In this study, we aimed to understand the factors that shape the acceptability of IBIs for problem gambling among end user groups (‘If this service existed, would you use it? Why or why not?’); and to identify factors that can increase the acceptability of IBIs for problem gambling (‘What would you like to see in this type of service?’). From the focus groups, we learned that it is important to recognize the motivations behind the choice to use IBIs in order to understand the factors that influence and increase the acceptability of IBIs for clients and clinicians. Our findings are thus reported in this order.
Part 1 Motivations for using IBIs
Clients and clinicians identified motivating factors associated with their current or intended use of IBIs. Findings from the client groups clarified the barriers they experience in access existing face-to-face treatment services, which suggested that two primary reasons are behind clients’ decision to use IBIs, namely dissatisfaction with existing services and difficulty attending face-to-face treatment. As for clinician groups, findings showed that the primary motivator was a desire to reach clients experiencing barriers, which is influenced by a consideration of the advantages and disadvantages associated with providing treatment through IBIs.
Part 1.1 Clients
Clients revealed that the more they feel dissatisfaction with existing services, the more they are likely to consider IBIs as an alternative form of treatment. They cited lack of availability, lack of support during high-risk situations, lack of lived experience among service providers, and lack of access to professional support as factors that contribute to their dissatisfaction. Client responses also suggest that while most clients prefer professional guidance over peer support groups like Gamblers Anonymous (GA), professional guidance is significantly less accessible.
Client responses were valuable in gaining an understanding of the different barriers that they experience when seeking treatment. They reported barriers and challenges resulting into difficulty attending face-to-face treatment. This includes distance, transportation, timing constraints, waiting lists, financial challenges, feelings of shame and guilt, and implications of concurrent disorders. Table 2 illustrates these factors with example quotes from clients.
Table 2 Client motivations for using IBIs
Themes
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Subthemes
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Example quotes
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Dissatisfaction with existing services
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Lack of availability
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“Just availability. More treatment offered in my area, more services… I think with addiction and mental health and gambling, it's all such a big thing that's going on, it affects people's lives so much, and I feel like they should just have more services.”
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Lack of support during high-risk situations, including nighttime, weekends, and holidays
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“A lot of the times the easiest time to get to a program is on the weekend and there’s hardly any programs here on the weekend.”
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Lack of lived experience among treatment providers
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“There’s a lack of lived experience, in my opinion. It’s a lot of textbook, but there isn’t actually a person that has lived experience.”
“It’s very theoretical rather than practical.”
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Preference for professional guidance over peer support groups
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“I did like going [to GA sessions], but then it's not so structured… There's no professional counselor running them… There's no structure to it.”
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Difficulty attending face-to-face treatment
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Distance to services
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“I know that with a lot of people in small towns, there is absolutely nothing. I know someone right now that’s going through hell and can’t access anything within a hundred miles, so automatically this puts him in harm’s way.”
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Transportation
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“For me, to travel for like an hour is really difficult, so for them to have more services in my area would be better.”
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Timing constraints
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“A lot of people finish work at 5 pm so to get to group by 5:30 pm is quite difficult. I think if group started at 6 pm, a lot more people would be able to attend. A later time would be good.”
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Waiting lists
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“There’s a huge waiting list. We’re talking about two or three months waiting time. I could’ve lost my house in two to three months.”
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Costs and financial constraints
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“Downtown parking, it’s too much.”
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Feelings of shame and guilt
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“A huge barrier for me is shame sometimes. If I haven’t been perfect or let’s say I missed a session with my therapist or my group or I missed a week… I’m embarrassed to come back.”
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Implications of concurrent disorders
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“I think mostly it’s the weather and just being retired and lazy. And suffering from depression, I really find it hard to do anything.”
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Part 1.2 Clinicians
Focus groups with clinicians demonstrated that many of them have some experience working with clients remotely—most commonly via Skype, phone, or email. It is not clear from the clinician responses whether these were sanctioned by the institution. Findings suggest that the clinicians’ desire to reach clients who are experiencing barriers is the primary motivator behind the decision to work with clients remotely.
