Evaluation of Gambler's Helpline: A Consumer Perspective

Abstract

This paper reports on the results of an evaluation of Gambler's Helpline (GHL) in Victoria, Australia. Particular focus was given to consumers' experiences of accessing the helpline and the overall effectiveness of the service. GHL callers were recruited to participate in an immediate post-call questionnaire-based telephone interview (N = 90) and one-month follow-up interview (N = 56). The first aim of the study was to present a descriptive profile of those accessing the helpline. The second aim was to examine the effectiveness of the counselling intervention through measures taken post callers' contact to GHL. The final aim was to examine referral uptake at a follow-up. Results of this study reflected positively on GHL. Callers reported general overall satisfaction with the service. Consumer feedback highlighted the importance for GHL counsellors of providing a balance of both emotional and practical support for callers, and the importance for callers to access referrals was identified.

Introduction

Legislative changes to Australian gaming laws in the last 15 years have resulted in a dramatic expansion in new and existing forms of gambling across the country (Blaszczynski, Walker, Sagris & Dickerson, 1999). It is estimated that 2.3% of Australia's adult population experience significant problems with their gambling, with 1% experiencing severe problems (Productivity Commission, 1999). In 2001/02 the total net expenditure/loss on legal gambling products in Australia was A$14.37 billion, representing a loss of A$988 per head of adult population. This figure has doubled in the last decade and is triple that of 15 years ago (Bostock, 2005). With increased availability and ease of access to gambling facilities, more people are at risk of potentially developing a problem than ever before (Blaszczynski et al., 1999). Consequently it is necessary to closely examine the role and effectiveness of treatment services set-up to assist individuals who are both directly and indirectly suffering as a result of a gambling problem.

Motivations and Barriers to Treatment

Blaszczynski et al. (1999) contend that the majority of problem gamblers enter treatment either due to a crisis, such as debt, depression, feeling suicidal and crime, or as a result of pressure from others. Two recent Australian studies provide support for this contention. A study by McMillen, Marshall, Murphy, Lorenzen and Waugh (2004), commissioned by the Australian Capital Territory (ACT) Gambling and Racing Commission, concluded that reasons to seek help fell into two categories (1) financial stresses and (2) relationship/social stresses. Self-identified gamblers primarily accessed help due to financially related concerns, whereas family members cited reasons to seek help across both categories. Evans and Delfabbro's (2005) study of 77 Australian problem gamblers also indicated that professional help-seeking was largely crisis-driven as opposed to the recognition of a developing problem. Such studies suggest that by the time treatment is accessed, substantial problems may be present.

In Australia, specific gambling-related services are available including face-to-face and financial counselling, support and self-help groups, community education, and self-exclusion from licensed gaming venues and casinos. However it appears rare for problem gamblers to access professional treatment. For example, Dickerson (2004) reported that during the 2001/02 reporting period only 25% of Victorian-based callers referred to Gambler's Help for face-to-face counselling from Gambler's Helpline acted upon the referral. A review of the recent literature indicates that help-seeking barriers may be grouped according to whether the issue is of a psychological, practical or treatment service related nature.

Psychological barriers include the belief that the problem can be resolved without professional assistance or that gambling will result in a financial payoff resolving or life improvements (Boughton & Brewster, 2002; McMillen et al., 2004); ambivalence about changing (McMillen et al., 2004); the stigma of admitting to having a problem and the possibility of being criticised, judged or discriminated against as a consequence (Boughton & Brewster, 2002; Hodgins & el-Guebaly, 2000; McMillen et al., 2004; Rockloff & Schofield, 2004); feelings of guilt, shame or embarrassment about gaming behaviour (Boughton & Brewster, 2002; Hodgins & el-Guebaly, 2000; McMillen et al., 2004; Rockloff & Schofield, 2004); and negative attitudes towards seeking treatment (Rockloff & Schofield, 2004).

Practical barriers that interfere with seeking treatment include time constraints such as work demands and child care concerns (Boughton & Brewster, 2002; Miller & Weissman, 2002); financial issues relating to costs of attending treatment or resultant income loss (Boughton & Brewster, 2002, Miller & Weissman, 2002; Rockloff & Schofield, 2004); and issues with personal physical health or disabilities (Boughton & Brewster, 2002).

