problem gambling service - ministry of health nz · and supervision ltd for their work preparing...

2008

Problem Gambling ServiceIntervention service practice requirements handbook

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Version 1.1

Problem G

ambling Service: Intervention service practice requirem

ents handbook Version 1.1

Problem Gambling Service Intervention Service Practice Requirements Handbook Version 1.1

Citation: Ministry of Health. 2008. Intervention Service Practice Requirements Handbook (version 1.1). Wellington: Ministry of Health.

Published in July 2008 by the Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 978-0-478-31781-7 (print) ISBN 978-0-478-31782-4 (online)

HP 4620

This document is available on the Ministry of Health’s website: http://www.moh.govt.nz

Reproduction of Material The Ministry of Health permits the reproduction of material from this publication without prior notification. Copyright information is at http://moh.govt.nz/copyright

Disclaimer The Ministry of Health gives no indemnity as to the correctness of the information or data supplied. The Ministry shall not be liable for any loss or damage arising directly or indirectly from the supply of this publication. All care has been taken in the preparation of this publication. The data presented was deemed to be accurate at the time of publication, but may be subject to change.

Enquiries Direct enquiries about or comments on this publication to:

Manager, National Problem Gambling Team Population Health Directorate Ministry of Health PO Box 5013 Wellington Phone: (04) 496 2000

Problem Gambling Service: Intervention Service Practice Requirements Handbook iii

Acknowledgements The Ministry of Health would like to thank the team from Abacus Counselling, Training and Supervision Ltd for their work preparing the core material for this document and for their patience and advice through the extensive reviewing and refining process it took to get this handbook into a final version.

iv Problem Gambling Service: Intervention Service Practice Requirements Handbook

Contents

1 Introduction 1 1.1 Purpose 1 1.2 Content of this document 1 1.3 Intended audience 2 1.4 Related documents 2

2 Strategic Context 3 2.1 Objectives of problem gambling strategic plan 3 2.2 Māori health 3 2.3 Strategic outcomes framework 3 2.4 Principles 4 2.5 Components of model to prevent and minimise gambling harm 4 2.6 Collaboration and key service linkages 5 2.7 Political neutrality 6

3 Problem Gambling Services 7 3.1 Introduction 7 3.2 Services 7 3.3 Service type 8

4 Intervention Services 11 4.1 Introduction 11 4.2 Problem gambling intervention services 11 4.3 Background to the intervention service model 12 4.4 Client pathways and ideal patterns of care 13 4.5 Eligibility 18 4.6 Problem gambling practitioner competencies 20

5 Brief Intervention 22 5.1 What is a brief intervention? 22 5.2 Settings for screening 23 5.3 Family/whānau screening 23 5.4 Goals of brief intervention 24 5.5 Summary of brief intervention service specification 24 5.6 Examples of brief interventions 28 5.7 Screening for brief intervention 32 5.9 Frequently asked questions 37

6 Full Intervention 39 6.1 What is a full intervention episode? 39 6.2 Summary of full intervention service specification 41 6.3 Key steps for first sessions 50 6.4 Screening for full intervention 51

Intervention Service Practice Requirements Handbook: Contents v

6.5 Examples of full interventions 63 6.6 Frequently asked questions 70 6.7 Intervention planning 72

7 Facilitation 79 7.1 What is facilitation? 79 7.2 Summary of facilitation 79 7.3 Rationale for facilitation 80 7.4 Summary of the facilitation service specification 81 7.5 Examples of facilitation 83 7.6 Recommendations for facilitation planning 86 7.7 Frequently asked questions 87

8 Follow-up 88 8.1 What is follow-up? 88 8.2 Rationale for follow-up 88 8.3 Obstacles to client follow-up 89 8.4 Summary of follow-up intervention service specification 90 8.5 Follow-up procedure 93 8.6 Closing a follow-up episode 93 8.7 Follow-up screens 94 8.8 Family/affected other screens for follow-up 95 8.9 Examples of follow-up 97 8.10 Recommendations for follow-up 100 8.11 Frequently asked questions 101

9 Public Health 103 9.1 Introduction 103 9.2 Problem gambling public health services 103

10 Infrastructure Services 106 10.1 Introduction 106 10.2 Infrastructure services 106

11 Glossary 108 11.1 Flowchart symbols 110

12 Version History 111

Appendix 1: Screens 112 Brief Gambler Screen 114 Brief Family/Affected Other Screen 115 Gambler full intervention screens 116 Family/affected other full intervention screens 119 Follow-up gambler screens 122 Follow-up family/affected other screens 125

vi Problem Gambling Service: Intervention Service Practice Requirements Handbook

Appendix 2: Intervention Planning Tools 128 Agreed intervention plan (gambler) 128 Agreed intervention plan (family/affected other) 129 Follow-up agreement 131

Appendix 3: Review and Assessment Tools 132 Review tools: The gambler 132 Review tools: Family/affected other 133 Review tools: Practitioner 134 Review tools: Support person 135

References 136

List of Tables Table 5.1: Ending brief intervention episodes 25 Table 5.2: Brief intervention service specification (purchase unit PGCS-02) 26 Table 6.1: Full intervention service specification description (purchase unit PGCS-03) 43 Table 6.2: Ending full intervention episodes 48 Table 7.1: Facilitation service specification description (purchase unit PGCS-04) 82 Table 8.1: Follow-up service specification description (purchase unit PGCS-05) 91 Table 8.2: Ending follow-up episodes 93 Table A.1 List of screens 112

List of Figures Figure 4.1: Preferred pathways for intervention sessions 14 Figure 4.2: Typical client pathways into intervention services 15 Figure 4.3: Order of use for forms and form sections 17 Figure 5.1: Typical client pathways and practitioner decisions for brief interventions 27 Figure 6.1: Missed sessions and reconnecting with clients 47 Figure 6.2: Typical client pathways and practitioner decisions for full intervention 49 Figure 8.1: Typical client pathways and practitioner decisions for follow-up 92 Figure 11.1: Guide to flowchart symbols 110

Intervention Service Practice Requirements Handbook: Contents vii

1 Introduction

1.1 Purpose The Intervention Service Practice Requirements Handbook was previously titled Revised Practitioner Manual (see problem gambling intervention service specifications). The manual has been renamed to distinguish it from other manuals and earlier guidelines. The purpose of this handbook is to: • clarify aspects of problem gambling intervention service delivery • detail the screening and intervention practice requirements for service providers. The term ‘provider’ refers to organisations that have a problem gambling intervention service contract with the Ministry of Health (see also the Glossary, section 11). It is important to note that this handbook is intended as a guide only. The handbook is indicative of the Ministry of Health’s intentions for problem gambling intervention services and a guide for typical client pathways and practices, but practitioners should use their clinical judgement when dealing with exceptions, particularly when clients are presenting in crisis or issues of safety are involved.

1.2 Content of this document This handbook is structured in the following way.

Section 1 introduces the purpose of the handbook and its context in the Problem Gambling Service.

Section 2 outlines the strategic context for Ministry of Health-funded problem gambling services.

Section 3 summarises Ministry-funded problem gambling services and dedicated service requirements.

Section 4 outlines the requirements for Ministry-funded problem gambling intervention services.

Section 5 describes the requirements specific to brief intervention sessions. It explains what is required for brief intervention session activity to be counted towards the contract targets.

Section 6 describes the requirements specific to full intervention sessions. It explains what is required for full intervention session activity to be counted towards the contract targets.

Section 7 describes the requirements specific to facilitation sessions. It explains what is required for facilitation session activity to be counted towards the contract targets.

Section 8 describes the requirements specific to follow-up sessions. It explains what is required for follow-up session activity to be counted towards the contract targets.

Intervention Service Practice Requirements Handbook: Introduction 1

Section 9 outlines Ministry-funded public health problem gambling services and relevant relationships with intervention service activity.

Section 10 outlines problem gambling infrastructure services that are funded to support intervention and public health service delivery.

Section 11 contains a glossary of terms used in this document.

Section 12 provides a version history for the handbook. Use this section to identify when a particular change was introduced. The latest version of this handbook is available from the Ministry’s intranet (http://www2.moh.govt.nz/problemgambling). Three appendices contain complete versions of the forms and templates described in this handbook for practitioners to use in their work. The report concludes with a list of the references cited in the handbook.

1.3 Intended audience This document is intended for problem gambling intervention service providers.

1.4 Related documents The Problem Gambling Service has a set of manuals that define standards and processes for problem gambling intervention service providers. This handbook specifies the minimum activities for problem gambling intervention services and typical client pathways. Use the handbook with the following related documents. • Your service provider contract with the Problem Gambling Service, Ministry of Health.

The contract contains the service specifications and should be regarded as the final document in any dispute.

• Data Management Manual (Ministry of Health 2008). This manual specifies the minimum standard for data and information. The latest version of the manual is available from the Ministry’s intranet (http://www2.moh.govt.nz/problemgambling).

• Data Collection and Submission Manual (Ministry of Health 2008). This manual specifies the process and timeframes for providers to collect and submit monitoring data. The latest version of the manual is available from the Ministry’s intranet (http://www2.moh.govt.nz/problemgambling).

• CLIC Database Manual (Paton-Simpson & Associates Ltd 2005). This manual is for providers that use a local CLIC system for client management. It describes how a provider should operate the CLIC system. The manual is available from Paton-Simpson & Associates’ website (http://www.p-s.co.nz/CLIC_manual.php).

2 Problem Gambling Service: Intervention Service Practice Requirements Handbook

http://www.p-s.co.nz/CLIC_manual.php

2 Strategic Context

2.1 Objectives of problem gambling strategic plan Preventing and Minimising Gambling Harm: Strategic Plan 2004–2010 outlines seven objectives that set the parameters for problem gambling services (Ministry of Health 2005). The seven objectives are to: • promote healthy public policies in relation to gambling harm • encourage supportive environments to minimise gambling harm • enhance the capacity of communities to define and address gambling harm • maintain and develop accessible, responsive and effective interventions • assist the development of people’s life skills and resilience in relation to preventing or

minimising gambling harm • enhance workforce capacity • develop a programme of research and evaluation.

2.2 Māori health Health providers are expected to contribute to improvements in whānau ora (Māori families supported to achieve their maximum health and wellbeing) and to the reduction in Māori health inequalities, using He Korowai Oranga: Māori Health Strategy and Whakatātaka: Māori Health Action Plan (Minister of Health and Associate Minister of Health 2002b, 2002a). Specific Māori health priorities are outlined in He Korowai Oranga. Health and disability service providers need to recognise the cultural values and beliefs that influence the effectiveness of services for Māori and must consult and include Māori in service design and delivery.

2.3 Strategic outcomes framework Over the period of the service plan (2007–2010), the Ministry of Health expects to continue developing its strategic outcomes framework for problem gambling. The strategic outcomes framework is likely to outline short-, medium- and long-term outcomes for an integrated approach to problem gambling. Such outcomes will link directly to the existing strategic plan for preventing and minimising gambling harm. The strategic outcomes framework aims to ensure the sector has a common understanding of the objectives of an integrated approach. This will guide: • key stakeholders at national, regional and local levels • the Ministry’s strategic decisions for purchasing services that prevent and minimise

gambling harm • the priorities for monitoring and evaluating progress made in reducing and minimising

gambling-related harm.

Intervention Service Practice Requirements Handbook: Strategic Context 3

The Ministry notes that this work will continue to be developed. It will suggest amendments and adjustments to service reporting, monitoring and evaluation work throughout 2007–2010. The Ministry expects providers to support this process as part of their commitment to ongoing quality improvement.

2.4 Principles Based on its strategic context for problem gambling and its priorities, the Ministry of Health has contracted services to be delivered that: • ensure the provision of service coverage nationwide • support the delivery of a comprehensive range of public health services based on the

Ottawa Charter for Health Promotion and recognised New Zealand models of health (eg, Whare Tapa Whā (Durie 1994), Te Pae Mahutonga (Durie 1999) and Te Wheke (Pere 1984))

• target priority populations • strengthen communities • reduce health inequalities • improve Māori health gains • apply an intersectoral approach to address the broader social determinants of health • link to public health services and intervention and addiction services.

2.5 Components of model to prevent and minimise gambling harm The problem gambling services the Ministry of Health funds are underpinned by the objectives of the strategic plan, the principles described above, and the strategic outcomes framework. The Ministry’s model to prevent and minimise gambling harm is comprised of seven components that provide a continuum of harm prevention activities. The components are: • population health approaches – local, regional and national • national co-ordination services • national helpline services • screening in primary care and social service settings • psychosocial interventions – secondary and tertiary • facilitation services (eg, budgeting advice, alcohol and other drug services, Work and

Income New Zealand services, housing services) • follow-up services and motivational support. The Ministry has contracts with providers to deliver all or some of the above service delivery components. The Ministry will, wherever practicable, seek to ensure a comprehensive range and mix of services within each region. However, regardless of the range of services an individual provider delivers, all providers must work collaboratively to co-ordinate services within their region and ensure the populations they serve have access to those services.


2.6 Collaboration and key service linkages Not all problem gambling service providers will be contracted to deliver all purchase units. (Purchase units are defined in the Glossary, section 11, and relate to the services specified in the provider’s contract.) It is important all providers work, and show evidence of working, with other providers to ensure the full range of problem gambling services the Ministry of Health funds are provided locally and regionally in an effective and complementary manner. As a minimum, providers should use their best endeavours to ensure: • service users have access to the full range of services included in this handbook • they participate in local planning or co-ordination forums (eg, local mental health and

addiction network meetings and regional problem gambling hui) • Māori service users are offered the choice of using dedicated Māori services or

general services (where a choice of services is available) or a combination of both services

• Pacific people are offered the choice of using dedicated Pacific services or general services (where a choice of services is available) or a combination of both services1

• Asian people are offered the choice of using dedicated Asian services or general services (where a choice of services is available) or a combination of both services.2

Providers must establish working protocols with other services that interface in some material way with the services they provide. Interfaces and linkages should exist between problem gambling service providers and other service providers or referral agencies. Such providers include: • other providers of problem gambling services • health promotion and public health services • local mental health and addiction networks • alcohol and other drug treatment services • budgeting and other social service agencies • Māori health and social service agencies • Pacific health and social service agencies • Asian health and social service agencies • refugee and migrant health and social service agencies • child, adolescent and young peoples health and social services primary care

providers • community mental health services • local Department of Corrections services.

1 The Ministry acknowledges that the Pacific population is not a single homogeneous group, but is

made up of a diverse range of ethnic groups. However, at this stage, services are not being provided for each Pacific group.

2 The Ministry acknowledges that the Asian population is not a single homogeneous group, but is made up of a diverse range of ethnic groups. However, at this stage, services are not being provided for each Asian group.

Intervention Service Practice Requirements Handbook: Strategic Context 5

2.7 Political neutrality The Ministry of Health must comply with the conventions relating to the political neutrality of the State service. Providers must perform the agreed services in a manner that is consistent with and maintains the Ministry’s actual and perceived political neutrality. This does not limit a provider’s ability to carry out any other activities. However, it must ensure activities outside the services contracted for are clearly separate from and independent of the services contracted with the Ministry.


