Introduction
Such factors as an increasing availability of gambling over the last decades, a low social knowledge on gambling disorders, and a perception of gambling rather in terms of moral weakness than a medical disorder have an impact on a social acceptance of gambling behaviors (Petry and Blanco
2013; St-Pierre et al.
2014; Hing et al.
2015).
A prevalence of gambling is diversified and depending on the region of the world. In the United States 70–90% of adult population has experience of gambling within a whole of life (Ladouceur et al.
1999; Raylu and Oei
2002). Studies conducted in different countries show that a prevalence of problem gambling in 12 moths before the study vary between 0.3% in Sweden and 5.3% in Hong Kong (Wardle et al.
2011). In Poland in the group of 15 years-old and more, in the period of 12 moths before the study, the prevalence of problem gambling was set at level of 0.7% (CBOS Report
2015).
Existing studies show that treatment is undertaken by 10–20% of people with gambling disorders (Volberg et al.
2006; Slutske et al.
2009). The majority of gamblers do not seek treatment (Cunningham
2005) Almost three quarters (71%) people with pathological gambling had never sought a professional treatment as well as an assistance in self-help groups (Suurvali et al.
2008). A study conducted in Australia among 2060 adults indicated that from 24% of problem gamblers declared a need of help, 17% accessed one or more services (Davidson and Rodgers
2010). People with gambling disorders whose problems are more severe, more often than others, decide to initiate a treatment (Pulford et al.
2009).
Reasons why people with gambling disorders do not initiate treatment are complex and include social, cultural, individual and structural factors. The studies usually show barriers to the treatment divided into two groups depending on their background: barriers arising from personal beliefs (individual barriers) and connected with the structure of the treatment (structural barriers). In the first group following barriers can be distinguished: denying that someone has a problem with gambling/non-acknowledgment of gambling problems, beliefs that someone can solve problem with gambling by themselves, unwillingness to receive an therapeutic advice related to the gambling and to talk about private life, beliefs that financial problems can be solved by gambling, a shame, a fear against stigma, a pride, a willingness to keep the problem with a gambling in a secret, a lack of support in the process of changing behavior, doubts about a quality and effectiveness of the treatment, feeling too overhelmed by other issues, not liking to be told what to do, rationalizing that gambling was permissible since the person had no other problematic behaviors as well as feeling of loneliness because of gambling disorders are rare among others treated. In the group of structural barriers respondents mentioned a lack of awareness of services, a large distance from the place of residence to the facility, high costs of the treatment, lack of culturally and linguistically appropriate services, opening hours of clinics not relevant to the needs, unsatisfying program rules including abstinence, a lack of information from therapists about treatment regiment, high availability of gambling (Evans and Delfabbro
2005; Gainsbury et al.
2014; Suurvali et al.
2009).
This article aimed at the presentation of barriers to the treatment for people with gambling disorders identified in discussed study in comparison to barriers experienced by people with alcohol and drug disorders based on the literature review.
Two main research questions were formulated:
1.
What barriers to the treatment are identified by people with gambling disorders and professionals involved in helping them?
2.
What are the differences and similarities between barriers to substance treatment and barriers to gambling treatment?
Methodology
Local Context of the Study
In Poland, as in other countries, therapeutic offer for people with gambling disorders is very often the same offer which is addressed to people with alcohol or drug disorder (Toneatto and Brennan
2002). There is a lack of facilities dedicated exclusively to people with gambling disorders. If gambling disorders comorbid with alcohol or drug dependence, a major concern is a disorder related to the substance. People with gambling disorders, similar to those with alcohol or drug disorders, can receive an inpatient or an outpatient form of treatment as well as nonmedical support—Gamblers Anonymous. Behavioral, cognitive and cognitive-behavioral approaches dominate. Availability of brief interventions and programs aimed at reducing of gambling is marginal (PARPA web page on alcohol treatment system
2016, PARPA web page on therapist certifying program
2016, KBPN web page on drug treatment system
2016, KBPN web page on system of therapist certification
2016).
Selection of the Respondents: Sample Selection
Interviews were conducted with people with gambling disorders, social workers, therapists employed in addiction treatment facilities, General Practitioners and psychiatrists. Selection of the respondents was based on purposive sampling. The aim of such selection was to choose only those respondents who would provide complete and comprehensive information from the perspective of research questions (Wasilewska
2008).
