Background
Intimate partner violence (IPV) against women is a pervasive public health problem, affecting approximately one in three women globally [
1]. IPV has been defined as behaviour by an intimate partner or ex-partner that causes physical, psychological, emotional or sexual harm [
1]. Economic abuse, defined as a pattern of control, exploitation or sabotage of money, finances and economic resources, has been a relatively ‘invisible’ form of IPV, but is now increasingly recognised [
2]. Problem gambling is also a public health issue and is clearly and strongly linked with both the perpetration and victimisation of IPV, including economic abuse [
2‐
4]. While prevalence figures vary, international studies report that a little over one-third of individuals with a gambling problem have been a victim of physical IPV or have perpetrated physical IPV in the previous 12 months [
3]. In Australia, research undertaken by Dowling et al. [
5], revealed 27% of gamblers attending a gambling help service had experienced physical violence. Existing research also recognises the relationship between gambling and IPV as bi-directional; problem gambling contributes to IPV and IPV contributes to problem gambling [
6,
7]. As noted by Freytag et al. [
8], IPV and problem gambling are significant public health problems in their own right, but they regularly co-occur and create an even more dangerous combination.
Problem gambling and IPV are both significantly gendered: problem gambling is twice as common among men compared to women [
9], with gender also playing a clear role in IPV with a preponderance of male perpetrators and female victims [
10,
11]. Of note, men are more likely to perpetrate IPV if they hold attitudes supporting gender inequality [
10]. While experiences of gambling harm do not solely cause IPV, when the gendered drivers of violence are present, gambling problems and the associated stressors can intensify and exacerbate IPV [
12]. IPV can co-occur with the perpetrator’s gambling problem and subsequent anger about gambling losses; or with the perpetrator’s anger about the victim’s gambling and associated stressors [
7,
13]. Concerningly, some women impacted by IPV seek refuge in gambling venues as they often provide the only safe space to escape from a violent partner [
12]. However, by using gambling venues as safe spaces, many women become trapped in a vicious cycle by chasing gambling losses; this cycle increases their vulnerability to IPV [
14]. International studies and those undertaken in Australia, report higher IPV victimisation rates amongst women with a gambling problem than men [
4,
5,
15]. Not surprisingly, women experiencing both gambling harm and IPV often find themselves in very complex and challenging situations.
Health and social support services can play a crucial role in preventing and managing gambling related IPV and its harmful health impacts. In Australia, however, delivering and managing these services is a difficult task; consequently, individuals with multiple needs face additional barriers exacerbated by navigating a complex service delivery system [
16]. As highlighted by the Productivity Commission [
17], every level of government is involved in funding or delivering human services, with access and availability of services differing between States and Territories. The existing system is based on public payments to primarily non-government service providers (nonprofit and profit), referred to as a ‘mixed economy of care’ [
18]. While the level of funding assistance to service providers varies across Australia, users rarely face the full cost of service provision. However, who receives the funding, when and on what basis, is a significant driver of health and social support services outcomes [
17].
It is widely recognised that front-line healthcare and social support workers can be IPV survivors’ first and only contact with professionals [
19,
20], representing an opportunity for routine enquiry regarding other health-related issues. There is a consensus that health service providers should ask women about IPV, stay alert to possible signs and symptoms, provide health and social support, provide information on available resources, and co-ordinate timely referrals to other agencies [
20]. These actions should ensure privacy and confidentiality in a supportive environment where women’s experiences are validated and their decisions respected [
19]. Freytag et al. [
8] noted that seeking safety, dignity, and respect for gambling-related IPV can be met with escalated violence and abuse; help-seeking efforts must be carefully and strategically planned to minimise unintended consequences. Crucially, women may choose to use non-DFV services such as relationship or family dispute resolution (FDR) services for IPV, or gambling help services where gambling is an issue [
21]. In short, non-DFV service providers, including gambling help and financial support services, must be skilled at responding constructively to gambling related IPV as they are highly likely to see clients impacted by this issue.
The service experiences of women seeking help for IPV, particularly IPV with co-occurring health issues, are not always satisfactory [
22,
23]. While stigma and shame have been widely reported as barriers to help-seeking [
24,
25], organisational and individual level barriers within services have also been identified. Barriers facing service providers can include time constraints, victim-blaming attitudes, lack of professional development, limited referral options, and lack of specialist support [
19,
22,
24]. Health and social service workers (outside of specialist and integrated DFV services) rarely ask about IPV, and service users are frequently reluctant to disclose in the absence of direct questioning [
26,
27]. While studies have shown a high occurrence of IPV in family members seeking help for problem gambling issues [
7], screening for problem gambling in community services and healthcare settings is ad-hoc, rarely happens or is at the discretion of individual practitioners [
28,
29].Lack of integrated services and inadequate triage and referral systems have also been identified as significant barriers to effective service responses [
27,
30]. This situation is highly problematic, given that non-DFV services may see a more significant volume of women impacted by IPV than specialist DFV services do [
21]. Mason and colleagues [
31] highlighted that specialist services and those with limited networks are not usually funded to screen for other issues beyond their specialisation and typically apply a narrow lens. Siloed responses are particularly problematic for women who have complex, interconnected needs.
