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Chapter 10
Improving treatment services and systems
Introduction
10.1
This chapter will discuss ways to improve treatment services for problem
gambling. First, it will look at a range of possible improvements to the
current system from the perspective of those working in the sector, in
particular the concept of integrated treatment services to deal with the
complications of treating people with comorbid conditions. The chapter will
then look at the need to integrate awareness of gambling addiction across the
wider health profession to ensure better referral pathways. Finally, the
chapter will cover qualifications and training, particularly in the context of clinical
versus non-clinical services.
How can we improve treatment systems?
10.2
The committee heard about ways to improve the current treatment system
including:
-
lifting the rate of help-seeking;
- having a good mix of services to address all stages of gambling
addiction, including online services;
-
establishing better linkages between gambling treatment and other
help services; and
- offering an integrated service designed to treat 'the whole
person', particularly those who suffer from comorbid conditions.
10.3
These features are all discussed in further detail below.
10.4
Professor Dan Lubman, Director, Turning Point Alcohol and Drug Centre,
succinctly described to the committee the challenges facing the sector:
...how we engage a very
stigmatised population into treatment, how we think in a much more
sophisticated way around systems and pathways of care, and how we assertively
reach out to people and to professionals in terms of increasing the reach of
service provision for gambling across the country.[1]
Lifting the rate of help-seeking
10.5
The previous chapter explored the challenges of increasing the rate of
help-seeking from the current low rate of 8 to 17 per cent. While acknowledging
that a 100 per cent response rate would be unattainable, the Turning Point
Alcohol and Drug Centre suggested that a rate of about 35 per cent would initially
be a reasonable target:
Senator XENOPHON: You are never going to have a perfect
system but 10 per cent of problem gamblers getting help is quite imperfect. In
terms of a strategy of advertising, social media—the sorts of things you are
talking about—what do you think a benchmark or a target should be for the next
two or three years if there were a concerted effort? What would be a good
percentage of people in terms of other public health work that you have done to
actually get through the door to get that help?
Prof. Lubman: If we benchmark ourselves against other mental
disorders, for example, what we see in the area of anxiety and depression is a
figure of around 35 per cent. So 35 per cent of people with a diagnosed anxiety
depression seek health support.
Senator XENOPHON: So we should be aiming for that?
Prof. Lubman: I think we should be aiming for that. As I
spoke about before, I think that is about a cultural change. That is not just
about presenting services; it is about a cultural change about the role of
gambling in society. It is a broader discussion and a community engagement
about the harms it causes. It is a recognition that it is a real disorder that
needs treatment and it is about hearing visible voices of people who have
gambled who have recovered and who have good stories to tell about success
stories about how recovery is possible.[2]
A good service mix
10.6
The Statewide Gambling Therapy Service (SGTS) advocated for a 'service
mix' that catered for people at all stages of gambling addiction, from moderate
to severe. Professor Malcolm Battersby, Director, SGTS, described the core elements
of this 'step care'[3]
model:
You can have a range
from brief intervention right through to the severe end, which is an inpatient
program which I know you are aware we run at Flinders. The service mix should
include people with that range of skills, but even brief interventions, which
should now be around cognitive behaviour therapy, need to have properly trained
staff. The brief interventions can include the internet. I think one of the big
missing resources that we are not using in Australia is peers—people who have
recovered from gambling problems. We can use them as part of the treatment mix
as well.[4]
Online services an important part
of the mix
10.7
As covered in chapter eight, online interventions and counselling have
been shown to be relatively effective forms of help. According to the Turning
Point Alcohol and Drug Centre, the surprising success of this mode of treatment
provides an 'opportunity to think about how we reconfigure services to be much
more aligned to people's needs':
We see huge traffic coming through and the challenge for us
is how to cope with this. The way that we have been funded traditionally is to
be in the old mindset of taking a call and referring on to face-to-face because
face-to-face is better. What we now know from other areas of the health system
is that telephone and online can be just as effective. Rather than just being a
triage point, we need to start thinking about how we can deliver interventions
and do assertive outreach using telephone and online means to engage a much
broader proportion of the population in treatment.[5]
10.8
'Assertive outreach' is another potential improvement to online and
telephone services, with Professor Lubman suggesting that greater 'two-way
traffic' could be incorporated into Turning Point's service mix. Noting that
currently, a person may send a couple of chat messages through an online forum
