by

Gerry Cooper Ed.D.¹

and

Guy Doucet MSW (Candidate)²

Paper presented at the Canadian Foundation On Compulsive Gambling

Paper Available At: <http://www.problemgambling.ca/cfcg2001.htm>

1. Program Director, Centre for Addiction and Mental Health (CAMH), 888 Regent Street, Suite 302, Sudbury, Ontario, Canada, P3E 6C6, E-mail: gcooper@vianet.on.ca.

2. Clinical Social Worker, PineGate Addiction Services, Northeast Mental Health Centre (NEMHC), 336 Pine Street, Sudbury, Ontario, Canada, P3C 5N2, E-mail: mailto:gdoucet@networknorth.on.ca

The opinions expressed in this paper are those of the authors and do not necessarily reflect the views or policies of CAMH or NEMHC.

Gerry Cooper gcooper@vianet.on.ca

and

Guy Doucet mailto:gdoucet@networknorth.on.ca

Despite the increasing prevalence of gambling problems in today’s society, evidence suggests that most people are not receiving help for these issues. Frequently, the issue of stigma is cited as a contributing factor.

New technological advances have now made it possible for individuals who are concerned about stigma, to seek help for their problems without making any personal disclosures. This has meant that many who are initially reluctant to seek help, will be more likely to follow through in the future. The inherent advantages of the Internet: privacy, convenience, safety, portability and so forth ensure that help is always available. Taking these steps does not have to involve others; in this way, feelings of being stigmatized are negated.

Unfortunately, many that might benefit from Internet-based assistance are unaware of the possibilities. Unless an individual has been lucky enough to successfully find an online support group on their own, they likely do not know of their existence. While clinicians and other point-of entry service advisors (for example: problem gambling hotline personnel) are quick to suggest the benefits of face-to-face self-help groups (such as GA) and treatment programs, they seldom recommend that help-seekers consider utilizing online interventions.

This presentation will focus on: 1) what is available to problem gamblers through the Internet, 2) what is known about the efficacy of such services and 3) possible reasons why problem gamblers have not been referred to the Internet by point-of-entry personnel. Implications for future action will be discussed with importance being placed on participant’s feedback.

Despite the increasing prevalence of gambling problems in today’s society, evidence suggests that most people are not receiving help for these issues (National Gambling Impact Study, 1999). Frequently, the issue of stigma is cited as a contributing factor (for example, see Cooper, 2001a; Hodgins and el-Guebaly, 2000; Marotta, 2000).

New technological advances have now made it possible for individuals who are concerned about stigma, to seek help for their problems without making any personal disclosures (Cooper, 2001a). This has meant that many who are initially reluctant to seek help, will be more likely to follow through in the future. The inherent advantages of the Internet: privacy, convenience, safety, portability and so on, ensure that help is always available to those with access. Taking these steps does not have to involve others; thus, stigma is minimized.

Unfortunately, many that might benefit from Internet-based assistance appear to be unaware of the possibilities. Unless an individual has been lucky enough to successfully find an online support group on their own, they likely do not know of the existence of such sites. While clinicians and other point-of entry service advisors (for example: problem gambling hotline personnel) are quick to suggest the benefits of face-to-face self-help groups (such as GA) and treatment programs, we have anecdotally observed that they seldom recommend online interventions to help-seekers.

This paper will suggest some likely reasons for this and what might be done to better educate the problem gambling community about these important resources. Prior to that, we will examine what is available online and what is known about outcomes associated with such Internet resources.

There are a growing number of Internet websites devoted exclusively to the issue of providing information and support to problem gamblers and those interested in the subject. Most of these sites concern themselves with information dissemination (for example, signs and symptoms of a problem gambler) and where to go for face-to-face treatment and/or peer-support. Most search engines if prompted with key terms like "problem + gambling" will yield a wide selection of websites like the following (not an exhaustive list):

It is not always readily apparent if a website is primarily educational or therapeutic; indeed, some would argue that the two are quite similar in appearance and effect. That being said, websites offering direct help to problem gamblers beyond simple information dissemination are not yet as common but they can be found. Here are some examples:

Unfortunately, very little is known about the effectiveness of online resources as they specifically concern problem gamblers. To be sure, online assistance is a very recent phenomenon generally speaking. Some have reported very favourable outcomes in comparing the results of online help to face-to-face help for a variety of other health/social problems (for example: Ferguson, 1996; Zimmerman, 1987).