3 Problem Gambling Services

3.1 Introduction Section 3 overviews the problem gambling services the Ministry of Health purchases.

3.2 Services The problem gambling services the Ministry of Health purchases include: • national and local intervention and public health services (section 3.2.1) • national helpline support (section 3.2.2) • national co-ordination services (section 3.2.3) • national workforce development services (section 3.2.4) • national social marketing services (section 3.2.5) • national and local research projects (section 3.2.6).

3.2.1 National and local intervention and public health services The Ministry of Health funds services at national and local levels. Intervention services provide psychosocial support and clinical interventions for individuals affected by their own or someone else’s gambling. Public health services involve primary prevention initiatives such as short- and long-term community development and action projects.

3.2.2 National helpline support The Ministry of Health funds helpline support in the form of an information and national intervention service (Gambling Helpline). Helpline support is primarily a national crisis support service for individuals, but also provides intervention services for client’s who are unable to access face-to-face services.

3.2.3 National co-ordination services The Ministry of Health funds a national co-ordination service to support intervention and public health service providers. The co-ordination service works closely with the Ministry and workforce development providers to build sector capacity, consistency and best practice.

3.2.4 National workforce development services The Ministry of Health funds training and capacity-building services for intervention and public health providers. These services align with national co-ordination services to build sector capacity, consistency and best practice.

Intervention Service Practice Requirements Handbook: Problem Gambling Services 7

3.2.5 National social marketing services The Ministry of Health funds national social marketing services that use the mass media in strategic campaigns to raise public awareness about gambling harm, encourage community discussion on the role of gambling in the community, and support aware and resilient communities.

3.2.6 National and local research projects The Ministry of Health manages an ongoing research project that includes a range of specific projects to inform the sector, policy direction, intervention and public health practice.

3.3 Service type All problem gambling intervention and public health services are considered to be a ‘type’ of service. The four types of service the Ministry of Health recognises are: • dedicated Māori services • dedicated Pacific services • dedicated Asian services • general services. Dedicated services focus on a specific population group. Therefore, they are expected to: • be based on a non-mainstream cultural paradigm • be delivered in a manner that utilises culturally derived beliefs, values and practices • employ staff who are of the same ethnic descent as the population being worked with

wherever reasonably possible. • have a mandate from the local communities being worked with. However, no service should exclude a service user who is not of the same ethnicity as the population that is the focus of the service.

3.3.1 Dedicated Māori services The purpose of dedicated Māori services is to minimise problem gambling-related harm particularly to and for Māori. A dedicated Māori problem gambling service must demonstrate that it, among other things: • is based in a Māori cultural paradigm • utilises Māori derived beliefs, values and practices • has staff of Māori descent, wherever reasonably possible • facilitates access to and support of kaumātua (male and female)


• emphasises whanaungatanga (kinship) • does not exclude non-Māori service users.

3.3.2 Dedicated Pacific services The purpose of dedicated Pacific services is to minimise problem gambling-related harm particularly to and for Pacific peoples. A dedicated Pacific problem gambling service must demonstrate that it, among other things: • is based in a Pacific cultural paradigm • utilises Pacific-derived beliefs, values and practices • has staff of Pacific descent, wherever reasonably possible • is mandated by local Pacific communities • does not exclude non-Pacific service users.

3.3.3 Dedicated Asian services The purpose of dedicated Asian problem gambling services is to minimise problem gambling-related harm particularly to, and for, Asian people. A dedicated Asian problem gambling service must demonstrate that it, among other things: • is based in an Asian cultural paradigm • utilises Asian-derived beliefs, values and practices • has staff of Asian descent, wherever reasonably possible, • is mandated by local Asian communities • does not exclude non-Asian service users.

3.3.4 General services General services aim to minimise problem gambling-related harm for all members of the community, including delivering services to Māori, Pacific, Asian and other priority population subgroups. A general problem gambling service must demonstrate that it, among other things: • is delivered in a manner that is accessible to all groups regardless of gender,

ethnicity, age or health status • is culturally safe and appropriate for the diverse populations in its area of delivery • has a focus on improving Māori health gains • has a focus on reducing health inequalities • accesses cultural support and expertise as required • is responsive to the needs of Māori service users by delivering services that are

culturally safe and that may include skills programmes based in Māori cultural paradigms

Intervention Service Practice Requirements Handbook: Problem Gambling Services 9

• offers Māori service users, where a dedicated Māori service is reasonably available (whether or not provided by the general service), the choice of using dedicated and/or general services

• is responsive to the particular cultural needs of service users by delivering services that are culturally safe and that may include programmes based in culturally specific paradigms

• offers Pacific or Asian service users, where a dedicated Pacific or Asian service is reasonably available (whether or not provided by the general service), the choice of using dedicated and/or general services.


4 Intervention Services

4.1 Introduction Section 4 overviews the national and local problem gambling intervention services the Ministry of Health purchases.

4.2 Problem gambling intervention services Problem gambling intervention services include: • helpline and information services (section 4.2.1) • brief intervention services (section 4.2.2) • full intervention services (section 4.2.3) • facilitation services (section 4.2.4) • follow-up services (section 4.2.5).

4.2.1 Helpline and information services The focus of helpline and information services is to provide an accessible information and intervention service to individuals experiencing gambling harm who are unable to access face-to-face intervention services. The helpline services complement face-to-face services, because they are open longer hours and provide anonymity for people concerned about their privacy. In many cases, the helpline may represent a first point of access for a person who will later receive face-to-face support.

4.2.2 Brief intervention services Brief intervention services are for people early in the course of developing gambling problems. The services aim to encourage individuals experiencing harm from gambling to recognise and acknowledge the consequences of their gambling and to change their gambling behaviour or seek specialist support where necessary. The focus of this service is people who are at risk of gambling harm and who may be experiencing some of the effects of such harm, but who do not yet associate their gambling with the problems in their lives. Brief intervention services will typically delivered in settings frequented by people likely to be at risk of gambling harm. If someone comes to your service seeking help for gambling, they are ready for a full intervention rather than a brief intervention.

Intervention Service Practice Requirements Handbook: Intervention Services 11

4.2.3 Full intervention services Full intervention services are community-based assessment and intervention services for people with gambling-related problems. They aim to minimise problem gambling-related harm to the service user and their family/whānau and significant others by providing a range of psychosocial interventions. Full intervention services make up the core clinical work that most face-to-face intervention staff engage in every day.

4.2.4 Facilitation services Facilitation services involve minimising gambling-related harm to individuals and their families/whānau and significant others by facilitating people’s access to health and social services. Many people presenting at gambling services have more problems in their life than just gambling; sometimes they are connected to the gambling and sometimes they are separate from the gambling. Facilitation services recognise that merely referring someone to another service is not usually effective. Active effort and support are often required to help clients to receive the support they need for other problems in their life.

4.2.5 Follow-up services Follow-up services provide follow-up and motivational support to clients for 12 months after their last full intervention session with a problem gambling intervention service (ie, from full intervention or facilitation services). Many people recovering from addiction benefit from support even after having received intervention services. The focus of follow-up is for the practitioner to maintain contact with clients for a year after they have stopped coming to scheduled sessions and to continue to offer support and to motivate the client.

4.3 Background to the intervention service model The system of intervention described in this handbook is based on a multi-modal approach. This approach acknowledges the widespread impact of problem gambling on the gambling individual and their family/whānau and significant others. All intervention service providers are responsible for promoting their services through appropriate and effective marketing that is targeted at at-risk and high-need populations. The intervention service model recognises that people affected by gambling harm can benefit from a range of services. The model aims to address not only the gambling behaviour, but also to reduce the impact of harm by facilitating the client’s access to other services, including:


• financial counselling • relationship counselling • other social service agencies • mental health services • alcohol and other drug services. The model acknowledges that individuals are at different points in their acknowledgement of and readiness to change their gambling behaviour. Therefore, they require a range of interventions from screening and brief intervention to intensive interventions.

4.4 Client pathways and ideal patterns of care The pathways and patterns of care presented in Figure 4.2 represent service patterns for typical clients. The Ministry of Health will periodically review client presentation data and update the typical pathway and pattern of care guidelines accordingly. Practitioners should use their clinical judgement and advice from their clinical supervisor to identify appropriate interventions and decisions for an atypical presentation. It is important to understand the terminology used in the following explanation of client pathways and patterns of care, particularly the definitions of ‘episode’ and ‘session’. These terms are defined in the Glossary, section 11. Section 4.4.3 outlines the key forms and documents used to represent the client’s journey through the problem gambling service.

4.4.2 Ideal pattern of care The Ministry of Health is funding: • brief interventions of 15–30 minutes over one or two sessions • several 60-minute full psychosocial intervention and facilitation sessions • four follow-up sessions 15–30 minutes each. The preferred pattern of intervention sessions is outlined in Figure 4.1.


Figure 4.1: Preferred pathways for intervention sessions

Intervention Services

Brief Intervention

Full Intervention

Facilitation Services

Follow-up

Brief EpisodeB B [B]

Full Intervention EpisodeF F F F F

C C C

Entry

Entry

Exit

UFollow-up Episodes

U U U Exit

Notes: • Brief episode: One or two brief sessions (B) followed by a third brief session if it is deemed clinically

appropriate. A brief session is 15–30 minutes long. • Full intervention episode: A maximum of eight sessions comprising a mix of full intervention sessions

(F) and facilitation sessions (C). A full intervention or facilitation session is typically 60 minutes long. • Follow-up episode: A scheduled follow-up session (U) undertaken at one month, three months, six

months and 12 months after the last full intervention episode session. A follow-up session is 15–30 minutes long.

The Ministry acknowledges and accepts that clients experiencing greater levels of gambling-related harm and/or presenting with co-existing issues may require greater levels of support and intervention than is shown in Figure 4.1. However, these presentations are atypical, and the Ministry expects that the majority of a provider’s interventions will be delivered within the preferred pattern of intervention sessions.

4.4.2 Typical client pathways Figure 4.2 represents a range of typical pathways that clients use to access problem gambling intervention services. This figure also outlines the typical pathways clients take between categories of problem gambling service and to and from recovery.


Figure 4.2: Typical client pathways into intervention services

Note: See Figure 11.1 in section 11 for a guide to the symbols used in this figure.


4.4.3 Forms Providers who do not enter client data directly into the Ministry of Health’s problem gambling database must be familiar with four standard forms. The forms are the: • Batch Submission Form • Client Form • Client Multiple Sessions Form • Group Therapy Form. Details of how to use these forms is in the CLIC Database Manual. The order in which practitioners should use these forms and the different sections on each form are outlined in Figure 4.3. The correct use of the forms is important for correctly identifying the start and end points of different episodes. Each episode type has its own conditions for ending. These are detailed in: • section 5.5.2 for brief intervention episodes • section 6.2.6 for full intervention episodes • section 8.6 for follow-up episodes.


Figure 4.3: Order of use for forms and form sections



4.5 Eligibility As well as the characteristics of the service determined by the service type, that is, dedicated Māori, Pacific or Asian or general (as set out in section 4.3), providers must ensure their services are provided to eligible people as set out below.

4.5.1 Eligible people Eligible people are people: • with any of a range of gambling problems • with co-existing gambling problems and mental health (including substance use)

problems • at risk of developing pathological gambling problems • who have been affected by the gambling of a family/whānau member or significant

other.

4.5.2 Age of eligible people Eligible people must be: • young people/taitamariki (14–17 years) • adults/pakeke (18 years or over). Providers should establish and maintain relationships and key linkages with child, adolescent and young peoples health and social services, and primary care, education, and other statutory agencies as appropriate to meet the needs of young service users. Joint approaches to care and case management that combine the expertise of each service will involve negotiation about which service has primary responsibility for care. Referrals from other agencies for assessment and intervention are accepted by community problem gambling intervention services.

4.5.3 Primary problem gambling mode The primary problem gambling mode is the key criterion the Ministry of Health uses to identify valid clients for ongoing support from problem gambling intervention services. Exceptions to this criterion are noted throughout this handbook. However, the support provided to clients who do not have a primary problem gambling mode will typically be short in nature (one or two sessions) and will focus on supporting the client to access an appropriate service.


4.5.3.1 Identifying and recording a client’s problem gambling mode When a client (a gambler or significant other) is starting a new treatment episode, the practitioner must ask the client to identify the gambling activities or venues (ie, the problem gambling modes) that are causing the client significant harm (eg, out-of-control gambling, the loss of excessive amounts of money, or a lot of time spent gambling) and record these as primary problem gambling modes. The practitioner must record at least one and no more than five primary problem gambling modes for the client. The counsellor must also ask the client to identify any other gambling activities or venues that are not causing significant harm. These gambling activities or venues are recorded as additional problem gambling modes. A maximum of five additional problem gambling modes are permitted.

4.5.3.2 Problem gambling modes: Gaming machines From 1 April 2008, providers must record gaming machines as one of: • casino gaming machines • club gaming machines • pub gaming machines. If the client identifies a gambling activity or venue as the ‘pokies’, the practitioner needs to ask further questions to identify which one or more of the three gaming machine modes the client is referring to. While it is usually clear if a venue is a casino, it can be difficult to determine whether the venue is a club or pub.

4.5.3.3 Determining whether gaming venue is a club or pub If a client is unable to provide sufficient information for you to identify the venue as a club or pub, then make the determination using your knowledge of the client and the gambling venues in the area. A club is usually a venue where a person has to be a member to enter in order to drink, eat or participate in activities. Questions that might assist in identifying the venue as a club (when the ‘pokies’ have been identified) include the following. • What is the name of the venue where you play pokies? The name of the venue

might indicate whether the venue is a club. The three main types of clubs are: – chartered clubs (eg, cosmopolitan clubs and workingmen’s clubs) – sports clubs (eg, rugby clubs and racing clubs) – Returned Services Associations (RSAs).


• Do people usually have to be a member to go into the venue to drink, eat or participate in activities? If the client answers yes, the venue is most likely a club. If the client answers no, the venue is most likely a pub.

4.6 Problem gambling practitioner competencies

4.6.1 No official competencies No official competencies guide the minimum requirements for practising as a qualified problem gambling practitioner in New Zealand. However, some initial work was started in 2003. The development of competencies is now being prioritised. Later versions of this handbook will clarify the appropriate competencies for each service type (ie, brief, full, facilitation and follow-up). To progress this work the Ministry of Health will draw on the development of competencies for allied addiction services. The Ministry recognises the importance of ensuring specific cultural competencies are included to reflect the expertise of Māori, Pacific and Asian practitioners and the competencies necessary to work with different cultural groups safely and appropriately.

4.6.2 No professional association The Ministry of Health is also aware that no professional association or body specifically oversees problem gambling practitioners. Many problem gambling clinical practitioners rely on membership to professional associations or registrations that acknowledge their work in the problem gambling field, and qualifications or previous job experiences from allied practices are seen as transferable skills and experiences. Many practitioners working in problem gambling come from health and mental health professions. Alcohol and other drug practitioners, in particular, are drawn to the problem gambling field of practice and bring valued skills.