Treatment service barriers include waiting times (New Focus Research, 2003; Miller & Rollnick, 1991); lack of access to counsellors who are ex-gamblers (New Focus Research, 2003); lack of culturally appropriate services (McMillen et al., 2004); reservations about treatment availability and effectiveness (Rockloff & Schofield, 2004); lack of knowledge about treatment availability and methods (Boughton & Brewster, 2002; Hodgins & el-Guebaly, 2000; McMillen et al., 2004; Rockloff & Schofield, 2004); and fear of being recognised or privacy being jeopardised (Boughton & Brewster, 2002; Dickerson, 2004; McMillen et al., 2004).

Telecommunications technology provides a means of overcoming some of these barriers, or at least providing an alternative means of accessing professional help.

Helplines

Within the health and welfare sector telephone counselling services constitute an important first point of contact for individuals within the community seeking assistance. Coman, Burrows and Evans (2001) suggest telephone counselling services can be divided into two broad categories, generalist services that target the community as a whole dealing with a range of issues (e.g. Lifeline), and specialist services that either address a particular issue (e.g. Hepatitis C Helpline) or target a specific segment of the community (e.g. the Gay and Lesbian Switchboard). Specialist services are further subdivided into crisis counselling and referral services that usually provide anonymous counselling, often at a point of crisis (e.g. Gambler's Helpline) and continued support services that provide ongoing counselling as required (e.g. Quitline).

Advantages and Disadvantages of Helplines

Telephone counselling has received attention in the literature as a feasible alternative to conventional face-to-face counselling. Furthermore, evidence demonstrates that the benefits of helplines can make them a preferred method of contact (Bartram, 2000; Conte, Fisher, Callahan & Roffman, 1996; Cook-Gotay & Bottomley, 1998; Hugo, Segwich, Black & Lacey, 1999; Tait, 1999). The advantages and disadvantages of helplines have been well documented. An exploration of the helpline literature highlighted the key benefits of this service medium as low cost (e.g. Reese, Conoley & Brossart, 2002), high accessibility (e.g. Bryant, 1998; Haas, Benedict & Kobos, 1996; Takabayashi et al., 2002), anonymity and confidentiality for clients (e.g. Coman et al., 2001; Stratten, 1999) and as an adjunct to face-to-face counselling (e.g. Coman et al., 2001; Rosenfield, 1997). Additionally, accessing helplines may serve as the catalyst needed to empower individuals to make the next step towards conventional treatment (Bryant, 1998; Coman et al., 2001; Hugo et al., 1999). For some people the thought of attending face-to-face counselling elicits a fear-provoking response. Furthermore, for individuals with difficulties relating or talking in person the option of a telephone service may be less threatening thereby giving them a greater sense of control over the exchange (Coman et al., 2001; Haas et al., 1996).

Key helpline disadvantages or challenges consistently cited in the literature include lack of visual cues to assist the counselling process (McLennan, Culkin & Courtney, 1994; Haas et al., 1996), the frequency of inappropriate and hoax calls which can be desensitising and detrimental to counsellor morale (Conte et al., 1996; Hunt, 1993; Stratten, 1999) and limited opportunities to use the full range of therapeutic techniques (Coman et al., 2001; Rosenfield, 1997).

Furthermore, the time-limited nature of telephone counselling necessitates primarily the use of brief intervention and problem-focused strategies normally targeted at assisting the client with their current presenting problem. Consequently Hunt (1993), McLennan et al. (1994) and Rosenfield (1997) report that counsellors experience an ‘inner pressure’ to completely resolve callers' problems due to the expectation that the call will be an isolated interaction. This is compounded by the actuality that some callers expect a solution to be provided (Hunt, 1993).

Finally, helplines, particularly those of a crisis counselling and referral nature are difficult to evaluate. Such services are usually anonymous and generally do not have an inbuilt function to follow-up with callers to determine outcomes. One method of addressing these methodological issues has been the use of simulated callers (e.g. Bobevski & Holgate, 1997; McLennan et al., 1994). However, there is some question as to whether use of this fabricated environment delivers outcomes that are transferable to real world settings.

Helpline Evaluations

Helpline evaluations are rare (see above) however existing published studies and reports commonly convey high levels of user satisfaction (Hetzel, Wilkins, Carrig, Thomas & Senior, 1993; Hugo et al., 1999). Nevertheless, Mishara and Daigle (1997) warn that satisfaction with the call alone does not necessarily indicate caller improvement. Smith, Thomas and Jackson (2004) also caution that there is not always a link between caller satisfaction and how successful the service has been in delivering good outcomes to clients.

