicians might argue that they have been slow to embrace online forms of assistance because there is a paucity of scholarly discussion, research and debate about the topic. This is understandable, but one wonders if there is a double standard at play. Many clinicians, for instance, have been known to refer to other more traditional face-to-face interventions in the absence of supportive empirical outcome data.
   
   Still, the absence of consistent rules of conduct and ethical fair play on the Internet make this point worth considering. Once again, to illustrate this point, when we used a variety of popular search engines to locate online help for problem gamblers (for example the meta-search engine Dogpile), several sites were listed that could clearly pose difficulties for unsuspecting problem gamblers. In other words, several online casino/gambling sites apparently have managed to convince some search engines that they provide a helpful service to problem gamblers. In some cases, these casinos may have a link buried within their content to qualify them to use the term "problem + gambling" (see for instance, the "Ask Pinocchio!" Web site [when we began writing this paper in early 2001, the Pinocchio site was easily linked from the "FindWhat.com" search engine; this has since changed]). In other instances, advertisers unabashedly take the user directly to betting action without any intention of providing a link to problem gambling help despite their claim to provide "links to sites for problem gamblers" (e.g., Gamblenet which had been linked from the Looksmart search engine). For example, to the question "Want to try "problem gambling" at the world's #1 site?" one is taken to an online sports casino). Sometimes, the user must move through several screens bearing the casino's logo before getting to the intended destination (www.casinogambling.about.com/). and/or endure a series of pop-up screens calling attention to various online gambling opportunities. For some, this might even suggest an affiliation with credible problem gambling sites like Institute for Problem Gambling, essentially making that Web site appear to reside within the casino's boundaries for those not familiar with how hypertext links work.
   
   Arguably, many if not most online casinos are well resourced. They appear to easily persuade search engines to include multiple links, even if these links appear through inappropriate key terms. This also contributes to making it more difficult for people to find bona fide resources; that is, if a helpful Web site for problem gamblers is overshadowed by what some might term "fraudulent links" to casinos, the person who is seeking help may be easily dissuaded, or worse, harmed by unexpectedly finding themselves at an online casino instead of his or her intended abstinence-oriented support group. Of special note in this regard is the fact that many North American casinos tend to favour responsible gaming practices. These practices are not necessarily shared by several online casinos (now numbering in the hundreds); casinos which are typically difficult to hold accountable.
   
   
7. Many clinicians may be concerned, when referring clients to online resources, for themselves either because of legal liability or because they fear being accused of promoting, what some might consider, competition.
   
   Some clinicians might be concerned that if they refer a client to an online support group for adjunctive assistance and he or she becomes involved with online gambling, the client has not been well served, or worse, that the clinician might be held accountable for such a referral. Again, this may speak to a double standard since clients are often referred to face-to-face interventions without the same kind of considerations. In fact, several researchers have found that the health-related information and advice found in asynchronous bulletin boards is quite accurate, and moreover, that false information is typically corrected in a timely fashion. Some have even suggested that online help compares to help from experienced clinicians.
   
   Consider, for example, the following account reported by Internet researcher and physician, Dr. Tom Ferguson. He describes a very moving letter from "Jack in Utah" who had posted a message in a "death and dying" support group. Jack discussed his son's accidental death by strangulation while attempting to make a haunted house for Halloween in the family's garage. The father's anguish was overwhelming as he asked for help from those associated with the online group. Within the next two days, Jack received dozens of responses of support, empathy and advice. Sometime afterwards, Ferguson presented Jack's story at a conference where he illustrated the powerful possibilities of online self-help. Following his address, Ferguson was approached by "two very distinguished therapists" who concluded that had Jack come to them for help "that although they [were] both well-trained, highly respected therapists, that they probably would not have been able to help him in nearly such an immediate, compassionate, practical and powerful way (Ferguson, 1996a, paragraph 34)." Powerful stories like this are common within computer-mediated literature.
   
   Clinicians may be less apt to refer to other traditional or non-traditional resources because of the nature of their professional training and way they've done business historically. This might be especially true if agency caseloads are low and there is pressure to see more clients to stop the risk of funding reductions.
   
   While there is no direct evidence to suggest that clinicians are fearful of losing their jobs because of these online resources, there is a possibility that this is true for some. Many labour disputes in other sectors have centered on job security because of advances in technology such as automation. Perhaps this is an issue, which needs further attention to better understand the thoughts and concerns of point-of-entry personnel and clinicians regarding their professional relationship with the Internet.

Implications and summary

Now that help for problem gamblers is available through the Internet, the opportunity exists to engage and impact on many lives successfully. In the past, many of these people might have avoided seeking any help from traditional face-to-face counselling, and their problems may have worsened as a result. Work now must be undertaken to ensure that those in need of Internet-based assistance can readily find it. This is a task that will require action on many fronts.

