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Most people with gambling problems have at least one co-occurring condition and many experience multiple co-occurring conditions
simultaneously. In many Western jurisdictions, a specialist service response has developed, with separate agencies and workforces
established to respond to gambling problems. Despite the number of co-occurring issues that occur alongside gambling, research
is limited on the prevalence of problem gambling across some service systems, such as mental health and family service sectors.
However, it is reasonable to conclude that significant numbers of people with gambling problems are currently engaged in other
health and welfare service sectors. Partnership work with other service sectors is therefore vital to respond to the needs
of these people. In Victoria, Australia, a partnership program was established in gambling help services to improve integration
and co-ordination between gambling, alcohol and drug, family support, and mental health service sectors. From the experience
acquired in developing the program, we seek in this article to outline the benefits and challenges of implementing a cross-sector
approach in gambling treatment service systems and to recommend effective strategies to develop a cross-sector approach, including
creating an authorising environment at the government policy level.
La majorité des personnes qui ont des problèmes de jeu présentent au moins un trouble concomitant et un grand nombre, plusieurs
troubles concomitants. De nombreux pays occidentaux ont mis en place une structure d’intervention dédiée aux problèmes de
jeu, constituée d’organismes et d’effectifs spécialisés. Malgré la prévalence des troubles concomitants, toutefois, les problèmes
de jeu ont peu été étudiés dans des secteurs comme la santé mentale ou les services aux familles. Néanmoins, il est raisonnable
de supposer qu’un nombre important de personnes souffrant de problèmes de jeu consultent aussi certains services relevant
de la santé et des services sociaux. La collaboration intersectorielle s’impose donc comme un moyen essentiel de répondre
à leurs besoins. À Victoria, en Australie, un programme de partenariat a été mis sur pied par les services d’aide spécialisés
dans les problèmes de jeu en vue d’améliorer l’intégration et la coordination des services dans différents secteurs d’intervention,
soit le jeu, l’alcool et les drogues, le soutien aux familles et la santé mentale. S’inspirant de l’expérience acquise durant
l’élaboration du programme, cet article vise deux objectifs : présenter les avantages et les défis d’une approche intersectorielle
pour les services de traitement des problèmes de jeu; recommander des stratégies propices à sa mise en place, dont la création
d’un contexte favorable sur le plan des orientations gouvernementales.
It is well established that people with gambling problems frequently experience co-occurring issues, including mental illness,
substance abuse, family and relationship difficulties, health conditions, and social problems such as socio- economic disadvantage,
homelessness, and crime (Miller, 2014). Problem gambling is highly associated with co-morbid substance abuse (Petry, Stinson, & Grant, 2005) and mental illness and has also been linked to suicide (Productivity Commission, 1999). Other risk factors associated with problem gambling include unemployment and coming from a lower socio-economic background
(Delfabbro, 2011). In addition, emerging evidence suggests that problem gambling may be a specific risk factor for family violence (Suomi et al., 2013). Problem gambling has a much higher prevalence among people in prison (Turner, Preston, McAvoy, & Gillam, 2013) and in homeless populations (Nower, Eyrich-Garg, Pollio, & North, 2014) than it does in the general population.
Most problem gamblers have at least one co-occurring condition. In an online survey of 267 problem gamblers in treatment,
less than 2% had not experienced one of the other health conditions studied, in addition to their problem gambling (Haw, Holdsworth, & Nisbet, 2013). Further, most people with gambling problems experience multiple co-occurring conditions simultaneously. A study of 15,000
problem gamblers in Victoria (Billi, Stone, Marden, & Yeung, 2014) found that less than 10% of problem gamblers had no co-occurring condition and nearly 40% of problem gamblers had four or
more co-occurring issues (K.Yeung, personal communication, November 2014).
These figures support the view that in the area of health and addiction, co-morbidities should be understood to be the “expectation
rather than the exception” (Minkoff & Cline, 2012).
There is a huge variation in government health responses to problem gambling. Some approaches include no or limited gambling-specific
services in which people with gambling problems are absorbed into self-help systems such as Gambler’s Anonymous. Such models
leave people with gambling problems to access the broader health and welfare system themselves in order to address co-morbid
mental or physical health conditions. Other jurisdictions fund dedicated gambling treatment services with a specialist workforce
to respond to people presenting with gambling problems. Services are usually a combination of clinical and financial counselling,
self-exclusion, and community education and are often funded from some form of hypothecated tax or levy on gamblers’ losses.
