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		[This article prints out to about 31 pages.] Clients' perspectives of, and experiences with, selected Australian problem gambling services Alun C. Jackson, The University of Melbourne and University of Melbourne/La Trobe University Gambling Research Program, Melbourne, Victoria, Australia. E-mail: aluncj@unimelb.edu.au Shane A. Thomas, The University of Melbourne and University of Melbourne/La Trobe University Gambling Research Program, Melbourne, Victoria, Australia. Abstract Although there continues to be interest in documenting the evidence base for problem gambling interventions, little has been published on service users' perspectives on services provided to them. To gain a greater understanding of this issue, group interviews were held with present and past users of two services in Victoria, Australia—the government-funded state-wide Gambler's Help program and the privately funded self-help Free Yourself Program. Service users articulated a range of views about factors leading to the propensity to gamble, causes of problem gambling, the action that they would take to protect problem gamblers, the effectiveness of self-exclusion from venues, the features of a good problem gambling counselling service, unhelpful service characteristics, and the issue of abstinence or control as desired endpoints of intervention. Key words: problem gambling services, client perspective, service design Introduction Although there is continuing interest in documenting the evidence base for problem gambling interventions (National Centre for Education and Training on Addiction, 2000; Blaszczynski, 1993; Petry & Armentano, 1999; Lopez Viets & Miller, 1997; Oakley-Browne, Adams, & Mobberly, 2001), little has been published on clients' perspectives on what makes for an effective problem gambling service, although this would be generally acknowledged, we believe, as important information for program planners and evaluators to have. Unfortunately, even when clients' views of services are sought, they too often come from a narrow "satisfaction" perspective, without adequate recognition of the conceptual and methodological problems that attach to the concept of satisfaction (Pekarik & Wolff, 1996; Forbes, 1996; La Sala, 1997). This paper presents data from two focus groups held with clients of Gambler's Help, a state-wide problem gambling counselling service, and one with clients of Free Yourself, a self-help organisation in Melbourne, Australia. Problem gambling service models The approach taken to treating gambling-related problems at the level of the individual and family is determined by the view taken of the causes of problem gambling. Broadly speaking, there are three main schools of thought that have dominated discussion about the causes and consequent required treatment of problem gambling: the medical model, the behavioural model, and the cognitive model (Petry & Armentano, 1999). The medical model sees problem gambling as an addiction akin to alcohol and substance dependence, as a compulsion, or as an impulse-control disorder, each of which must be treated by interventions appropriate for an illness, with the goal being abstinence from all gambling (Hollander, Buchalter, & De Caria, 2000; Bianco, Moreyra, Nunes, Saiz-Ruiz, & Ibanez, 2001; Wedgeworth, 1998). The behavioural model, on the other hand, interprets problem gambling as a learned behaviour, motivated and/or reinforced by the personal experiences and social context of the gambler. As with any other problem of behaviour, the treatment focus is on unlearning bad habits and learning how to minimise the harm arising from gambling through controlled gambling (Petry & Roll, 2001). Abstinence, although theoretically consistent with this approach, is not usually specified as an endpoint. Cognitive theories of gambling suggest that problem gambling behaviours are maintained by irrational beliefs and attitudes about gambling. Theories of gambling behaviour cover the realm of biological, sociological, and psychological perspectives. Most theories, however, have focused on only one aspect of gambling behaviour. More recently, there has been a move towards taking an eclectic approach to explaining the development, maintenance, and persistence of gambling behaviour (Blaszczynski & Silove, 1995). This eclecticism, in turn, is increasingly reflected in problem gambling intervention models. There is now a broad range of interventions in use, as well as a growing number of multimodal treatment programs that utilise a range of different therapeutic techniques and strategies. Treatment programs are increasingly developing a client-centred orientation in that the needs of the client are the focus of treatment, "not the models and methods of the helper" (Egan, 1994). This paradigm shift reflects an appreciation of the multifaceted nature of problem gambling behaviour. To date, a great deal of the treatment literature has described clinical trials of various methods of intervention or efficacy studies, which in a lot of cases have not been systematically translated into treatment programs (Blaszczynski & Silove, 1995). Furthermore, of those established treatment programs that are described in the published literature, very few are accompanied by controlled effectiveness studies (Jackson, Thomas, & Blaszczynski, 2003). The study undertaken by the U.S. National Gambling Impact Study Commission (1999) supports this. They concluded that few studies exist that measure the effectiveness of different treatment methods, and those that do exist "lack a clear conceptual model and specification of outcome criteria, fail to report compliance and attrition rates, offer little description of actual treatment involved or measures to maintain treatment fidelity by the counsellors, and provide inadequate length of follow-up" (National Gambling Impact Study Commission, 1999, pp. 4–15). In attempting to make judgements about what constitutes best practice from a programmatic perspective, we need to recognise that the problem gambling treatment literature has also been dominated by theoretical and nonempirical studies, weakening the possibility of generalisation to different populations (Ciarrocchi & Richardson, 1989) or different sites of service delivery. As pointed out by Blaszczynski (1993), problems associated with sample selection have also restricted the ability to generalise across specific subgroups of gamblers. Evaluating the appropriateness of various treatment programs—for whom, at what level of problem intensity, for what type of problems, for what types of gamblers, in what mode of service delivery—is further complicated by the fact that there are "no internationally established models of best practice in existence" (Elliott Stanford and Associates, 1998). Although there is a growing number of reviews of best practice in problem gambling services (National Centre for Education and Training on Addiction, 2000; el-Guebaly & Hodgins, 2000; Jackson, Thomas, & Blaszczynski, 2003), there are few reported studies that explicitly address the views of clients of problem gambling services on what constitutes good practice and that draw attention to the frames of reference that these clients use to explain gambling behaviours and interventions. This paper is an attempt to make a contribution to this area. Problem gambling services used by these clients As noted earlier, the people interviewed for this study used the Gambler's Help program and the Free Yourself Program. The Victorian government implemented and developed a Problem Gambling Services Strategy from 1993, primarily through the Department of Human Services. Through the strategy, two sorts of services were established: problem gambling counselling services, including those that are integrated with financial counselling services, and a range of counselling and support services addressing family issues which may have arisen as a result of problem gambling through the