Among the clinicians, there was consensus that IBIs can be beneficial in mitigating the negative impacts of barriers to treatment. However, clinicians were also quick to clarify that they do not perceive IBIs as a standalone service that would replace face-to-face treatment. Instead, IBIs were perceived as an adjunct service that can help mitigate the harms experienced by underserved populations, and as an opportunity to provide a more client-centred approach to treatment where clients are met in the context in which they live.
Clinicians were instrumental in understanding the advantages and disadvantages associated with engaging with IBIs by healthcare professionals. Advantages associated with IBIs were that in can reach clients experiencing barriers, promote client-centred care, free up time for clinicians, and increase uptake. Disadvantages associated with IBIs were that it can decrease trust due to anonymity, come with limitations of technology, and reduce quality of therapeutic work. Clinicians also discussed the possibility of IBIs posing unique barriers to clients who can’t afford an Internet connection or a computer. This list is reflected in Table 3 with example statements from clinicians.
Table 3 Advantages and disadvantages of IBIs according to clinicians
Themes
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Subthemes
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Example quotes
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Advantages
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Reaches clients experiencing barriers
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“Can reach rural clients who don’t have transportation or access. ‘Cause if somebody lives a couple hours away from any service provider, that’s a significant barrier to coming in and accessing treatment.”
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“Sometimes my clients will say, ‘I can’t afford to come and see you. I don’t have gas money.’ And so it’s cheaper to [go online].”
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“[Can reach] people with health issues. ‘Cause I have a gentleman who has a lot of hip issues right now, and so I just do contact over the phone instead of him coming in cos that was a huge barrier for him.”
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“[Can reach people with] mental health issues too. Phobias.”
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“They might be more comfortable because of the stigma piece.”
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“I have several gambling clients that are in rural areas so they’re about an hour, an hour and a half away… and so I sit at my desk and remote in with them.”
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Promotes client-centred care
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“It gives the clients the power, the opportunity to choose what they want, what they feel they need at that time.”
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“Could be anonymous if people want to.”
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Frees up time for clinicians
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“It’s time for me. It’s like any other client that I know is going to be there just clicks on, boom, the client’s there, I see them, see the next client that’s in the waiting room. I don’t have to drive too. I don’t have travel time. I don’t have anything, really, except to sign in and it pops up.”
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Increases uptake
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“I think it could generate more numbers for our programs if people could connect and do like an assessment or screening and then come in to see us.”
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Disadvantages
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Decreases trust
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“Am I trusting without knowing who’s behind that name online?”
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“Confidentiality could be breached.”
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Comes with technological limitations
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“You only see a proportion [on the screen].”
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“Sometimes technology fails us.”
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Reduces quality of therapeutic work
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“Distractions from our end ‘cause I even find if I’m on the phone with a client, I might be sometimes multitasking, like, I’m not even focusing.”
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Comes with its own barriers
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“Clients can’t always afford the Internet, or own a computer.”
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Part 2 Factors that influence the acceptability of IBIs for problem gambling for both clients and clinicians
In this section, we used the theoretical framework of acceptability developed by Sekhon and colleagues (12), which is comprised of seven component constructs. The framework recognized the distinction between perceived acceptability and experienced acceptability, noting that acceptability can be assessed prospectively or retrospectively (12). In this study, we asked clients and clinicians questions focused on their perceptions of acceptability of IBIs prior to any exposure to the intervention.
It should be noted that when the focus groups were held, we were in the design phase of the intervention and only two features were distinctly known to all focus group participants, namely that the intervention would be conducted over the Internet, and that it would be therapist-guided. Table 4 has a list of the constructs arranged alphabetically with corresponding definitions and example quotes from the focus group participants in each end user group.