Although there are many benefits of specialist responses to problem gambling, the clinical presentation of many people with
multiple conditions requires a service response that is well integrated with other service sectors in order to better meet
the multiple needs of clients.
Despite the number of co-occurring issues that may occur alongside gambling, research is limited on the prevalence of problem
gambling in some service systems, such as mental health and family service systems (Miller, 2014). Nevertheless, it is reasonable to conclude that significant numbers of people with gambling problems are currently engaged
in other health and welfare service sectors. Partnership work with other service sectors is therefore necessary in order to
effectively respond to the needs of these people.
It is notable that the uptake of gambling-specific clinical services is often not high. In Australia, only up to about 10%
of people with gambling problems access gambling help services (Delfabbro, 2011), a rate not dissimilar to rates in jurisdictions within Canada, the United States, and New Zealand. For clients with multiple
issues, the complexity of their needs may hamper access to gambling help services. When problem gambling is identified in
other service systems, it is not likely to be the most significant presenting issue. When there is no screening or assessment
in other services, the problem may not be identified until well into treatment, because for some clients, the need to address
the impact of the gambling may be more critical than the concerns about the underlying gambling behaviour (Department of Justice, 2008).
Problem gambling may be a low priority for the individual; where people with gambling problems are accessing other services,
referral to gambling help services for this cohort is more likely to result in non-attendance or early dropout (Department of Justice, 2008). This means that the person affected by gambling is likely to miss out on help with their gambling issues, but not treating
the gambling may also have a detrimental impact upon recovery in other areas (Miller, 2014). People with gambling problems also face significant barriers to help seeking, most prominently community stigma and subjective
pessimism regarding the effectiveness of treatment, such that help is not sought until a crisis point has been reached (Bellringer, Pulford, Abbott, DeSouza, & Clarke, 2008). Clients who do seek help tend to do so a considerable time following the initial recognition of the problem, by which time
gambling and its associated problems may have become entrenched in these individuals and in their families. Gambling may be
framed as a moral issue or a choice by the community, health providers, and affected individuals alike, rather than as an
addiction. Such attitudes may underpin the low priority assigned to providing and accessing help for people experiencing problems
with gambling.
Over the last 20 to 30 years in Australia and the United States, integrated dual diagnosis systems in the area of mental health
and substance abuse have been developed and evaluated. Integrated treatment that simultaneously addresses mental health and
substance use conditions is associated with lower costs and better outcomes such as reduced substance use, improved psychiatric
symptoms and functioning, decreased hospitalisation, increased housing stability, fewer arrests, and improved quality of life
(Drake et al., 2001). Integrated dual diagnosis programs are demonstrably more effective than non-integrated programs. By contrast, dual diagnosis
clients in mental health programs that fail to integrate substance abuse interventions have poor outcomes (Drake et al., 2001).
The high co-morbidities between problem gambling, mental health, and substance abuse suggest it would be beneficial to include
problem gambling in a dual diagnosis platform. Drake et al. (2001), for instance, note that dual diagnosis is a misleading term because the individuals in this group are heterogeneous and
tend to have multiple diagnoses rather than a dual diagnosis. The classification of gambling as an addictive disorder within
the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; American Psychiatric Association, 2013) provides an added impetus for greater inclusion of gambling services within the broader health and mental health sector.
A recent meta-analysis of the prevalence of psychiatric co-morbidity in treatment-seeking problem gamblers recommends routine
systematic screening and comprehensive assessment for co-occurring psychiatric disorders in those seeking treatment for gambling
problems. Approaches include screening for multiple psychiatric disorders, or targeted screening for prevalent disorders such
as alcohol and substance abuse disorders, mood disorders, and anxiety disorders. The clinical response of specialist gambling
agencies to psychiatric co-morbidity should include appropriate referral pathways, or a workforce with adequate skills to
appropriately manage these disorders (Dowling et al., 2015).
Systemic responses to addressing complexity in the population of people with gambling problems in Australia have been limited
by the fact that historically, gambling help service systems have largely developed in relative isolation from the broader
health and human services sector. Gambler’s help agencies remain separately funded from alcohol and drug, mental health, and
other welfare services, and the development of government policy pertaining to problem gambling service delivery is often
administered through departments (such as justice departments) that do not administer health and human services.