Reducing gambling related IPV against women requires a multi-pronged approach that reduces problem gambling and gender inequality and simultaneously improves service responses to these issues. Applying a comprehensive public health approach to promote upstream factors that mitigate the burden of harm at a population level is critical [
32]; the importance of addressing the determinants of IPV and problem gambling have been documented elsewhere [
6,
10]. At an individual level, supporting women impacted by gambling-related violence is important, however, women’s experiences of seeking help remain unexplored. Although women’s experiences of help-seeking for IPV [
19,
33] and for problem gambling [
34,
35] have been widely documented in systematic reviews, women experiencing gambling related IPV face unique and challenging circumstances. Studies undertaken into family violence with gambling help-seeking populations [
3,
36] highlight the need for better treatment and support services for women and call for further research to be undertaken on this issue. Capturing the lived experiences of women accessing services for gambling related IPV is important, as findings can be used to inform targeted public health interventions and tailored treatment.
This paper aims to explore the service experiences of women impacted by gambling related IPV in Australia; the paper explores positive experiences of help-seeking by adopting a strengths-based research approach. Strengths-based approaches concentrate on the inherent strengths of individuals, groups and organisations, and embrace asset-based approaches which are solution-focused rather than problem-focused [
37]. To our knowledge, this is the first study of services experiences of women affected by gambling related IPV to take a strengths-based approach.
Methods
Ethical approval for this study was obtained from Central Queensland Human Research Ethics Committee (Protocol code # 20,852).
Design
In the present study, we draw upon qualitative data collected as part of a larger study funded by ANROWS (project number#) which explored the nature of the relationship between gambling and IPV against women by a male partner using a social-ecological approach. This approach explores complex interactions between various individual and contextual factors, paying explicit attention to these relations’ social, institutional, and cultural contexts [
38]. Specific research questions included: “How does gambling by a male partner interact with his violence against his female partner?”; “How does gambling by a female partner interact with violence from her male partner?” The study focused on gambling related IPV by men against a female partner as this is the most common form of IPV linked to gambling [
5,
39]. Adaptive grounded theory [
40] and situational analysis [
41] were used as the methodological approach; this combined approach facilitated a richer and more credible understanding of women’s experiences of gambling related IPV. The specific design and methods have been detailed elsewhere [
12]. Using interview data from the larger study, we performed a secondary analysis of data to answer the following research question “How can health and social service agencies be strengthened to better address the needs of women seeking support for gambling-related IPV?” This analytical stage of the research specifically focused on reanalysing interviews from the preceding stages of the study: 48 transcripts from women with lived experience of IPV related to a male partner’s gambling; and 24 transcripts from women with lived experience of IPV related to their own gambling.
Recruitment and sample
Women throughout Australia who had experienced IPV (including economic abuse), linked to their own or male partner’s gambling, were purposively recruited to the study. Recruitment and data collection were conducted simultaneously between July 2018 and June 2019. Recruitment occurred through professional networks and direct contact with support services (e.g., gambling help services, domestic violence services, financial counselling services, legal services, women’s health services, culturally specific services). To minimise risk, participants were offered multiple options for contacting the research team: online registration, telephone, email and SMS; participants were encouraged to use a pseudonym. A female project officer spoke with each woman to ensure they met the inclusion criteria and to arrange an interview.
The inclusion criteria for participants were: being aged 18 years or over, currently living in Australia, willing to consent to and participate in an interview, and having lived experience of IPV (including economic abuse), linked to their own or male partner’s gambling. In line with ethics requirements and approval, we recruited only women who had experienced gambling related IPV and received professional help for one or both of these issues.
Data collection
After confirming informed consent, telephone interviews lasting 50–90 min were undertaken with each woman. Each interview was facilitated by a female researcher with experience in conducting qualitative research on sensitive topics. Upon reflection, the interviewers felt that sharing the same gender as participants helped to build rapport and facilitate open communication. Participants were asked to tell their story of how gambling and IPV had impacted on their life. Unstructured interviews were used to allow the women to focus on their lived experience, however, each interviewer used a set of potential prompts to clarify issues such as the type(s) of problematic gambling, the trajectory of the gambling and IPV, and people, groups, and organisations that may have helped or hindered the situation. Most participants provided detailed accounts of their experiences with minimal prompting, including their experiences of help-seeking. All interviews were audio-recorded, professionally transcribed, and deidentified before analysis.