when they are distressed, he stated:
Most of the time,
most of our services are one-way traffic—they just come to us—whereas I think services
should be set up to be two-way. If somebody rings us up we should have the
facility to ring them or send them a text a couple of weeks later just to check
up, saying: 'You rang our service and we wondered how you're doing. We wondered
if you need any more help. We wondered if you're feeling on top of your
gambling.' Being able to think in that much more assertive way, to reach out to
the community rather than waiting for the community to come to us, would be a
really helpful way of engaging more people in treatment.[6]
10.9
He described studies from other fields of mental health when people who
had been treated in emergency departments for self-harm were followed up with
weekly postcards:
The people who
received the postcard, even though it was automated and just had support
messages, showed significantly better outcomes over the follow-up period. Even
though they knew that the postcards were automated they actually felt that
there was somebody out there looking after them and thinking about them. We
certainly know for this population they often feel very alone and isolated. So
I think there is a lot of work we could do in terms of assertive outreach,
either directly over the phone or online with either both automated and
follow-up calls. I think assertive outreach is the way to go in terms of
reaching out and keeping hold of people and encouraging them to seek treatment
and support.[7]
10.10
Ms Simone Rodda, Coordinator, Gambling Treatment Programs, Turning
Point, discussed future improvements to the existing online services, including
having 'moderated forums' to engage more visitors to the website in
conversation. With over 100,000 visits to the website, but only 2,000 to 3,000
people taking up the interactive counselling option, moderated forums could
engage more people earlier, before they reach a crisis point.[8]
Better linkages between services
10.11
The need for better linkages between gambling treatment services and
other health services was raised in evidence to the committee.
10.12
For example, Associate Professor Peter Harvey, Manager, Statewide
Gambling Therapy Service (SGTS), stated that services in South Australia tend
to be set up in 'independent organisations that do not have a very effective
nexus'.[9]
Better coordination of services, such as gambling treatment, family
counselling, financial counselling and social support is required. Mission
Australia told the committee that it aimed for a holistic service for its
gambling help clients:
...we drill down to see what the underlying issues are for the
client and where we can help. So, if a housing issue comes up, an alcohol issue
comes up or even an unemployment issue comes up, because of our service suites,
we can link them into either our services or other services that are in the
area. We do not just focus on the one issue with our clients. We always look at
the bigger picture.[10]
Example of service collaboration
10.13
A example of improvements to service collaboration involving gambling
treatment services was provided to the committee by Associate Professor Peter
Harvey, Manager, SGTS. He described a pilot program underway between Anglicare
and Flinders University which aims to map out 'a process of cross-referral and
self-management support for people in relapse prevention'. He noted that
collaboration, not competition, between services was the key:
...the way the different services were set up tends to have
them more in competition with each other for clients and activity rather than
organised in a way that they can cross-refer, exchange data and work together
to support the same client. So there are a number of pilot programs underway
and we are hoping to build on that, basically using...our self-management
initiative, which is based on a chronic disease self-management program, led by
peer educators who have been through the treatment process themselves. We are
offering that as a self-management forum so that a range of agencies can send
clients at various stages of treatment along to those groups. Those sorts of
mechanisms seem to be working; certainly there is more activity between us and
other agencies than there was four or five years ago.[11]
10.14
Having funding bodies support a collaborative approach between services
has been the key to change at a systemic level:
I think what changed significantly in South Australia a few
years ago was the way agencies were funded and the central agency that was
providing the funding through the Office for Problem Gambling, which made a
statement to the providers. It said, 'We are now happy for a client to exist in
two or three programs and be counted in that way,' whereas prior to that
clients virtually belonged to a service and there was competition across the
agencies for that space. So, at more of a systematic level, having the funding
bodies support that kind of collaboration is positive as well.[12]
10.15
Professor Malcolm Battersby, Director, SGTS, made some practical
suggestions around how collaboration between services could be encouraged; for
example, with financial rewards for cooperation and referrals. He also proposed
an electronic referral system which would also assist with outcome measurement
and data collection:
Another strategy would be to have a common outcome
measurement system across the agencies such as if everyone were collecting the
same data—or at least a minimum data set—and that was facilitated
electronically. In other words, it could be an electronic referral system.
