Published on January 12, 2008
Help Seeking by Problem Gamblers, their Families and Whänau including Barriers to and Relevance of Services: Help Seeking by Problem Gamblers, their Families and Whänau including Barriers to and Relevance of Services Dave Clarke Ruth DeSouza Maria Bellringer Nature of the Problem(Australian Government Productivity Commission, 1999; Evans & Delfabbro, 2005; New Zealand Ministry of Health, 2005): Nature of the Problem (Australian Government Productivity Commission, 1999; Evans & Delfabbro, 2005; New Zealand Ministry of Health, 2005) Only ~10% of problem gamblers seek help, and ~50% do not think they have a problem. Up to 5 other people are affected, but research on barriers has not included impact on family members. Family, friends, support groups, then GPs, social workers, clergy are primary sources. Culturally specific problems apply especially for migrants and indigenous groups. Overview: Overview Intrinsic and extrinsic barriers defined Social and cultural issues derived from literature on barriers to help for problem gambling Ways of changing barriers to health care access and utilisation, including cultural competence Definitions: Definitions Intrinsic barriers: personal emotions, cognitions and behaviour, including shame, fears of stigma and treatment; attitudes: self-reliance, handle problem on own, not serious, like feeling Extrinsic barriers: diagnostic criteria and practical limitations such as accessibility; also the attitudes, values and beliefs of social/cultural groups and of treatment providers Intrinsic Barriers: Intrinsic Barriers Most problem gamblers want to handle problem on their own, and seek treatment agencies as a last resort. Denial, lack of recognition, embarrassment and shame are greater barriers than extrinsic ones. Shame, fears of stigma and isolation are affected by social/cultural attitudes, values and beliefs. Suspicion of mainstream services, concerns with trust and confidentiality are high for migrants. Unfamiliarity with and resistance to the concept of counselling are also high for migrants. Extrinsic Barriers1 : Extrinsic Barriers1 Predisposing factors – demographics Enabling / access factors availability accessibility affordability acceptability (and appropriateness) Need factors - severity of a disorder, diagnoses, co-morbidity, treatment history, negative consequences such as work-related and financial difficulties 1Social Behavioral Model (SBM; Andersen, 1995) Predisposing Factors – Gender: Predisposing Factors – Gender Females are equally likely to be problem gamblers as males, but males more likely to be in treatment in the USA and Australia. Male problem gamblers in Australia are more likely to prefer group support to mainstream counselling. Female problem gamblers in NZ are more likely to seek professional help and use telephone help services. Female problem gamblers are more likely to play luck games such as gaming machines, while male problem gamblers prefer skill-based, competitive games such as horse races or card games. Predisposing Factors –Pacific Peoples in NZ: Predisposing Factors –Pacific Peoples in NZ Problem gambling stigma associated with failure to fulfil social obligations. Pacific peoples are at high risk for problem gambling, yet make low use of services. Samoan women are more likely to use telephone help services than Samoan men. Maori also under-utilise professional services, have greater shame and are more likely to want to handle the problem on their own than NZ Europeans. Predisposing Factors –Migrant Asians: Predisposing Factors –Migrant Asians Australians have higher stigma tolerance and knowledge about services than Vietnamese. High stigma of problem gambling among Chinese, Koreans, Vietnamese and Arabs: shame, pride, loss of face and instability for gambler and whole community. Chinese seek help from trusted family member; mainline professionals only as a last resort. Most at risk: workers in food industry, tourist operators, international students, refugees Enabling Factors - Appropriateness: Enabling Factors - Appropriateness Language barriers, lack of information and lack of culturally appropriate services not only mitigate against help-seeking and utilisation, but also restrict entertainment options, leading to boredom and isolation. Compared with indigenous groups, migrants are underemployed, and have more problems with acculturation and settlement. Compared with the dominant culture, migrants are more likely to have greater financial hardship and to be underemployed. Need Factors: Need Factors Deteriorating physical and mental health, serious financial hardship are more salient than relationship, employment and legal problems in seeking professional help. Problem gamblers with numerous problems are more concerned about costs, availability and effectiveness of treatment than those with less. Problem gamblers with co-morbid alcohol or drug problems are not more likely to seek help than those without. Changing Barriers to Access & Use: Changing Barriers to Access & Use Social networks large social networks, closely tied communities and employee assistance programmes can be effective, especially for women community leaders can provide legitimacy and support to services encourage and inform social networks in ways to apply pressure to problem gamblers for seeking help or treatment information dissemination: symptoms, referral sources and alternative forms of entertainment empowerment: clients and families prepare in advance their concerns, and question suitability or feasibility of recommendations Changing Barriers to Access & Use: Changing Barriers to Access & Use Changing social attitudes increase public awareness of the symptoms of problem gambling information about availability of services and their effectiveness; e.g. local radio, community newspapers and newsletters care-giving skills training for relapse prevention lowering the expectations of adverse reactions from society, friends, family and social networks Changing Barriers to Access & Use: Changing Barriers to Access & Use Accessible appropriate services provide services where people live & work financial & social care; travel, waiting time flexible service delivery; e.g. telephone trained bilingual & bicultural counsellors nominated interpreters, rapport & trust assistance for families of problem gamblers child care facilities for problem gamblers Changing Barriers to Access & Use: Changing Barriers to Access & Use Changing professional attitudes clinicians need to ensure that clients understand technical terms, what they need to do and match explanations with realistic outcomes awareness of professional attitudes and ways of changing them to provide appropriate services for men and women, and different ethnic groups professional knowledge and training more important for impulse control disorders than for mental health problems Changing Barriers to Access & Use: Changing Barriers to Access & Use Case management integration case managers to coordinate multi-disciplinary teams clinicians trained in assessment, treatment planning and interventions for comorbid disorders motivational interviewing and cognitive behavioural strategies for treatment and relapse prevention Changing Barriers to Access & Use: Changing Barriers to Access & Use New technologies advertisements that appeal differently to men and women, and ethnic groups cellphone text messaging anonymous Internet groups for personal assessment, mutual help, privacy, reduction of shame, and recognition of problem improved enabling factors for rural dwellers Conclusions: Conclusions This review of literature has highlighted some social and cultural barriers to health care access and utilisation for problem gamblers and their families. By changing barriers, integrating health services, and promoting public and professional awareness of the barriers, social policies can be adopted to encourage them to seek and obtain help. New technologies offer the potential for dealing with some of these barriers, especially those associated with the intrinsic factors of shame and self-reliance.