Data analysis
To answer the research question “How can health and social service agencies be strengthened to better address the needs of women seeking support for gambling related IPV?”, we performed a secondary analysis of the interview data following the six phases of thematic analysis suggested by Braun and Clarke [
42]. The first phase involved the first author reading and rereading the transcripts and noting help-seeking experiences and service interactions. Following this phase, codes (words or short phrases to capture key ideas) were generated from the data set and noted by the first author. Codes were clustered together to create potential themes. Provisional themes were discussed with the second author and agreed upon at this stage. Once provisional themes were selected, the first (COM) and second authors (NH) reviewed, defined, and named the final themes and sub-themes. The final phase of analysis involved selecting appropriate data excerpts to use for the final manuscript.
Discussion
This is the first in-depth qualitative study to explore the service experiences of women impacted by gambling related IPV. By focusing on positive experiences through a strengths-based approach, this study provides insight into what works for women. The findings highlight existing strengths and capacities and identify areas where further support is required. In short, the ways individual practitioners and services engage with women seeking help for the intersecting issues of gambling and IPV, and the protocols for screening, assessing and helping them are central to supporting and protecting women. Consistent with other research exploring IPV when other co-occurring health conditions are present [
26,
31], this study found that women valued responses from practitioners and services that addressed their multiple, intersecting and complex needs. As well as needs arising from IPV victimisation, women impacted by gambling related IPV require support to cope with the emotional, relationship and psychological stress arising from their partner’s gambling. Men with gambling problems often have mental health and substance misuse problems, further exacerbating IPV and potentially leading to devastating consequences [
5]. In addition, women with gambling problems also struggle with substance misuse problems, mental health and other comorbid issues [
43]; it was not unusual for women in our study to find themselves in a relentless self-reinforcing cycle of gambling and abuse. Examining IPV through an intersectional lens [
44], enables service providers to tailor support for victims with complex intersecting health issues.
Encouragingly, and in line with other studies [
20,
26], routine inquiries and screening processes were valued by women, providing insight into the different ways that risk from problem gambling and violence manifest, and encouraging further disclosure. Whilst surveys show people are aware that a physical assault constitutes IPV [
45], other behaviours such as economic abuse, or intimidating and controlling behaviours aimed at manipulating the woman into providing funds for gambling, may not be recognised as such. Our findings highlight the importance of screening for economic abuse, given its strong link with problem gambling and the unrecognised, underreported and invisible nature of this abuse [
46‐
48]. Professional development for practitioners in IPV, gambling help and financial counselling could develop knowledge and skills to encourage screening for and responding to gambling related economic abuse. While our findings do support the use of structured screening tools, such tools must be short and practical to use, yet thorough enough to cover the risk [
49]. Freytag and colleagues [
8] recommend the ‘DOOR 1’ risk screen, a validated risk screening measure that takes clients 15 min to complete by tablet or paper, and covers around 100 risk items [
50]. The DOOR 1 can be used as part of a collaborative interagency and case management approach by practitioners who are not DFV specialists.
Women in our study also appreciated timely referrals to other agencies within and outside the health sector. From a public health perspective, the importance of working beyond the health sector to improve health outcomes is well documented [
51]. As Ragusa [
52] highlights, understanding and improving service delivery for IPV demands an interdisciplinary approach considering the varied and complex factors involved. Front line practitioners, such as DFV counsellors, are vital in ensuring clients can disclose their abuse in a safe and supportive environment [
31] and receive information regarding options available. However, financial concerns play a prominent role in women’s lives when struggling with the decision to leave or not, especially when gambling has depleted their financial resources [
12,
14]. In recent years, the DFV field has increasingly recognised the importance of addressing women’s financial security [
52,
53]; this is especially relevant when working with women impacted by violence related to gambling. Gambling help and financial counsellors are uniquely positioned to identify and deal with the fallout from gambling related IPV [
8]; in Australia, economic abuse casework is typically an important part of the role [
54]. In our study, referrals to gambling help and financial support services helped women alleviate monetary challenges, gain insights into their situation, manage debt, and safeguard finances. These findings reinforce the importance of well-linked service provider networks that transcend traditional health sector responses.
Problem gambling and IPV are both highly stigmatised and associated with negative stereotypes [
14,
55,
56], hence practitioners need to be aware of the double stigma facing women impacted by gambling related IPV. Women with a gambling problem face intense stigma; high levels of damaging self-stigma are evident in this group [
57]. In our interviews, multiple aspects of stigma were uncovered, leading to women feeling ashamed and inadequate, compounding emotional and social isolation. Our study supports evidence from other research that women impacted by highly stigmatised health issues value a non-judgmental, trauma-informed approach, tailored to their needs [
19,
31]. Support for women needs to be non-judgmental due to the stigmatising nature of both problem gambling and IPV [
12], and trauma-informed due to their varying and intersecting needs [
20]. Sharing lived experiences through group counselling or support groups, was a crucial part of the healing process for many women and has been shown to an effective in other settings [
58,
59], especially for highly stigmatised issues. Cultural, anticipated and internalised stigma can deter help-seeking [
24,
25]; hence practitioners working with women must address the many facets of the woman’s complex situation and the shame associated with the struggle to move forward.