establishment of state-wide family skills and regional family resource centres. The strategy comprised a number of important and interrelated components as well as the counselling services. These included the appointment of gaming liaison and community education officers in each Department of Human Services region; a range of community education initiatives and media campaigns; a free, 24-hour telephone counselling and referral service; and a social research and evaluation program to provide information regarding problem gambling in the community and inform appropriate service responses. Developments in the service model in recent years have seen a rebranding of the original BreakEven Problem Gambling Counselling Service as Gambler's Help and the G-Line telephone counselling service as Gambler's Helpline. Financial counselling was integrated into the Problem Gambling Services Strategy in 2000–2002, while discretionary funds were introduced in 1999–2000 and fully implemented by 2000–2001. The Gambler's Help services have been extensively reviewed and documented (Jackson, Thomas, Thomason, Borrell, Crisp, Enderby, et al., 2000; Jackson, Thomas, Thomason, Borrell, Crisp, Ho, et al., 2000; Thomas & Jackson, 2001). A variety of theoretical models underpin the delivery of counselling services within Gambler's Help as the counsellors within the service choose which approach they will take with clients and how they will design client interventions. In a study by Jackson, Holt, Thomas, and Crisp (2003), the range of counselling and intervention approaches used in Gambler's Help is described and indeed the variety of approaches used served as a stimulus for the development of a tool designed to document the tasks undertaken as part of the counselling function. Thus, there is no single approach taken in Gambler's Help, but there are service standards and funding and service agreements in place that serve to ensure that minimum standards of professional practice are observed in the delivery of services. The service is free to all users as the Victorian Government funds all the Gambler's Help services. Free Yourself, the self-help program included in the study, is described by its creator (Byrne, 1999) as a positive, holistic, proactive, and effective approach to helping people deal with problem gambling. The program is based on an addictions framework with an abstinence goal and aims to provide strategies that people can use "in the moment" when the urge to gamble threatens to become overpowering. Based on neurolinguistic programming, a major strategy taught in the program is for people to learn to become aware of the "split" that occurs when a person develops a gambling problem, with one part wanting to give up the behaviour while the other part wants to continue the behaviour. The Free Yourself Program places a lot of emphasis on how to win what is described as an "internal war" that takes place before the person engages in the gambling behaviour. The use of specific language patterns is designed to help people take back control of the part of themselves that does not want to stop gambling. As a holistic intervention, the Free Yourself Program also incorporates the positive effects of diet, exercise, and meditation or prayer, as well as exercises to strengthen what the program describes as the "willpower muscle." The program was designed by Gabriela Byrne, following over four years of problematic poker machine play, which had lead to employment, financial, and relationship problems, as well as suicidal ideation. She developed the program following her use of a range of conventional therapy approaches such as Gamblers Anonymous, counselling, and hypnotherapy in an attempt to create a total lifestyle-based intervention. The program includes individual sessions with a facilitator qualified in the Free Yourself Program; group support sessions, providing support for people using the Free Yourself Program; telephone counselling, supplemented with the Free Yourself Program workbook; the Free Yourself Program workshop, involving a seminar held over four weeks (two hours per week) teaching the Free Yourself Program strategies to people directly or indirectly affected by problem gambling; the Free Yourself Program Facilitator Training (four-hour) Workshop. After the four-week workshop, participants are encouraged to start a new group. In addition to training people who have directly experienced gambling-related problems, the facilitator workshop is designed to integrate the program into existing interventions and is thought to be suitable for psychologists, social workers, psychotherapists, ministers, family lawyers, medical practitioners, youth workers, etc., who are involved in helping people with a gambling-related problem. In addition, the program has established a restaurant and entertainment facility in a suburb of Melbourne to provide a supportive alternative venue for those not wishing to use venues with gambling facilities. Methods Group interviews were carried out at Gambler's Help offices and at the Free Yourself offices, with a total of 19 people in three groups, with members including, in the case of the Gambler's Help clientele, people attending established group work sessions, and in the case of the Free Yourself clientele, people who responded to an invitation to join the discussion group. The Free Yourself group was formed by the Free Yourself Program on the basis of invitations to program participants chosen to reflect the diversity of clients of this service. Similarly, one of the eighteen Gambler's Help services servicing a large urban and rural fringe catchment area recruited two groups of clients and ex-clients to participate in the focus group discussions. Once again, the participants were chosen to reflect the diversity of clients of this service. Interview questions used to guide discussion in the groups were as follows: What do you think affects a person's wish to gamble? What would make someone go from being a regular gambler to being a problem gambler? If you ran things, what would you do to better protect problem gamblers? Do you have experience of self-exclusion, and does it work? What are the features of a good problem gambling service? Do current problem gambling services give you what you need? Is the aim of your involvement with a problem gambling program abstinence or controlled gambling? Qualitative data in the form of detailed information provided by clients of Gambler's Help and the Free Yourself Program in the three group discussions were formed into categories and analysed thematically (Cresswell, 1994). According to Patton (1990), there are two ways to represent the patterns emerging from analysis of such data. First, the analyst can use the categories developed and articulated by the people studied to organise the presentation of particular themes. Second, the analyst may also become aware of categories or patterns for which the people studied did not have labels or terms, and the analyst may develop terms to describe these inductively generated categories. In this study, broad categories were suggested by the structure and purpose of the group interviews, while subthemes emerged from the data. From detailed reading of the group interview transcripts, themes were identified until a point was reached where no new categories of behaviour could be identified. This is akin to the theoretical saturation of Glaser and Strauss (1967). The following themes and subthemes emerged with, inevitably, some overlap between them: propensity to gamble; causes of problem gambling: heredity or family background, personality type, early wins, escape, issues for women; actions clients would take to protect problem gamblers: leisure- and entertainment-based strategies, venue-based strategies, elimination of gambling advertising, advertising gambling help services; self-exclusion; features of a good problem gambling service: availability of group work as an intervention, a range of demand-driven