4.6.3 Requirements for problem gambling practitioners For a problem gambling practitioner to competently work in this field, evidence of training in comprehensive assessment (see the definition in the Glossary, section 11) and intervention and discharge planning is essential. Practitioners should have good diagnostic skills and be able to refer to diagnostic screens and tools that assist with the assessment of clinical needs that are beyond problem gambling issues and make up a comprehensive assessment. They should also possess competence in evidence-based interventions in a range in psychosocial and culturally based modalities. Practitioners also need to work competently in important areas such as early intervention, case management, relapse prevention and risk management.


4.6.4 Competencies for co-existing issues The importance of ensuring co-existing issues are addressed is emphasised within the revised service model outlined in this handbook. Often problem gambling intervention practitioners have appropriate qualifications for addressing co-existing issues, such as alcohol and other drug or budgeting problems. The Ministry of Health believes that, providing practitioners have appropriate training and qualifications, they may provide support to clients for any issue directly relating to the client’s gambling through a full intervention session. When a practitioner does not have the necessary skills to address the client’s additional needs or complex presentation, the practitioner should refer the client or facilitate the client’s access to an appropriate service. However, some clients will present with co-existing issues that interact, but are not a result of the client’s gambling. The Ministry is funding problem gambling services, so the practitioner should refer or facilitate such a client to an appropriate service for support with these issues, even if the practitioner has the necessary skills.


5 Brief Intervention

5.1 What is a brief intervention? A brief intervention: • is a one-on-one intervention in a non-specialist setting • is typically one or two short motivational interview sessions with a client • involves people who do not acknowledge, recognise or accept the harms in their lives

from their or another’s gambling • involves people who have not yet made a commitment to seek support from their

gambling (either formally from a specialist gambling service or from another source) or to make necessary changes in their lives.

Brief intervention is a specialised intervention that focuses on engaging with people at risk of gambling harm and encouraging them to recognise the potential impacts of their own or another’s gambling on their life. Evidence suggests that, when combined with an appropriately targeted motivational discussion, recognition and awareness-raising is sufficient to encourage many people experiencing harm from gambling to recover, even if they never seek formal problem gambling support. Offering brief interventions is a relatively new concept for service providers who are used to providing services at the request of a potential client who is seeking help. In contrast to clients seeking help themselves, brief interventions rely on the initiative of the service provider to be well positioned in community settings where they can easily and appropriately engage with people who are likely have a high risk of experiencing gambling harm. Consequences that are often associated with problem gambling are financial, social and health related in nature. To be appropriately positioned and to support client access, service providers should build strong relationships and partnerships with community agencies and organisations that deal with these types of issues. Agencies and organisations with clients who may be at a higher risk for gambling harm than are other people include Community Corrections, Work and Income New Zealand, budgeting services, foodbanks, and Child, Youth and Family. The Ministry of Health has contracted with its intervention service training provider to provide training for allied services to raise their awareness of problem gambling. A goal of this training is to encourage non-specialist services to value the benefit of brief interventions for problem gambling and to understand how interventions for problem gambling can improve their own organisational outcomes. A brief intervention is often referred to as an ‘opportunistic’ encounter with a person who may not realise that they are experiencing a level of harm from gambling. The person may not be ready to take responsibility for any behaviour related to their gambling, may not realise the impact of their gambling on their life or on the lives of those around them, or may not realise that they have been affected by someone else’s gambling and can seek help for themselves.


5.2 Settings for screening Opportunities for brief interventions are mostly at the initiative of the service provider who seeks out environments in which to engage with populations who may be at high risk for problem gambling. For brief interventions to be likely to occur, service providers need to be available to these populations. Typically, people experiencing gambling harm do not present to problem gambling services until they are in crisis or experiencing a high level of harm. As a form of secondary prevention (ie, preventing the progression of the gambling harm), brief intervention screening can detect the early stages of a potential problem. This may mean that less intrusive forms of intervention are necessary. Brief interventions create an opportunity for people to rethink how gambling is affecting their life and consider changes at their own initiative or with limited involvement from a specialist service. People with increasing concerns about their gambling may initiate contact with a specialist service, but most often their self-awareness will be heightened by timely opportunities that are offered when they least expect them. Brief intervention can be provided in a family/whānau setting, providing all participants agree to discuss their screening results together. (This is different from group therapy as group therapy clients are likely to have already made a commitment to seeking assistance.) For example, several people may be attending a session with a client (for support or interest), and the practitioner may believe it would be appropriate and useful to provide a brief intervention to all the attendees (not already clients). These brief interventions are recorded on new Client Forms, and each client identification number (ID) is recorded on the original client session form as a ‘session attendee’ on the individual Client Form. Practitioners are expected to manage and document a client’s agreement (ie, their informed consent) to have their screening results discussed with others present.

5.3 Family/whānau screening It has been estimated that for each problem gambler, seven others are detrimentally affected by the person’s gambling. These people are often unaware of the extent of the stress the gambling is causing them or that the effects can continue long past their association with the gambler. Opportunistic screening of the gambler’s family/whānau can help to identify such impacts, and provide information to the family/whānau and motivate them to seek help for themselves.

Intervention Service Practice Requirements Handbook: Brief Intervention 23

5.4 Goals of brief intervention People with moderate to significant levels of problem gambling harm, may face barriers to initiating contact with specialist services. More likely than the development of other types of addiction, the development of problem gambling can go undetected for long periods. This causes symptoms to become more entrenched before they are detected, which often leads to increased shame, embarrassment and denial. A timely brief intervention and good use of motivational interviewing skills can encourage a person to take the next step and engage with a specialist service for treatment intervention, seek help and support from other help providers for other consequences of their gambling, or even to take steps on their own to change their gambling behaviour. Brief interventions can be effective in engaging problem gamblers and for building self-awareness in family/whānau and significant others who have also been harmed by problem gambling. The family of the problem gambler may have focused on controlling the gambler, so have overlooked their own deteriorating health. They may also benefit from a brief intervention that helps them to focus on their needs and address the impact gambling has had on them.

5.5 Summary of brief intervention service specification A brief intervention consists of no more than three sessions, usually 15–30 minutes each in duration. It usually takes place as part of a planned service initiative in the community, but can take place at a service centre by way of a phone call or an unscheduled meeting. A brief intervention can take place over the phone or face to face, but not in a group setting, because individualised engagement is necessary. With informed consent from all parties, brief intervention can occur in a family/whānau setting. Brief intervention sessions consist of the use of a self-administered or practitioner-guided screen (unless it is a telephone brief intervention, in which case the questions are read to the client). The practitioner discusses the client’s responses and results to show the level of problem gambling harm that is resulting from their, or someone else’s gambling. The practitioner also discusses education and information resources and suggests possible next steps for the client to address the issues raised. The service specification for brief intervention is outlined in Table 5.2. A flowchart of typical client pathways and practitioner decisions for brief interventions is in Figure 5.1.

5.5.1 Exceptions It is important to note that not all clients to the service qualify for a brief intervention. If a person has already been screened by the Gambling Helpline and is now being referred to the service, that individual should go directly into a full intervention episode.


Clients who have had a full or brief intervention episode closed in the past six months are not eligible for another brief intervention. If these clients seek further support from the problem gambling service or you want to offer further support after a follow-up session, open a new full intervention session. If a person initiates contact and is actively seeking help for concerns related to problem gambling, identify their contact as a full intervention episode. If a person scores zero on the Brief Gambler Screen or Brief Family/Affected Other Screen, shows no signs of other health or social issues, and does not acknowledge concerns about problem gambling, they cannot be counted for a brief intervention even if individual time was spent with them. Group therapy is not an accepted session type for a brief intervention. A minimum amount of data is required for a brief intervention to be counted. See the Data Management Manual for the service delivery rules and contract purchase units.

5.5.2 Closing a brief intervention episode The purpose of a brief intervention is specific; it focuses on motivating people to change, either on their own or with specialist support. Individuals who do not respond to one or two brief intervention sessions are unlikely to change without a period of reflection or a change in their personal circumstances. If a practitioner believes a client is showing genuine engagement and contemplation, a third brief intervention may be useful. Once a client has received one or two (three maximum) brief intervention sessions four outcomes are likely, but in each instance the episode should be closed. The four likely outcomes are listed in Table 5.1. Table 5.1: Ending brief intervention episodes

Client outcome Discharge code and action

Client no longer wants to discuss their gambling with the practitioner.

Treatment partially complete No further action

Client has received three brief intervention sessions and is not willing to receive specialist support (ie, to enter into a full intervention episode).

Treatment complete No further action

Client has agreed to receive specialist support (ie, to enter into a full intervention episode).

Treatment complete Schedule full intervention session

Client received one brief intervention session, agreed to discuss their gambling further (a second brief intervention), but was unable to be contacted within 90 days (three months).

Administrative No further action


Table 5.2: Brief intervention service specification (purchase unit PGCS-02)

Outcome All people identified as problem gamblers or being at risk of gambling-related harm received evidence-based brief motivational support and intervention that encourages reductions in gambling-related harm to them and their family/affected others.

Objectives To provide a service specifically for people early in the course of developing gambling problems. The service aims to encourage individuals experiencing harm from gambling to: •

•

recognise and acknowledge the consequences of their gambling and either make changes to their gambling behaviour or seek specialist support where necessary.

Activities Provision of brief intervention services will involve maintaining a primary point of contact for those experiencing some degree of gambling-related harm. The service will provide screening and brief assessment as well as brief interventions in the form of time-limited advice and intervention.

Services will aim at primary/secondary prevention of gambling problems and will generally be offered in non-problem gambling settings used or attended by people likely to be experiencing gambling related harm (eg, budget and financial support services, food banks, other social and health services).

Brief intervention services will include, but are not limited to, the following activities: •

•

•

•

•

•

•

•

screening for suicidality/homicidality potential assessment of gambling problems utilising tools approved by the Ministry of Health brief interventions (as outlined in the MoH revised practitioners manual) facilitation of culturally appropriate interventions or referrals accurate education and information giving on gambling harms and available interventions referral to more intensive problem gambling intervention services (including facilitation) where appropriate referral to other services where appropriate offering all clients, provided with brief intervention services, the option of a follow-up contact within two weeks of the previous intervention

Key processes

Services users will be able to, as a minimum, access all of the following processes described in the ‘Process Descriptions’: screening, assessment, brief intervention, management of risk, service handover, support, liaison and consultation, and referral.

Reporting Six-monthly narrative reports to the Ministry will use the provided report template and summarise: •

•

•

•

barriers and successes over the last six month period (ie, issues with referral processes) trends and patterns in client presentations FTE employed to deliver this service over the last six-month period (noting variances and any periods of unemployment) any other relevant information.

Provided by

Services will be provided by a team or person with appropriate qualifications, competencies, skills and experience in working with people with gambling problems and/or other behavioural addiction problems, as outlined in the revised practitioners manual.

Access Referral is from any source including self-referral

Minimum delivery

One FTE will deliver a minimum of 120 brief sessions per month (average 15–30 minutes each).


Figure 5.1: Typical client pathways and practitioner decisions for brief interventions



5.6 Examples of brief interventions

5.6.1 Case 1: Community hui You have partnered with a public health provider to run a community hui on gambling for 12 people who received notice of the hui from a variety of services (eg, a non-government organisation, District Health Board, Citizens Advice Bureau and budgeting service). The 12 attendees have never been assessed and are not clients of any gambling service. As part of the session, all attendees self-administered a brief screen. You offered to give feedback and discuss the results on an individual basis. Five attendees each had a brief discussion (about 15 minutes) with the facilitator about their score and other aspects of their personal experiences with gambling and about other resources available to them. One of the five asked for a subsequent appointment with your service as a result of their score and discussion, which had heightened their awareness of their problem gambling. Three of the five made no further commitments, even though their screen scores and discussion suggested problem gambling concerns. They have no further direct contact with the agency in the short term. The remaining one of the five is not interested in further face-to-face contact, but willingly gives their phone number to the facilitator, so the facilitator can make follow-up contact in a weeks time.

5.6.1.1 Questions After reading case 1, answer the following questions. • How would you account for the 12 people in your reports to CLIC and the Ministry? • How would you account for the five people who had additional time with the facilitator

and any subsequent contact? • How would it matter if the attendees were concerned about their own gambling

behaviour or about how someone else’s gambling was affecting them?

5.6.1.2 Answers How would you account for the 12 people in your reports to CLIC and the Ministry? You have completed an educational hui in the community for 12 people from various social services, so report this event in your six-monthly narrative report to the Ministry . It is the only way to account for the seven people who did not have individual time with the facilitator.


How would you account for the five people who had additional time with the facilitator and any subsequent contact? Register each of the five people who had about 15 minutes each with the facilitator as a client and recorded this as a brief intervention episode. See the Data Management Manual for the minimum data required. For the person who requested an appointment time, their next face-to-face contact could be opened as a new full intervention episode. This means their brief intervention episode would be processed for closure and a new full intervention episode would be opened. For the three people who did not want any further contact, their brief intervention episodes are opened and closed on the same day, based on their one session contact. Once the person who was willing to have a follow-up phone call with the facilitator has that second contact, a second session under a brief intervention episode is counted. If no further contact is planned at this point, the brief intervention episode is closed. How would it matter if the attendees were concerned about their own gambling behaviour or about how someone else’s gambling was affecting them? A brief intervention applies no matter whether the individual filled in a screen that was addressing their personal concern about their gambling or addressing the impact someone else’s gambling was having on them. As long as some level of harm has been experienced due to gambling, a person can be registered as a client after an individualised session face to face or by phone has occurred and the minimum data has been collected.

5.6.1.3 Guiding principles People are not counted as clients or given a file until they have received at least 15 minutes of individualised time in their own right that involves a discussion of their screen results, disclosure and discussion of clinically relevant information. This is the case even in a group setting where everyone is offered a screen. If 15 minutes of individualised time has been offered to discuss a person’s gambling screen results and other resources, create a client file under a brief intervention episode. It is likely this episode will be opened and closed after the one meeting. If a person wants another meeting after a brief intervention to examine their gambling behaviours in more detail, close the brief intervention and open another episode as a full intervention. Although case 1 involved a group of people, it was not group therapy. Group therapy is a specific mode of intervention and is different to a group of people being spoken to at the same time. Group therapy is defined in the Glossary (section 11) and discussed in section 6.2.2.


5.6.2 Case 2: Health expo Your organisation has run a health expo in the form of a public health awareness stall or health stall at a local community event. More than 1000 people attended. As part of the event, 500 problem gambling education packs and brief screens were handed out to interested people. Three hundred people returned their screens to your organisation’s stall. One hundred returned screens showed gambling harm (ie, were positive screens). On the screening form, you invited people to come and talk with the staff at the stall about gambling. The form also told people that if they answered yes to any of the questions on the form they were likely to be experiencing harm from their own or someone else’s gambling, so they should come and talk privately to one of your practitioners. Practitioners were available in a caravan behind the stall, so people could call in and leave discretely. Eighty people came and talked to the staff at your stall about gambling, and 40 asked for more information and took pamphlets and contact information. Twelve people went into the caravan. Of the 12: • eight talked privately with the practitioner for 15–30 minutes, and:

– two made appointments to see the practitioner at a later date – one said they needed to think about what the practitioner had talked about, but

agreed to see the practitioner in about a week’s time – five were not interested in discussing their scores further or receiving further

support • three felt uncomfortable and left the caravan quickly, although one said they might

call the practitioner at the office • one said they did not gamble, but discussed feeling suicidal, so was given support

and talked to the practitioner until a crisis team arrived (in an hour and a half).