Research has yet to be mounted to empirically address many of the relevant questions that relate to how well problem gamblers respond to online help. One of the few studies to inform this area was a recent exploratory study by Cooper (2001a) wherein about 70 percent who expressed an opinion felt that GAweb had made a difference to their gambling behaviour. One is quick to note, however, key methodological challenges with such a study: its participants were self-selected and were all recruited from just one website. Therefore, it is difficult to know how generalizable these findings might be to other problem gamblers who seek help online.

On the other hand, it is clear that increasingly, people are availing themselves of Internet resources. For example, it has been estimated that as of November, 2000, there were some 407 million people worldwide who were connected to the Internet (NUA Internet Surveys, 2001). This includes roughly 167 million North Americans (Ibid.) with as many as 53 percent of Canadians connecting to the Internet in 2000, compared to just 18 percent in 1994 (Brethour, 2001).

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

• the ready access of Internet-based services including their immediacy ("24/7"),
• availability regardless of geography, weather conditions, absence of public transportation and amount of time one has at their disposal,
• safety in knowing one is truly anonymous and therefore, able to be more honest with others without fear of reprisals, and
• the ability to overcome what might ordinarily be obstacles to their participation and hence, a sense of being connected with like-minded others from around the world (Ferguson and Madara, 1998).

There is some evidence to suggest that those who benefit the most are those who experience conditions that are accompanied by social stigma. Davison, Pennebaker and Dickerson (2000) for example, found that the highest online support group participation levels were correlated with the most stigmatizing health/social conditions - conditions that were not well served by the more traditional helping community.

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

Lastly, because geography is neutralized in cyberspace, individuals have a much greater array of support groups with different ideologies to choose from. Arguably, this might even create a closer relationship for many professional therapists and the self-help community. For example, the client can utilize online help as an adjunct to their professional treatments and the therapist can have a better assurance of the kind of support being rendered online. There, the therapist too can observe firsthand the kind of support and advice their client is exposed to at the support group.

To begin, it is important to note that we are not reporting new data, nor have we found any research to substantiate our claim that individuals seeking help for gambling problems from traditional point-of-entry personnel (toll-free help lines, local assessment agencies, family physicians and other caregivers) are not being informed of what is available to them online. At this stage, it is important to be clear that our premise is based on anecdotal observation and discussions we have had with colleagues in the field.

That being said, we postulate below, four principle reasons why this might be the case. These include:

1. there are too few online clinical resources specific to problem gambling and they are difficult to locate,
2. until recently, problem gambling training programs for clinicians have not paid much attention to the benefits of online assistance,
3. many have concerns about consumers’ safety and wellbeing while pursuing online help and
4. many clinicians may be concerned about their own fate (either because of exposure to legal liability or to promoting what some might consider to be a competitor) when referring clients to online resources. 

1. Too Few Online Clinical Resources And They Are Difficult To Locate

   This is a valid point since most of what is available to problem gamblers seeking help from the Internet in 2001 might best be described as information dissemination (as opposed to being more clinically useful or oriented). That is, much of what is available at websites either speaks to the etiology of problem gambling, the recognition of signs and symptoms and/or the prevalence of such problems in communities. It seems that very little website content is directed towards action a problem gambler might take to address their problem (eg. how to adjust one’s cognitions, how to inventory their high risk cues, how to establish alternative coping strategies and so forth) and peer-support and advice they can obtain quickly from others online. In short, the majority of our collective online efforts seem to be going towards influencing pre-contemplators and contemplators versus helping those already in the action stage of the Prochaska and DiClemente Model (1982).

   To be sure, if point-of-entry personnel are to be more prolific with their recommendations about online resources, more sites will need to be established that focus primarily on the action-oriented stages of clinical issues.