A national review of Australian telephone and web counselling organisations by social research consultants Urbis Keys Young, commissioned by the Australian Government Department of Health and Ageing, has extended upon user satisfaction reports. Urbis Keys Young (2003) evaluated three helplines, Men's Line, Care Ring and Lifeline (N = 80 across the three services) exploring what makes telephone counselling a satisfactory experience for consumers. Participants reported being satisfied if they (1) felt they had been provided with good ideas, strategies and suggestions; (2) were given sufficient time to tell their story and felt heard; (3) found the service to be accessible; (4) felt counsellors were respectful, skilful and professional; (5) valued the low-cost/free nature of the service; and (6) were provided with referral information.

An Overview of Gambler's Helpline

Gambler's Helpline (GHL), formerly Break Even G-line, was established in 1993 as a collaborative initiative of the Addiction Research Institute (defunct), Mental Health Foundation of Australia and the Victorian Council on Compulsive Gambling (defunct). The service was developed to provide a first-point of access for individuals in Victoria, Australia affected by problem gambling behaviour. The overarching philosophy was that such individuals should have equitable access to a professional, non-judgmental, anonymous, confidential and high quality telephone counselling, referral and information service (Coman, Burrows & Evans, 1997). Following a competitive tendering process Turning Point Alcohol and Drug Centre Incorporated took over operation of GHL in 2001.

GHL is the first-point of contact for many individuals with gambling-related concerns, including the problem gambler, family, friends, work colleagues, venue workers and professionals. The helpline plays a critical role in referring clients to Gambler's Help (face-to-face counselling). In the 2001/02 reporting period GHL referred approximately 44% of its callers to Gambler's Help (Dickerson, 2004).

Rationale for the Study

Since the inception of GHL the service has undergone only one evaluation as part of a longitudinal study of problem gambling counselling services, community education strategies and information products in Victoria (Jackson et al., 2000). The findings demonstrated a high level of caller satisfaction with 98% of callers ‘satisfied’ or ‘very satisfied’ with the service received. Evidence of high levels of therapeutic bonding and therapeutic outcome was also found. However the value of the data was compromised by the low number of participants (N = 39).

Given the importance of ensuring effective treatment and the costs already invested in services such as GHL it is important to develop an understanding about the service from the perspective of the consumer and whether it is having a beneficial impact. As such the rationale for this study is derived from the need for an independent exploratory evaluation with GHL as the central focus. Furthermore there is need to obtain a reasonable sample size to achieve meaningful outcomes.

Aims of the Study

The first aim of the study was to describe the sample of individuals accessing GHL from the perspectives of their demographic characteristics, prior help-seeking behaviour, motives for calling, expectations of the service, and level of functioning (via the Life Assessment Scale; LAS). Aim 2 was to examine the effectiveness of the counselling intervention through consumer feedback regarding satisfaction with the service, operationalised via items from the Follow Up Questionnaire on Interpersonal Counselling (FUQIC; Tracey & Ray, 1984) and callers' comments.

Aim 3 related to uptake of referrals. The first aspect of this was to determine how many callers actually accessed referrals and why some chose not to. Furthermore intuitively it would seem reasonable to suggest that callers who access referrals would be more likely to improve than those who do not. However there is no available research to prove or disprove this notion. Consequently this aim also involved determining whether gambling callers showed greater improvement (via the LAS) if they followed-up on referrals received.

Method

Participants

Ninety eligible callers accessing GHL consented to participate in an immediate post-call (Time 1) questionnaire-based telephone interview (response rate 35%). Sixty-five of these callers (72.2%) agreed to participate in a one-month follow-up (Time 2) interview of which 56 participants were successfully recontacted (see Table 1 for a breakdown of gender by gambling status frequencies at Time 1 and Time 2). The sample did not differ significantly from Time 1 to Time 2 based on gambling status (χ²(1, N = 90) = 0.65, p = 0.34), or gender (χ²(1, N = 90) = 0.00, p = 1.00). On average it took 2.45 attempts to recontact callers.

Table 1. Gender × gambling status frequencies at Time 1 (N=90) and Time 2 (N=56)

	Gambling status at Time 1		Gambling status at Time 2
Gender	Gambler	Non-gambler	Gambler	Non-gambler
Male	28	5	17	4
Female	36	21	25	10
N	64	26	42	14

Materials

Data for the study was drawn from three sources: (a) counsellor forms (b) Time 1 and (c) Time 2 questionnaire-based interviews. Details for each source and measures used follow.

Counsellor forms

Upon successful recruitment of a participant, counsellors completed a form, which required them to note basic caller demographic details (i.e. age, employment status) and which service/s, if any, they had referred the caller to.