5.6.2.1 Questions After reading case 2, answer the following questions. • How would you account for these people in your reports? • How many people would you count as receiving brief interventions?

5.6.2.2 Answers How would you account for these people in your reports? You have completed a public health event, so your public health team reports on this event in its six-monthly narrative report. The team reports its views of the event’s success and may note how many people were interested in further information and how many people screened positive for gambling harm. See the public health service specifications and reporting requirements for more detail. How many people would you count as receiving brief interventions?


For the 12 people who went into the caravan: • the eight people who spent more than 15 minutes with the practitioner are all counted

as receiving brief interventions – the two people who made appointments to see the practitioner at another time

have their brief intervention episode closed and a full intervention episode opened when they came for their appointment

– the person who wanted to think about their results and the discussion has their brief episode left open until a practitioner talks with the person again

– the five people who did not wish to have any further contact have their brief intervention episodes opened and closed on the same day, based on the one-session contact

• the three people who left quickly are not counted as receiving brief interventions • the one person who left quickly, if they rang back later to talk about their scores and

ask questions about getting help, is counted as receiving a brief intervention for the period of the phone call; but if they rang back saying they had thought about the information and then asked for help, a full intervention episode is opened and no brief intervention is scored

• the one person who did not gamble, but was provided with support for feeling suicidal, is counted as receiving a full intervention session for an hour and a half.

The 300 people who filled out screens, the 100 people who scored positive for gambling harm, the 80 people who talked to staff at the stall, and the 40 people who asked for more information are discussed as part of your public health activity report in your six-monthly narrative report to the Ministry of Health. You should report any of the eight brief interventions where the client did not have a primary problem gambling mode in your six monthly narrative reports to the Ministry. You cannot use CLIC to record work with people who do not have a primary problem gambling mode.

5.6.2.3 Guiding principles People are not counted as clients or given a file until they have received at least 15 minutes of individualised time that involves a discussion of their screen results, disclosure and a discussion of clinically relevant information. If 15 minutes of individualised time has been offered to discuss a person’s gambling screen results and other resources, create a client file under a brief intervention episode. It is likely that this episode will be opened and closed on the one meeting. If a person wants another meeting after a brief intervention to examine their gambling behaviours in more detail, close the episode and open another episode under a full intervention. If a person does not want to receive specialist support but agrees to be contacted to discuss their screen results once they have had a chance to reflect on their answers, keep the brief intervention episode open and schedule another brief intervention session.


5.7 Screening for brief intervention The Ministry of Health endorses two screens for brief intervention. The screens are the: • Brief Gambler Screen • Brief Family/Affected Other Screen. These screens are the minimum offered in brief interventions. Although only one screen may be offered in a particular setting, because both problem gamblers and their families may access similar settings for assistance, it is often beneficial to offer both. In some cases, a person may be both problem gambling and affected by another’s gambling (eg, a parent). The decision to offer a single screen or both screens is up to you. Both screens and how to score and use them are described below.

5.7.1 Brief Gambler Screen For people screening for their own gambling behaviours, the following is used for brief interventions. Instructions for the information to be entered into CLIC for each screen, is in bold and italics, for example (record the number of positive responses to questions 1 to 4). All screens are also in full in Appendix 1.

Introduction/opening statement: Many people in New Zealand enjoy gambling, whether it’s Lotto, track racing, the pokies or at the casino. Sometimes, however, it can affect our health. To help us to check your wellbeing, please answer the questions below as truthfully as you are able from your own experience. A ‘no’ answer can also mean that you don’t gamble at all.

Brief gambler screen (record the number of positive responses to questions 1 to 4. If there are no positive responses, then record a zero “0”) 1 Do you feel you have ever had a problem with gambling? (Only ask if not obvious)

2 If the answer to Q1 is yes, ask: And do you feel you currently have a problem with gambling?

3 Have you ever felt the need to bet more and more money? 4 Have you ever had to lie to people about how much you gambled? 5 If you answered yes to any of the above, what would help?

I would like some information I would like to talk about it in confidence with someone I would like some support or help Nothing at this stage


5.7.1.1 How is the Brief Gambler Screen used? If the client answers yes to any of questions 1–4 in the Brief Gambler Screen (ie, a positive screen), the client meets the conditions the Ministry of Health has agreed for funding further intervention services. If the client answers no to questions 1, 3 and 4, use your judgement or further assess the client as necessary. Responses to question 5 provide the intervention desired. Although the person may state that they require nothing at this stage, let them know that assistance is available if they change their mind. These responses can also be a topic for conversation in a later brief intervention session. If the screen is positive, but the person does not want to do anything at this stage, offer to recontact the person in a week or two to see if they have reconsidered the help offered. Note that the Ministry of Health regards ongoing support for individuals who have not met the criteria for a positive screen as unusual. While the Ministry accepts that sometimes services are provided to such clients, the Ministry believes such clients will be the minority of clients seeking help. The Ministry will seek clarification of such practices, if they become a significant portion of a service’s client load.

5.7.1.2 Why is the Brief Gambler Screen used? The Ministry of Health intends the Brief Gambler Screen (questions 1–4) to be the gateway screen for brief intervention services and to inform the need for ongoing engagement with the presenting individual. Deliver the Brief Gambler Screen within the parameters and guidelines detailed in the service specification and Data Management Manual.


5.7.2 Brief Family/Affected Other Screen For screening people for the impact another person’s gambling problem is having on them, use the Brief Family/Affected Other Screen for brief interventions.3

The Brief Family/Affected Other Screen is made up of two questions. You will see that the CLIC system refers to these questions as: • Brief Family/Other-Awareness • Brief Family/Other-Effect. Instructions for the information to be entered into CLIC for each screen, is in bold and italics, for example (record the number the response). All screens are also in full in Appendix 1.

Introduction/Opening Statement: Sometimes someone else’s gambling can affect the health and wellbeing of others who may be concerned. The gambling behaviour is often hidden and unexpected, while its effects can be confusing, stressful and long-lasting. To help us identify if this is affecting your own wellbeing, answer the questions below to the best of your ability.

1 Awareness of the effect of the gambler’s gambling (record the number of the

response ie, 0–3) Do you think you have ever been affected by someone else’s gambling? (0) No, never (you need not continue further) (1) I don’t know for sure if their gambling affected me (2) Yes, in the past (3) Yes, that’s happening to me now

2 Effect of gambler’s gambling (record the total number of positive responses

(ticks) between question 1 and 5. Record 0 or 6 if no other responses are ticked). How would you describe the effect of that person’s gambling on you now? (Tick one or more if they apply to you.) (0) It doesn’t affect me any more I worry about it sometimes

It is affecting my health It is hard to talk with anyone about it I am concerned about my or my family’s safety I’m still paying for it financially

(6) It affects me but not in any of these ways

(1-5)

3 The Brief Family/Affected Other Screen uses the Concerned Others Gambling Screen that was

developed by Dr Sean Sullivan of Abacus Counselling & Training Services Ltd.


3 Support requested (response not recorded) What would you like to happen? (Tick one or more.)


5.7.2.1 How is the Brief Family/Affected Other Screen used? The Brief Family/Affected Other Screen has three questions. Question 1 asks if the person has been affected by someone else’s gambling. If they answer ‘No, never’, the screen result is negative and the client need not continue. If the client answers ‘I don’t know for sure if their gambling affected me’, ‘Yes, in the past’ or ‘Yes, that’s happening to me now’, the screen result is positive. Research, although limited, indicates that people who ‘don’t know for sure’ are often just as depressed as those disclosing past or present gambling effects, and that anyone who responds with a positive screen is significantly more likely to be depressed than those who respond ‘No, never’.

Question 2 asks the client with a positive screen to focus on the effect on them of the person’s gambling. In many cases those affected by another’s gambling focus on trying to control the gambler’s behaviour and seldom focus on the effects of the gambling on themselves. The intention of question 2 is to direct the client’s attention to their own needs, often for the first time. The answers to question 2 help to raise the client’s awareness about the effects of the gambling on themselves. They may have become numb to, or have accepted that there is little they can do about, these effects, so have not dwelled on them. These answers become topics to be addressed in counselling. The answer ‘It doesn’t affect me anymore’ may be due to the client’s poor awareness, so focus on the client’s answers to later questions (eg, health items) to verify the client’s view. Research has also noted that those who selected the ‘It doesn’t affect me anymore’ option were more depressed than those never affected by problem gambling (question 1), so this answer may indicate negative effects not identified by the person. Question 3 asks the client what they would like to happen. It offers information, talking in confidence (counselling), support or ‘Nothing at this stage’. Clients may select more than one option. Family members are much less likely to seek help for themselves than for those affected by their own gambling. It is possible that even if the client does not require help at this stage, the ‘seed may be sown’ for later help-seeking. The intention of this question is to confirm with the client that they are in control of the process (ie, it is client-centred) by giving them a range of options and indicating what options there might be.


The term ‘counselling’ is avoided in the screen as family members may not want to see themselves as needing counselling. They may feel it implies that they are in some way contributing to the gambling behaviour.

5.7.2.2 Guidance for using the Brief Family/Affected Other Screen Offer the Brief Family/Affected Other Screen carefully, as family members may perceive that services are gambler-focused or that their problems would be solved if the gambler stopped gambling (so help for themselves is irrelevant). They may also feel that if they are seen as needing help, they must have been in some way contributing to the problem gambling. Use a motivational interviewing approach when offering the screen, rather than assuming the client is aware your service is available for them also. If you tell the client why they could be affected but unaware of the effect, that you will offer feedback as soon as the screen is completed, and that your service is accessed by family members, you may reduce their resistance to undertaking the screen. For people who remain focused on and concerned with the gambler’s recovery, offer them information that addresses their needs and supports them, and tell them how it might positively impact on the gambler’s recovery. This may persuade the family member to participate.

5.7.2.3 Why is the Brief Family/Affected Other Screen used? The Ministry of Health intends the Brief Family/Affected Other Screen to be the gateway screen for brief intervention services and to inform the need for ongoing engagement with the presenting individual. Deliver the Brief Family/Affected Other Screen within the parameters and guidelines detailed in the service specification and Data Management Manual. If the person has a positive screen but does not want to do anything at this stage, always offer to recontact them in a week or two to see if they have reconsidered the help offered. Note that the Ministry regards ongoing support for individuals who have not met the criteria for a positive screen as unusual. While the Ministry accepts that sometimes services are provided to such clients, the Ministry believes such clients will be the minority of people seeking help. The Ministry will seek clarification of such practices, if they become a significant portion of a service’s client load. Note that the session and episode criteria in the Data Management Manual do not allow sessions to be recorded when the family member/affected other does not know the gambler’s primary problem gambling mode. Record and report on brief intervention sessions with clients who do not have a primary problem gambling mode in your six-monthly narrative report to the Ministry.


Family members may seek help for themselves by directly approaching your service with or without the gambler. In these instances they should be provided with full intervention services. However, in many cases they may attend with the gambler to the services or ask about services available in the community for the problem gambler, not expecting to participate apart from having perhaps a support role. In these cases the family member may not be aware that the gambling behaviour and its consequences have affected their health and wellbeing, and that they would also benefit from your services.

5.9 Frequently asked questions

5.9.1 Why do a brief intervention? A brief intervention is an opportunity to: • intervene before the consequences of a person’s gambling are significantly damaging

to the individual, their family/whānau and society • intervene at an earlier stage of concern, making the intervention needed less

intrusive than might otherwise be the case • build awareness of problem gambling harm in communities and the importance of

communities’ involvement in the change process • engage people in intervention processes and increase their awareness and

recognition about the impact problem gambling has on their life.

5.9.2 Who can do a brief intervention? Even though brief interventions rely on community service involvement in screening the client base, brief interventions must be conducted by service providers who have assessment, screening and intervention skills in problem gambling. The intervention must be conducted by a provider with motivational skills and good knowledge awareness of the appropriate resources to recommend to potential clients. It is also important that the provider has a good understanding of the service delivery rules that guide the intervention processes.

5.9.3 What do I do if I screen a client in a public setting and they have a positive screen?

If you screen a client in a public setting such as an education group as part of awareness raising (see section 9.2.4) and they return a high score on the screen, it is important to find an opportunity to take the client aside and ask them if you can give them feedback on the screen results. Use motivational style feedback to encourage the client to consider making an appointment where the client can give and receive more information about their gambling and discuss its relationship with other aspects of their life. This is regarded as a full intervention session. If you cannot have a private conversation with the client at this time or the client is unsure about making an appointment, you may agree to have another brief discussion


in a week or so in a less public environment after they have had time to consider what has been discussed. Offer the client brochures and other information to read and consider further action. If the client makes an appointment for a full intervention session, open a file and ask the client to complete the appropriate screens (if they have not already done so), and complete any other assessment or engagement procedures as per usual agency policy. Note that some of the administration and completion of forms can be done by the practitioner after the session. See section 6.3 for a guide to key steps for welcoming clients to a session.


6 Full Intervention

6.1 What is a full intervention episode? A full intervention episode: • is one or more sessions in a specialist setting with people experiencing harm from

their own or someone else’s gambling • involves working with people who have to some degree acknowledged the harms

they are experiencing from gambling • involves working with people who have made some commitment to seeking support

from a specialist gambling service. A full intervention is an opportunity to work clinically with people who have been identified as experiencing gambling-related harm. This harm can be the by-product of an individual’s gambling behaviour or the negative impact of another person’s gambling behaviour. The person could also be experiencing harm from their own and someone else’s gambling behaviour, and the impact of this harm could be subject to current as well as past problem gambling experiences. You have several clinical options within a full intervention episode. You may deem that: • a full intervention need involve only the individual in assessment and counselling (full

intervention sessions) • that the client needs support to access other services for co-existing issues they

have concern with. Full intervention sessions may also be provided through group therapy. Full intervention is a complex service and represents the foundation of an intervention service. Full intervention loosely comprises five key parts: • screening (section 6.1) • full intervention episodes:

– the intervention or treatment plan (section 6.1.2) – relapse prevention (section 6.1.3) – planning for exit (section 6.1.4) – working with families/whānau and significant others (section 6.1.5).

6.1.1 Screening If you use a range of screens it ensures you formally ask about gambling harm and other associated issues, enables you to give feedback, raises the client’s awareness about the effects of the gambling, and provides information for treatment plans and a starting point from which you can measure progress.