Agencies will need to examine how their human resources are used in the development, maintenance and promotion of online forms of assistance to problem gamblers. Research organizations will need to study online services to better understand critical issues of client-to-intervention matching (who does best and under what circumstances). Training specialists including those who help to prepare our future clinicians and social service personnel will need to find ways to call attention to the existence of online resources as part of their efforts at informing users of what is available in the "counsellor's therapeutic tool kit." These individuals may benefit from a test of their receptivity towards and biases about online help. Those concerned about the potentially misleading advertising claims of some online casinos will need to find a mechanism to collaborate and lobby search engines in an effort to prevent possible harm to problem gamblers. There is much work needed ahead and across many domains.

Assuming that we aspire to ensure that problem gamblers have easy access to safe and affordable help for their problems, we cannot afford to miss this important opportunity. As we have attempted to illustrate in this brief paper, there are several reasons which may be limiting the availability of an important new resource to problem gamblers. These should not be seen as insurmountable, but neither should they be seen as unimportant. Our collective care, support and nurturing is required to further the advances of online forms of assistance.

References

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Women narrow Internet gender gap. The Globe and Mail, p. B1.

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Online assistance for problem gamblers: An examination of participant characteristics and the role of stigma. Doctoral dissertation, Ontario Institute for Studies in Education at the University of Toronto. Abridged version available: http://www.problemgambling.ca/Results.htm.

Cooper, G. (2001b).

Internet-aided assistance for problem gamblers. In R. Murray (Ed.), Helping the Problem Gambler (pp. 21–30). Toronto, ON: Centre for Addiction and Mental Health.

Davison, K. P., Pennebaker, J. W. & Dickerson, S. S. (2000).

Who talks? The social psychology of illness support groups. American Psychologist, 55 (2), 205–217.

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A guided tour of self-help cyberspace. Available: http://odphp.osophs.dhhs.gov/confrnce/partnr96/ferg.htm.

Ferguson, T. (1996b).

Health online. Reading, MA: Addison-Wesley Publishing Company.

Ferguson, T. & Madara, E. J. (1998).

25 Lessons from online support networks (26 paragraphs). DocTom's Online Self-Care Journal. (Formerly available: http://www.healthy.net/home/tomonline/25lessons.htm. More current articles available: http://www.fergusonreport.com/).

Griffiths, M.D. & Cooper, G. (in press).

Online therapy: Implications for problem gamblers and clinicians. British Journal of Guidance and Counselling.

Hodgins, D. C. & el-Guebaly, N. (2000).

Natural and treatment-assisted recovery from gambling problems: A comparison of resolved and active gamblers. Addiction, 95 (5), 777–789.

Marotta, J. J. (2000, June).

Recovery from gambling problems with and without treatment. Paper presented at the 11th International Conference on Gambling and Risk Taking, Las Vegas, Nevada, USA.

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Helping the Problem Gambler. Toronto, ON: Centre for Addiction and Mental Health.

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Final Report. Available: http://www.norc.uchicago.edu/new/gamble.htm.

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(1 paragraph). Available: http://www.nua.ie/surveys/how_many_online/index.html.

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Acknowledgements: A version of this paper was previously presented at the Canadian Foundation On Compulsive Gambling Annual Conference: Innovation 2001, April 22–25, 2001, Toronto, Ontario, Canada.

The opinions expressed in this paper are those of the authors and do not necessarily reflect the views or policies of the Centre for Addiction and Mental Health or the Northeast Mental Health Centre.

This article was peer-reviewed.
Submitted: October 4, 2001
Accepted: April 16, 2002

For correspondence:
Gerry Cooper, EdD
Unit Manager, North Region
Communications, Education and Community Health
Centre for Addiction and Mental Health
888 Regent St., Suite 302
Sudbury, Ontario, Canada P3E 6C6
Tel: (705) 675-1181
Fax: (705) 675-5048
E-mail:

 

Gerry Cooper, EdD, has been employed in many roles within the mental health and addiction fields since 1976. Currently employed as a regional unit manager (Northern Ontario) with the Centre for Addiction and Mental Health, Gerry has produced or co-produced educational resources (including course curricula, videotapes, CD-ROMs and Web pages). He has participated in the planning and delivery of training programs for adult learners and has taught at several post-secondary institutions. In addition, he has written extensively on mental health- and addictions-related topics. His doctoral thesis, "Online Assistance for Problem Gamblers: An Examination of Participant Characteristics and the Role of Stigma" (Ontario Institute for Studies in Education/University of Toronto), recently won the U.S. National Problem Gambling Council's 2001 Outstanding Dissertation Award.

Footnotes

1. The authors guarantee that the following hypertext links were active as of February, 2002, but caution that Internet Web sites can and often do change. < Go back

2. Even though the Internet per se is just over 30 years old, we refer here to about pre-1994 for this is when the Internet started to become popular. < Go back

3. In 2001, some frequent visitors to GAweb experienced problems with that Web site because it was not updated often enough. They have since established a new peer-support location at CG Hub (i.e., Compulsive Gamblers Hub): <http://cghub.homestead.com/pst.html>. GAweb discontinued its Internet presence as of September 2001. A link now exists which transports visitors who are looking for GAweb to the CG Hub web site. < Go back