There are examples of that in community and health sectors in South Australia
investing a huge amount of money in a new electronic system. That is
potentially another advantage of being in the health system rather than another
system. Everyone in the health system is trying to move towards electronic data
collection and sharing of communications, so that would definitely assist
people in being able to transfer and, at a click, find out the people you
should be referring to.[13]
Dealing with comorbidity
10.16
The term comorbidity refers to the co-occurrence of two or more
disorders.[14]
In the field of pathological gambling, comorbidity may refer to someone with a
gambling addiction also having a substance abuse or alcohol disorder and/or a
mental illness such as depression or anxiety.
10.17
Throughout the inquiry, the committee heard that people who are treated
for gambling problems often present with a comorbid condition. The Royal Australian
and New Zealand College of Psychiatrists (RANZCP) noted that people with mental
illness were particularly vulnerable to the harms occurring from gambling.[15]
Professor Dan Lubman, RANZCP Fellow, told the committee about a recent
meta-analysis which showed that around one-third of problem gamblers have an
anxiety or depressive disorder, about half have a substance use disorder and
about 60 per cent are nicotine-dependent.[16]
10.18
Dr Katy O'Neill, Clinical Psychologist, St Vincent's Hospital Gambling
Treatment Program, described how people with anxiety may be drawn towards
gambling, thereby developing a comorbid condition:
If you did not work with gamblers you would logically think
that, if you were anxious, gambling would be the last thing you should do; it
is only going to make things worse. But it does perform that sort of mental
escape.[17]
10.19
She also explained how easy it was in the current service system for people
with comorbid conditions to fall through the cracks:
I used to work in drug and alcohol, and there used to be this
thing called bump-and-turf: a new psychotic person would turn up and there
would be a bit of argy-bargy between, 'Is he one of yours?' as in, 'Is it the
first episode of schizophrenia?' or, 'Is he one of yours?' as in, 'Has he taken
too many amphetamines?' It is a people-fall-in-between-the-cracks problem when
they first present. Another problem is that some people think the way to deal
with co-morbidity is to say, 'Yes, about your depression—go and see that
person.' But a person is just one person in their life, and it has to be
treated in context because they are gambling due to the fact that they are
depressed or they obviously get more depressed after they have lost. But we
have seen people who have said themselves that the depression caused the
gambling, and a GP has made the assumption that if we keep treating the
depression then the gambling will logically fade away. We have seen people on
doses of antidepressants that would cheer up anyone if it was in the water
supply or something, and, while that may have been true at the start of
gambling, now there are separate maintaining factors. That is a crucial part
that clinical psychologists can tease apart.[18]
10.20
For a service like the University of Sydney Gambling Treatment Clinic
which offers cognitive therapy, it was acknowledged that people with some comorbid
conditions may find this form of treatment less effective:
...there are always going to be people, whether it is with
depression or anxiety or whatever you are working with, for whom psychological
treatments are not going to be effective—in particular, people with a traumatic
brain injury or people with a comorbid mental illness such as schizophrenia or
severe bi-polar disorder. For people in these sorts of categories, treatment is
going to be less effective.[19]
10.21
The submission from Turning Point Alcohol and Drug Centre pointed out
that very little is known about the best method to treat comorbid conditions
(e.g. before, during or after gambling treatment). Also unknown is:
...how comorbidity
impacts on outcomes or how clients would prefer to receive treatment for
comorbid conditions.