Intervention Service Practice Requirements Handbook: Full Intervention 39

Screens are used in brief and full interventions, to identify clients who have co-existing issues and will benefit from facilitation to another service, and in follow-up episodes for measuring outcomes of the full intervention episode, and they provide an opportunity to identify further client needs.

6.1.2 Intervention or treatment plan The intervention or treatment plan is an action plan a client develops with your help. The plan comprises a series of goals that the client wants to achieve during treatment. The plan should be informed by the screens used, your feedback, the client’s motivation to change, the client’s insight and priority the client places on the specific changes they want to achieve. The plan provides a structure for the goals of the full intervention and can be reviewed during therapy for evidence of the client’s progress or the need for change or further resources, or can be added to as new insights are found. The plan is discussed in more detail in section 6.7.

6.1.3 Relapse prevention Addictions are characterised by addictive behaviours that can return to pre-treatment levels due to biological, psychological or social influences. In relapse prevention therapy, the aim is to help the client establish adaptive coping behaviours and ways of thinking that can counter risky behaviours, thoughts and beliefs. You should also support the client to learn and engage in alternative behaviours that are inconsistent or incompatible with the addictive behaviour. In problem gambling, coping behaviours include avoiding gambling environments, addressing issues such as depression that may lead to relapses, and developing social support strategies. Relapse prevention is addressed throughout a full intervention episode, particularly at its end. However, as many clients feel despondent and guilty if they relapse, it is useful to discuss relapse early on in an intervention and to normalise the feelings and concerns the client may have.

6.1.4 Planning for exit Planning for exit is about ensuring you focus on empowering the client to independence whilst remaining supportive and ensuring the client’s needs are met. Planning for exit should begin in the early stages of an intervention and be reflected through all steps of the intervention process. It addresses other problems that might lead to gambling harm, establishes and maintains post-treatment goals, and ensures the client knows they can recontact the service if the need arises. Although the number of sessions the client attends for a full intervention episode is often agreed during the development of the treatment plan, it is useful to discuss relapse with clients and to acknowledge that while you are both talking about an end-point for treatment, they can enter and exit services as often as they need.


6.1.5 Working with families/whānau and significant others Family/whānau members and others affected by another’s gambling will often accompany gambling clients to sessions or may present to a service on their own. Often family/whānau and significant others will contact a service out of concern for someone else’s gambling. Ensure that people who contact the service for someone else or attend to support someone else are aware that they could be experiencing harm from the other person’s gambling and that they can receive support independent of the gambler. When the family/whānau member or significant others is attending to support another person they may focus on the other person’s needs and not be ready or able to acknowledge their own needs. In these cases, maintain an open offer for support. Screening and occasional motivational discussion can provide opportunities for the person to engage with the idea of seeking help for themselves. Working with family and significant others requires similar processes and skills as are needed for working with problem gamblers. Your main challenges are to ensure appropriate confidentiality is maintained between multiple clients if they are all attending and to help the person focus on their own needs, rather than on those of the gambler.

6.2 Summary of full intervention service specification A full intervention consists of a set of clinical intervention sessions (an episode) that are usually completed within eight sessions and within three months of the first session. Typically, sessions are at least 60 minutes long but they can be as short as 15 minutes, which mostly occurs when contact with a client is by phone. A full intervention episode must include at least one face-to-face session. A full intervention can commence from several opportunities. • If an individual is referred to the service by way of the Gambling Helpline, where a

screening of needs has already been conducted and it has been deemed that harm has occurred, start a full intervention episode with the referred individual. A brief intervention is not appropriate in this circumstance.

• If you have conducted brief interventions in the community where screening has occurred and a person has gained insights into the harm problem gambling has caused them and wants further contact on a clinical basis, ensure you have recorded your initial contact with this person as a brief intervention. Make sure the brief intervention episode has been close and start a full intervention episode for a comprehensive assessment.

• If an individual makes direct contact with the service or has been referred to the service from a referral source and gambling-related harm has been expressed, then start a full intervention episode. A brief intervention is not appropriate in this circumstance.


• If, through the follow-up process or by way of the individual’s own initiative, the client wants to re-engagement with the service for further support (ie, after a relapse), start a new full intervention for the individual. A brief intervention is never appropriate in this circumstance, because once a full intervention has been activated for a client, a brief intervention is not applicable.

The service specification for full intervention is outlined in Table 6.2. A flowchart of typical client pathways and practitioner decisions for full interventions is in Figure 6.1.

6.2.1 Exceptions To receive ongoing support from a problem gambling intervention service clients should: • have a primary problem gambling mode (see section 4.5.3) • show signs of gambling harm (see section 6.4). If clients are identified as needing ongoing support for other health and social issues and are not experiencing harm from gambling, refer or facilitate them to an appropriate service within one to two sessions. Clients receiving support from face-to-face intervention services should have some face-to-face time with their practitioner. For a valid comprehensive assessment to be recorded, a client must have had at least one session face to face. Email and text are not valid modes for a face-to-face brief or full intervention or facilitation or follow-up services. Evidence suggests that the client–practitioner relationship is a key component of successful outcomes for clients. The Ministry of Health believes practitioners should encourage clients to attend face-to-face sessions and offer phone support when the client cannot attend a face-to-face session.


Table 6.1: Full intervention service specification description (purchase unit PGCS-03)

Outcome All people identified as experiencing gambling related harm (from their own gambling or from the gambling of a significant other) receive evidence-based interventions that reduce the gambling related harm occurring to them and their family.

Objective To provide a community-based assessment and intervention service for people with gambling related problems that aims to minimise problem gambling related harm to the service user and their family/significant others through provision of a range of psychosocial interventions.

Activities Provision of full intervention services will include implementation of an intervention plan that addresses the problems identified during comprehensive assessment and ongoing review including the service users readiness for change. Intervention services will include, but are not limited to, the following activities: •

•

•

•

•

•

•

•

screening for suicidality/homicidality assessment for gambling problems utilising tools approved by the Ministry of Health education to the service user about gambling harm and management of that harm comprehensive assessment (including alcohol and other drug use, mental health, financial and cultural variables etc) development of an intervention and relapse prevention plans interventions including psychosocial therapy, support and case management (for individuals and groups) (as outlined in the MoH revised practitioners manual) referral to relevant life skills programmes, including self-help or support groups, appropriate cultural activities/services, budgeting services, relationship counselling or other follow-up services as negotiated with the service user. (Note: This refers to simple referral only, in-depth, supported facilitation services are covered in PGCS-04.) education and planning with clients about early intervention, maintenance of health, relapse prevention, problem prevention and promotion of health.

Key processes

Services users will be able to, as a minimum, access all of the following processes described in the ‘Process Descriptions’: support, service handover, assessment, management of risk, case management, discharge planning, early identification, liaison and consultation, referral, screening, therapy services, treatment and rehabilitation.

Reporting Six monthly narrative reports to the Ministry will use the provided report template and summarise: •

•

•

•

barriers and successes over the last six month period (ie, issues with referral processes) trends and patterns in client presentations FTE employed to deliver this service over the last six-month period (noting variances and any periods of unemployment) any other relevant information.

Provided by Services will be provided by a team or person with appropriate qualifications, competencies, skills and experience in working with people with gambling problems and/or other behavioural addictions, as outlined in the revised practitioners manual.

Access Access may be from any source, including self-referral.

Minimum delivery

One FTE will deliver a minimum of 60 Full Interventions sessions (average 60 minutes each) per month.


6.2.2 Group therapy sessions Group therapy can be provided within a full intervention episode. The session type is always considered to be counselling. Facilitation is not a valid session type for group therapy sessions. Group therapy is usually up to 120 minutes in duration, commences once an individual comprehensive assessment has been completed, and can be recognised only under a full intervention episode. When the duration of group therapy is longer than 120 minutes, record the actual duration. Note that the Ministry of Health counts up to four hours per session in any one day against contracted provider targets (ie, one day equals four hours).

6.2.3 Comprehensive assessment During a full intervention, it is expected that a comprehensive assessment on gambler clients as well as on those presenting as affected family/whānau is conducted. A comprehensive assessment should be conducted by an appropriately qualified clinical practitioner who has skills and experience in working with people with gambling problems. Redo a comprehensive assessment at any point you consider it to be useful. As a guide, the Ministry of Health recommends that a comprehensive assessment is redone for any client who has not been seen by a practitioner for three months (in a full intervention session or follow-up session). Most of the screening information necessary to inform a comprehensive assessment is asked in three-, six- and 12-month follow-ups. A comprehensive assessment occurring as a result of a client’s return to full intervention from follow-up, can build on the client’s responses to these screens.

6.2.3.1 Gambling screens Several gambling screens must be completed and discussed with the client to comply with contract specifications. Screens are effective for getting a basic understanding of a client’s level of concern about problem gambling and can be used to provide feedback to the client to increase their awareness and develop an incentive for change. However, it is important to assess beyond the screens to get a complete diagnostic view of the client’s problem gambling. This can be done by gathering information from the client through conversation and other diagnostic tools and assessing how problem gambling has affected them and their family/whānau and significant others. For example, gain a history of the client’s gambling behaviour development, find out what attempts the client has made on their own to change, find out what the client’s high-risk triggers to


gambling are, and find out how much problem gambling has affected other aspects of their life such as their health, financial and cultural wellbeing. As part of the requirement for a comprehensive assessment, service providers also need to assess (by screening and using diagnostic skills and tools) other health and social areas of the client’s life that may have been affected by problem gambling. Along with the client’s perception of these issues, it is also important to look at how concerned the family/whānau have been about the client. Key issues to be assessed during comprehensive assessment include: • suicidality (section 6.2.3.2) • alcohol and other drug use (section 6.2.3.3) • depression (section 6.2.3.4).

6.2.3.2 Suicidality Comprehensive assessment includes assessing for immediate risk factors such as suicidality, any history of suicidal behaviour, and the level of social support available to the client. You may need to refer the client to other community services early in the assessment process. Suicidal ideation is common among problem gamblers and their families. A history of past suicide attempts is a strong indicator of a future risk of suicide. If a client has a suicide plan, their level of risk increases, so it is important to find out how recently they considered their plan. If you are concerned about your client’s level of risk, you may override the usual confidentiality expectations and advise the emergency Crisis Assessment and Treatment Team.

6.2.3.3 Alcohol and other drug use Comprehensive assessment includes assessing for other possible addictions, such as alcohol and other drug use, as other addictive behaviours or substance use that go undetected may impact significantly on the changes a client wants to achieve. A high percentage of people affected by problem gambling also misuse alcohol and other drugs, so it is important to identify the client’s level of alcohol consumption and types of drugs used. Explain the relevance of addressing alcohol issues alongside the client’s gambling issues as a way of helping the client to stay motivated and prevent relapse.


Alcohol and other drugs are often sold at the venue where the gambling activity occurs. If the client continues one problem behaviour while being treated for another problem behaviour, the risk of relapse increases. In addition, alcohol reduces inhibitions, so can reduce the client’s control of their gambling. Many other drugs also reduce inhibitions, enable extended gambling by maintaining the client in a high level of wakefulness (eg, methamphetamine), or may produce a chain of behaviour, that once started, ends with the client gambling. Many practitioners have skills in alcohol and other drug treatment, and these combine well with skills in problem gambling treatment to address co-existing issues.

6.2.3.4 Depression Comprehensive assessment includes assessing for depression, because up to two-thirds of problem gamblers or their families may be experiencing depression. Depression can make change difficult and can lead to increased risk of suicide.

6.2.4 Intervention planning Intervention planning is a necessary component of a comprehensive assessment. Once you have gathered all the assessment material, negotiate an action plan with the client. This plan will guide your clinical work, such as appropriate therapy initiatives and community referrals. It also becomes the basis from which you can review and modify treatment plans and determine outcome measures.

6.2.5 Missed sessions A client’s enthusiasm, motivation and commitment to addressing the issues in their lives often changes over the course of an intervention, as do their personal circumstances. For a range of reasons outside the client’s or the practitioner’s control, clients may miss sessions. Figure 6.1 clarifies the Ministry of Health’s intentions for clients who miss sessions and provides guidance for how to proceed when clients cannot be contacted.


Figure 6.1: Missed sessions and reconnecting with clients


6.2.6 Closing a full intervention episode Full intervention episodes represent the core of most clients’ intervention journey. Closing a full intervention episode represents a change in the client’s needs, progress or willingness to continue to engage with the service. While some clients may return for support many times in the future, it is important to record the end of the episode as an accurate representation of the client’s experience. The four likely outcomes from a full intervention episode are summarised in Table 6.2. In each instance, close the episode and record the appropriate discharge code.


Table 6.2: Ending full intervention episodes


A non–problem gambling client, with n o primary problem gambling mode, with other social or health issues has been facilitated to an appropriate service.

Treatment complete Do not schedule follow-up session Report on the activity as part of your six-monthly narrative report to the Ministry

A problem gambling client has received full intervention and/or facilitation sessions and has agreed they no longer need specialist support.

Treatment complete Schedule follow-up session

A problem gambling client has received some full intervention and/or facilitation sessions and has decided, against clinical judgement that they no longer need specialist support.

Treatment partially complete Schedule follow-up session

A problem gambling client has received some full intervention and/or facilitation sessions, missed a scheduled appointment and was unable to be contacted further within 90 days (three months).

Administrative Do not schedule follow-up session


Figure 6.2: Typical client pathways and practitioner decisions for full intervention



6.3 Key steps for first sessions The first sessions with clients are critical for establishing a relationship with the client, discussing their expectations and clarifying their needs. The key steps below are intended as a guideline only, and many organisations have their own protocols and processes for engaging with clients. Some clients happily identify their needs in the first session, but others want to hear more about the service and the process before they discuss personal issues. The Ministry of Health believes that for most people, these steps should be addressed early in the client’s clinical journey. The key steps the Ministry views as important to cover early are: • welcoming the client and establishing a relationship (section 6.3.1) • identifying the client’s needs and agreeing to an intervention plan (section 6.3.2).

6.3.1 Welcoming the client and establishing a relationship Early in establishing a relationship discuss: • confidentiality • the client’s expectations, including whether the client knows:

– what counselling is – how you can help them – what a typical client pathway might involve.

Concern about confidentiality is a key barrier for many new problem gambling clients. Reassure the client that their information will remain private and that they can ask to see or hold their own information at any time. This can help the client to feel safe to discuss their gambling. Another key barrier to accessing intervention services and benefiting fully from the services, is that clients do not understand what counselling is, how it can help them and what they should expect. Reassure clients that they can regain control over their gambling, and outline the typical client journey. This will help many clients understand how intervention services can help them. If the client is a family/whānau member or significant other, they may need assurance that therapy can be appropriate for them too. Even if they are attending with the gambler to provide support, they may find it valuable to see the practitioner independently of the gambler to discuss their own needs and concerns.

6.3.2 Identifying the client’s needs and agreeing to an intervention plan As your relationship with the client becomes established: • screen for gambling harm, outcomes and other co-existing issues • discuss relapse and how you will support the client • agree to an intervention plan • discuss ending the full intervention episode • agree a follow-up plan.