Research sample consisted of 90 respondents and covered 30 interviews with people with gambling disorders and 15 interviews with each group of professionals—social workers, General Practitioners, psychiatrists and therapists. Inclusion criteria for professionals were status of employment in facility where treatment of gambling disorders is offered and their profession. In turn, inclusion criteria for people with gambling disorders was a diagnosis of gambling disorders confirmed by a psychiatrist. There were two kinds of places where respondents were enrolled—alcohol and drug treatment facilities and meetings of Gambling Anonymous (GA). In the case of the first place, patients were recruited by therapists and then contacted by researchers to conduct an interview. In the second case—the researcher contacted the leader of the group of Gambling Anonymous asking to provide information about the study on the meeting. Those interested in participating in the study contacted with the researcher directly and the interview was carried out at a convenient time and place.
Characteristic of the Sample
The vast majority of the sample in the group of people with gambling disorders were male; the study included only three females with diagnosis of gambling disorders. Average age in this group was 38.3 years (SD = 10.827 years). The youngest respondent was 25 years-old and the oldest—63 years-old. Due to the fact that the study was conducted in Warsaw majority of respondents resided in this town, however about 25% (n = 8) lived outside of the city, commuting to the facility. More than half (60%, n = 18) of respondents had a university degree (bachelor or master degree). In the study, there were no people with primary and lower secondary education, only 10% (n = 3) had a vocational education. Almost everyone had a regular source of income, about 70% (n = 20) of the respondents were employed on tenure, almost quarter (n = 7) had his own business and the rest were retired. Only one person was unemployed.
The most popular gambling game (answers: often and very often) were slot machines (56.7%, n = 17), casinos (53.3%, n = 16) and online gambling (43.3%, n = 13). On the other hand, the least popular type of gambling (answer: I did not gambled) were horse race betting (76.7%, n = 23), SMS lotteries (73.3%, n = 22) and sport betting without using the internet (53.3%, n = 16).
The group of professionals was dominated by females, which constituted 70% (n = 42) of the sample. Average age was 42.9 years-old (SD = 12.012 years), and varied depending on the group. The highest average age was noted in the group of psychiatrists 44.4 years (SD = 11.115 years) and the lowest among therapists—40 years (SD = 11.473 years). Average age for General Practitioners was 43.7 years (SD = 13.767 years) and for social workers—42.9 years (SD = 12.264 years). The vast majority of the professionals lived in Warsaw, only a few resided outside the city.
Three types of guidelines to conduct semi-structured interviews were developed—first one for people with gambling disorders, second—for social workers and the last one for professionals employed in the medical sector: General Practitioners, psychiatrists and therapists. Interview for people with gambling disorders was divided into six sections: experiences with treatment (the reason for entering treatment, the circumstances in which the respondent realized the problem, seek help outside the medical sector, reasons for choosing facility, difficulties in obtaining assistance), assessment of available treatment offer for people with gambling disorders (positive and negative experiences with treatment), social perception of people with gambling disorders based on the individual experiences, recommendations for improving treatment offer, types of preferred gambling games and comorbidity issue.
Second type of guideline was designed for social workers and included questions on reasons for seeking help in social welfare centers by people with gambling disorders, existing offer of social welfare for people with gambling disorders, demand for such offer among people with gambling disorders, perception of people with gambling disorders by social workers, influence of stigmatization on cooperation with people with gambling disorders, and recommendations how to improve offer of welfare centers.
Finally, guideline intended for therapists, General Practitioners and psychiatrists let to search reasons and circumstances of seeking treatment by people with gambling disorders, available offer of the assistance and treatment as well as patient’s experiences with seeking help outside the medical sector, stigmatization of people with gambling disorders and recommendations for improving situation in treatment.
All kinds of guidelines included section which allow to collect socio-demographic data such as age, place of residence, marital status, education level and employment.
The Study Protocol and Data Analysis
Individual interviews were conducted in the first half of 2015. Before the proper phase of the study, the pilot interviews were carried out (two interviews with respondents from each sample group). After the pilot study, interview guidelines were revised. Interviews from the pilot phase were included to the study material.