The rates of comorbid
conditions within helpline/online populations are unknown. Implementing screens
within the helpline/online services would provide information for both clients
and counsellors and contribute towards our knowledge of gambling and
comorbidity.[20]
10.22
Professor Dan Lubman, RANZCP Fellow, noted the recent push over the last
decade to integrate services to try to deal effectively with comorbidity for
both substance use and mental illness:
There is recognition that there is huge comorbidity between
the two and service systems for both need to know how to work to address those
issues. Gambling has been really silent in that space. While there has been
increasing recognition of managing alcohol, drug and mental health issues there
has really been no dialogue around gambling. It is seen as some sort of
completely separate issue that does not overlap in any way whereas... there are
huge underlying vulnerability markers of increased risk for all those
disorders.[21]
Integrated treatment services
10.23
A key feature of a best practice service model for gambling help
services is the concept of integrated treatment, particularly to address
comorbid conditions as discussed above. This differs from a case management approach
which may require people to seek a range of treatments from a number of
different agencies, or to recover from one disorder before treatment can
commence for another.[22]
An integrated treatment service, according to St Vincent's Hospital Gambling
Treatment Program, offers 'individually tailored integrated treatment of the
whole person'.[23]
10.24
Dr Enrico Cementon, RANZCP Fellow, stated that each service offering
integrated treatment packages needs to be 'welcoming to a person who presents
with multiple problems':
They have to have an empathic and hopeful approach for that
person and say, 'Yes, you have multiple problems, but let's have a look at all
of them. We'll assess them and then develop an integrated treatment plan which
looks at those problems and addresses them, perhaps in the order of priority of
which is the riskiest at the moment, which is causing the most harm. Then we'll
move through that in that sort of way. We may need to get in specialists to
help us, in which case we will work with the same treatment plan. Rather than
having separate treatment plans we will have an agreed management plan with
similar, mutually acceptable goals and objectives.[24]
10.25
He noted that having different clinical services—for gambling, for drug
and alcohol addiction and for mental health services—ran the risk of
frustration and poor outcomes for the individual seeking treatment if these
services were not properly integrated:
...each of those different service sectors has to have a
capacity within it to be able to manage these patients with multiple disorders
rather than say, 'You've got a gambling problem so you've got to go over to the
gambling service next door or in the next suburb.' Often that sort of
ping-ponging that occurs leads to the person becoming frustrated, getting
different messages from different service providers and then eventually
dropping out of treatment. There can be even worse outcomes as a result of
that.[25]
10.26
Professor Dan Lubman, RANZCP Fellow, also observed that 'people seek
help in the ways they are comfortable with' and people may present for
treatment for mental health issues and not mention gambling problems.
Integrated treatment services must be able to cater for people who are at
different 'stages of change' in relation to different disorders and problems:
We offer integrated treatment for, say, substance use and
mental health issues but we find the majority of people will present to us with
the mental health issue because that is the issue they want addressed. When
they initially come to treatment they will say that they do not see their
substance use as an issue. One of the ways we engage and work with them is to
work on the mental health issue but at the same time, through a series of therapeutic
approaches, have them over time come to acknowledge that their substance use is
contributing to their mental health problems. Then that allows us to also work
on the substance use issues.
One of the issues we have with gambling is that it is very
difficult for people to acknowledge, because of the stigma, that the gambling
is an issue. They are much happier to come forward and acknowledge, for
example, the mental health issues, on which, over the last 10 years there has
been an immense amount of work in terms of destigmatisation. Ten years ago
people probably would not have come for a mental health issue; they would have
come for a physical disorder and then we might have broached
mental health.[26]
10.27
The ideal service system would therefore be one where there is 'no wrong
door' through which to seek help when someone has variety of problems. The
Australian Psychological Society said that given comorbidity is often
associated with gambling problems, it is important that people are encouraged
to get help by 'screen[ing] for gambling in those types of areas where people
do seek help, although they are still not seeking help as much as they should.
That is where people are already engaging in the system'.[27]
10.28
The submission from St Vincent's Hospital Gambling Treatment Program
also argued that while brief interventions could be valuable, the best
treatment for problem gamblers must include the option of integrated treatment
programs:
Brief interventions definitely have their place, as do public
health information campaigns and the promotion of responsible gaming. However,
despite the best efforts at prevention, some problem gamblers will need
extensive treatment.[28]
10.29
St Vincent's Hospital confirmed that its service tackles gambling early
on, even if the client may have other comorbidities:
I think it is important to emphasise that we do actually
target the gambling from day one; we do not start looking at other things, like
whether they are depressed or not. The first focus is primarily on the
gambling, because that is a crisis, and we try to bring some resolution and
reduction of harm around the gambling.[29]
10.30
Professor Dan Lubman, RANZCP Fellow, suggested that building incentives
into the health system to encourage the implementation of certain treatments,
including integrated treatment models of care, was needed:
I think what we can learn from other parts of the health
system is that, if we want to increase the implementation of certain treatments
in key disorder types, we have to incentivise the system. For example, in the
area of immunisation, if we really want to see 100 per cent coverage or 90 per
cent coverage of the population for childhood immunisation, we add MBS
[Medicare Benefits Schedule] payments to general practitioners to encourage the
uptake of that practice. From the wealth of resources that have been put into
the primary care sector for alcohol abuse, if we were to follow a similar path
for gambling, there would need to be a dual strategy both to develop those
resources and to organise the top-down processes to make it an incentive for
primary care to implement that assessment and treatment package.[30]
Committee view
10.31
The committee notes that significant further research is needed to
understand the true effects of comorbid conditions on problem gambling, including
effects on help-seeking behaviour and the difficulties comorbidity may present
for delivering effective treatment services. More information about comorbidity
would enable treatment services to be better integrated and focused to meet the
needs of people with co-occurring mental health or drug and alcohol issues.