Screens are discussed in more depth in section 6.4. Although practitioners sometimes feel awkward introducing screens, they often help the client normalise their feelings, provide a context for the client to see the impact of gambling on their life, provide points of comparison to show progress, and indicate other issues the practitioner should be considering. Discussing relapse, agreeing an intervention plan and ending treatment are important for most clients. Normalising the concept of relapse early in the client’s journey helps to reduce the likelihood of treatment drop-out or the client’s sense of failure if relapse does occur. By beginning to agree on an intervention plan, the client gains a sense of a future without gambling and some feeling of control over their life and clarifies how the practitioner will be supporting them. Agreeing a follow-up plan as part of the intervention plan helps to maintain contact and support the client should they relapse, drop out of the service or become discouraged. It also helps to reassure the client that even though they are planning to become independent of their gambling and of treatment, you will still be in contact to support them.

6.4 Screening for full intervention The minimum screens for a full intervention episode are: • the gambling harm screen (gambler or family/affected other) (sections 6.4.1.1 and

6.4.3.1) • outcomes screens to assess change for the client (gambler or family/affected other)

and service (sections 6.4.2 and 6.4.4) • co-existing issues screens to assess other issues for the client (gambler or

family/affected other) (section 6.4.5). Comprehensive assessment involves asking the three groups of screening questions, discussing the responses and probing further as required. The gambling harm and outcome screens are different for gamblers and family/affected others. The co-existing issues questions are the same for both groups. The gambler screens are discussed in section 6.4.1 and the family/affected other screens are discussed in section 6.4.3.

Starting screening You should always start by determining whether the client is attending for assistance with their own gambling or are affected by someone else’s gambling. Rather than ask direct questions and racing from step to step, lead into an enquiry with interested concern. Remember clients will be interested in the questions you are asking and what their responses mean. Take the time to discuss the forms and explain how they can help the client (see section 6.3.2). Talking about the screens with the client will often start them thinking about the effects of gambling on their life in new ways.


Check whether the client is seeking support for their gambling or because of someone else’s gambling. • If the client is gambling, go to the Full Gambler Screen (see section 6.4.1). • If someone else is gambling, go to the Full Family Screen (see section 6.4.3).

6.4.1 Gambler screens The Ministry of Health has endorsed a screen for assessing gambling harm in a full intervention episode. This screen is the gambler harm screen. The Ministry has also selected three questions you should ask as outcome measures for clients seeking help for their own gambling. These questions are the gambler outcome screens. The gambler harm screen is described below. The gambler outcome screens are described in section 6.4.2. Instructions for the information to be entered into CLIC for each screen, is in bold and italics, for example: (record the number of positive responses to questions 1 to 4). All screens are also in full in Appendix 1.

6.4.1.1 Gambler Harm Screen For people screening for their own gambling behaviours the following screen is used for full interventions.4 The client may answer ‘never’, ‘sometimes’, ‘most of the time’, or ‘almost always’. Gambler Harm Screen (record the total score) • Thinking about the past 12 months, how often have you bet more than you could

really afford to lose? • Thinking about the past 12 months, how often have you needed to gamble with larger

amounts of money to get the same feeling of excitement? • Thinking about the past 12 months, how often have you gone back another day to try

to win back the money you lost? • Thinking about the past 12 months, how often have you borrowed money or sold

anything to get money to gamble? • Thinking about the past 12 months, how often have you felt that you might have a

problem with gambling? • Thinking about the past 12 months, how often have people criticised your betting or

told you that you had a gambling problem, regardless of whether or not you thought it was true?

4 The Gambler Harm Screen uses the Problem Gambling Severity Index, a subset of the Canadian

Problem Gambling Index.


• Thinking about the past 12 months, how often have you felt guilty about the way you gamble, or what happens when you gamble?

• Thinking about the past 12 months, how often has your gambling caused you any health problems, including stress or anxiety?

• Thinking about the past 12 months, how often has your gambling caused any financial problems for you or your household?

6.4.1.2 How is the Gambler Harm Screen scored? The Gambler Harm Screen is scored by the client’s response to each question. • Never = 0. • Sometimes = 1. • Most of the time = 2. • Almost always = 3. If a client’s total score is 3 or more, the client meets the conditions the Ministry of Health has agreed for funding full intervention services. A positive screen of 3–7 indicates moderate risk and 8–27 indicates problem gambling. If the client scores less than 3 (a negative screen), use your judgement or assess the client further.

6.4.1.3 Why is the Gambler Harm Screen used? The Gambler Harm Screen is the gateway screen for full intervention services. Deliver the screen within the parameters and guidelines detailed in the service specification and Data Management Manual. The Ministry of Health regards ongoing support for individuals who have not met the criteria for a positive screen as unusual. While the Ministry accepts that sometimes services are provided to such clients (ie, other issues are identified during comprehensive assessment), the Ministry believes such clients will be the minority of clients seeking help. The Ministry will seek clarification of such practices, if they become a significant portion of a service’s client load.

6.4.2 Gambler outcome screens As part of the comprehensive assessment, ask your clients who are receiving support for their own gambling about: • their control over their gambling (section 6.4.2.1) • the amount of money they have lost (‘dollars lost’) (section 6.4.2.2) • their annual household income (section 6.4.2.3).


6.4.2.1 Gambler Outcome-Control screen The CLIC system calls this question ‘Gambler: Outcome-Control’. Control over gambling (record the number of the response ie. 1, 2, 3, or 4) During the past month: (1) I have had complete control over my gambling Or (2) I have had some control over my gambling Or (3) I have had little control over my gambling Or (4) I have had no control over my gambling Why use the control over gambling outcome measure? The response given to the question about the client’s perceived control over their gambling provides a starting point or baseline. The question can be asked again after the full intervention treatment, and the answer may provide evidence of a positive outcome from the treatment. The response may also indicate whether your therapeutic approach is inconsistent with other evidence. For example, if the client selects ‘no control’ but describes control measures they have put in place but undervalued, you may highlight these to improve their confidence of success (since a belief in success may be an important factor in trying to or maintaining change). Alternatively, if the client is presenting under pressure, they may overestimate their control over their gambling. Your focus here may be to motivate change by making the client aware of the costs to themselves or others and reconsidering the importance of changing. A belief in the importance for change is also an important factor in even starting to change.

6.4.2.2 Dollars lost screen The CLIC system calls this question ‘Gambler: Outcome-Dollars lost’. Dollars lost (record the response ie, $5,000) In the last month when you were gambling, roughly what amount of money did you spend on gambling? This is the total amount of money in dollars that you used on your gambling activity/ies (ie, money you took to gamble with PLUS any additional money you obtained and gambled with such as from cash machines and eftpos). Ignore any money you won during your gambling sessions. Dollars spent on gambling: $...............


Why use the dollars lost outcome measure? The sum of money lost can provide a baseline for before the client participates in the full intervention treatment. When this question is asked again after treatment, the response, if lower, may indicate a positive outcome that could be due to the treatment. The question focuses on the amount spent not the money won. If the client had won a jackpot in the past month, they may have offset many of their losses. If they took this win into account, the result might be a lower amount spent than in a usual month.

6.2.4.3 Annual household income screen The CLIC system calls this question ‘Gambler: Outcome-Household income’. Approximate total annual household income (record the number of the response ie, 1, 2 ... 6, or 7) (1) < $20,000 (2) $20,000–$30,000 (3) $31,000–$50,000 (4) $51,000–$100,000 (5) $101,000–$200,000 (6) $201,000–$500,000 (7) $501,000+ Why use the annual household income outcome measure? The annual household income question helps you to estimate the financial impact of the client’s gambling. The amount of ‘dollars lost’ requires a context in which to assess the impact – a client spending $100 a week with an annual household income less than $20,000 is likely to be experiencing considerably more financial difficulty than a client spending the same amount with an annual income of more than $200,000. The answer to this question can help you to raise your client’s awareness about their gambling, If they have not previously compared their gambling losses against their disposable income. Many clients will not have calculated the weekly costs for themselves and their family that must be paid before gambling. It may help them to take advice from a budgeter in the service or to whom they can be referred, as part of their intervention plan.

6.4.3 Family/affected other screens When you are screening people for the impact of someone else’s gambling on them in a full intervention use the following screens. The Ministry of Health has endorsed two questions for assessing the gambling harm in a full intervention episode. This screen is the family/affected other harm screen (section 6.4.3.1). The Ministry has also selected two questions you should ask as outcome measures for clients seeking help for someone else’s gambling. These questions are the family/ affected other outcome screens. The family/affected other harm screen is described below. The family/affected other outcome screens are described in section 6.4.4.


Instructions for the information to be entered into CLIC for each screen, is in bold and italics, for example (record the number of the response). All screens are also in full in Appendix 1.

6.4.3.1 Family/Affected Other Harm Screen5

For screening people for the impact of another person’s gambling problem on them, use the Full Family/Affected Other Screen for full interventions. This screen is the same as the Brief Family/Affected Other Screen. The Family/Affected Other Harm Screen is made up of two questions. You will see that the CLIC system calls these questions: • Family/Other: Harm-Awareness • Family/Other: Harm-Effect

Introduction/opening statement: Sometimes someone else’s gambling can affect the health and wellbeing of others who may be concerned. The gambling behaviour is often hidden and unexpected, and its effects can be confusing, stressful and long-lasting. To help us identify if this is affecting your own wellbeing, please answer the questions below to the best of your ability.

1 Awareness of the Effect of the Gambler’s Gambling (record the number of the

response ie, 0, 1, 2, or 3) Do you think you have ever been affected by someone else’s gambling? (0) No, never (you need not continue further) (1) I don’t know for sure if their gambling affected me (2) Yes, in the past (3) Yes, that’s happening to me now





(1-5)

5 The Family/Affected Other Harm Screen is the same as the Brief Family/Affected Other Screen. The

Brief Family/Affected Other Screen uses the Concerned Others Gambling Screen that was developed by Dr Sean Sullivan of Abacus Counselling & Training Services Ltd.


3 Support Requested (response not recorded) What would you like to happen? (Tick one or more.)


6.4.3.2 Why use the Family/Affected Other Harm Screen? For information about the Family/Affected Other Harm Screen, see section 0. If a client has recently completed the screen as part of a brief intervention, discuss the client’s previous responses and current views. This provides a further opportunity for the client to consider the current effects of the gambling on them, and these may vary with further consideration between the two episodes. If the client has not completed this screen, do so now to help them to focus on the impact of the gambling and choose their options for support.

6.4.3.3 How is the Family/Affected Other Harm Screen used For information about using the Family/Affected Other Harm Screen, see section 0.

6.4.4 Family/affected other outcome screens As part of the comprehensive assessment, ask your clients seeking support for someone else’s gambling about: • the gambler’s gambling frequency (section 6.4.4.1) • how they are coping with the gamblers gambling (section 6.4.4.2) The client or you may fill in the outcomes screens.

6.4.4.1 Gambler’s gambling frequency screen The CLIC system calls this question ‘Family/Other: Outcome-Gambling Frequency’. The statements below are about the person who was gambling at the time you sought help and about you. Gambler’s gambling frequency (record the number of the response ie, 0, 1, 2, or 3) Which of these four statements is true about the person’s gambling over the past three months? (Tick ONE box only.) (0) The gambler in my life has not been gambling during the last three months. (1) The gambler in my life has been gambling less during the last three months. (2) The gambler in my life has been gambling about the same as usual during

the last three months.


(3) The gambler in my life has been gambling more than usual during the last three months.

Why is the gambler’s gambling frequency screen used? The client affected by another’s gambling may continue to be affected adversely by the gambler’s behaviour if their gambling has continued to be maintained at the same or greater level. Alternatively, the gambling may be less or not occurring at all, and improvement may be influenced more by this reduction than by the therapy. This screen assesses the gambler’s behaviour, which can be useful to discuss with the client. Changes in the gambler’s gambling levels that are not reflected in changes in other issues in the client’s life may suggest further areas requiring for support. For example, if the gambler had stopped gambling, but the client was still having relationship or financial difficulties, the answer to this screen may suggest underlying issues are emerging that were masked by the gambling or aggravated by the gambling to the point where they cannot be easily addressed. How is the gambler’s gambling frequency screen used? The gambler’s gambling frequency screen is not a measure of the gambling of another client also in (or previously in) therapy. The screen provides a context for the coping with the gambler’s gambling screen.

6.4.4.2 Coping with the gambler’s gambling screen The CLIC system calls this question ‘Family/Other: Outcome-Coping’. You can ask this screen during normal discussion with the client or over the phone, or the client can complete the screen on their own. Coping with the gambler’s gambling (record the number of the response ie, 1, 2 or 3) Which of these three statements is true about your ability to cope with the person’s gambling over the last three months? (Tick ONE box only.) (1) I am coping better with the gambler’s gambling than I have in the past. (2) I am coping about the same with the gambler’s gambling as I have in the

past. (3) I am coping worse with the gambler’s gambling than I have in the past. Why the coping with the gambler’s gambling screen is used? The coping with the gambler’s gambling screen provides an opportunity for the client to realise (and you to acknowledge) that the client’s wellbeing is not contingent on the gambler reducing their gambling and to focus on their own recovery. It is also an opportunity to discuss any non-improvement in coping and consider further therapy. How the coping with the gambler’s gambling screen is used? Interpret the client’s response to the coping with the gambler’s gambling screen alongside the gambling frequency screen. Although the client may be improving


because the gambler has reduced or stopped their gambling, they may have improved even if the gambler has not. This is an opportunity to emphasise this outcome and to demonstrate that the client’s wellbeing is independent of the gambler’s. The gambler may reduce their gambling as a result of the family member/affected other’s change in response to the gambling behaviour (eg, refusing to bail out the gambler). If you have asked the coping with the gambler’s gambling screen as part of follow-up (see section 8) and there is no improvement, offer the client the opportunity to reconnect with the service for further support; especially if the gambler has reduced their gambling, so you would expect the client to be coping better.

6.4.5 Co-existing issues screens Ask the co-existing issues screens as part of a comprehensive assessment for all clients (gamblers and family/affected others) who are in a full intervention episode. The co-existing issues questions are the minimum the Ministry of Health considers necessary in a comprehensive assessment. Questions 1–8 (below) represent a core set of questions that should be asked of all clients presenting for help. Deliver the co-existing issue questions within the parameters and guidelines in the service specification and Data Management Manual. Ask other questions and use other screens you think are clinically useful. The co-existing issues screens are listed below with an explanation of why each is important (see sections 6.4.5.1–6.4.5.5).

6.4.5.1 Alcohol use screen Alcohol use (AUDIT-C) (record the total score) One standard drink is 30 ml straight spirits (two nips/shots, one double), 330 ml can of beer or 100 ml glass of wine • How often did you have a drink containing alcohol in the past year?

(Never = 0, monthly or less = 1, two to four times a month = 2, two to three times per week = 3, four or more times a week = 4)

• How many drinks did you have on a typical day when you were drinking in the past year? (1 or 2 drinks = 0, 3 or 4 drinks = 1, 5 or 6 drinks = 2, 7 to 9 drinks = 3, 10 or more drinks = 4)

• How often did you have six or more drinks on one occasion in the past year? (Never = 0, less than monthly = 1, monthly = 2, weekly = 3, daily or almost daily = 4)

How is the alcohol use screen used? A score on the alcohol use screen of 5 or more for males or 4 or more for females indicates that the person’s use of alcohol is at a risky level and warrants an enquiry.