services, staffing, interventions, particularly early intervention, residential option; service elements found to be unhelpful; waiting times to see counsellors, seeming irrelevance of explanations; abstinence or control. These themes are discussed in more detail below. Propensity to gamble In discussing their propensity to gamble, some participants expressed their enthusiasm for the excitement associated with the act of gambling: Some people just love it. They love the adrenalin rush. Others described the act of gambling as involving an escape from the circumstances of everyday life: I just love it because I love turning off from the world. You blank everything out. Some participants described their participation in gambling as being precipitated by crises or difficulties in other areas of life: It wasn't really the money for me; it was crisis sort of for me. At the time I was seeing a girl and pretty involved and stuff and so when you're pretty involved you tend to let friends drift away a little bit so when I broke up with her my friends were sort of a bit distant and it was like, "Where do I go; what do I do?" and I just sort of went to the club. So it was somewhere to drink and stuff and I put a few coins in and then... Maybe you get a crisis and something happens and bang you play it to get through the crisis. For others, propensity to gamble was a function of a complex array of reasons, such as boredom and desire to escape from anxiety or problems of loneliness. Some of these reasons were purely instrumental (but unrealistic): Trying to gain wealth to cover bills and that you think you can make up extra money. Get rich quick. Causes of problem gambling Participants offered a range of reasons why people may develop gambling problems. These reasons included the issue of heredity or family background: I grew up with it: family—mother, father, grandmother, uncle. You lived it and breathed it. It is hereditary in some people. I will go to my grave believing in that. Although there was quite a lot of disagreement about the role of personality in causing problem gambling, and whether such a thing as an addictive personality existed and explained problem gambling for some people, one male problem gambler was in no doubt about the validity of this sort of explanation: Well honestly in my situation I think that looking back at myself I am a compulsive person in a lot of regards. When I play sport I am full at it when I work I am full at it and it was a matter of time when I was introduced to gambling that I took the same attitude that I had with my work and my normal life and I just went at it full ball. And it is different to your work because it is devastating because financially it ruins you. In my case I believe it my compulsive attitude towards when I pursue something I like I am full on. Another member of this group commented about the addictive potential of gambling: You get hooked. It is the love of getting hooked. It's a stupid thing but it is reality for some people. Early wins and also large wins were cited by some participants as a cause of subsequent problematic play: I used to work in the railways and I used to watch everyone else put fifty dollars, and it used to make me sick and I'm thinking, "Oh they're crazy," but I put five dollars in one day and all of a sudden I won fifty dollars. This was about twelve years ago.… That's what got me—how easy is this; everybody can do it, you don't have to work again. That's what happened to me too. I won four hundred dollars and I was hooked—boom just like that. I know when I had this first big win I got such an adrenaline rush and I had all these people standing around me this machine went for forty-five minutes. Gambling to escape as a feature of problem gambling rather than routine gambling was mentioned by other clients: In my case it wasn't money like it is different I felt like it distracted me from the world out there and I basically wanted that feeling again because I won big at times and it was never enough you know if I won big I wanted more and I wanted more of that feeling. I felt like I was like a drug addict wanting a fix that's how I felt. That's what takes over after a while though isn't it you know the initial win might be the thing that starts you going um but then it is lots of other things take over, you know, especially I live by myself just me and the dog and it's boredom you having a lousy day lots of things happen in my life. I went through lots of grief issues. It's a great way of hiding; it's a great way of having company that you don't have to talk to anybody if you don't want to. So you know there's a lot of aspects to it you know that gradually take over and then it becomes a miserable existence because you keep going. It's horrible. A number of clients noted that gambling venues being a safe place for women may encourage them to go there rather than other entertainment venues: It's a safe place to go for women. You could have sort of stayed in a public bar but for us it wouldn't have been quite safe. When I was growing up I was told that women never went to pubs alone and this particular night changed everything—the night we went from bingo to the pokies machine. I thought, "Oh you can come to hotels without having a man; oh that's wonderful," and that's what set it off for me. You know guys don't latch on to you like if you go to a public bar and you have a drink on your own. Can you imagine—they pounce! It's great no one talks to you but I feel really sad for women cause women haven't really got places to go on your own whereas a guy can go to a pub and just mix in and talk crap to other blokes but women... Actions clients would take to protect problem gamblers When asked what they would do to protect problem gamblers if "they ran things," the participants suggested a range of strategies. These included leisure- and entertainment-based strategies, including provision of better youth services and provision of entertainment venues with a larger range of leisure opportunities: I think that the whole attitude towards entertainment should change and … we need to look at it and say, "Hey we need entertainment venues. People don't want to do another arts and craft class, you know; we want to have fun but we've got to go somewhere where it is safe," and look at really changing the attitude of venues and emphasise the ones that have no pokies. Make them advertise … that women are welcome you know we have live music at lunch time you know things like that would make a difference. Venue-based strategies included banning all gaming venues, reducing the number of venues, getting rid of all electronic gaming machines (EGMs) in venues, removing automatic teller machines (ATMs) from venues, restricting opening hours, removing note acceptors, reducing the number of lines and credits that can be played on an EGM, slowing the rate of play on machines, and training venue staff to identify problem gamblers and remove them: A lot of the staff who work at the casinos probably know who the problem gamblers are. I don't know if they know all of them but I think they should know some of them. In a way there has got to be some way. I know it is just the first step if people who have a problem with gambling don't have complete access to these places until they have somehow dealt with their problems. A variant of venue-based strategy mentioned by a small number of people with on-course track-based gambling problems was simply to reduce the opportunity to gamble by reducing the number of race meetings held. Other suggestions included better practices regarding provision of cheques for paying winnings: If you have a large win and you are waiting on a cheque they will take up to twenty-five minutes for that cheque and in that twenty-five minutes you can lose half of what is on that cheque. Because they say they have got to go out to the safe and get a chequebook and wait for the manager to come in and pay you so in that delay you have had a