10.32
The committee notes that integrated treatment plans are already being
utilised to deal with co-occurring substance abuse and mental health
conditions. The committee recognises that integrated treatment services should be
able to provide assistance to people at any 'stage of change' at which they
find themselves. For example, in the case of those who seek help firstly about
a mental health issue, but who have a co-occurring gambling problem which they
may or may not have acknowledged, treatment providers would ideally be able to
offer a 'no wrong door' approach to service provision so that people may be engaged
in integrated therapies. However, the committee recognises that more information
is needed to help treatment providers deal effectively with comorbidities.
10.33
Recognising that further research on comorbidity and problem gambling is
required, the committee considers that the Department of Families, Housing,
Community Services and Indigenous Affairs should facilitate this further work.
Recommendation 7
10.34
The committee recommends that the Department of Families, Housing,
Community Services and Indigenous Affairs undertake further research on the
impact of comorbidities on problem gambling and how integrated treatment
services can be developed and implemented to effectively address comorbid
conditions.
Strengthening referral pathways
10.35
The Productivity Commission's (PC) 2010 report recommended that stronger
formal linkages be forged between gambling help services and other health and
community services.[31]
10.36
This was supported by Dr Katy O'Neill, Clinical Psychologist, St
Vincent's Hospital, who also said:
We agree with people
like Dr Clive Allcock and the Royal Australian and New Zealand College of
Psychiatrists that clients of all health professionals should be assessed for
gambling, even one or two questions, and then be referred to us.[32]
10.37
Professor Dan Lubman, RANZCP Fellow, explained there was a real need to
strengthen the role of the primary care sector in relation to referrals and
screening:
...it is a key role of primary care to deal with these issues.
However, when speaking to my health colleagues in those fields, often they do
not know what to do, how to identify it or, if they do identify it, where they
should refer to or how they should manage those problems. It is a huge gap in
our treatment sector and a huge issue to do with both workforce capacity
building and development and also the development of appropriate screening and
treatment paradigms.[33]
10.38
He noted that a possible way to ensure a strengthening of referral
practices was to tie assessment and screening requirements to incentive
payments to primary health care professionals through the Medicare Benefits
Schedule (as is done, for example, for childhood immunisation).[34]
10.39
The Australasian Gaming Council's submission noted research[35]
which had found that many Australian general practitioners (GPs) are not
screening for gambling problems because screening tests may be considered to be
'too time consuming' for routine use. A one-item screening tool may be a
reasonable compromise for use by GPs and other health care professionals.[36]
10.40
In 2010, the PC specifically recommended providing a 'one-item screening
test' for optional use by health professionals and counsellors to help identify
gambling problems and that this should be targeted at high-risk groups,
especially those presenting to services with anxiety, depression and heavy drug
and alcohol use.[37]
Committee view
10.41
The committee affirms the need for better linkages and collaboration
across the health care system to strengthen assessment, screening and referral practices
for problem gambling. Developing stronger pathways for referral will facilitate
earlier intervention and help-seeking and enable individuals to address
problematic gambling behaviour much earlier.
10.42
The committee agrees, in line with the Productivity Commission, that
clients of primary care health professionals and counsellors who are considered
'high-risk' (particularly those who present with anxiety, depression, high drug
and alcohol use) should be assessed for gambling problems using an optional
one-item standardised screening test.[38]
Embedding awareness of gambling across the health system
10.43
The committee heard evidence on ways to further strengthen the health
system to incorporate knowledge and awareness of problem gambling among health
professionals. Professor Dan Lubman's view was that there was a 'failure across
the medical profession to understand and treat gambling issues'.[39]
Training of medical students
10.44
The RANZCP noted that there was a need for further capacity building in
the gambling treatment sector and that this could be improved by changes to the
training system:
Addictions are rarely taught in any great detail within most
undergraduate and postgraduate courses, so there is a lack of training and
capacity building in the recognition and management of addictions across a
whole range of health professionals, including primary care providers.