   Sites, which specialize in clinical issues, will also need to be more vigilant in the future, in promoting their presence to others. By way of an illustration, we were unable to locate one of the busiest online peer-support groups for problem gamblers through repeated and differential use of a variety of the most popular web search engines. In addition, we found very few problem gambling specific websites that hyper-linked to GAweb. This suggests that many who might be looking for this kind of help, will fail to find it online.

   In part, this likely speaks to the lack of resources associated with the development and maintenance of online websites specializing in clinical issues for problem gamblers. As it now stands, proprietors of sites like GAweb may be unable to devote much time to promotion since they are so busy with maintenance issues. Indeed, if they were to promote the website more, it could easily result in more traffic to an already overburdened website and hence more maintenance work for an exhausted webmaster.

2. Until Recently, Problem Gambling Training Programs For Clinicians Have Not Paid Much Attention To The Benefits Of Online Assistance

   Again, it has been our experience that training programs, training guides and professional conferences specific to the issue of problem gambling have paid little attention to how the Internet might help problem gamblers. This is likely related to the above point, but many who do know of the existence of online sources of help have been slow to incorporate them into their standard packages of references to others in the field. If professional training venues are not educating clinicians about the existence of online forms of assistance to problem gamblers, then many might not know of them; without that knowledge, it cannot be expected that clinicians and point-of-entry personnel will be able to notify their clients.

   Fortunately, this is beginning to change as word spreads of the potential benefits of Internet-facilitated recovery. One might expect that as new training resources and conferences include discussions of how the Internet might be able to contribute to problem gamblers obtaining help, that this will stimulate others to take up the discussion as well. Respectively, the Centre for Addiction and Mental Health’s Helping the Problem Gambler resource guide (Murray, 2001) which includes a related chapter (Cooper, 2001b) and this session at the Innovation 2001 Conference, are examples of a growing profile being placed on this subject.

3. Many Have Concerns About Consumers’ Safety and Wellbeing

   Many might argue that they have been slow to embrace online forms of assistance because there has been a paucity of scholarly discussion, research and debate about this subject matter. This is understandable, but one wonders if there might not be a double standard at play. Many for instance, have been known to refer to other more traditional face-to-face interventions in the absence of supportive empirical outcome data.

   Still, the absence of consistent rules of conduct and ethical fair play on the Internet makes this a point worth considering. Once again, by way of illustration, in utilizing a variety of popular search engines to locate online help for problem gamblers (for example the meta-search engine "Dogpile"), several sites were identified and linked which clearly could pose difficulties for unsuspecting problem gamblers. In other words, several online casino/gambling sites apparently had managed to convince various search engines that they were providing a helpful service to problem gamblers. In some cases, these casinos may have had a solitary link obscurely buried within its broader gambling/casino holdings to qualify using the terms "problem + gambling" (see for instance, the "Ask Pinocchio!" link from the "FindWhat.com" search engine). In other instances, advertisers unabashedly took the web traveler directly to the betting action without any intention of providing a link to problem gambling help despite their claim to provide "links to sites for problem gamblers" (eg. Gamblenet from the Looksmart search engine; also at the same search engine, in answer to the question: "Want to try "problem gambling" at the world's #1 site?" one is taken to an online sports casino). Sometimes, the traveler must pass through several screens bearing the casino’s logo before getting to the intended destination (www.casinogambling.about.com/). For some, this might even suggest an affiliation with credible problem gambling sites like Institute for Problem Gambling, essentially making that website appear to reside within the casino’s boundaries for those not too familiar with how hypertext links work.

   Arguably, many if not most, online casinos are well resourced. They appear to easily persuade search engines to include multiple links, even if these links appear through inappropriate key terms. This also contributes to making it more difficult for people to find bonafide helping resources. That is: if a helpful website for problem gamblers is overshadowed by fraudulent links to casinos, the online help-seeker may be easily dissuaded, or worse, harmed by unexpectedly finding themselves in an online casino instead of their intended online abstinence-oriented support group. Of special note in this regard is the fact that many North American casinos tend to favour responsible gaming practices. Such practices are evidently not necessarily shared by several (perhaps many) online casinos (now numbering in the hundreds); casinos which are typically difficult to hold accountable.