Time 1 interview

The Time 1 interview was conducted with participants by a researcher immediately following their contact with GHL. The interview was composed of questions pertaining to accessing GHL (e.g. motive for calling, expectations of the service), prior help-seeking behaviour for gambling-related issues, the FUQIC, open-ended questions designed to elicit detail regarding caller satisfaction with the service, interaction with the counsellor and assistance received, and the LAS (gambling callers only).

Time 2 interview

The Time 2 interview was conducted with participants by a researcher one-month following their Time 1 interview. The interview was composed of questions pertaining to referral uptake, and the LAS (gambling callers only).

FUQIC (Tracy & Ray, 1984)

The FUQIC consists of three items – the extent to which callers (a) felt understood by the counsellor; (b) believed that the counsellor had been helpful; and (c) were satisfied with the counselling provided. Each item is scored on a 5-point Likert scale ranging from 1 = ‘totally disagree’ to 5 = ‘totally agree’. The three items ratings can be summed to provide an overall index, ranging from 3 to 15, of caller-perceived counsellor effectiveness. High scores represent satisfaction with the overall service provided.

McLennan et al. (1994) reported internal consistency coefficients as greater than 0.90 and it has been suggested that the FUQIC is a valid instrument for measuring counsellor effectiveness (McLennan, 1990).

LAS

The LAS was developed specifically for this study to determine callers' overall levels of functioning. The measure requires that gambling callers assess their current status in 10 life areas: anxiety, mood, self-control, energy levels, family, work, finances, social life, overall physical health and overall well-being. Gambling callers gauge on a 10-point scale how well they believe they are functioning in each life area where 1 = ‘not at all well’ and 10 = ‘completely well’.

This scale is scored by obtaining a composite average for the 10 life areas. High scores are indicative of an individual who is functioning well. The LAS was used to ascertain level of functioning at Time 1 and improvement between Time 1 and Time 2. The alpha reliability was 0.90 at Time 1 and 0.91 at Time 2.

Procedure

GHL counsellors recruited participants during specified recruitment periods by reading a script at the completion of each GHL call; taking into consideration the exclusion criteria and the counsellors' own discretion. The exclusion criteria included callers displaying signs of psychological or intellectual disabilities and language difficulties; callers under 18 years of age and callers currently case-managed by GHL.

Eligible, consenting participants were transferred to a researcher at the completion of their GHL call. During the research interview the GHL counsellor completed the counsellor form which they handed to the researcher at the conclusion of the interview. Upon successful completion of the Time 1 interview participants were invited to participate in a follow-up interview. Those agreeing to do so were contacted approximately one-month later. If they could not be reached in three days no further attempts were made.

Results

Aim 1

Characteristics of the sample

The majority of the sample were self-reported problem gamblers (71.1%; n = 64), primarily experiencing a problem with electronic gaming machines (EGMs; 79.7%; n = 51). The greatest proportion of callers in the gamblers group were over 40 years of age (52.7%) whereas for the non-gamblers group the greatest proportion were aged under 40 years (57.1%). Of the participants who provided employment details (n = 80) more than half were employed (60%, n = 48), 61.4% of gamblers and 56.6% of non-gamblers worked in either a paid full-time, part-time or casual capacity. A high proportion of the sample lived with others, 65% of problem gamblers and 81.7% of non-gamblers lived with partners, other family members, or in some form of share accommodation.

Prior help-seeking behaviour

For 58 (64.4%) participants this was their first contact with GHL. Approximately one-third (n = 34) had previously sought help for a gambling-related concern of which the most common form of help sought was counselling (n = 23) either with Gambler's Help, a private psychologist, psychiatrist or generalist counsellor. Some participants had previously implemented self-exclusion (n = 6) or had attended Gambler's Anonymous (n = 6). Other services accessed included Gam-Anon, legal aid and charity organisations for material aid. In some cases participants had utilised multiple services.

Motive to call

Overall, the most frequent motive to call cited across all participants was the impact that gambling (whether on self or others) was having on the caller's personal life, such as missing work, health problems, or the degeneration of a relationship. Some example quotes were:

Missed an appointment that I should have made yesterday … not slept since yesterday.

Just separated from (my) wife.

Living a double life.

For the gambler group (n = 64), the most common reason stated for accessing GHL was loss of money (28.1%), particularly the loss of more money than normal in recent gambling sessions. This was followed by the psychological impact of gambling (25%), particularly in relation to the caller reaching a breaking point in their ability to cope with their problem; financial issues (25%), such as debts and inability to pay rent or utilities; and the impact of gambling on their personal life (23.4%), for example sleep difficulties, health- and relationship-problems.