Similarly, in terms of opportunities for postgraduate expertise and training,
again there are limited opportunities for placements or postgraduate training
in the addictions field, so again there is a lack of capacity building in this
sector when it comes to the recognition and management of gambling by primary care
and other health providers.[40]
10.45
Dr Enrico Cementon, RANZCP Fellow, also mentioned efforts made in
Melbourne to have psychiatrists interested in problem gambling impart their
knowledge to medical students, although this was not a systemic practice:
I know that there were a couple of sporadic efforts within
Melbourne where certain psychiatrists are interested in problem gambling. They
consciously make an effort to talk to the medical students that they are
teaching about problem gambling but I do not think there is any cohesive
strategy in relation to medical student teaching and problem gambling. Perhaps
there needs to be some policy around that in the universities.[41]
Promotion of problem gambling
across the health profession
10.46
In order to promote awareness of problem gambling throughout the health
profession, the RANZCP undertakes activities directed towards up-skilling their
professional counterparts. These activities were described by Professor Lubman
and Dr Cementon, RANZCP Fellows:
Professor Lubman: The college is part of the mental health
professionals network where it links with psychologists, general practitioners and
nurses and it arranges professional development activities that include
management of mental health, substance and gambling issues. There is a range of
activities that it is involved in. We have position statements; we promote it
heavily. We are both involved through the section with presentations at our
congresses, with professional development and other activities that we run.
Certainly, we promote it very heavily in there but even within our own college
there is a lot of work to be done in upskilling our college membership in the
recognition and management of gambling issues. There is a lot of work to be
done in this area. Unfortunately, we are a long way behind where we would like
to be.
Dr Cementon: We had a small win about 10 years ago when the
college training was revised with addiction training for all training
psychiatrists. We introduced in the first three years of training the
requirement to compile a logbook of 10 addiction cases. Nine of them were
substance related and one of them was a gambling case where the gambling
problem was identified, assessed and managed as a focus of the overall
treatment of the patient. We consider that to be an important win. There was a
bit of training that went out with that—for example, the DAG [drug, alcohol and
gambling] assessment which was determined by Dr Allcock in Sydney. You might
have come across Clive in your travels. The drug, alcohol and gambling
assessment has been a very core part of the overall psychiatric assessment of a
patient.[42]
10.47
St Vincent's Hospital agreed that further education of health
professionals would assist in helping to break down stigma across society about
problem gambling:
We see a lot of people who have seen psychiatrists, general
practitioners and other psychologists and they have not mentioned their
gambling problem, which gives you an idea of the stigma.[43]
A helpline for health professionals
10.48
The committee heard from the Turning Point Alcohol and Drug Centre about
a practical idea to assist health professionals more broadly to understand,
recognise and help people with gambling problems:
...in the drug and alcohol space we are funded through
government to provide a service called the Drug and Alcohol Clinical Advisory
Service...There is a number that is put across a number of jurisdictions where
any health practitioner can ring up and get advice about how they manage a
client. Most of [the] calls we get are from GPs. They know that they can speak
to a psychiatrist or an addiction medicine specialist about somebody with
alcohol and drug problems in their clinic at that moment. They ring us and we
give them advice. A similar sort of service for problem gambling is needed, so
that GPs knew that if they had somebody there that there is somebody they could
ring immediately to speak to to work out who to refer to and what they should
do next. That level of support would really enhance the amount of pickup
amongst general practitioners and other professionals.[44]
10.49
According to its website, the Drug and Alcohol Clinical Advisory Service
(DACAS) is a 24 hour, 7 day specialist telephone consultancy service available
to all health professionals in Victoria, Tasmania and the Northern Territory.