The study was anonymous, opinion of the respondents were denoted only by a number; personal data were not collected. All respondents were informed about the aim of the study and signed the consent form for participation in the study. All interviews were recorded and then transcribed.
Each interview was analyzed separately. The analysis was initiated by reading full text and making notes on the margin of the interview. In the next step, relevant codes were made to cover topics interesting from the perspective of the aims of the study. Then, codes were aggregated into thematic categories which were assigned to the broader categories—dimensions. Coding and data analysis was made manually, without using any software.
Access to the treatment has been conceptualized in numerous ways (Levesque et al.
2013). Within health care, access is understood in terms of access to a service, a provider or an institution and defined as the opportunity or ease with which consumers are able to reach appropriate services in proportion to their needs (Whitehead
1992). While the access issue is often used in relation to factors determining the initial contact or use of services, opinions differ regarding aspects included within access and whether the emphasis should be put more on analyzing characteristics of the providers or the actual process of care (Frenk
1992).
The analysis in this study covered the factors that hinder the decision to undertake treatment or refrain from such a decision, as well as factors that appear already in the course of treatment. The latter factors can reduce the chances of keeping the patient in the treatment and influence the decision to take treatment again if need arises. In the first case answers concerned difficulties in obtaining assistance, in the second—negative experiences with treatment were analyzed.
Furthermore, the analysis takes into account dimension of the source of information, so statements of patients, social workers, General Practitioners, psychiatrists and therapists were encoded separately.
The authors had to make a decision regarding the presentation of research material in the article. It was possible to present the material with regard to several dimensions: to describe barriers from the perspective of people with gambling disorders and professionals, or/and present barriers divided into barriers to access to treatment and negative experiences at the stage of taking treatment. Another way was divide material into individual and structural dimensions. It was chosen by authors for two reasons. Firstly it was the way to avoid too many repetitions, as a lot of barriers mentioned by professionals overlapped with those mentioned by patients. Secondly this presentation facilitated comparison of barriers revealed in this study with barriers identified in other studies as it is the most widespread way of presenting barriers regarding the discussed issue.
It should be noted that the most barriers can be described with regard to both perspectives: individual and institutional. For example, little knowledge of existing therapeutic offer may have an individual dimension, if the person does not have the motivation to become familiar with the offer or institutional, when there is no easy access to the knowledge about treatment services. For this reason, the authors when deciding how to qualify particular barrier took into consideration the context in which the barrier was recalled. This distinction was largely a contractual nature.
Review of the Articles About Barriers to the Alcohol and Drug Treatment
The aim of the review was to identify the publications related to barriers to the alcohol and drug treatment facilities. The articles to the review were identified in the Medline database with using search words barriers and alcohol dependence (162 articles), and search words barriers and drug dependence (142 articles). Based on abstracts we included 7 articles to the analysis, which directly corresponded to the aim of the study. The review also included articles identified in the references of the eligible publications (4 articles).
Ethical Approval
Ethical approval to conduct the study was obtained from Bioethical Commission of the Institute of Psychiatry and Neurology from Warsaw, Poland (ref. 24/2015).
Discussion
The aim of the study was identification of barriers to the treatment for people with gambling disorders revealed in the described study comparing with barriers experienced by people with alcohol and drug disorders. Individual barriers in the perception of people with gambling disorders cover fear and aversion to speaking about their problems at the forum of therapeutic group, the difficulty to recognize that you are a dependent person and admitting that before the family and others. Most of the people with gambling disorders do not see the need of starting the treatment, because they are convinced that treatment is intended for people with alcohol or drug disorders. Furthermore they believe in the possibility of self recovery. Treatment in psychiatric facilities and being a client of social welfare sector can be associated with a greater feeling of stigma in comparison with other forms of help or assistance.
There are similarities between the individual barriers highlighted by persons with gambling and alcohol or drug disorders. In a study of cannabis users appears the belief in the opportunity to deal with the problem without professional help (van der Pol et al.
2013). People with gambling disorders are often convinced that gambling is not a disease and that self recovery is possible in the situation of addiction.