The National Drug Strategy 2010-2015 (Ministerial Council on Drug Strategy, 2011) emphasises the importance of partnerships and integrated service approaches with alcohol and other drug treatment, social
welfare, income support, and job services; housing and homelessness services; mental health care providers; and correctional
services. Gambling is not specifically mentioned in this strategy and is often neglected at a government policy level when
partnerships in the broader health and welfare sector are considered. Without adequate incentives or government commitment
to cross-sector integration of problem gambling treatment services, clients with gambling problems and complex co-occurring
issues may be overlooked in service delivery responses.
A further area of concern is that the field of gambling utilises multiple terms to identify and describe a person who is experiencing
acute levels of distress related to their gambling (e.g. problem gambler, pathological gambler). The same level of confusion
exists for individuals who do not meet set diagnostic criteria (e.g. at-risk or recreational gamblers). This issue affects
the literature related to gambling (Miller, 2014), but also applies to delivery of treatment services. In order to work effectively with other service areas, the funded gambling
treatment service sector and other service sectors need to use consistent terminology to improve responses to people with
gambling problems.
Given the evolution of a separate and specialist gambling service response in many jurisdictions, the challenge is to develop
and deliver services that are better integrated and coordinated across the range of health and human service areas. Even for
those gambling services that are co-located within other health and welfare agencies, integration cannot be assumed.
A substantial body of literature describes the benefits and challenges of cross-sector collaboration. Collaboration can be
defined as “working across boundaries and in multi-organizational arrangements to solve problems that cannot be solved – or
easily solved – by single organizations or jurisdictions” (O’Leary, 2014). Cross-sector collaboration is a more efficient and effective way of providing services to individuals and families with
complex needs. It is widely accepted that collaboration can achieve outcomes that are more effective, efficient, and sustainable
than can be realised if organisations work alone (Gray, Mayan, & Sanchia, 2009).
Cross-sector collaboration is increasingly assumed to be both necessary and desirable as a strategy for addressing many of
society’s most difficult public health challenges (Bryson, Crosby, & Middleton Stone, 2006):
Problems like inadequate access to care, substance abuse, obesity, environmental hazards, and poverty go beyond the capacity
of any single person, organization, or sector to solve. These problems are influenced by a variety of social, economic, environmental,
and biological determinants … Only by combining the knowledge, skills, and resources of a broad array of people and organizations
can communities understand the underlying nature of such problems or develop effective and locally feasible solutions to address
them. (Lasker & Weiss, 2003)
At the service delivery level, cross-sector collaboration allows agencies and staff to better manage the complex needs of
clients. Benefits of cross-sector collaboration for agencies include more efficient distribution of resources, an increase
in staff morale resulting from a decrease in isolation, improved transfer of information between professionals resulting in
more holistic and coordinated service delivery, and increased responsiveness of services to clients (Davidenko et al.).
It is already acknowledged in the mental health sector that government and organisational promotion of and incentives for
cross-sector collaboration are needed, along with education for staff about co-morbidity and capacity, in order for agencies
to support shared clients across sectors (Lee, Crowther, Keating, & Kulkarni, 2013).
Although cross-sector collaboration is necessary and desirable, research evidence indicates that it is not easy to achieve
(Bryson et al., 2006). The literature on collaboration identifies a number of barriers that have an impact on the ability to implement partnership
work effectively between problem gambling and other service sectors.
O’Leary and Gerard (2012) identify the following challenges in introducing collaborative approaches:
Despite considerable interest and investment in partnership work, because it is difficult to build productive working relationships
among people from different backgrounds, many partnerships do not survive their first year and others falter in the development
of plans and interventions. It is therefore difficult to document the impact of partnerships in improving community health
or service delivery (Lasker & Weiss, 2003).
In 2008, the Department of Justice in Victoria (now the Victorian Responsible Gambling Foundation)1 introduced a partnership development program into the delivery of problem gambling treatment services, with the aim of developing
a more integrated response to problem gambling across different service sectors. The program requires gambling help services
to develop collaborative partnerships between gambling help, alcohol and other drug, mental health, and family service sectors.