It is operated by the Turning Point Alcohol and Drug Centre and is funded by
the Victorian Department of Health. The service provides clinical advice to
health professionals who have concerns about the clinical management of
patients and clients with alcohol and other drug problems. Initial inquiries to
the service are handled by professional drug and alcohol counsellors. If the
inquiry is medical in nature, it is referred to a DACAS consultant (addiction
medicine specialists) for a secondary consultation. Consultants aim to respond
to calls within one hour, or as soon as possible if the matter is urgent.[45]
Committee view
10.50
The committee supports the efforts currently underway to embed awareness
of problem gambling across the health profession, from medical students to
practising health professionals. Initiatives such as a helpline for health
professionals to assist them to identify and help patients with gambling
problems are good practical measures which the committee hopes will lead to
improvements in service provision for people with gambling problems across the
health service system.
Recommendation 8
10.51
The committee recommends that the Commonwealth Government fund the
establishment of a national helpline, similar to the Drug and Alcohol Clinical
Advisory Service, as a practical resource for primary health care professionals
to assist them to identify and refer patients who present with gambling
problems.
10.52
The issues of qualifications and training for both clinical and
non-clinical gambling treatment services were raised with the committee as an
area for further attention and standardisation.
10.53
The committee discussed the variability of qualifications and training
with the Productivity Commission (PC). Dr Ralph Lattimore noted that for
non-professional staff who perform interventions and referrals in a gambling
venue, for example, it is important that people not 'stray over the line...we do
not want people being amateur psychologists'. He described the different levels
of qualifications expected depending on the intervention or treatment:
So that goes to the
heart of the question of qualification that may be needed for venue staff as
compared with people who may be actively involved. It is also then a
distinction between people who are undertaking, effectively, clinical roles. If
you are applying or researching cognitive behavioural therapy at a professional
level—people like professors Blaszczynski and Delfabbro—then you need to be a
highly trained professional. Similarly, pharmacological interventions require
that level of training.[46]
Calls for a clinical approach
10.54
Clinicians who gave evidence to the committee advocated strongly for the
value of a clinical approach to treatment of problem gambling. For example, Dr
Katy O'Neill commented on the rigorous approach offered by clinical
psychologists at St Vincent's Hospital:
I think what psychologists
bring to this is that we know how to read research. We do not take things as:
you must see people for six sessions, you must cover this et cetera. We do not
have that cookbook approach. We can see what the research is aimed at, what the
theory is and then apply it.[47]
10.55
Clinical psychologists undertake a minimum of six years full time
university training, including at least two years post-graduate clinical
studies with extensive supervised placements in mental health settings.[48] Dr O'Neill
told the committee that 'treating gamblers is a specialist skill' and that only
those properly trained in psychology and learning theories are best placed to
help problem gamblers:
I do think that a
fairly robust, self-motivated person could probably succeed no matter who they
saw, but there is deep ambivalence when people come in; there is embarrassment.
Some of the learning principles involved in why they keep getting hooked into
it are quite complicated.
...We run a lot of our
clients through a mini psychology course: this is why you are reacting like
this; this is why you might be at home, slumped, and you think of gambling—you
have not even gone yet—and suddenly you have got a little bit more energy. What
causes that motivation? We explain to them things to do with the dopamine
system. They do end up with quite a lot of specific knowledge about gambling,
and that, to me, is possibly why our rates might be higher.[49]
10.56
Ms Abigail Kazal, Senior Clinical Psychologist and Program Manager, St
Vincent's Hospital, added that clinical psychologists are well placed to
provide integrated treatment as they are 'trained to assess the entangled
functional relationships between presenting problems and can thus offer
individually tailored integrated treatment of the whole person'.[50]
10.57
Particularly for the treatment of comorbid conditions, St Vincent's Hospital
emphasised that only appropriately qualified health professionals should
deliver treatment and that poorly informed treatments 'no matter how well
intentioned, can occasionally exacerbate mental health problems':
The addition of a few
mental health units in the minimum qualifications for a problem gambling
diploma is no substitute for the extensive training involved in post-graduate
mental health qualifications.[51]
10.58
These views about qualifications were echoed by the University of Sydney
Gambling Treatment Clinic, which noted that many people who work with problem
gamblers do not necessarily come from a mental health or psychology background.