For the non-gamblers (n = 26), the most common reasons stated for accessing GHL were to obtain suggestions and strategies for how to deal with the problem (34.6%); the impact gambling was having on their personal lives (26.9%); and the suspicion, or actual knowledge of a gambling problem, or relapse of a problem (23.1%).

Helpline expectations

Participants were asked to describe what they were expecting by calling GHL. Some participants had several expectations about the service. The majority (54.4%, n = 49) expected to receive gambling information/education and advice regarding techniques to manage their own or someone else's gambling behaviour. The next most common expectation of GHL was that they would simply receive a referral (24.4%, n = 31). Some participants in this group lacked awareness regarding the role of GHL and for the most part were unaware that they would be speaking to a trained counsellor. Other participants from this group were specifically seeking a referral because they had lost the number, called previously but were not offered a referral at that time (or had not taken it up), or wanted alternative referral options. The opportunity to speak with someone supportive, non-judgmental and objective was also an important expectation of the service (27.7%, n = 25). Interestingly some participants (18.8%, n = 17) lacked knowledge of the service and therefore had no real expectations.

Level of functioning

Gambling callers were asked to estimate on a 10-point scale, where 1 = ‘not at all well’ and 10 = ‘completely well’, the extent to which they were functioning in a variety of life areas. Average level of functioning was relatively low at Time 1 (M = 4.24, SD = 1.89). Self-control and finances appear to be the most affected life areas across participants (see Table 2).

Table 2. Means and standard deviations for gambling callers level of functioning at Time 1 and Time 2

	Time 1		Time 2
Life area	N	Mean (SD)	N	Mean (SD)	t(df)
Anxiety	64	3.35 (2.69)	42	6.50 (2.59)	6.10 (41)*
Energy levels	63	4.35 (2.38)	42	6.85 (2.08)	7.50 (41)*
Family	62	5.16 (2.69)	41	6.99 (2.44)	3.96 (40)*
Finances	64	2.81 (2.24)	42	6.02 (2.89)	6.68 (41)*
General well-being	64	4.45 (2.18)	42	6.92 (1.78)	3.67 (41)*
Mood	64	4.08 (2.46)	42	6.36 (2.07)	5.04 (41)*
Physical Health	64	4.88 (2.47)	42	6.55 (2.22)	6.19 (41)*
Self-control	64	2.72 (2.23)	42	6.74 (2.76)	3.16 (41)*
Social Life	64	4.34 (2.57)	42	6.19 (2.61)	3.63 (41)*
Work	50	5.63 (2.83)	31	7.60 (1.98)	6.54 (29)*
Total		4.24 (1.89)		6.64 (1.80)	7.42 (41)*
*p < 0.001.

Aim 2

Satisfaction with the service

As one measure of effectiveness of the service, all participants were asked the three items from the FUQIC. Callers rated the extent to which (1) they felt understood by the counsellor; (2) thought the counsellor had been helpful; and (3) were satisfied with the counselling provided on a 5-point scale (5 = highest level of satisfaction). Item and overall mean scores from the FUQIC are provided in Table 3. Participants were also asked to expand upon each item by identifying what elements of the call they reflected on when making their assessment.

Table 3. Means, standard deviations for ratings on the FUQIC at Time 1 (N=90)

Item	Mean	SD
(1) Felt understood by the counsellor	4.60	0.63
(2) Believed that the counsellor had been helpful	4.37	0.74
(3) Were satisfied with the counselling provided	4.63	0.51
Total	13.62	1.55

For Item 1 of the FUQIC, three-quarters (n = 60) of the callers ‘totally agreed’ with the statement that they felt understood by their counsellor. When asked to describe how they were able to determine whether they were understood by the counsellor, the most common response (37.8%) related to the degree of professionalism demonstrated by the counsellor. The concept of professionalism included the apparent gambling knowledge of the counsellor and the quality of suggestions and strategies provided regarding management of the situation faced by the caller. The impartiality of the counsellor was also considered to be reflective of professionalism. Some example quotes were:

Listened and hit the nail on the head in response to what I said. Impressed with their knowledge in the psychology of gambling and its relationship to me.

Saying why I go and how I feel when I'm there. (The counsellor) understood what I was saying.

Preparing me in advance for possible things that might happen and how to handle them. Felt like (the counsellor) knew where I was coming from.

Callers also felt understood if they detected support and compassion from the counsellor (31.1%). This quality was most commonly reflected by the use of empathy and affirming to the caller that they were understood and were making sense.