Table 4 Factors that influence the acceptability of IBIs
Component construct
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Description of the domain (D) and example quotes from client groups (C1) and clinician groups (C2)
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Affective attitude
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D: How an individual feels about the intervention
C1.1: “I’d be very comfortable with it.” C1.2: “I’d be interested in a trial.”
C2: “I’d be fearful of suicide ideation, how do you deal with that when that takes place? You don’t know who they are, where they are, and how to send help.”
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Burden
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D: The perceived amount of effort that is required to participate in the intervention
C1: “If I thought it would be simple for me to do or somebody could do it for me, then yeah I could access it that way.”
C2: “Definitely a lot of supervision or training on suicidal and homicidal thoughts. I feel like that’s really huge.”
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Ethicality
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D: The extent to which the intervention has good fit with an individual’s value system
C1.1: “Accessibility, it’s everything. And something like this [could] maybe make a difference, right.” C1.2: “I want it to be confidential and private.”
C2.1: “When I think about this, I don’t think about the physical barriers of distance or employment. I think about people who just wouldn’t be comfortable coming in to a treatment agency… And maybe who aren’t quite ready to actually walk in and take that ownership and do that face-to-face. We can give them something less threatening.”
C2.2: “The success of our work is based on the relationship, and so if you take out components of that, then you’re increasing risk in the probabilities of success.”
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Intervention coherence
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D: The extent to which the participant understands the intervention and how it works
C1: “I’d love to see that group, either a separate group online, but a closed group, not people stop by whenever they want like a Gamblers’ Anonymous... Maybe 10 if it’s online, and it’s the same people every day every certain time, but it’s online.”
C2: “There are certain clients that maybe this can benefit or maybe it won’t benefit. So there can be some limitations in terms of what types of issues will be addressed.”
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Opportunity costs
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D: The extent to which benefits, profits, or values must be given up to engage in the intervention
C1: “I wouldn't want to share so much information. I would say just a limited amount of information. Just enough to get the help I need.”
C2: “You lose that human connection.”
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Perceived effectiveness
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D: The extent to which the intervention is perceived as likely to achieve its purpose
C1: “A lot of people in remote areas would be able to access CAMH. For the moment, those of us in Toronto with access to Toronto benefit, so people with mobility issues would be able to take part. So I think it would be excellent.”
C2: “If the general population comes in but then there’s people who have barriers, we want to increase access to those people and this is how we do it, that seems to make sense to me.”
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Self-efficacy
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D: The participant’s confidence that they can perform the behaviour(s) required to participate in the intervention
C1: “I’m sure I can learn. I don’t think it would be difficult.”
C2: “I think for me, to start with, because I’ve never done it before, I want to kind of start from bottom-up. Like, narrow it and then widen it as I improve whatever that I need to do.”
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Note: Component constructs were adopted from the theoretical framework of acceptability developed by Sekhon and colleagues (12). The quotes above are a small sample of the transcript data and do not represent an exhaustive list of quotes.
Part 3 Factors that increase the acceptability of IBIs
Clients and clinicians identified a number of physical and social factors that can increase the acceptability of IBIs for problem gambling. We documented these factors as they were described by focus group participants.
Table 5 Factors that increase the acceptability of IBIs for problem gambling
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Clients
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Clinicians
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Physical
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Availability of services 24/7
Synchronous over asynchronous communication
Therapist guidance
Skills-focused programming
Supports and services for loved ones
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Closed sessions
Video calling over text-only communication
Good and reliable technology
Basic and user-friendly technology
Personalized messages
Paperwork aid
Tech support
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Social
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Integrated approach to treatment
Privacy and data security
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Policies and protocols
Safety protocol
‘Netiquette’
Rigorous screening of clients
Tiered approach to implementation
Complete programming
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Part 3.1 Clients
For clients, acceptability can be advanced by the integration of certain features, such as the availability of services on a 24-hour basis. Clients also preferred programs with therapist guidance over purely self-help resources, and synchronous communication over asynchronous communication. Skills-focused programming that integrates the use of worksheets, homework and exercises, and guided meditation is also favoured by clients. Recognizing that gambling-related harms have an impact not just on the individual gambler but those around him or her as well, clients also identified the value in supports and services for loved ones, such as online forum discussions. As one client described:
“A lot of the time, by the time we get here, our families are like ‘yeah okay this is just another cycle.’ If this [online service] gets in, instead of making a whole trip there [or] here, maybe they only have to go online for a little bit to be able to get some of their vent out.”