4. Many Clinicians May Be Concerned About Their Own Fate (Either Because Of Exposure To Legal Liability Or To Promoting What Some Might Consider To Be A Competitor)

Now that help for problem gamblers is available through the Internet, the opportunity exists to successfully engage and impact many lives. Previously, such individuals might have avoided seeking any help from traditional face-to-face venues; their problems may have worsened in many instances. Work now must be undertaken to ensure that those in need of such assistance can readily find it. This is a job that will require action on many fronts.

Agencies will need to examine if some of their human resources should be deployed in the development, maintenance and promotion of online forms of assistance to problem gamblers. Research organizations will need to embark on a course of study of online services to better understand critical issues of client-to-intervention matching (who does best and under what circumstances). Training specialists including those who help to prepare our future clinicians and social service personnel, will need to find ways to call attention to the existence of online help as part of their efforts at informing others of what is available in the ‘counsellor’s therapeutic tool kit’. Individuals in those positions may benefit from a personal examination of their receptivity towards and biases about online help. Those concerned about the bogus advertising claims of online casinos will need to find a mechanism to collaboratively lobby search engines in an effort to prevent possible harm to problem ga mblers. To be sure, there is much work ahead and plenty of it to go around.

Assuming that we aspire to ensure that problem gamblers have easy access to safe and affordable help for their problems, then we cannot afford to miss this important opportunity. As we have attempted to illustrate in this brief paper, there are several reasons why the availability of an important new resource to problem gamblers is limited. These should not be seen as being insurmountable, but neither should they be seen as unimportant. They require our collective attention, care and support. Without such, we may soon witness a process whereby a potentially powerful clinical intervention is undermined at the hands of some unscrupulous online casino operators.

Brethour, P. (2001, March 27). Women narrow Internet gender gap. The Globe and Mail, p. B1.

Cooper, G. (2001a). Online assistance for problem gamblers: An examination of participant characteristics and the role of stigma. Doctoral dissertation, Ontario Institute for Studies in Education/University of Toronto. (An abridged version is available online at: http://www.problemgambling.ca/Results.htm).

Cooper, G. (2001b). Internet-aided assistance for problem gamblers. In: R. Murray (Ed.) Helping the Problem Gambler (pp. 21-30). Toronto: Centre for Addiction and Mental Health.

Davison, K. P., Pennebaker, J. W., and Dickerson, S. S. (2000, February). Who talks? The social psychology of illness support groups. American Psychologist, 55 (2), 205-217.

Ferguson, T. (1996a). Health Online. Reading, MA: Addison-Wesley Publishing Company.

Ferguson, T. and Madara, E. J. (1998). 25 Lessons from online support networks [26 paragraphs]. DocTom’s Online Self-Care Journal [Available online at: http://www.healthy.net/home/tomonline/25lessons.htm].

Hodgins, D. C., and el-Guebaly, N. (2000, May). Natural and treatment-assisted recovery from gambling problems: A comparison of resolved and active gamblers. Addiction, 95 (5), 777-789.

Marotta, J. J. (2000, June). Recovery from gambling problems with and without treatment. Paper presented at the 11'th International Conference on Gambling and Risk Taking, Las Vegas, Nevada, USA.

Murray, R. D. (Ed.). (2001). Helping the Problem Gambler. Toronto, ON: Centre For Addiction and Mental Health.

National Gambling Impact Study Commission. (1999). Final Report. [Available online at: http://www.ngisc.gov/].

Nua Internet Surveys. (2001). How Many Online? [1 paragraph]. [Available online at: http://www.nua.ie/surveys/how_many_online/index.html].

Prochaska, J. O., and DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Therapy, Research and Practice, 19, 276-288.

Zimmerman, D. P. (1987). A psychological comparison of computer-mediated and face-to-face language use among severely disturbed adolescents. Adolescence, XXII (88), 827-840.