Even those who are trained in psychology, social work and psychiatry may
require more specialised training in problem gambling because most training
programs for these professions do not specifically address problem gambling.[52] To address
this, the Clinic suggested that a review and adjustment of tertiary training
programs for formal mental health qualifications should take place, as well as
the development of centres of excellence, capable of retraining mental health
professionals in best practice methods for treating problem gambling.[53]
10.59
Mr Christopher Hunt, Psychologist, University of Sydney Gambling
Treatment Clinic, raised serious concern about people without proper expertise
working with problem gamblers:
I would argue that
this is a problem, because the government—not just this government but also
governments in the past—have noted the importance of getting properly trained
people to work with sufferers of depression, anxiety, schizophrenia, bipolar
disorder. But in the area of problem gambling we are seeing that there is still
this preponderance of people with minimal qualifications working on treating
this disorder, and we would say that is far from an ideal situation.
Essentially, anyone that puts their hand up and says, 'Yes, I want to help
problem gamblers,' is able to get funding. But it is not an ideal situation for
the gamblers that there are these people with lower levels of qualification who
are offering treatment.[54]
10.60
The Clinic's submission cited a lack of training for counsellors, 'who are
not typically trained to attend to the various mental health comorbidities that
frequently occur in problem gamblers'.[55]
Committee view
10.61
The committee acknowledges the views of the Productivity Commission and
the health professionals who presented evidence regarding the need for a clinically
rigorous approach to treatment of problem gambling, particularly when dealing
with comorbid mental health conditions. It is important to have the highest
standards of care and service available for those dealing with gambling
problems. While this would be an ideal situation, the committee also notes that
clinical services exemplifying best practice are not in reach of or suit
everyone who has a gambling problem, particularly people in regional and remote
communities. The committee therefore acknowledges the good work being
undertaken at all levels, by both clinicians and non-clinical counsellors.
Minimum standards for counsellors
10.62
Ms Rosalie McLachlan, Inquiry/Research Manager, Productivity Commission
(PC), explained why the PC's recommendation on minimum training standards for counsellors
was made:
A number of
participants to our inquiry actually expressed concerns about the level of
qualifications of counsellors, and there was certainly evidence of variability
of levels of qualifications. But, even in terms of just understanding the
technologies, I remember going to a gambling counsellor conference and being
amazed at some of the questions that were being asked about how the
technologies work. Given that they are seeking to correct misperceptions about gambling,
I suppose I was surprised at the lack of understanding of some counsellors of
how gambling worked and how the technologies worked. So an absolute minimum
requirement would be to actually understand the technologies and how problem
gambling comes about in terms of misconceptions.[56]
10.63
The Gambling Impact Society NSW acknowledged that many in the
counselling sector were doing well with the few resources they have at hand.
However, Ms Kate Roberts, Chairperson, noted there was still room for better
'theoretical grounding' in relation to counselling people with gambling
problems, especially those with comorbidities:
We know that people
need a gamut of different forms of treatment and I am certainly an advocate for
people having choices, but there needs to be at least a baseline of people
being able to have a range of skills. So the area in New South Wales has
developed very much around a treatment area and consequently the recruiting to
that has had people coming from a whole range of different kinds of counselling
backgrounds. Whilst there is nothing wrong with that initially, what we are
really saying is that as we know more about it there are huge co-morbidities
and you really do need to have a baseline of very good theoretical grounding
about dealing with those co-morbidities.[57]
10.64
To improve training, Professor Malcolm Battersby suggested a national
training program for therapists or counsellors:
...which teaches in a
rigorous way at least a graduate certificate level those with mental health
qualifications mental health assessment with a gambling focus, anxiety and
depression assessment and management similar to that provided by the Master of
Mental Health Science course at Flinders University, a course for non-psychologists
in evidence based psychological therapies.[58]
10.65
The PC examined the issue of qualifications and training in its 2010
report, concluding that a minimum standard of training for counsellors was
desirable, given the complex nature of gambling problems. National
accreditation was considered as an approach by the PC but was deemed too costly
and difficult to be approved across all jurisdictions.[59]
Committee view
10.66
The committee supports the Productivity Commission's recommendation to
establish a minimum standard for counsellors to enhance the quality of service
provision. The committee supports jurisdictions and professional bodies working
together to develop national minimum standards of training for counsellors who
deal with problem gambling, in line with the Productivity Commission.
10.67
The committee also sees merit in exploring other ways in which best
practice in problem gambling treatment could be better shared between clinical
and non-clinical services (that is, between professionals and
non-professionals) without compromising clinically rigorous approaches—for
example, through courses offered by clinicians for non-psychologists as
recommended by Professor Malcolm Battersby.
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