Why is the alcohol use screen used? Risky alcohol use can interfere with ongoing treatment attendance and maintaining reduced gambling harm once attained, and contribute to relapse. It can also be a health issue in its own right. Both problem gambling and alcohol misuse are related to depression and reduced motivation. Raising motivation to change gambling behaviour may be offset by continuing depression due to alcohol abuse. In addition, many premises selling alcohol also provide gambling, so intoxication can result in reduced inhibitions to restrain from gambling. Alcohol abuse and problem gambling together may result in more intensive problems, demotivate help-seeking, and introduce anger and violence issues to be addressed. Because of their relationship, alcohol and gambling issues may be best addressed at the same time. Tracking how the client’s alcohol abuse fits within the client’s gambling behaviour may be insightful for the client.

6.4.5.2 Drug use screen Drug use (record the code for the response No = 0, Yes = 1) In the past 12 months, have you ever felt the need to cut down on your use of prescription or other drugs? How is the drug use screen used? A ‘yes’ response to the drug use screen is a positive result, so further enquiry is appropriate. Why is the drug use screen used? Some drugs other than alcohol can become part of the gambling ‘chain’ of behaviour that can lead to problem gambling. For example, gamblers may use stimulants such as methamphetamines to stay awake or alert for longer gambling sessions. A perception of increased power and energy from many stimulants may result in controlled gambling becoming uncontrolled. Depressant drugs that also disinhibit, may contribute to excessive gambling. If continually done together, gambling and drug use may become linked behaviourally, with drug use often leading to excessive gambling. Addressing the drug use and gambling at the same time may be the best approach, either through your own service or by referring the client to a specialist alcohol and other drug service provider. Tracking how the drug use interrelates with the gambling may be insightful for the client.

6.4.5.3 Depression screen Depression (record the total number of positive responses ie, 0 = no to both, 1 or 2) • In the past 12 months, have you often felt down, depressed or hopeless? • In the past 12 months, have you often had little interest or pleasure in doing things?


How is the depression screen used? A ‘yes’ response to either depression screen question is a positive result, so further enquiry is appropriate. Why is the depression screen used? Depression is highly associated with problem gambling for gamblers and others affected by the gambler’s behaviour. Depression demotivates people and, if not addressed, clients may not believe they can change their behaviour or if they make progress, may be easily discouraged if relapses occur. Depression can arise as a result of the consequences of problem gambling, but may not abate simply because the client reduces their gambling (or if the client is a family member/affected other and the gambler has reduced their gambling). Ongoing debt, guilt and trust continue to be casualties, with the gambler no longer having gambling to provide an escape or the hope of a debt-solving win. Family losses can be substantial and the effects ongoing. Also, with symptoms of recovery from depression less clear than for drug recovery, uncertainty can persist. Some clients may have had long-term depression before their gambling, finding that gambling initially provided an effective escape from the depression (but eventually contributed to it). For these clients, stopping and reducing gambling may result in the emergence of an ongoing, unrelieved depression. Therefore, do not assume that addressing the gambling will automatically reduce the depression. Strategies to address depression include exercise, support, financial hope, new or regained social activities, an appropriate diet, appropriate sleep, and therapies using, for example, cognitively based strategies. For people with severe depression, refer them to a general practitioner for consideration of anti-depressants in addition to the approaches you are using.

6.4.5.4 Suicidality screen Suicidality (record the number of the response that best fits ie, 0, 1, 2, or 3) Within the last 12 months, have you had thoughts of self-harm or suicide? (0) No thoughts in the past 12 months. (1) Just thoughts. (2) Not only thoughts, I have also had a plan. (3) I have tried to harm myself in the past 12 months. How is the suicidality screen used? The suicidality screen establishes whether there are any concerns about suicidal ideation in those harmed by problem gambling, because a high prevalence has been identified among both gamblers and family/affected others. When clients have a suicide plan and/or have previously harmed themselves, their risk for future suicidal behaviour is heightened. If, on enquiry, you consider there is a


serious and imminent risk of suicide, you are not restricted by the Privacy Act 1993, so may disclose your concern to others outside of your service in order to reduce the risk. Discuss your concerns with others in your service. Should this level of risk arise, decide at what stage to notify others (such as the emergency Crisis Assessment and Treatment Team). When you identify a risk (even ‘just thoughts’), continue this enquiry at subsequent sessions and when clients are distressed in subsequent sessions, even if they respond ‘no’ in an assessment screening session. Why is the suicidality screen used? Suicidal thoughts are high among people affected by gambling, so enquire about them in an appropriate way. If a client has only had thoughts about suicide without making a plan or attempting suicide, this is clearly a topic for further enquiry at the assessment session and in subsequent sessions. If the client describes how they had thought they might effect the suicide (ie, they made a plan), the risk for a future attempt is heightened. Your enquiries should then cover the recency of the plan thoughts, accessibility to the means, how regularly these thoughts and plans occurred, and what support the client has should they consider putting the plan into effect. If a client has attempted suicide in the past 12 months, discussion should include any attempts before the past 12 months. Previous suicide attempts are a strong predictor of future attempts and of suicide completion. Ask if the client is receiving, or has received, support from a Crisis Assessment and Treatment Team as a result of a suicide attempt, and seek their permission to liaise with the team (and they with you) if necessary. This permission must be in writing. It is important you are engaged with the client if they are to be open with you about any escalation in their risk. Discuss with them any further support they would like if this occurs. As a practitioner, you should contact the Crisis Assessment and Treatment Team with or without your client’s support if the risk of suicide is imminent (see rule 11(2)(d) of the Health Information Privacy Code 1994).

6.4.5.5 Family/whānau concern screen Family/whānau concern (record the code for the response No = 0, Yes = 1) In the past 12 months, has anyone in your family/whānau worried about your health or wellbeing (including spiritual health)? How is the family/whānau concern screen used? A positive response to the family/whānau concern screen enables you to enquire further about any health issues (mental and physical) that the client may be receiving assistance for. It can also raise the client’s awareness about the effects the gambling may be having, including on their spiritual health. You should use the client’s response to this question as a starting point for further discussion. Why is the family/whānau concern screen used?


The health issues that your client’s family/whānau worry about may reflect underlying or co-existing issues that your client is not yet ready to acknowledge. By asking this question you have a chance to encourage the client to consider other issues they may want to address at a later date, and how their health problems may be affecting their relationships. You may find your client’s responses to this question useful when you help them agree on goals (see section 6.7.2).

6.4.6 Screening for homicidality The purchase unit specifications for full intervention refer to screening for ‘homicidality’ or the client’s intention to kill another. This occurs only rarely, so no formal screen is provided. However, should a conversation with a client raise homicidality as a possibility, and you believe the threat is real and imminent, you should, with or without your client’s support, disclose this possibility to an appropriate person to prevent or lessen the threat (see rule 11(2)(d) of the Health Information Privacy Code 1994).

6.5 Examples of full interventions

6.5.1 Case 3: Affected family member who attends with gambler Jim is a 52-year-old European man who arranged his first appointment with you for today through the Gambling Helpline. He has brought along Adele, his partner of one year who is a 42-year-old woman of Pacific and European descent, and John, his 25-year-old son, who is staying with them while on holiday. John says little during the session, and says he is there mainly to support his father. During the interview, Jim is animated and at times upset as he talks about his worsening financial situation, the time spent at home waiting and wondering where Adele is, and, on one occasion, going to the casino and finding Adele in front of a pokie machine, where she refused to talk to him. As you try to draw Adele into the conversation and ask her questions, she says she did not really want to come today, does not want to get involved in counselling and appears quite passive. She was, however, fully co-operative with filling out the Brief Gambler screens at the beginning of the session and was anxious to hear the feedback on these. Jim appears defensive and says to Adele that he just wanted her to listen to his concerns and what the practitioner says and maybe cut back a little on her spending. Jim would like to come back again, but Adele says she would rather not at this stage.


6.5.1.1 Questions After reading case 3, answer the following questions. • What forms would you use for these clients and how would you account for them

statistically? • What would you offer for Adele in feedback? • How would you approach ongoing case management for these clients?

6.5.1.2 Answers What forms would you use for these clients and how would you account for them statistically? Jim was the presenting client, so as an ‘family/affected other’ he has a file opened in his name. Jim should fill out the family/affected other harm screen and the family/affected other outcome screens. Adele is not seeking support for her gambling at this stage. If you do discuss Adele’s screening results with her you should open a brief intervention episode for Adele (see section 5). If Adele later agrees to attend full intervention sessions and seek support for her gambling (she is currently attending to support Jim) you should close Adele’s brief intervention episode (if it is still open) and open a full intervention episode. If Adele does not agree to seek help for her own gambling, but does agree to continue to attend to support Jim you should leave the brief intervention episode open for another one or two sessions. You may find that Adele is more motivated to seek support for her gambling after some time to reflect. If Jim and Adele each attend sessions on their own, each is an individual session. Ensure Jim and Adele answer the co-existing issues screen as a part of their assessments and create treatment plans. While Adele has an episode open (brief intervention or full intervention) and attends again with Jim, it is a couples session (ie, both are clients of the service and attend the same session), so make notes in both files. Cross-reference the client IDs on Client Multiple Session Forms. If Adele does not want to become a client, or has had three brief interventions (see section 5.5.2) but agrees to continue to attend to support Jim, she is not counted as an individual client. John is not counted as an individual client, unless he has individual concerns as a family member or gambler and receives an assessment and feedback in his own right. What would you offer for Adele in feedback? Adele was anxious to hear feedback but did not want to commit herself, which indicates ambivalence and contemplation. This is an excellent opportunity for you to use motivational feedback styles to raise her motivation to consider change. Give Adele feedback on her Brief Gambler Screen score and discuss any concerns she has.


How would you approach ongoing case management for these clients? Adele may respond to an opportunity to attend an individual session, as she may not want to reveal the extent of her gambling or relationship concerns with family members present. Offer her the choice of an individual session and the time for such a session. This session could be empowering and motivational for Adele.

6.5.1.3 Guiding principles A file must be opened for every individual who has a comprehensive assessment and treatment plan and therefore is a client in their own right. Ongoing notes on files must be individualised, even when the client attends a couples or family session (ie, each client must have their own file). Not everyone who attends a session needs individualised treatment or assessment. These individuals do not have files and are not accounted for in any individual statistics.

6.5.2 Case 4: Gambler with potential risk features Moana is a 32-year-old Māori woman who is separated with two children aged six and eight. She is on a social welfare benefit. Since both children have been at school, she has a lot more time on her hands than she did when they were preschoolers. Moana has been using this time to gamble at the local pub, and has found herself drinking during the day when she has lost too much money and feels guilty about not having enough money to buy things for the children any more. She has recently felt embarrassed after having to ask for a food parcel when she was broke and had no food in the house – something she thought she would never do. She said she didn’t know what she would do if she gambled her benefit away again. Moana has attended two sessions, but has just missed her third session. As you look through her notes, you see that the Gambling Helpline referral indicated that she had thought about suicide. You also recall that she was quite tearful at her first two sessions, and has not completed all the assessment forms.

6.5.2.1 Questions After reading case 4, answer the following questions. • What actions would you take now? • What feedback and support could you give Moana if she returns for further

counselling?


6.5.2.2 Answers What actions would you take now? Phone Moana to ask her if she would like to reschedule her session. This also provides you with an opportunity to check on her safety. If Moana does not have a phone, then send her a brief personal note inviting her to contact you. What feedback and support could you give Moana if she returns for further counselling? If Moana returns for further counselling, make it a priority to ensure she completes all screens, including the co-existing issues questions, and check her safety. Offer Moana the opportunity to use dedicated Māori services. The Gambling Helpline Māori call service is a good starting point. In counselling, discuss how Moana might develop an adequate support network to improve her long-term prognosis.

6.5.2.3 Guiding principles Gambling problems are associated with a high risk of suicide, so check your client’s safety as part of the comprehensive assessment. Do this as early as possible in the engagement process. In case important documentation is incomplete at the end of an appointment, make sure you have a system for identifying incomplete documentation, so you can make sure it is completed at the next session. In case a client fails to attend an appointment, make sure their contact details are specific and accurate so you can contact them. Ask your client if it would be okay for you to contact the client to see how they are going as a part of a relapse prevention process.

6.5.3 Case 5: Gambler with anonymity issues Gustav is a middle-aged man with a strong eastern European accent, who comes in off the street without an appointment, wanting to speak to someone about his gambling. You have just had an appointment cancelled, so make time to talk to him. Gustav makes it plain from the outset that he doesn’t want to commit himself to anything until he has had time to check if the service is going to be useful to him. Also, no one knows he is here and he is concerned about being on any kind of database because ‘anyone can get information from computers’. Gustav says he knows this because he spends hours daily on computers and ‘knows all the tricks’. As you talk with Gustav, it becomes clear that he has problems with his gambling on machines and the Internet and owes a lot of money on a personal loan and two credit cards. His wife appears to know nothing about this, and he says that he wants to sort everything out before she finds out about the debt.


You notice that you have spent nearly an hour with Gustav. He is prepared to come back and see you next week, but doesn’t want his name or contact details recorded.

6.5.3.1 Questions After reading case 5, answer the following questions. • What would you do about recording this session, and what feedback or information

would you give Gustav? • What documentation could you use if Gustav continues to not want his details

recorded? • What would your approach be to recording and accounting for future sessions?

6.5.3.2 Answers What would you do about recording this session, and what feedback or information would you give Gustav? Explain the Privacy Act 1993 to Gustav as it applies to gambling treatment services, and that his information would be stored in files locked away, accounted for by number, and with access only by those who have signed confidentiality forms. Tell him that no one receives information about him without his signed and informed consent. Explain that his information is anonymously added to statistics, which are then grouped together and do not identify individuals. What documentation could you use if Gustav continues to not want his details recorded? If Gustav is still concerned about the confidentiality of his details, suggest he uses a pseudonym (ie, another name) to maintain his anonymity. Explain to Gustav that if he provides some contact details it will benefit him because the agency will be able to provide better support for him. What would your approach be to recording and accounting for future sessions? The same documentation is required for future sessions, for example, the gambler harm screen and the gambler outcome-control, gambler outcome-dollars lost, and gambler outcome-household income screens. Even with a pseudonym, as long as the other details are accurate, the needs for privacy and statistics are both met.

6.5.3.3 Guiding principles All clients who are seen individually and assessed, must fill out the same relevant documentation, have an individual file, and have a unique number for all treatment presentations, regardless of the name or pseudonym they use. All clients must have their rights under the Privacy Act 1993 explained adequately and be assured that all staff are obliged to respect their rights, including the Gambling Helpline, and tell them what that entails.