rush from a high win so you keep playing on another machine and you can give up to half of it back. So that is a ploy that they are using to get half their money back. Because to me you walk out to the safe and collect the chequebook and write the cheque it doesn't take twenty minutes. Sometimes you can't get it until the next day. Clients were, by and large, cynical about the possibility of meaningful regulatory change aimed at limiting gambling opportunity, the time spent in venues, and money spent, because of the reliance on gambling taxation by the state government: But you would never convince the government because they are getting about twenty percent every week. They don't want to know because they are getting so much kickback from it all. They will never be banned. They say people should give up cigarettes but the government is never going to cut it out completely; they get too much revenue. Reduction or elimination of gambling advertising was mentioned as a strategy, already shown to be effective in other areas such as tobacco: I don't think they should advertise it at all. And we talk about the Quit campaign for cigarettes—I am a smoker. Okay, that is my personal belief and if I want to do it it is my business but I honestly believe. You are not allowed to advertise cigarette smoking on TV, newspapers; it is supposed to be our big health problem we have got but as we spoke about before they are never going to ban it because the government make too much money out of it. And honestly I certainly believe and as someone said before we are all here for the same reason, we have all got a gambling problem whether it be big, small, or otherwise. I think it is irrelevant to what someone has lost or won or whatever. I just think they shouldn't be able to advertise it. Advertising of counselling services was mentioned, particularly with materials available in restrooms as in HIV and other blood-borne disease materials: And what I was saying too is maybe, you know, when that lady left her child in a car [at a venue] and it died and now on the back of each toilet door it says you can't leave children unattended. That's great but what if they had like, five forms of different gambling cards and brochures. When they have a gambling card [advertising a problem gambling service] it's normally near the gambling counter where you get your money and you feel like a right goose, "Oh I'll have twenty dollars of ones," and trying to grab the card with fifteen people behind you. That's pretty embarrassing stuff so if you had them in the toilet—all five on the back of the doors. Group participants also suggested providing more advertising to encourage people to seek help early: There was one brilliant ad on television about a young apprentice kid who started gambling when he was 18 and all his mates were going out and he wouldn't go with them and he lost all his money and then he started stealing money from his workmates. That was a great ad; that was brilliant. If there is to be any advertising or forewarning it has got to be harsh it has got to be similar to the TAC [Transport Accident Commission] ads—graphic. And the fact is I remember watching a show in America about where they took in these problem juveniles into prisons and they exposed them to life-sentenced prisoners and these kids come out and they changed their mindset straight away because these blokes in there were in for triple murders, rape, this and that and they said, "Look you come in here and you will be my little boy and you won't like it." The same thing with gambling … Expose us to someone that says, "Listen this is the stark reality and don't joke around with it. This is what is going to happen to you." Self-exclusion There was considerable doubt expressed as to the worth of self-exclusion from gambling venues by participants: I self-excluded myself for the very first time in six months from half a dozen but then I found my little car could travel further. So then when that time was up I would go up and got to a wider area. I self-excluded myself three times over a period of eighteen months. Well there was two times that I have been into a place purposely. They didn't recognise me. They didn't notice. But there was one occasion where they did recognise me. They said, "Oh I am sorry I thought the self-exclusion stopped last week." I self-excluded a long time ago from the [venue] but that had zero effect. I went back hundreds of times after that and I didn't really care ... There was a very low chance of being caught. They did actual research on this they had someone that was excluded from eight venues and they took the person to the eight venues and on seven out of eight there were no questions asked. Interestingly, a number of clients suggested that because of perceived problems with enforcement, the deterrent value of self-exclusion was primarily psychological, and its appeal was a matter of personality: Well I kind of took it that um ah as a deterrent. Even though you could go and do it I said to myself I am banned. Psychological. [Q: Did you try to get in?] No I haven't. It is a personality thing. It wouldn't be right for me. Features of a good problem gambling service Not surprisingly, many of the group participants, having experienced Gambler's Help, Gamblers Anonymous, and other programs such as Free Yourself, had strong opinions on what features they wished to see in a problem gambling service, drawing on their positive and negative experiences of these services. Group work and contact with other problem gamblers through this group experience and in individual counselling was highlighted by a number of participants: Being involved in a group and a one-on-one service. Being able to come to the group and being an equal with everyone. We are all here for the same reason. Oh I think being around people that are like you they have the same problems as yourself. They don't judge you. You don't judge them but you worry about them in a caring way. And talking about it and understanding and you are not on your own. I think the most important thing you see new people come into the group and it is always the same story and it doesn't change. It doesn't get far off track but that central way of thinking how they were all introduced and the kick start and then the habit so and when you see new people come in after you have been here for six months or six years it is all the same situation.… I will be damned if I want to sit around for many more years doing this but I really appreciate the effect that I get from these groups because of the fact that that reinforces each time. Many of the Free Yourself participants noted the benefits of working in a "therapeutic/commercial" restaurant and "alternative space" enterprise: It is just the spirit of the whole thing and the people that you are working with have the same problem as you. We just love to work together we have a lot of fun. But it is good because there are days when I have come in and I feel like.... They know here I am either talking my head off or I am quiet. And usually when I am quiet I am either mad or I have just been to the pokies the day before or something and I have come in and just blown X amount of dollars and then I come in and say, "I went to the pokies last night." And they are not like nongamblers, "I don't get it. I think you are an idiot." But these guys say, "How are you doing now? Do you want to talk about it? Do you want to have a coffee? Do you want to keep busy? I know what it is like." A big hug you feel all safe and you can open up. We know they are not judging. Yeah there is no pointing and judging. It was noted by some clients that a useful service was one that provided a range of services to meet changing demand and acute demand, particularly citing the usefulness of the Gambler's Helpline: You have got the helpline which gives you 24 hour access. And sometimes that is good in the middle of the night or late at night. Odd hours when you are not counsellors