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.
Insert Table 2 Motivations for clients here
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.
Insert Table 3 Advantages and disadvantages of using IBIs according to clinicians
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.
Insert Table 4 Factors that influence here
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
Availability of services 24/7
Synchronous over asynchronous communication
Supports and services for loved ones
Video calling over text-only communication
Good and reliable technology
Basic and user-friendly technology
Integrated approach to treatment
Privacy and data security
Policies and protocols
Rigorous screening of clients
Tiered approach to implementation
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 emailsa 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.”