Introduction

In a number of jurisdictions, problem gambling treatment services are well established, and attention is increasingly turning to how to prevent and minimise gambling related harm. The terms prevention and early intervention are being used with increasing frequency, but they are problematic because the underlying frameworks vary and the focus of stakeholders can be narrow.

Many service providers are abstinence focused, and even when we‘re operating from a harm minimisation perspective, treatment goals often end up targeting abstinence or damage limitation. Many services also lack an education or prevention knowledge and funding base. Academia also tend to focus on the problem gambling end of the spectrum or on broader social impact, though some have recognised the lack of attention to prevention and early intervention. Government policy positions are also lagging: most are either developmental or silent on this issue. Finally, within the gambling industry there is enormous variation in positions, from silence to denial to acceptance of problem gambling as pathology for treatment. Even the more progressive resist moving beyond information and education

Given the increasing attention to this area, the range of initiatives across jurisdictions and the divergent understanding of the issues, we need to develop a comprehensive, coherent and consistent approach.

A Starting Point

In 2002, the Victorian state government established a Problem Gambling Round Table, including an Early Intervention Working Group, bringing the issues into sharp relief. It comprised the expected stakeholders, fostered robust debate and confirmed substantial differences in knowledge and positions. Symptomatic of the challenges in this area, the working group lacked a framework and definitions, and despite agreement to focus on at risk groups, there was a drift toward treatment issues.

As a result of these concerns, a briefing paper was prepared for participants. This process further reinforced the problems in this area. A literature and Internet search revealed prevention and early intervention were referred to extensively. However, initiatives were primarily oriented toward education and information. Awareness of the gaps was reflected in some documents, and Mark Dickerson’s recent paper on informed consent identified the same issues. He cited: lack of definition of terms, failure to draw on the literature from other fields, and failure to develop strategies based on research.

Distilling the results of the literature review, early intervention includes initiatives to promote health and well being and prevent the development of problems. Interventions are aimed at ‘at risk’ groups. Early intervention blends with prevention and treatment at the borders, and different professions define these boundaries in varying ways. Early intervention can occur at many levels: across major systems (societies/populations), in parts of systems (particular community groups, family units etc) and at an individual level. Early intervention is both direct and indirect.

Prevention focuses more on broad information and education approaches, alternative activities, community development and public policy at a stage preceding early intervention. It is less targeted. For example, community building might be employed to foster social networks therefore preventing later problems.

A Framework for Action

Mental models of problem gambling are central to prevention and early intervention. Continuum based definitions have different implications from clinical models.

Clinical models tend to have strict boundaries, implying all problem gamblers are like those in treatment and will respond to a treatment approach. These models push the focus toward problem awareness and service access. Continuum models encompass a broad group of affected and non-affected individuals, displaying a range of behaviours. This is a much more inclusive group than would ever attend treatment. These differing conceptions encourage tensions around the issue.

So, where to from here? The public health perspective has much to offer, with well developed frameworks and a substantial evidence base relevant to prevention and early intervention. Gambling related harm can effectively be addressed through the encompassing, holistic approach offered by the public health model. Using this model provides a starting point for the development of a framework for action, with a set of guiding principles. A framework might include the following principles:

• First, Strengthening Communities: Gambling stakeholders will work systemically and collaboratively to strengthen communities, addressing broad social, cultural and economic issues known to be associated with gambling related harm

• Second, Targeted interventions: Gambling stakeholders will use available research and practice wisdom to develop targeted pre-treatment interventions for known higher risk groups

• Third, Community self management: Communities will be highly resourced to self manage problem gambling issues

• Fourth, Breaking down the barriers: Community members will be well informed, willing and able to access services required to address gambling issues

• Finally, Therapeutic alliances: Service clients will be provided with treatment that is designed around effective engagement and strong therapeutic relationships, is client centred, responsive, professional and ethically sound.

These guiding principles are compatible with the provisions of the Ottawa Charter, and a range of other public health documents. By developing a framework that is in accord with accepted principles and practices, lessons from other jurisdictions can readily be incorporated into the gambling field and consistency with well researched and supported frameworks can be maintained.

Further Steps

This is a challenging and complex task requiring an ecological approach, which is cognisant of systemic issues. We need to work amongst multiple stakeholders, not in isolation, and we also need to work across jurisdictions and outside of the immediately obvious players in order to develop the most effective framework.

Once a broad framework and principles are established, application to each arena can be planned. Every environment and stakeholder group will require a tailored approach that takes into account the set of variables unique to each. What is applicable and useful in a community based setting may be less relevant in a gaming environment, for example. Nor are all community based settings alike, or all gaming environments. By using an established framework, the necessary variations can be developed whilst ensuring the targeted outcomes conform to accepted principles.

The gambling field is one which easily fractures along stakeholder lines. Even within stakeholder groups, unity of views is often far from the norm. For prevention and early intervention efforts to succeed, those people active in the field need to embrace open dialogue with no vested interest in particular outcomes. If this can be done, much can be achieved in the prevention and reduction of gambling related harm across our communities.