It encourages innovative and flexible ways of responding to problem gambling to give clients the opportunity to maintain their
primary therapeutic relationship with other services while still receiving a specialist problem gambling intervention. The
program supports a “no wrong door” approach to service delivery. Flexible service responses include the following and are
provided by all gambling help agencies in Victoria as part of their standard service delivery:
In a survey of partnership development workers delivering this program in 2014,3 the workers reported that they were effectively able to implement the following activities. Percentages refer to the proportion
of workers reporting success in achieving these activities:
The most difficult interventions for these workers to implement were as follows: The partnership development workers identified the following main barriers and constraints to collaboration: The five principles below are based on the experience of implementing the partnership development program into gambling help
services. They draw on the literature of cross-sector collaboration and have been developed specifically for the gambling
help sector (The Bouverie Centre and the Victorian Responsible Gambling Foundation, 2014).
Lack of other sector understanding and engagement was identified by partnership development workers in the Victorian gambling
help sector as a significant barrier to promoting partnership work. The creation of an “authorising environment” is a critical
component in a three-pronged approach in which public sector organisations must (a) create public value, (b) be endorsed by
the authorising environment, and (c) be operationally and administratively feasible. Crafting and implementing successful
strategy in the public sector requires managers to maximise the degree of alignment among the three identified elements of
public value, authorising environment and operational capabilities (Alford & O’Flynn, 2009).
Creating an authorising environment for cross-sector collaboration to occur in problem gambling requires commitment and innovation
from government departments and may be hampered by insufficient resources devoted to collaborative goals. Unless government
departments prioritise working across sectors to address problem gambling (e.g., through the development of memoranda of understanding
at the government level), the needs of people with gambling and related co-morbidities may be overlooked by the broader service
system.
However, even if collaboration across services is embraced at the government policy level, extensive barriers to collaboration
at the service delivery (agency) level may still remain. Challenges include separate performance management systems, budget
systems, and accountability requirements, particularly where agencies are answerable to different funding authorities (Davidenko, Goodyear, Weir, & Sundbery, 2014).
Effective partnership work requires a specific skill set. Leadership has been identified as a strong predictor of partnership
effectiveness (Gray et al., 2009), whereby successful partnerships “benefit from having boundary-spanning leaders who have backgrounds and experience in multiple
fields, understand and appreciate different perspectives, can bridge diverse cultures, and are comfortable sharing ideas,
resources, and power” (Lasker & Weiss, 2003).
Although much of the literature exploring collaboration in the public sector focuses on organisations, “important is who is
representing an organization, agency, or jurisdiction at the table and whether they have the necessary skills to be an effective
collaborator” (O’Leary, Yujin, & Gerard, 2012). In implementing the Victorian partnership development program, clinicians identified not having the right skill set as
a significant barrier that had an impact upon their confidence and ability to build capacity in other services to identify
and screen for problem gambling. To address the issue of capabilities in Victoria, some gambling help agencies opted to employ
workers who demonstrated skills and experience in capacity building work in addition to the existing clinical skill set within
the organisation.
The principles outlined in this section have been expanded into a working eight-page document for use in guiding the development
of cross-sector collaboration approaches and for the training of staff (The Bouverie Centre and the Victorian Responsible Gambling Foundation, 2014).
Implementation science can provide insight into how to deliver sustained improvements in cross-sector collaboration. Thoughtful
and effective implementation strategies at multiple levels are essential in implementing cross-sector collaboration, as every
aspect, from system transformation to changing service provider behaviour and restructuring organisational contexts, may be
fraught with difficulty.
Changes in skill levels, organisational capacity, and organisational culture require education, practice, and time to mature.
However, change does not occur simultaneously or even in all parts of a practice or organisation (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). Implementing the changes required for gambling services to sustainably collaborate more effectively with other service
sectors may demand considerable time and resources prior to measurable improvement of outcomes. Measurement of cross-sector
collaboration outcomes is difficult and, although a number of tools have been developed, further work is needed in this area.
In relation to the Victorian partnership development program, one clinician noted:
Initially agencies appear confused as to why we are contacting them, often stating that they never see clients with problem
gambling issues. After a second or third visit/call/discussion though, this stance has softened and agencies are beginning
to report some clients with problem gambling or, more often, affected others as clients.
Most people with gambling problems have at least one co-occurring condition and many experience multiple co-occurring issues,
including mental health, substance abuse, family and relationship issues, and social problems such as socio-economic disadvantage,
homelessness, and crime (Miller, 2014). Although research is limited on the prevalence of problem gambling in some service systems, such as mental health and family
services, in view of the multiplicity of issues experienced, it is reasonable to conclude that a significant proportion of
people with gambling problems are presenting to other service systems for assistance with other issues.