are available it has been good [sic]. I rang the 1-800 number last week and last Monday no Sunday last week and the girl who answered the phone spoke to me for over half an hour. I found it pretty encouraging because at the time I was pretty low and pretty flat because my problem has just come to a head in just the last week and I found it was really good. I came here today on a one-on-one session this morning and I found it very draining when I left. I was fine when I was going through it and I went out and sat in my car for ten minutes before I could drive away and I felt absolutely drained. And I just think it is really great that this is available to people and I find the 1-800 number was really good for me last week. I rang them on Sunday and also again on Monday. I found them really good. Other clients thought that the extension of this idea to incorporate 24-hour one-on-one counselling would be useful: I personally think the 1-800 number is great a lot of things happen late at night. You can't tell me there is no money out there a lot of people put a lot of money into gambling there should be a one-on-one 24 hours a day seven days a week. That you could go somewhere and speak to someone face to face if you didn't want to speak to [the Helpline]. Sometimes I can't get on the phone late at night because I have got my husband in the other room. Because we are not good I can't do it. I have that problem when I am at the beach sitting by myself and it would be good to talk to someone. Instead of going to a venue or going to the beach and thinking stupid things I think it would be good to have a 24 hour service one on one and you can't say that the money isn't there. Another suggestion, following the establishment of a counselling service at Crown Casino, was extending this idea into the community: And also having these at the venues would be fantastic too. Having a counselling person at the larger venues. It might not be feasible for all of them, but if you were there and you suddenly realised it was getting out of hand you could actually go and see a counsellor. Participants had strong views on who should staff the problem gambling services: It's got to be someone who's been there. There's absolutely no doubt about it 'cause they know how you tick; they know how you think; they know your next step right before you even know it and that's the best thing about Free Yourself. Gabby [Gabriela Byrne] has been there so she knows your next step. She's one step ahead of you all the time and to me that's the most important thing. Although we understand this sentiment, it is obviously impractical to ensure that problem gambling services are staffed by people who have experienced problem gambling firsthand. What we understand people to be saying is that they expect counsellors to know the cognitive, affective, and behavioural aspects of problem gambling and to respond sensitively to their clients with respect for the meaning of lapse and relapse and for the struggle to change. Clients endorsed a multimodal approach to the provision of interventions, again, in some cases emphasising the relevance of training or experience of counselling staff: I think that the ideal service would sort of combine a lot of approaches to find out like an initial interview stage. I really think it would be great to have a lot of people who have been there done that to get that rapport going. But, I mean, where we're lacking here is in general that there are underlying issues that they are not trained to deal with, you know, and I believe to work together with professionals to be able to combine the academic approaches with self-help's passionate support—I think that's where an ideal service would go to. Group members, as seen in the quote above, endorsed a service model that addresses those issues that many see made them vulnerable to gambling in the first place but also returned to the question of counsellor competence: It could also be like one of the things like you just said, you know, the night before your husband's funeral ... so there was grief involved there. With me there was grief issues involved. You can't cope anymore. I lost five family members in three years and enough was enough so it [EGM venue] was a great place to bury myself. So I think probably most people would agree. I mean, that's pre-gambling. I mean that's something I guess you feel you would want to address; have an opportunity to do that. So I guess that's where a professional counsellor type person could be of use, couldn't they? And it has to be a very well checked out person because a friend of mine has just gone through a horrendous experience with a counsellor so you have to be able to have a person that has a good reputation and is associated with the counselling academy and all the rest of it; not somebody that does a few courses and hangs up a shingle. Other clients noted their preference for continuity of staff and the ability of staff to work with individuals with gambling problems as well as other family members, either singly or conjointly. A small number of group participants argued strongly for the establishment of a residential treatment facility (there is no publicly funded residential program for problem gamblers in the study jurisdiction at present): All these services—come for half an hour, come for an hour, and stuff like that you know. I am not at rock bottom at the moment but some people are at rock bottom and plenty of people don't even come to these groups. We have an addiction and that is why we are here and maybe we need to look at these services needing to be expanded into like we've got for drug rehabilitation. You go for three weeks' or a month's time; you go into a centre and you spend your time and you face the problem. You are not put into temptation. You know even in three weeks, like you feel good. You feel great. Three weeks I haven't had to hit the pub but the temptation is right in front of you. And maybe we need to look at programs that are a month-long program, in-house, staying somewhere in like an addiction. But as I see it I think you need to be able to do when you do decide that you need help. I think you need to get it pretty quick. It is also to the point where, alright, if you did have those programs there would be so many wait lists for those too I am sure. But I am just saying if you did have those programs on offer to go and live in … I know when I hit the bottom rung you have got the support of some of your friends and you haven't got the support of some of them. It is a real mix of who you have got the support from. But you need that support professionally as well. Service elements found to be unhelpful A number of group participants were concerned with identifying service elements that they found unhelpful. These included, in contrast to those who were very positive about the Helpline, the perceived failure of the Gambler's Helpline on some occasions to offer appropriate assistance: Get someone on there who has some idea of what they are talking about and don't go, "Well you've got to figure out why you gamble. Would you like to speak to a counsellor?" Well if I knew why I gambled I wouldn't go out and gamble again and there I am thinking I'm going to get sympathy and some sort of help and she's going, "Why do you gamble? You've got to figure what's missing in your life and you filled it in with gambling." Oh, there we go. How easy is that? Obviously I'm missing [deceased husband] so therefore knowing that, I won't gamble. I was really annoyed because I'd just spent a thousand dollars I was in tears and this lady on the phone I think had obviously had no idea. It would seem that for some of these clients Gambler's Helpline was seen as a crisis line and not simply a means to receive counselling through a different modality, that is, by telephone rather than face-to-face. We have commented elsewhere (Jackson, Thomas, Thomason, Borrell, Crisp, Enderby, et al., 2000) on the need to clarify the