For Item 2 of the FUQIC, half (n = 45) of the callers ‘totally agreed’ that the counsellor had been helpful. Callers were asked to elaborate on how the counsellor demonstrated their helpfulness or otherwise. The provision of referral/s (37.8%) was the clearest indication that the counsellor had been helpful. Providing understandable and appropriate strategies to manage concerns presented was also a sign of helpfulness. Some example quotes were:

Advice on speaking to husband, when/how.

Psychology of gambling, I think I can incorporate that into my thinking about going gambling.

Some callers (12.2%) stated that they were not helped as much as they expected to be. Comments indicated that the caller had expectations that were beyond what GHL could reasonably provide or that they were not given ample strategies, or strategies were not as informative as expected.

Wanted to be given specific words on how to speak with my sister.

Hasn't made the problem go away … get it out of my head … . It doesn't change my situation, but that's not the fault of the counsellor.

Wanting someone to make the contacts for me because feeling overburdened and am going into hospital next week.

For Item 3 of the FUQIC, 64.4% (n = 58) of callers ‘totally agreed’ that the counselling provided was satisfactory. When asked to elaborate on why they were, or were not satisfied the most frequently identified reasons for satisfaction were the provision of referral/s (15.6%) and counsellor qualities (15.6%). The latter incorporated the counsellor's ability to relate to the caller in a sincere, patient and caring manner. The desire for a facilitated referral and a greater number or range of strategies than given were the two most common reasons for dissatisfaction.

General functioning of gambling callers

At Time 2 gambling callers' mean level of functioning significantly improved in all 10 life areas with the biggest improvement occurring in the area of enhanced self-control followed by improved finances and reduced anxiety. Paired samples t-tests were conducted on each life area using all 42 Time 2 problem gamblers to examine whether the change from Time 1 to Time 2 was significant. The changes for all life areas were statistically significant (see Table 2).

Aim 3

Referral uptake

Of the 56 Time 2 participants (42 gamblers, 14 non-gamblers) three-quarters (n = 42; 34 gamblers, 8 non-gamblers) had received a referral from GHL at Time 1. Twenty-eight (66.7%) of these participants followed through with the referral by, at a minimum, making an appointment for an upcoming date. Several callers had attempted to access services but experienced difficulty with, for example, appointment times or making contact with the intake worker. Table 4 summarises the referral uptake outcome.

Table 4. Referral uptake (n=42)

	Referral received^1
Accessed service?	Gambler's Help	Gamblers Anonymous	Gam-Anon	Financial Counselling	Self Exclusion	Other^2
Yes	22	3	2	5	4	5
Attempted	3	0	0	0	0	1
No	13	4	0	8	6	0
N	38	7	2	13	10	6
1 Some participants received multiple referrals.
2 ‘Other’ includes legal aid, GP, psychiatrist, family counselling and gambling information sessions.

Callers who had not followed-up with their referral at Time 2 were asked why they had not done so. The most common reason related to independence (n = 9, 40.9%). In such instances the caller wanted to attempt to work through the problem on their own first without further professional help. In some cases the caller's situation started improving after their contact with GHL and they did not feel further help was warranted. Anecdotally this fits with counsellors' experiences on the helpline. It is not atypical for callers to recontact GHL after a period of weeks, months and sometimes years to obtain further assistance, either specifically from the helpline or other service.

The next most common reason for not accessing a referral related to being busy. Callers in this category comprised two groups. The first group provided no indication of intending to follow through with the referral (n = 6, 27.3%), whereas the second group said that they had not yet had a chance to do so (n = 5, 22.7%). There was some suggestion that the former group were experiencing barriers of an emotional and/or practical nature intruding upon their willingness to utilise the referral. For example one caller acknowledged that failure to access help was probably due to ‘cold-feet’, another caller stated that it was ‘probably just an excuse’ compounded by their partner's lack of awareness regarding the problem.

Impact of referral uptake

Referral uptake was examined to determine whether it was associated with improvement from Time 1 to Time 2. Improvement was defined as a positive mean score difference between the LAS composite scores at Time 1 and Time 2. All gambling callers (n = 42) at Time 2 were included in the analysis. Those callers not receiving/wanting a referral at Time 1 were classified as not having accessed a referral. Of the 23 gambling callers who accessed at least one referral between Time 1 and Time 2, 100% demonstrated improvement on their level of functioning. Of the 19 gambling callers who did not access a referral 63.2% demonstrated improvement on their level of functioning (see Table 5). The difference was significant, χ²(1, n = 42) = 7.69, p < 0.05.

