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Response Strategies Response Strategies
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The problem gambling continuum sets the stage for the development of focused response strategies, consistent with the over-arching concepts of prevention and treatment. In general terms, prevention refers to the rate at which problems develop, known as the incidence rate, and endeavours to reduce it over time. By definition, therefore, prevention is aimed at people who have yet to develop problems. By contrast, treatment focuses on people with existing problems, as reflected by the prevalence rate, and endeavours to reduce these numbers over time. Often, treatment services are paired with rehabilitation services, which include measures to restore health to the extent possible.
Within the concepts of prevention and treatment, four response strategies can be identified: risk avoidance, risk reduction, brief intervention, and intensive intervention. Each is defined by three criteria: targeted risk status, problem status, and goals.
1. The Risk Avoidance Strategy
The Risk Avoidance strategy targets people in the no-risk category, along with those in the low risk category who have not developed problems. The goals are to:
reduce the rate at which target group members adopt risk practices and cognitions; and
insulate target group members from the influence of indirect risk factors.
For those in the no-risk category who are under the legal age for gambling, an additional goal may be to delay the onset of gambling activity. Whether this includes all gambling - for example, marbles or flipping sports cards - or be limited to gambling where there is an exchange of money remains a topic of debate. On another front, some argue to extend this goal to the prevention of gambling altogether - that is to create a group of young people who choose not to gamble at all as they enter adolescence and adulthood. As yet, there is little evidence to indicate whether such an outcome is desirable or achievable.
Initiatives within the Risk Avoidance strategy include program and policy interventions. In general, programs are used to introduce changes to target groups that reduce the adoption of risk practices and cognitions, and that insulate people from the effects of indirect risks. Policy initiatives are official positions or mechanisms adopted by governments, municipalities, gambling venues, and organizations such as school boards and employers. In general, their purpose is to impede the adoption of risk practices among members of identified target groups.
For reference purposes, Risk Avoidance initiatives are considered as primary prevention in the public health perspective.
2. The Risk Reduction Strategy
The Risk Reduction strategy targets people in the moderate and high-risk categories who have yet to develop problems. The goals of this strategy are to:
replace risk cognitions among target group members with less harmful alternatives;
reduce or eliminate risk practices among target group members; and
reduce the extent of involvement with risk practices among target group members who are unable or unprepared to eliminate them.
In everyday terms, this strategy targets people who are "problems waiting to happen", and endeavours to reduce levels of risk exposure before the fact. It is noteworthy that, in many instances, the profile of risk practices and cognitions in this group may be similar to those among people who have developed problems, further underscoring the futility of trying to draw a line between people with problems and those without.
Initiatives within the Risk Reduction strategy include both program and policy interventions. In general, programs endeavour either to change risk practices and cognitions among target group members, or to insulate people from the effects of indirect risks. Policies within this strategy include measures adopted by governments and organizations to encourage the adoption of low and no-risk practices among target groups whose current practices place them at risk.
The Risk Reduction strategy is usually combined with Brief Intervention and classified as secondary prevention in the public heath perspective.
3. The Brief Intervention Strategy
The Brief Intervention strategy targets people in the low and moderate-risk categories who are experiencing problems of mild-to-moderate severity. The goals of this strategy are to:
eliminate risk practices and cognitions; and
eliminate problems that have resulted from gambling.
In general, research suggests that the targeted population responds well to less intensive treatment interventions, which usually range from one to eight sessions in length. Moreover, moderate gambling outcomes can be achieved by many people who are suitable for brief interventions, and can be considered as an alternative to abstinence. Some evidence suggests that the very availability of moderation as a treatment option will, in itself, improve overall recruitment rates. Finally, those who are unable to succeed with moderation are more likely to accept an abstinence goal in successive efforts to resolve their problems.
Note that, regardless of whether abstinence or moderate gambling outcomes are selected, the goal is to eliminate harm resulting from excessive gambling - neither specifically adopts the reduction of harm as its primary goal. Abstinence-based approaches address this goal by eliminating gambling altogether, while moderation-based approaches address it by eliminating risk practices and cognitions. In the former, successful treatment moves clients to no-risk status while, in the latter, it moves them to low-risk, problem-free status.
Increasingly, brief interventions are being aligned with the Transtheoretical Model, with specific offerings for problem gamblers in the pre-contemplation, contemplation, and preparation stages of change. These program variants recognize that readiness to change is a key determinant of treatment success, and that imposing treatment on someone who is not ready to change is often futile.
As mentioned, brief interventions are usually classified as secondary prevention in the public health perspective. Such programs may be delivered in a several formats, including self-help or "self-directed", group and individual counselling delivered face-to-face, and telephone-based counselling. In addition, these formats potentially lend themselves to internet-based applications. Some evidence suggests that allowing clients to choose their preferred format yields superior rates for program completion which, in turn, are associated with better outcomes.
4. The Intensive Intervention Strategy
The intensive intervention strategy provides treatment to people in the high-risk category who are experiencing severe gambling problems. On occasion, people in the moderate-risk category will also develop severe problems, and be appropriate for intensive treatment. The goals for this strategy are:
eliminate all gambling and risk cognitions; and
restore healthy functioning.
As indicated, the clinical goal for this strategy is abstinence, although the related research does not preclude moderate gambling goals for some. Intensive treatment programs usually extend from two to twelve months in duration, and include outpatient or community-based counselling, day treatment, and inpatient or residential care. Often treatment and rehabilitation services are integrated into a phased model that offers stabilization, behaviour modification, cognitive restructuring, debt management, and relapse prevention.
An increasing body of evidence identifies a high degree of co-morbidity among problem gamblers who are appropriate for intensive treatment. Co-existing problems include alcohol and other drug dependencies, depression and anxiety disorders, and attention-deficit/hyper-activity disorders, among others. As treatment models evolve, they will have to address the question of how best to effectively manage concurrent disorders.
The relationships among the response strategies described above and the problem gambling continuum are depicted in Figure 6.
Although we have aligned response strategies with health status categories, this does not suggest that all people within any one category are the same. In fact, evidence from related fields suggests that discrete groups or segments exist within each category. Commercial interests, such as the producers of beverage alcohol and tobacco, and even organizations that operate lotteries and casinos, have long been aware of this, and undertake market segmentation studies to define the various groups they wish to engage.
Segment members share key characteristics, including essential values, beliefs, personality traits such as self-efficacy and locus of control, sources of influence, self-image, and so on. Identifying segments within a larger population allows actions to be tailored to particular characteristics of the segment. This knowledge can be used to improve engagement rates, and to develop more effective interventions that are matched to segment characteristics.
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