purpose of telephone help lines, and, if these clients' views are representative of the expectations that many people have of Gambler's Helpline, then it is clear that such a clarification still needs to be made and sold to the intended clients of such a service. There was concern about waiting times to see counsellors, with clients believing Gambler's Help should be an "on-demand" service: But I had a counsellor, a local counsellor, and I used to have to ring him and beg for an interview. I mean he didn't make an appointment to say come back and where we'll talk more about it and to see how you are going. He left it with me and said, "Ring me when you need me," and when I tried to get him he couldn't see me for a month. In discussion of specific interventions, there was a view expressed by some people about the seeming irrelevance of explanations about the odds of winning: Gamblers Help, okay? In the end I threw my hands in the air and I thought, "What help am I getting?" All he gave me was a list of figures like, you know. My mind was racing, "How am I going to cope?" I didn't want to look at all these figures. I mean yes they had bearing on it but I wanted him to talk to me to try to find out what I was doing. I didn't get that help. Then I went to Gamblers Anonymous and that was even worse! Abstinence or controlled gambling Most members of the groups suggested that abstinence was the goal of their help-seeking: I want to give it up totally. Go in there and not want to do it. I don't think you can keep it under control. Your addiction is there or the problem as you might call it. You couldn't go back and just put five dollars in. As far as the pokies are concerned I don't think I could possibly go a little bit and not worry about it taking over. I have never heard of anyone with problems just going a little bit and having it under control. A small number, however, thought that while abstinence might be the ultimate goal, controlled gambling was a possible and desirable intervention goal: When I was gambling I didn't have any plan about it. I was thinking that you had to give up altogether. But I think that sometimes some people can probably do it with a strategy. They can control it. I think it is possible to do that. I know that I could go to a venue now and know that I could put money in and I don't think it would bother me in the slightest. But I don't want to. I have just lost the whole thing about it. I mean, even bingo! I love bingo and I say I am never going to give up bingo but I haven't been this year. But I know that I can go; I have a choice but it is not like, "No I can't go." I have a choice, and I really learned from doing the program that I have a choice. In what I can do and what I want to do. My real choices. If I chose to go to bingo I will go. It is not going to rule my whole life and my family's life if I go to bingo a couple of times a year. Oh it has been at least three months since I gambled last but it hasn't been much of a problem in the last two months roughly. I mean I have gambled but it hasn't been an obsession to the same extent that it was before although I have gambled too much. But I guess the actual difference it has made to my life is the fairly obvious thing to say, I suppose, is that gambling can easily become the worst problem. I know in my life I have got a few problems but gambling easy becomes the worst and by not gambling in the last few months and by it not being the kind of obsessional problem it's been the last couple of years, I guess it means I have got one less problem in life and it also allows me to focus more on other things. Others suggested that a mixed strategy of control and abstinence was also possible: To try and give up the addiction you have got but not give up gambling. Because Tattslotto can be classed as gambling and I still play Tattslotto so what I want to give up and have so far succeeded in is horse racing. My problem was the pokies but at the same time I was probably a bit out of control with the horses as well. I have been able to just cut that back anyway. I used to go up every Saturday and have bets all over the joint and things like that I only bet now in the Spring carnival. The consequences of not beating their problem gambling As part of the discussion on abstinence and control, a number of group participants made the case strongly for why it was worth it to them to give up gambling: Can I say just quickly for me it is pretty simple? It is cutthroat because if I keep going I destroy my relationship, I destroy myself financially, I lose respect in the workplace which means I am no longer employable—I have become unemployable because the word gets around. I think when you gamble you become a "gonna." I am gonna do this and I am gonna do that and it just got to the stage, and I feel almost angry talking about it; there was so many things that I wanted to do by this stage that I haven't done and I guess there is anger. There is the shame of what I have done but also the anger that yeah I was going to do this that and the other. I don't think that it has gone but it is still there. Discussion This study has demonstrated the richness of data, readily available from service users, which may be used both as a quality assurance measure in terms of perceived impact of interventions and as a guide to determining whether the program design, in terms of the service model, theory of problem causation, and theory of intervention, is understood and endorsed by the service users. However, it is acknowledged that the participant numbers in this study were modest and, although they were chosen by the services as being representative of their client groups, it is certainly the case that they were not randomly selected. Although there are many issues raised by the study, we wish to highlight three elements: the broad issue of what clients believe makes for a good problem gambling service, the use of regulatory strategies such as self-exclusion, and the issue of controlled gambling. What makes for a good problem gambling service? One of the main issues raised in the group discussions of what makes a good problem gambling service is that it be demand driven and be seen as relevant to client needs. The ability to see a counsellor for individual sessions at a time determined by the client was seen as a prerequisite for a service to be considered accessible. Many participants endorsed the notion of a multimodal approach to interventions, although in this cohort, there seemed to be little support for cognitive-only interventions, which some participants saw as mistakenly assuming that their problem gambling behaviour was a product of faulty thinking or knowledge. Rather, they were aware that there were multiple and complex pathways into gambling (Blaszczynski, 2002) and that problem gambling services should be able to work with precursor issues such as bereavement, loss, and change as well as what they saw as symptomatic gambling behaviour. Another issue was the presence in the Gambler's Help service of people who had experienced gambling problems themselves. We have already noted that it is impractical to staff problem gambling services solely with people who have experienced gambling problems firsthand. Perhaps this issue could be addressed by the use of a peer education or peer counselling approach. For example, groups could be jointly led by a problem gambling counsellor and a person with direct personal experience of the problem. The use of regulatory strategies: The case of self-exclusion A recent review of self-exclusion programs in Victoria (O'Neil et al., 2003), the jurisdiction in which the clients in this study have predominantly gambled, noted the Productivity Commission's (1999) view that even within the limitations of existing self-exclusion programs, they are, overall, a useful adjunct to responsible gambling policies. O'Neil et al. concluded, along with Nowatzki & Williams (2002) and Ladouceur et al. (2000), that when properly