As noted by Freytag and colleagues [
8], therapeutic approaches should never oversimplify a woman’s predicament or perpetuate misguided information such as “Why doesn’t she just leave him?” or “She should just stop gambling!”. Importantly, practitioners also need to consider whether strategies promoted to assist women dealing with gambling related IPV may increase the risk of harm. For example, when working with women who gamble, it is crucial to understand the role gambling plays. For some women, gambling venues are seen as accessible, safe and welcoming spaces, and may provide respite from their partner’s violence [
60]. Electronic gaming machines (EGMs), in particular, are highly accessible and attractive to women as they facilitate dissociation, and help women extend time away from pain, worries and difficult realities [
61,
62]. Furthermore, lack of financial independence traps women in violent relationships [
63,
64]; gambling provides one of the few sources of hope for women in these situations. Supporting women impacted by gambling related IPV requires a multi-pronged approach that addresses the harms caused by IPV and problem gambling. Counselling, therefore, needs to focus on expanding a women’s coping capacity and exploring safer respite options.
It is important to note that women escaping gambling related IPV have safety needs and complex financial needs (resulting from gambling related economic abuse or because funds have been depleted through their own gambling). Consistent with the broader DFV literature [
10], women highlighted the importance of having access to safe shelters, more affordable and stable housing, and emergency funds. Accessing affordable, permanent housing is critical to the long-term safety and well-being of women and their families [
65]. Encouragingly, access to safe places and emergency accommodation for women impacted by IPV is prioritised in the Australian “National Plan to Reduce Violence against Women and their Children 2010–2022” [
66], a key document outlining government regulations and responses to DFV. Also consistent with findings from other research [
67,
68], women highlighted the importance of developing a tailored safety plan focused on the woman’s unique life circumstances and plans. Safety planning aims to collaborate with women to help them identify acceptable and feasible options to increase their safety and decrease their exposure to harm [
69]. Strategies that don’t match risks and circumstances may not improve safety and may increase risk [
68].
Problem gambling has devastating financial consequences and creates additional financial stressors for women and their families [
14,
70], hence instrumental support from financial counsellors and gambling help was seen as critically important. Evidence suggests that practical support, aimed at encouraging women to manage their finances, improve economic empowerment and build self-efficacy in a way that minimises the risk of exploitation, can be used as a mechanism to address and prevent further abuse [
53,
71]. Women were positive about the assistance received from financial counsellors; strategies such as securing loans to pay off debts and practical strategies to safeguard finances such as opening new bank accounts or strengthening the security of their accounts helped protect the household’s money. For women seeking help for IPV related to their own gambling, practical strategies and support from gambling help were valuable. In addition, services can assist women to use concrete tools such as voluntary self-exclusion, designed to limit access to gambling. By increasing the likelihood of reductions in gambling behaviour, problem gambling symptomatology, gambling urges and gambling harm, self-exclusion can be an important adjunct to treatment [
72‐
74].
Limitations
This study provides a unique insight into the service experiences of Australian women impacted by gambling related IPV, however, the study is not without its limitations. Women were purposefully sampled to explore and unpack their experiences of IPV victimisation linked to gambling; the researchers recognise that this study does not represent the service experiences of all women impacted by gambling related IPV. Although women who participated were from diverse backgrounds, the relatively small sample size did not allow analysis by characteristics such as race or ethnicity. Future research would benefit from exploring the service experience of women from a different cultural perspective. Exploring experiences through a cultural lens will help support the design and delivery of culturally and linguistically appropriate support services for women impacted by gambling related IPV. Though women are the focus of this paper, the service needs of children in this family situation cannot be overlooked. Further research could integrate the voices of children impacted by gambling related IPV and identify effective service responses for women and their children.
Acknowledgements
The authors would like to acknowledge the women who consented to participate in this study. We would like to acknowledge the contribution to various aspects of this study from Annabel Taylor, Andrew Frost, Rebecca Jenkinson, Angela Rintoul, Julie Deblaquiere, Uma Jaktar, Anna Thomas, Nancy Greer, Erika Langham, Jamie Lee, Alun Jackson and Vijay Rawat. We would also like to thank our research partners who helped to recruit research participants and provided general guidance for the study: Relationships Australia Queensland, Relationships Australia South Australia, Relationships Australia New South Wales, Relationships Australia Australian Capital Territory, Women’s Health in the North, Salvation Army Crossroads Family Violence Service, and Cairns Regional Domestic Violence Service.
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