Table 5. Comparison between referral access at Time 2 and improvement in functioning for gambling callers (n=42)

	Improvement in level of functioning
Accessed at least one referral	No	Yes	N
No	7	12	19
Yes	0	23	23
N	7	35	42

Discussion

Helplines have become a well-established part of the health and welfare sector in the past several decades. However few studies have sought to gain an understanding of consumers' experiences of using helplines and the impact of the contact. One such service, GHL, plays a central role in the delivery of Victoria's response to problem gambling. GHL has been in operation since 1993, however it has not been systematically evaluated except as a small part of a larger study (see Jackson et al., 2000). Consequently it was the purpose of this study to specifically focus on GHL and examine the service from the perspective of the caller. A semi-structured, questionnaire-based telephone interview was conducted with consenting callers at two time points, (1) immediately following their contact with GHL (Time 1), and (2) one-month later (Time 2).

Aim 1

The first aim of the study was to describe the characteristics of the sample. At Time 1, the sample comprised approximately two-thirds gamblers and one-third non-gamblers. Callers were most likely to be under 40-years of age, employed in some capacity and living with others. For more than half of the sample this was their first contact with GHL, while a substantial minority were repeat callers. EGMs were the most common form of problematic gambling. This is unsurprising given the growth of EGMs witnessed in Victoria, Australia. These general demographic characteristics provide information that can be used for training and tailoring the services of helpline counsellors, for example it is clearly important to be prepared to deal with the needs of non-gambling as well as gambling clients. Additionally, such data helps to break down stereotypes or assumptions about typical callers, for example the mistaken stereotype (based on this data at least) that they tend to be unemployed.

Interestingly participants' expectations of GHL uncovered a deficiency in knowledge of the helpline role, implying an inadequacy of information accompanying advertising of the number. Barriers such as lack of service awareness or incorrect information about the service's role may interfere with help-seeking or result in an unsatisfactory and potentially disempowering consumer experience. This can reflect badly on the service and decrease the likelihood of an individual following through on counsellor suggestions. The apparent need for clarification of the role of helplines has been highlighted by other authors (Jackson et al., 2000).

Previous research (Blaszczynski et al., 1999; McMillen et al., 2004) suggests that problem gamblers are most likely to seek assistance when experiencing a crisis, usually of a financial nature. The results of this study provide support for such findings showing that gambling callers tended to call when concerned about the loss of recent sums of money, debts or the inability to pay for basic necessities. However, it should also be noted that approximately one-third of participants had previously accessed some form of help, usually counselling, for a gambling-related concern. This finding could be considered in relation to Prochaska and DiClemente's (1982) stages-of-change model which considers a ‘relapse’ or ‘slip-up’ to be a natural part of recovery. Thus, problem gamblers and concerned others may access help at multiple points during gambling-related crises. This is also an important factor for helpline counsellors to know.

Aim 2

The second aim of the study examined the effectiveness of the service provided by counsellors through measures taken immediately after the call.

Consistent with other helpline evaluations (e.g. Hetzel et al., 1993; Hugo et al., 1999; Reese et al., 2002), the service provided by GHL counsellors was rated highly. Out of a maximum composite score of 15 on the FUQIC, callers gave an average satisfaction rating of 13.6.

Open-ended responses regarding what constitutes a satisfactory contact from the caller's perspective fell into two categories: practical support and emotional support. Practical support included the provision of referrals, strategies and advice, whereas emotional support related to the counsellor's use of micro-counselling skills, such as empathy, genuineness and positive regard. These findings are supportive of earlier studies (e.g. Bobevski & Holgate, 1997) suggesting that it is important for counsellors to provide a balanced service focusing not only on the emotional needs of the caller but also the practical needs. There is not only need for counsellors to ‘hear’ the caller's story, demonstrating understanding, humanity and support but there is also need to demonstrate knowledge of referral services appropriate to the individual caller. Furthermore, in this study the practical aspects of advice, strategies, information and referrals were regularly occurring themes of caller expectations of a satisfactory helpline service.

The results relevant to the second study aim suggest that on the whole, callers were reasonably satisfied with the service provided. Callers report feeling heard and valued indicating the formation of a positive rapport between caller and counsellor. The establishment of such a relationship is of central importance to helplines. Helpline counsellors usually have limited opportunity to empower callers to take beneficial steps. It would seem reasonable to suggest that clients who perceive positive relationships with their counsellors are more likely to be amenable to counsellor suggestions, and subsequently facilitate better counselling outcomes overall. Callers also considered the provision of referrals and strategies to be an important part of the service. As such it is important for counsellors specifically, and the service generally, to maintain updated knowledge regarding pertinent referrals and effective strategies to deal with circumstances affecting gamblers and non-gamblers alike.