implemented, self-exclusion can be valuable in helping to curb problem gambling: In behavioural terms, self-exclusion can be a valuable tool because, by preventing the commencement of a session (theoretically), it is preventing engagement with gambling cues that could easily become a temptation to return to old gambling patterns. Again, a critical determinant of effectiveness is the ability/success in prevention of commencement. (O'Neil et al, 2003, p. 35) O'Neil et al.'s (2003) study concurs with the clients in the present study in their assessment of self-exclusion programs that while they appeal to some and may be useful in efforts to maintain abstinence, their potential seems to be undermined by implementation design issues and the problems associated with enforcing bans from multiple venues rather than the single-venue casinos reported in the literature. The wide availability of gambling venues and opportunities poses significant challenges to self-exclusion of determined individuals. Controlled gambling Although self-exclusion is based on an abstinence model, and many of the clients in this study endorsed an addiction/abstinence model of gambling, a number of clients supported the concept of controlled gambling or a mixed abstinence/control strategy to address their gambling behaviour, particularly where this involved multiple forms of gambling, or what we might term 'polygambling.' It is important to note, if this treatment goal of control were to be adopted, that Rankin (1982) and others (Greenberg & Rankin, 1982; Baucum, 1985; Blaszczynski, 1988) have questioned the validity of regarding episodes of relapse as indicative of treatment failure without adequately taking into account frequency or intensity of gambling characteristic of such relapse episodes. Individualised and nuanced endpoints have to be the norm in this approach. Perhaps contrary to expectation, controlled gambling does not appear to increase the probability of relapse into uncontrolled gambling. This was demonstrated in an Australian treatment outcome study on 63 of 120 pathological gamblers on whom data were successfully obtained. Blaszczynski, McConaghy, and Frankova (1991) classified eighteen abstinent gamblers into two groups; those reporting complete abstinence and those abstinent with intermittent relapse episodes over the follow-up period. Relapse was defined as an episode of, or period of, excessive gambling accompanied by a subjective sense of loss of control. The mean number of reported relapses was 1.89. Prolonged periods of abstinence were regained after lapses. Results indicated that both groups improved significantly on posttreatment psychological and sociodemographic measures and did not differ from each other. Russo, Taber, McCormick, and Ramirez (1984) similarly found 21% of their sample who reported abstinence in the month preceding the follow-up interview had earlier experienced gambling lapses without resurgence of pathological gambling behaviour patterns. Lapses may be beneficial in enhancing the learning process of identifying and subsequently coping with or avoiding situational and emotional determinants leading to gambling relapse (Blaszczynski et al., 1991). Rosecrance (1989) has expressed a somewhat different view of controlled gambling and rejected the medical model of gambling in favour of the notion that problem gambling was the expression of poor gambling strategies in play. He offered an interesting and highly innovative alternative to clinical management, a controlled gambling treatment program, which placed reliance on active gamblers in the mode of peer counsellors. The primary aim of his approach was to replace defective with sensible gambling strategies learnt through exposure to those tactics employed by experienced gamblers. While no empirical evaluation of such an approach has been undertaken, Rosecrance went on to provide anecdotal evidence of its efficacy. Given this limited evidence base and its apparent appeal to some clients in this study, it would be good to see some methodologically sound controlled gambling intervention studies undertaken in a variety of service settings such as Gambler's Help as well as in the more clinically oriented inpatient and outpatient settings. Conclusion This study of service users' perspectives of their experiences and expectations of two Australian problem gambling intervention programs has indicated that such service users are able to articulate a wide range of views relating to the aetiology of problem gambling, including issues such as trigger factors in the progression from social gambling to problem gambling. In addition, these service users have presented a number of challenges to service providers: Can agencies offer both control and abstinence as goals to accommodate the varied expectations and desires of problem gambling clients? How can problem gambling counsellors solicit trust and confidence in them by clients without gaining legitimacy by having directly experienced problem gambling themselves? This is obviously not an issue unique to this clientele (it is common in health and human services), but this desire has been strongly expressed by these groups of service users. How can gambling-specific counselling services work with other service providers, if possible, to provide early intervention when people are showing early signs of vulnerability to gambling problems occasioned by other life events such as loss and bereavement? Although it is based on modest participant numbers, the present study shows the benefits of obtaining consumer feedback on problem gambling services. It does, however, need wider replication with larger systematically chosen study samples. It would also be interesting to extend the focus from the present study of evaluation of experiences of existing programs to wider issues, such as why and how service users choose to seek help and then which programs to access to obtain that assistance. References Baucum, D. (1985). Arguments for self-controlled gambling as an alternative to abstention. In W.R. Eadington (Ed.), The gambling studies: Proceedings of the sixth national conference on gambling and risk taking (Vol. 5, pp. 199–204). Reno, NV: University of Nevada, Reno. Bianco, C., Moreyra, P., Nunes, E.V., Saiz-Ruiz, J., & Ibanez, A. (2001). Pathological gambling: addiction or compulsion? Seminars in Clinical Neuropsychiatry, 6 (3), 167–176. Blaszczynski, A.P. (1988). Clinical studies in pathological gambling: Is controlled gambling an acceptable treatment outcome? Unpublished doctoral dissertation, University of New South Wales, Australia. Blaszczynski, A.P. (1993). Juego patologico: una revision de los tratamientos. Psicologia Conductual, 1, 409–440. Blaszczynski, A.P. (2002). Pathways to pathological gambling: Identifying typologies. Journal of Gambling Issues: eGambling, Issue 1, 14pp. Available: http://www.camh.net/egambling/issue1/feature/ Blaszczynski, A.P., McConaghy, N., & Frankova, A. (1991). A comparison of relapsed and non-relapsed abstinent pathological gamblers following behavioural treatment. British Journal of Addiction, 86 (b), 1485–1489. Blaszczynski, A.P., & Silove, D. (1995). Cognitive and behavioural therapies for pathological gambling. Journal of Gambling Studies, 11 (2), 195–220. Byrne, G. (1999). Free Yourself Program: A way out of the gambling trap. Melbourne: Gabriella Byrne. Ciarrocchi, J., & Richardson, R. (1989). Profile of compulsive gamblers in treatment: Update and comparisons. Journal of Gambling Behaviour, 5 (1), 53–64. Cresswell, J.W. (1994). Research design: Qualitative and quantitative approaches. Thousand Oaks, CA: Sage Publications. Egan, G. (1994). The skilled helper. A problem management approach to helping (5th ed.). Pacific Grove, CA: Brooks/Cole. el-Guebaly, N., & Hodgins, D. (2000). Pathological gambling: The biopsychological variables and their management—Interim report. Edmonton, AB: Alberta Gaming Research Institute. Elliot Stanford & Associates. (1998). Evaluation