Among people with drug and alcohol disorders, similarly like in the group of people with gambling disorders, stigmatization was seen as an obstacle to the treatment. Stigma and shame are barriers that seem to be the most frequently identified in both groups: the substance-dependent and gambling (Digiusto and Treloar
2007; Radcliffe and Stevens
2008; Keyes et al.
2010; Wallhed Finn et al.
2014; Gilchrist et al.
2014; Wieczorek
2016, Evans and Delfabbro
2005; Gainsbury et al.
2014; Suurvali et al.
2009). But among people with gambling disorders it is not seem to be so important as in the group of people with alcohol and drug dependence. The reported study found that exposure to condemnation in the case of gambling can be much weaker than in the case of alcohol or drug disorders, because it is a relatively new phenomenon, socially not defined as dependency.
The vast majority of barriers identified in the study have administrative and organizational background. First of all, there is a lack of offer addressed exclusively to the people with gambling disorders, thus the offer is perceived as inadequate to the needs. This means in the practice that examples which are discussed during the therapy are not related to the everyday life of people with gambling disorders and educational materials do not address their specific needs. As a consequence, patients do not engage enough in the treatment, do not identify themselves with the group and they have a feeling of marginalization during the therapy. For people with gambling disorders treatment in the same therapeutic group with people with alcohol or drug disorders who constitute the majority in the group, is a barrier which discourage them to start the treatment and decrease the satisfaction with treatment.
A whole group of barriers is related to the patient-therapist relationship and competences of therapists and other staff. Respondents claimed that therapists have not enough experience in the treatment of gambling disorders, they provide the therapy despite they do not have theoretical background. Personnel tends to overcontrol patients, e.g. comprehensive explanation absence from therapy is required, which puts patients in the role of person which do not deserve to the trust.
Other barriers identified by respondents refers to the long waiting time for the treatment, limited possibilities of free treatment (people with gambling disorders without insurance cannot take the therapy), difficulties in reconciliation of the therapy and the employment. Some of the barriers are related to the particular institutions. In the case of the primary health care as well as in the psychiatric care, patients do not know that they can ask for help General Practitioners or visit a psychiatrist without referral. In terms of social assistance, the barrier is that gambling disorders are not included in administrative forms as a problem which entitle to getting support. If gambling disorders are exposed in official client documentation it could be a concern that financial support will be wasted. Otherwise clients have to fulfill the contract for the provision of support. The progress in implementing the contract is evaluated by a social worker, which can be perceived as a form of control.
Discussed structural barriers are in many areas similar with those which are identified by people with alcohol or drug dependence, e.g. access to cheap or free treatment (Bobrova et al.
2006; Digiusto and Treloar
2007), waiting time for the treatment (Redko et al.
2006; Digiusto and Treloar
2007), therapy in unfavorable hours (Welbel et al.
2013), inability to reconcile the treatment with other obligations (Laudet et al.
2009), attitudes of therapists (acceptance for patient, trust) (Digiusto and Treloar
2007; Laudet et al.
2009; Gilchrist et al.
2014).
Still, there are other barriers that are not found out in this study, but emerge in the other studies searching for barriers faced by people with gambling disorder. The study of Evans and Delfabbro (
2005) revealed that people with gambling disorders are convinced that gambling is an attractive way to spend time and entertainment, and they reluctant to give it up. Doubts efficacy of the treatment were expressed by respondents of one of the study reviewed by Suurvali et al. (
2009). Australia Productivity Commission (
1999) study shows that an important factor that influences satisfaction with the proposed offer is the geographical distribution of services and their hours of operation.
Interestingly, the respondents of discussed study not treated geographic localization of facility as a barrier, although they claimed that there is a low number of facilities providing treatment for gamblers. One explanation is that the study were conducted in Warsaw where the public transport is pretty good. It can be that people with gambling disorders believe that their disorder is so rare that they do not even expect a network of institutions dealing with this problem. Another explanation is that patients avoid treatment centers, which are located close to their place of residence because they do not want to meet friends or neighbors (Wieczorek
2016).