Findings also show that an integrated approach to treatment is highly desired by clients. This was illustrated by the following exchange in the first client focus group:
“What I love about CAMH is that I have two addictions and mental health issues, and they’re able to treat all of them together. They [service providers] communicate.”
“Yeah, it’s actually a very good statement. I totally agree with that… The great thing is that you can get all the therapy within the same confines ‘cause lots of times there is crossover.”
Part 3.2 Clinicians
Clinicians described how the design and implementation of IBIs for problem gambling could be advanced by physical (e.g., closed sessions, video-based over text-based communication) and social (e.g., comprehensive safety protocol, rigorous screening process) factors.
Closed sessions, which was described as sessions having an element of start and end that can reinforce boundaries and structure, are preferred by clinicians. There was consensus among clinicians that platforms with an online face-to-face video component, also known as video calling, would work better than text-only communication models.
Noting their experiences of volatility with other Internet-based tools like Skype or Adobe Connect, clinicians emphasized the importance of good and reliable technology, including picture and audio quality. One participant spoke specifically about her experience with the problem gambling clients she sees, describing: “I find a lot of times when it gets complicated, people just get discouraged and then they stop. It just has to be basic and user-friendly.”
Another clinician spoke about her own problem gambling clients and their propensity for personalized messages: “I have a lot of clients that love those motivational emails a day.” To which, another member of the group added: “They really want to see what they’re doing, and they want to track changes, and they want to see their successes and failures as well.”
One clinician’s call for paperwork aid (“Can someone do our paperwork?”), including the automated scoring of screeners and assessment tools, generated laughs and endorsement from the group. Lastly, there was an agreement between clinician groups that tech support should be available whenever needed either by clients or clinicians: “Tech support available and ready to jump in while the session is going in”
In terms of social factors, the development of policies and protocols was seen as a priority. This refers to a broad array of potential issues ranging from safety protocols to expectations from clients. As one clinician asked:
“Are we going to counsel somebody who accesses this service on their cellphone and they’re walking on the street and then they’re receiving counseling and they cross the street without looking where they’re going?”
Next, the clinicians also saw the value in developing group norms tailored for an online audience, which they called “netiquette instead of norms” – a play on Internet etiquette. This set of netiquette would also cover expectations of any client participating in an online group.
“I think expectations of the clients. So if it’s going to be more skill-based or structure-based, if they pop in for their video session and they haven’t done the worksheet that they’re supposed to have done… there’s only so much you can do around motivation… If they’re not going to put the work in, then it’s really not going to work.”
The development of a comprehensive exclusion criteria and rigorous screening for clients was another priority for clinicians. There was a consensus that if a client’s condition is severe, IBIs may not be the best fit.
“If their situation is severe, I’d say no. If it’s kind of mild and kind of assessing the safety stuff and all of that, I say yes. So, it depends on the client situation. I can’t say it would work for everyone.”
A number of clinicians raised the possibility of a tiered approach to implementation of IBIs wherein instead of treatment, dissemination would start with services deemed to be of lower risk, such as assessment, continuing care, or relapse prevention. Two clinicians from different groups shared their belief that IBIs would work best as a follow-up service. As one of them described: “In my experience, the only time it does work is when you have a really established relationship with someone and then they move, but you’ve already got the connection.”
Finally, clinician perspectives pointed towards the value of a complete programming for clients: “I think if somebody used the online service, it should be able to take them through their recovery. It should be a complete cycle. A complete program so to speak. That’s important.”