Aim 3

Aim 3 examined the impact of referral uptake.

An important role of the helpline is to provide callers with suitable referrals. More than 65% of callers participating at Time 2 who received a referral at Time 1 chose to access the referral. A further small number had attempted to follow-up on a referral but experienced difficulty with issues such as the service intake procedure or appointment availability. The primary reason for not following through on a referral for both gamblers and non-gamblers related to the decision to tackle the problem on their own. This finding supports prior studies (e.g. Marotta, 2000; Hodgins & el-Guebaly, 2000) suggesting that individuals experiencing gambling-related concerns often prefer to address the problem with minimal professional help in the first instance.

Intuitively it would seem reasonable to suggest that referral uptake would increase the chances of a positive outcome. This study provides support for this notion. Gambling callers accessing referral/s were significantly more likely to show improvement in their level of functioning than those who did not access a referral. It could be argued that callers who follow through on referrals are simply more ready to change and therefore more likely to show improvement. This possibility is beyond the capacity of this study to determine, although on face value it would appear that there are tangible benefits to increasing the likelihood of callers following through on referrals. It would appear to be a worthwhile aim of telephone counselling to motivate callers to move through the contemplation and preparation phases of Prochaska and DiClemente's change model into the action phase where they are not only sufficiently ready to accept a referral but to actually follow through with it. Consequently it becomes a question of integrating the callers' desire for independence with the apparent benefits of accessing help.

Overall gambling callers showed significant improvement in their level of functioning between Time 1 and Time 2 suggesting that while the problem may not have been completely overcome, callers perceived a sense of improvement in their day-to-day lives. Interestingly, for a few of the callers the change in some of their life areas such as anxiety showed a worsening effect. In such cases reasons were usually volunteered, for example, one caller had commenced therapy and was experiencing heightened anxiety due to the issues being raised.

Overall, the results of this study reflected positively on the helpline service, indicating that GHL plays a useful role in the Victorian Government strategy against problem gambling.

Limitations

The evaluation needs to be viewed in light of the methodological limitations of the study. First, there was no control group of problem gamblers who did not access the helpline, but who were followed-up one-month after they recognised their problem to assess self-induced improvement. Practical issues make such a study design difficult to implement, for example it is not clear at what point it would be appropriate to ‘pretest’ such a group, or how the control and treatment group could be matched.

Second, a month may have been too early for the follow-up call as some callers had not yet attended the referral service. However, leaving it longer may have jeopardised response rates.

A risk of evaluations of this kind is that there may be a bias effect regarding callers who participate in the study at Time 1 and Time 2. Callers not satisfied with the service may be less likely to participate in an interview at Time 1. Furthermore less satisfied callers, or those who do not change in a positive way, may be less inclined to participate at Time 2.

Strengths

The methodological design of the study proved to be quite robust and consequently resulted in a reasonable number of participants in comparison to the previous GHL evaluation. Another strength of this study was the inclusion of both gamblers and non-gamblers. The brief of the helpline is to assist anyone affected by problem gambling. Including both groups gives a more complete picture of helpline callers' experiences. Further, the inclusion of open-ended questions allowed for a greater understanding of helpline caller experiences and a more in-depth understanding of caller satisfaction.

Implications

Benefit could be derived from focused training on the provision of financial information or the possible employment of specific financial helpline counsellors given the large number of callers whose specific concerns were of a financial nature. The results also suggest the benefit of helplines developing suitable strategies to deal with non-gamblers who call with request for information, advice and support.

Callers for the most part were very responsive to a follow-up and in some cases invited further calls. This suggests there could be benefits to investigating the implementation of a series of call-backs (or offers of such) to provide further support, encouragement and empowerment for callers to make changes.

The study indicates that there are tangible benefits to increasing referral uptake. Implementing systems such as facilitated referrals may decrease the number of callers failing to act upon referrals.

In summary, the evaluation of GHL showed that callers generally find the service valuable particularly when emotional and practical support is evidenced. There is some suggestion that the service could be improved by providing further counsellor training in some specific areas and the implementation of a facilitated referral process.

Acknowledgements

The first author wishes to acknowledge the support provided by Turning Point HealthLink management and staff in conducting this evaluation.