Novelty of this study is to identify barriers which relate to the specific forms of assistance and treatment offered to people with gambling disorders. Especially interesting is distinction between the nature and severity of the stigma depending on the type of offered help. In the psychiatric sector greater fear against stigma is connected with the risk of identification with mentally ill people. Another type of an assistance charged with various stereotypes is a social welfare. Using this type of services involves not only the stigma of the addict person but additionally stigma of life loser.
This study allowed for recognizing the barriers to treatment which are common to people with substance and gambling disorders, but also specific to those with gambling disorders. It is important to capture the specificity of gambling clients, who are often treated in the system of help offered to people with alcohol and drug disorders.
Moreover, this study enables to recognize the barriers to gambling treatment both at the individual and structural level from the perspective of clients of services offered gambling treatment and the various professional groups involved in helping them. Criticism regarding studies of barriers to treatment is related to using a self-reported information on barriers to seeking help and in particular information spontaneously expressed by respondents. Doubts concern to self—awareness of barriers and the reluctance to share with the researcher intimate thoughts or experiences (Suurvali et al.
2009). In the case of this study, the use of complementary source of knowledge (professionals) allowed least partially to respond to this problem. Professionals turned their attention to structural barriers that may be overlooked by patients.
To identify barriers in access to the treatment a qualitative approach was used, what allowed for taking into consideration opinion of the respondents expressed spontaneously. In quantitative research, respondents choose from a closed-ended barriers list that makes difficult or even impossible to identify new and non-obvious barriers. As Suurvali et al. (
2009) stated open-questions can contain a richness of details and nuances difficult to replicate in closed-ended questions. Understanding the barriers, both at the objective and subjective level allows for a better understanding of what could contribute to increasing the availability and attractiveness of treatment.
And last, but not least studies on the treatment of gambling disorders are very scarce in Poland, and there is no studies investigating problem of barriers to the treatment. Meantime the results of this study may have practical application in improving the availability and quality of the treatment.
Some of barriers identified in current study may be due to the specifics of how treatment of gambling disorders is organized in Poland, e.g. in other countries access to specialized gambling treatment can be greater. In Poland problem of gambling is poorly recognized socially, and it is not always perceived in terms of addiction. Beliefs of respondents that gambling is not a disease and it is impossible get addicted from it influence the decision to start treatment. While in Poland, there are two government agencies that deal with the problem of alcohol and drugs disorders, the problem of gambling is rather neglected and is given much less weight in discussions on public health. This can results in insufficient professional background of therapists for conducting gambling therapy, because there is no system of certification of therapists who specialize in gambling disorders, as is in the case of alcohol and drug therapists. Another problem that can be attributed to polish treatment system is the mismatch between the content of the therapeutic programs and needs of people with gambling disorders.
The study has a number of limitations. In the study participated only those who already had experiences with gambling treatment, so identified barriers not include perspective of people who are outside the care system. The recruiting procedure of people with gambling disorders could have impact on answers of respondents as some of them were recruited via therapists.
Conclusions and Implications
Studies focused on issues related to the access to the treatment for people with gambling disorders allow better understand needs of this group and improve an offer of help for them. Better meet the needs of people with gambling disorders could contribute to the increase in the number of people who initiate the treatment and maintain in the therapy.
Results of this study indicate the need for education of society about gambling as behavior from which one can become addicted and also about the various treatment options. Efforts are necessary to better respond to the treatment needs of people with gambling disorders and improve quality of treatment. These efforts should primarily include better professional preparation of therapists and other professionals to help people with gambling disorders, taking into account the problem of gambling disorders in the diagnosis, better fit the contents of therapeutic programs to the specificity of gambling disorders, creation of materials used in therapy tailored to needs of patient with gambling disorders and as far as possible establishing a therapeutic groups, which would be at least a couple of patients with gambling disorders.
Psychological barriers emerge in the studies as the most substantial (Hodgins and el-Guebaly
2000; Pulford et al.
2009). It is precisely these barriers are more difficult to overcome in comparison to structural barriers (Gainsbury et al.
2014). One of the major barriers are the shame and fear of stigmatization (Hodgins and el-Guebaly
2000; Pulford et al.
2009; Suurvali et al.
2009.) Web-based counseling has the potential to address these barriers (Rodda et al.
2013). Therefore creating a support network on the Internet should be considered, for people who for various reasons do not want to have contact with the health care services.