of the gamblers rehabilitation fund final report. Adelaide: Department of Human Services. Forbes, D. (1996). Clarification of the constructs of satisfaction and dissatisfaction with home care. Public Health Nursing, 13 (6), 377–385. Glaser, B., and Strauss, A. (1967). The discovery of grounded theory. Chicago: Aldine. Greenberg, D., & Rankin, H. (1982). Compulsive gamblers in treatment. British Journal of Psychiatry, 140, 364–366. Hollander E., Buchalter A.J., & De Caria, C.M. (2000). Pathological gambling. Psychiatric Clinics of North America, 23 (3), 629–642. Jackson, A.C., Holt, T.A., Thomas, S.A., & Crisp, B.R. (2003). Development of an instrument for the analysis of problem gambling counselling practice. International Gambling Studies, 3 (1), 67–87. Jackson, A.C., Thomas, S.A., & Blaszczynski, A. (2003). Best practice in problem gambling services. Melbourne: Gambling Research Panel. Jackson, A.C., Thomas, S.A., Thomason, N., Borrell, J., Crisp, B.R., Enderby, K., et al. (2000). Longitudinal evaluation of the effectiveness of problem gambling counselling services, community education strategies and information products—Volume 1: Service design and access. Melbourne: Victorian Department of Human Services. Available: http://www.problemgambling.vic.gov.au Jackson, A.C., Thomas, S.A., Thomason, N., Borrell, J., Crisp, B.R., Ho, W., et al. (2000). Longitudinal evaluation of the effectiveness of problem gambling counselling services, community education strategies and information products—Volume 2: Counselling interventions. Melbourne: Victorian Department of Human Services. Available: http://www.problemgambling.vic.gov.au La Sala, M. (1997). Client satisfaction: Consideration of correlates and response bias. Families in society. The Journal of Contemporary Human Services, Jan./Feb., 54–64. Ladouceur, R., Jacques, C., Giroux, I., Ferland, F., & Leblond, J. (2000). Analysis of a casino's self-exclusion program. Journal of Gambling Studies, 16 (4), 453–60. Lopez Viets, V.C., & Miller, W.R. (1997). Treatment approaches for pathological gamblers. Clinical Psychology Review, 17 (7), 689–702. National Centre for Education and Training on Addiction (NCETA) (2000). Current 'best practice' interventions for gambling problems: A theoretical and empirical review. Melbourne: Victorian Department of Human Services. National Gambling Impact Study Commission (1999). (Chairman, Kay C. James) Washington D.C. Available: http://www.ngisc.gov/reports/fullrpt.html Nowatzki, N., & Williams, R.J., (2002). Casino self-exclusion programmes: A review of issues. International Gambling Studies, 2, 3–25. O'Neil, N., Whetton, S., Dolman, B., Herbert, M., Giannopoulos, V., O'Neil, D., et al. (2003). Evaluation of self-exclusion programs. Melbourne: Gambling Research Panel. Oakley-Browne, M.A., Adams, P., & Mobberly, P.M. (2001). Interventions for pathological gambling. Cochrane Database of Systematic Reviews, Issue 4. In The Cochrane Library, 4, 2001. Oxford: Update Software. Abstract available: http://www.cochranelibrary.com/Abs/ab001521.htm Patton, M.Q. (1990). Qualitative evaluation and research method. London: Sage Publications. Pekarik, G., & Wolff, C.B. (1996). Relationship of satisfaction to symptom change, follow-up adjustment, and clinical significance. Professional Psychology: Research and Practice, 27, 202–208. Petry, N.M., & Armentano, C. (1999). Prevalence, assessment, and treatment of pathological gambling: A review. Psychiatric Services, 50 (8), 1021–1027. Petry, N., & Roll, J. (2001). A behavioral approach to understanding and treating pathological gambling. Seminars in Clinical Neuropsychiatry, 6 (3), 177–183. Productivity Commission (1999). Australia's Gambling Industries. Report No. 10. Canberra: AusInfo. Rankin, H. (1982). Control rather than abstinence as a goal in the treatment of excessive gambling. Behaviour Research Therapy, 20, 185–187. Rosecrance, J. (1989). Controlled gambling: A promising future. In H.J. Shaffer, S.A. Stein, B. Gambino, & T.N. Cummings (Eds.), Compulsive gambling: Theory, research and practice (pp. 147–160). Lexington, MA: Lexington Books. Russo, A.M., Taber, J.I., McCormick, R.A., & Ramirez, L.F. (1984). An outcome study of an inpatient treatment program for pathological gamblers. Hospital and Community Psychiatry, 35 (8), 823–827. Thomas, S.A., & Jackson, A.C. (2001). Longitudinal evaluation of the effectiveness of problem gambling counselling services, community education strategies and information products—Volume 6: Project discussion paper. Melbourne: Victorian Department of Human Services. Available: http://www.problemgambling.vic.gov.au Wedgeworth, R. (1998). The reification of the 'pathological' gambler: An analysis of gambling treatment and the application of the medical model to problem gambling. Perspectives in Psychiatric Care, 34 (2), 5–13. This article was peer-reviewed. Submitted: March 12, 2003. All URLs were active at the time of submission. Accepted: May 27, 2005. For correspondence: Professor Alun C. Jackson, PhD, School of Social Work, The University of Melbourne, Victoria, 3010, Australia. Phone: 613 8344 9402; fax: 61 3 9347 2496; e-mail: aluncj@unimelb.edu.au Contributors: AJ and ST were the principal investigators on the research program from which this paper was derived. They conceived the study, carried out searches and extracted data. They jointly wrote the initial and final drafts of the paper. Competing interests: None declared. Ethics approval: Data collection and analysis was carried out as part of a publicly tendered research project awarded by the Victorian Gambling Research Panel, and ethics approval was deemed by the GRP to be not needed. Funding: This project was funded by the Community Support Fund, a hotel electronic gaming machine tax, administered by an independent board through a grant to the Gambling Research Panel, which commissioned this research through a public tender process. The grant was administered through Melbourne Enterprise International. Alun C. Jackson, PhD, is professor of social work at the University of Melbourne; Co-Director of the University of Melbourne /La Trobe University Gambling Research Program; adjunct professor in Public Health, La Trobe University; a fellow of the Murdoch Children’s Research Institute, and a fellow of the Centre on Behavioural Health, University of Hong Kong. He has been involved in the design and direction of many large-scale research programs including: an evaluation of the Victorian Gambler’s Help service, an assessment of the health and mental health effects of gambling on women, an analysis of best practice in treatments, a study of the impact of gambling on children and adolescents, a review of prevalence measures, and the design of practice standards. He has also worked with the Australian Institute for Gambling Research on a range of studies with state governments relating to prevalence, service design and the design of industry-specific and whole of industry responsible gambling policies. E - mail: aluncj@unimelb.edu.au Shane A. Thomas, PhD, is professor in the School of Public Health at La Trobe University, co-director of the University of Melbourne /La Trobe University Gambling Research Program and is a director of Thomas and Associates. He has been involved in the design and direction of many large-scale research programs including an evaluation of the Victorian Gambler’s Help service, an assessment of the impacts of gambling on specific cultural groups; an analysis of best practice in treatments; a study of the impact of gambling on children and adolescents; a review of prevalence measures; and the design of practice standards. The author of Introduction to research in the health sciences, and Clinical decision making for nurses and health care professionals, Professor Thomas is an international authority in research and evaluation methodology and in particular the development and validation of measurement tools. E-mail: ShaneThomas@bigpond.com

		issue 14 — september 2005