Gambling help services in many jurisdictions provide a specialist response; however, their separation from other health and
human service delivery areas (even if located physically within other organisations) means integration can be challenging,
reducing the ability to respond effectively to clients with multiple co-morbidities. A number of factors are necessary to
facilitate effective collaboration between gambling help and other sectors, including the establishment of an authorising
environment at the government policy level. A commitment to cross-sectoral and interdepartmental collaboration may be developed
through memoranda of understanding. Consistency of terminology across sectors when referring to people with acute gambling
problems, as well as those at risk of developing problems, would improve service responses. Providing staff with the relevant
skill set to undertake capacity building work is also crucial to the success of partnership building so that gambling help
services can work more effectively with other agencies to raise awareness of gambling as an issue and build referral pathways
for clients with multiple co-morbidities. At an agency level, commitment to collaboration is needed from managers within the
organisation in addition to clinicians, as leadership is an important predictor of partnership effectiveness (Gray et al., 2009).
The formation of successful partnerships across different sectors can be challenging. However, this process is vital to the
creation of a service system capable of responding effectively to the significant number of gamblers with multiple and complex
needs.
Until 2012 when the Victorian Responsible Gambling Foundation was established as an independent statutory authority under
the Victorian Responsible Gambling Foundation Act (2011), responsibility for administration of problem gambling treatment was within the Victorian Department of Justice.
Single session therapy is a structured process for meeting with a client that is focussed on achieving realistic and negotiated
goals and maximising the value of one or more counselling sessions in recognition of the fact that many clients derive benefit
from attending one or two sessions and may not want to attend more regularly (Young, Weir, & Rycroft, 2012).
The survey was administered to 18 workers whose role was to specifically create partnerships between gambling help and alcohol
and other drugs, mental health, and family service sectors. This was not a formal evaluation of the program; however, it provided
insights into some of the difficulties in developing and sustaining partnerships with other service sectors.
At the time this paper was written, both authors were employed at the Victorian Responsible Gambling Foundation, Victoria,
Australia. This article expands on material presented at the National Association of Gambling Studies Conference (Gold Coast,
2014) and a keynote address at the New South Wales Problem Gambling Counsellors Conference (Sydney, 2015).
Copyright © 2021 | Centre for Addiction and Mental Health
Journal Information
Journal ID (publisher-id): jgi
ISSN: 1910-7595
Publisher: Centre for Addiction and Mental Health
Article Information
The Centre for Addiction and Mental Health
Received Day: 26
Accepted Day: 7
Publication date: September 2016
First Page: 68 Last Page: 81
Publisher Id: jgi.2016.33.5
DOI: 10.4309/jgi.2016.33.5
Addressing the Needs of Problem Gamblers With Co-Morbid Issues: Policy and Service Delivery Approaches
1Department of Justice & Regulation, Melbourne, Victoria, Australia
2Drug and Alcohol Rehabilitation Asia (DARA), Koh Chang, Thailand
This article was peer reviewed. All URLs were available at the time of submission.
For correspondence: Kathya Martyres, Department of Justice and Regulation, GPO Box 123, Melbourne VIC 3001., e-mail: Kathya.Martyres@justice.vic.gov.au
Competing interests: None declared.
Ethics approval: None required.
Abstract
Résumé
Notes
References
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Article Categories:
Keywords: problem gambling, health, co-morbidities, cross-sector collaboration, service delivery.
Related Article(s):
Editor-in-chief: Nigel E. Turner, Ph.D.
Managing Editor: Vivien Rekkas, Ph.D. (contact)
Co-Morbidities of Gambling
Addressing Complexity in the Problem Gambling Service Sector
Advantages of Incorporating Cross-Sector Collaboration Approaches Into Gambling Treatment Service Systems
Barriers to Cross-Sector Collaboration
Development of a Partnership Program in Victorian Problem Gambling Treatment Services
Effective Strategies for Implementing a Cross-Sector Approach to Problem Gambling
Summary of Principles to Assist Cross-Sector Collaboration
Creating an Authorising Environment
Skill Set for Cross-Sector Collaboration
Sustaining the Benefits of Cross-Sector Collaboration as an Approach
Conclusion
Acknowledgements