To be counted against contract targets you must record the minimum data requirements for a full intervention. See the Data Management Manual for details. To be accepted as a valid client in CLIC you must record at least one primary problem gambling mode. Any work you do with clients who do not have at least one primary problem gambling mode should be reported in your six-monthly narrative reports to the Ministry.

6.5.4 Case 6: Support group encounter One night, a regular member of your women’s support group brings along two of her friends: Jenny, a 22-year-old European woman, and Suzie, a 24-year-old New Zealand-born woman of Chinese descent. At the end of the group, Jenny and Suzie say they got a lot out of the group and would like to come on a regular basis. Jenny was wondering about her gambling and agreed to fill in the Brief Gambler Screen. She wasn’t sure if she wanted counselling yet, but wanted to engage with the service as a group member anyway. Suzie filled out the Brief Gambler Screen and scored zero. You talk to Suzie about her screen score and she tells you that she plays lotto every now and then. You discuss Suzie’s gambling further and assess her gambling as low risk and note that you did not identify a primary problem gambling mode. Suzie does acknowledge that she was always arguing about money with her family. Her concerns were financial problems and strained relationships because of her high spending and the lies she told to keep her family from finding out her true financial situation. She said she felt that all her problems were the same as those of others in the group, and she wanted counselling with you as well as group sessions, as she felt desperate.

6.5.4.1 Questions After reading case 6, answer the following questions. • What feedback would you give to Jenny? • How would you count Jenny statistically for the week? • What forms are most appropriate for Jenny? • How would you account for Suzie? • What feedback and information would you offer Suzie?

6.5.4.2 Answers What feedback would you give to Jenny? Give feedback to Jenny in a motivational style about what the results of her screen score and motivate her to undertake further assessment and counselling.


How would you count Jenny statistically for the week? If Jenny had personalised feedback of 15 minutes or more about her screen results, open a brief episode with Jenny as a brief intervention client. If Jenny decides afterwards to have more help, close her brief intervention episode and start a full intervention episode for her. At your first full intervention session with Jenny you will begin a comprehensive assessment. If Jenny does not agree to receive individual support, she cannot be counted as a client attending group therapy. You need to complete a comprehensive assessment with Jenny before she can start group therapy (see section 6.2.3). Note that not all groups are considered group therapy. What forms are most appropriate for Jenny? If Jenny: • had personalised feedback of 15 minutes or more and did a screen, open a brief

episode using a Client Form • had her brief intervention episode closed and was moved to full intervention, use a

Client Multiple Sessions Form • attends the group, enter her subsequent group attendances on a Group Therapy

Session Form under her client ID. How would you account for Suzie? Suzie does not have primary problem gambling mode (see section 4.5.3). You cannot record work with people who do not have a primary problem gambling mode in CLIC. You should record your work with Suzie in your six month narrative report to the Ministry of Health. What feedback and information would you offer Suzie? Feedback to Suzie that although she may have a problem with compulsive spending and needs help, she does not meet the criteria to be counselled as a gambling client. The options for her include referral to budgeting services, alternative counselling services and other women’s groups. It would also be prudent to check out safety issues by asking her the co-existing issues questions. When a client does not have a positive gambling screen, but does have a positive co-existing issues screen, the Ministry of Health expects the problem gambling service to facilitate the client’s access to an appropriate service within one or two sessions. You will have to report on any further time spent work with Suzie (facilitation) in your six-monthly narrative report to the Ministry as Suzie does not have a primary problem gambling mode and cannot be recorded in CLIC.

6.5.4.3 Guiding principles Group members are not ‘clients’ until they receive individualised assessment and treatment in their own right.


Brief and full intervention screens provide criteria against which to measure whether prospective clients are appropriate for the service. If a person does not meet these criteria, their needs may be better met elsewhere than a gambling treatment service. You should give appropriate advice, make a referral, or if necessary facilitate access to an appropriate service within 1 or 2 sessions.


6.6.1 When should I introduce the gambling assessment screens? It is primarily a matter of your own working style and preference when you introduce the gambling assessment screens. If you introduce the screens at the beginning of the first session, you can interpret and discuss your client’s answers with the client during that session. If you introduce the screens at the end of the session, you can first build your relationship with the client before asking for their involvement in filling out forms. This is also advantageous if you need to help the client with the forms because of their literacy problems. If you leave the screens until a subsequent session, you risk the forms not being completed if the client does not return for further sessions. The screens and other instruments are necessary for generating the data the Ministry of Health requires. The Ministry also requires a comprehensive assessment to be completed within the first three sessions of a full intervention episode. The screens do not make up a comprehensive assessment on their own, but they do allow you to check for other problems and potential co-existing addictions and mental health problems. This is necessary in order for the treatment plan to address the impacts on the client’s life and functioning from, not only the gambling, but also the interaction of the gambling with other factors. A full intervention episode requires that a comprehensive assessment is completed during the episode; otherwise, it is flagged in the CLIC Data Quality Report under Errors and Warnings. This is generated when you complete the ‘Comprehensive assessment completed in this session’ yes/no box. The warning is activated if no assessment has been done by three sessions into a full intervention episode. You must have at least one face-to-face session with a client to complete a comprehensive assessment.

6.6.2 How do I explain to clients the purpose of these screens? Highlight to the client that the screens are to help you work with them and to gain a greater understanding of their situation, and that you will provide them with feedback on the outcome of the screens. It can be helpful to also highlight to your client that the information from the screens contributes (anonymously) to an annual data set, which raises the profile of gambling problems in New Zealand. This may contribute to further prevention and treatment resources, thereby helping others affected by problem gambling. When clients are receiving a free service, they may feel that offering something back is positive.


6.6.3 What happens if a client has a zero score on the Gambler Harm Screen? If a client has a zero score on the Gambler Harm Screen, further assessment is required, particularly as the screen only focuses on the past 12 months. It may be that the client has had control of their gambling for some time, but is now feeling at risk of gambling again, and that they are losing control and require an intervention. It may also be that the client is more appropriately seen as a family member/significant other, rather than as a problem gambler, so needs to fill in the family/affected other screen. If the client does not have a gambling problem, they do not qualify as a gambling client for ongoing support. Refer or facilitate this client to an appropriate service to meet any needs identified in the assessment. It is ethical and best practice to ensure that clients seeking assistance are supported to receive the appropriate support. For more details about facilitation, see section 7. For details about the Ministry of Health’s expectation for facilitating clients with a nil problem gambling harm score, see section 7.7.3.

6.6.4 What do I do if a client will not provide details for the screens? Clients can choose a pseudonym, although this may mean that follow-up is more difficult, so discuss this with the client. The client may be willing to offer the correct details once you have established trust . Screens should still be completed and a file opened under the pseudonym.

6.6.5 Can I ask just the screening questions I think are useful? While it can sometimes seem that the information collected at assessment is primarily for data collection purposes, each individual question does have clinical significance. This information can be used in a counselling session to identify and prioritise particular areas for dealing with, and it is also useful for the client to understand the connection between the questions being asked and what the plan following on from the initial assessment will be. Also, clients often get therapeutic value out of understanding where their experience sits on a screening tool that can be scored. Even though the score is often just used as a guide, it can help a client put into perspective their experience in relation to others that have been negatively affected by problem gambling. If not all the questions are asked, the screen cannot determine the level of the problem.

6.6.6 Who is my client when a client brings family or other people? Your client is always the person or people who have been negatively affected by problem gambling and have been individually assessed. If a problem gambling client brings to a session their partner as a significant other and the partner fills in the appropriate screens, agrees to discuss their results with you, and they indicate harm arising from gambling, they too become a client who is registered and identified on a Client Form.


However, if this same problem gambler and the partner come to a family session with their eight-year-old son, the son is not registered as a client because the minimum age for a client is 14. On the Client Form, the primary client whose ID appears at the top of the form is most likely the problem gambler. The partner’s client ID is entered under ‘Other Client IDs attending’ and the son is identified only as a family session attendee.

6.6.7 What if some of my clients need more than eight sessions? The Ministry of Health expects a full intervention episode to usually be completed within eight sessions and within three months of the first session. Evaluate the need for extended sessions based on intervention planning and outcome measure achievements. If co-existing issues are evident, then refer and if necessary facilitate the client to appropriate services.

6.7 Intervention planning During a comprehensive assessment, clients (problem gamblers or family/affected others) may identify a range of issues they would like assistance with. Negotiate an intervention plan with the client based on the needs that have been revealed through the comprehensive assessment. This plan forms the agreed basis by which a provider and client will work together and the parameters that will be used to judge the treatment’s successfulness. It is through intervention planning that a client learns the importance of relapse prevention. The more following through with a plan leads to positive outcomes, the more the client will learn they can limit their risk of relapse. By creating an intervention plan early in the process of clinical engagement with a client, the plan becomes the focal point which the clinical relationship revisits and modifies as needed. This often happens when the client meets goals or is addressing setbacks. The following strategies may assist with: • intervention and referral planning (section 6.7.1) • committing to goals (section 6.7.2) • reviewing progress and discharge planning (section 6.7.3). Modify these strategies as you need to.

6.7.1 Intervention and referral planning Seven ‘general’ items are listed below. Invite the client to tick those items they would like to address. Approaches to dealing with the issues identified are varied and depend on the size of your organisation (eg, larger organisations may have specialist practitioners who can address particular items), the existing skills of, or enthusiasm to up-skill, its practitioners, and the availability of these resources outside the provider organisation.


You should ensure your organisation establishes and fosters a contact person in each organisation mentioned below to create effective pathways for your clients in the future. General items I would also like help with (tick any items)

Budgeting or financial advice Assistance regarding legal matters Assistance regarding housing Assistance regarding employment matters Help with Work & Income assistance Help with family/relationship matters General health matters

Also, I would like to (tick as appropriate)

Be given information about support groups (ie, Gamblers Anonymous or GamAnon)

Involve my family or support person in my counselling Join a group as well as individual counselling

6.7.1.1 Budgeting or financial advice Budgeting assistance can require comprehensive and time-consuming attention. Overall, a range of matters fall in this category. • Assisting with budgeting in order to increase the client’s awareness of the level of

disposable income available for (controlled) gambling where gambling problems may be moderate.

• Budgeting to address accumulated debt, including assistance with negotiations with creditors (this is for more severe problem gamblers and family clients)

• Strategies to avoid ‘blowing the budget’ through gambling or other means. • Addressing skewed thoughts around gambling risk or the resolution of financial

problems through further gambling. • Advice about insolvency or bankruptcy (also addressed under legal matters in section

6.7.1.2). • Assistance with benefits and allowances (also addressed under Work and Income

assistance in section 6.7.1.5). Some of these matters may be addressed by budget advisors visiting a provider’s service on a structured basis. This is especially useful when ‘full budgeting’ appears to be needed, for example, when the service holds the client’s benefit or wages in a trust account for so the client can experience respite from uncontrolled gambling and family members are protected from poverty.


It is possible that many of the issues listed above will arise in counselling, and you may need to have a wide knowledge to motivate clients to refer to specialist budgeting services, even if the service is provided within your organisation or building. Identify which approach is appropriate for your organisation, what arrangements are available for budgeting services to provide at least an onsite introduction to their services to maximise referral completion, or whether a practitioner with skills or interest in this area of work is willing to specialise in providing budgeting and financial advice for the organisation.

6.7.1.2 Legal assistance Problem gamblers and their families are often affected by legal issues, which may be civil or, in the case of the gambler, criminal. It is estimated that 60 percent of problem gamblers will be illegally obtaining gambling money, and their help-seeking may largely be a result of escalating or crisis legal issues. Legal issues are complex and it is not expected that you become a legal expert. However, some knowledge about how to access help, costs and debt recovery from gambler’s families can help to reduce stress and, therefore, harm, encourage continued attendance at counselling, and avoid relapse. Some lawyers provide legal aid services. They can be identified by the district law society, legal aid service (the District Court has their contact numbers), or Citizens Advice Bureaux. Often, a local Citizens Advice Bureau will have a lawyer available in evenings for one-to-one advice and referral and will know the legal aid lawyers available. Legal aid committees also provide money for legal assessments that may reduce a sentence, pending a person’s sentencing on serious criminal charges. However, many lawyers appear not to access this for their clients, possibly because they are unaware of this option. Clients may be under pressure from civil claims such as for outstanding rent, and the client may have to attend the District Court for an examination as to their financial means. Clients may not be aware that courts will not impose payment schedules where these are beyond the client’s means, but that honesty and support from a practitioner or budgeter may substantially reduce the stress of the situation. Clients may be on the edge of insolvency or bankruptcy when they present to your service. Insolvency is when a person is unable to pay their debts as they fall due. Bankruptcy is a legal process that enables a client to get relief from the burden of debt that they cannot repay, despite their best efforts. Bankruptcy is generally regarded as a protective measure, rather than a punishment, but the bankrupt person will face a number of restrictions and limitations on what they can and cannot do for three years after being declared bankrupt. You should always make sure that a client receives specialist financial and legal advice before considering bankruptcy.


6.7.1.3 Housing assistance Contact your Housing New Zealand regional office or council office about available housing. Social services such as the Salvation Army may also be able to help. In many cases, these enquiries will accompany a request to Work and Income New Zealand for financial assistance (see section 6.7.1.5). Work and Income may also be able to assist with accommodation, especially if it can assure the landlord that the rent will be paid.

6.7.1.4 Employment assistance Work and Income New Zealand (see also section 6.7.1.5) is the primary source for jobs, but clients may be seeking advice about retraining or upskilling in order to attain a goal that has appeared unattainable in the past and contributed towards compensatory gambling. Advice about how to attain a goal, but particularly motivation to attain the desired goal and to avoid self-limiting thoughts when barriers arise, may be important in counselling.

6.7.1.5 Work and Income New Zealand assistance Many clients do not wish to disclose to Work and Income New Zealand their gambling issues, because they fear their benefit will be cancelled. Work and Income is becoming aware that many problem gamblers (or their families) are being affected by their inability to retain their money. Strategies include paying welfare benefits into safer accounts, replacing money lost in gambling (provided steps are take to reduce the reoccurrence of this), and waiving stand-down periods when jobs end as a result of problem gambling. Contact your local Work and Income office and identify a contact person who understands the situation, and can help to avoid possible misunderstandings when the rest of the service is unaware that problem gambling is an issue for a person.

6.7.1.6 Help with family and relationship issues Poor relationships arising from deceit can be a barrier to family support for problem gamblers (if this is a goal for them). Many practitioners are able to address family issues and provide conjoint counselling.

6.7.1.7 General health matters Health problems can contribute to problem gambling. Many health issues, especially if ongoing, can result in increased stress with the gambler finding an escape through gambling. Unless health problems are disclosed, you may be unaware of a barrier to your client’s recovery. Many ongoing health problems can be helped by the client joining social support organisations, for example, Diabetes New Zealand. If you know about these problems, strategies can be designed that account for any limitations and minimise the risk of the client becoming demotivated through failing to meet goals that have been set too high.


6.7.1.8 Information about support groups While support groups are not right for all clients, many do find them useful for socialisation and ongoing support. GamAnon is a support group for family/affected others who have been affected by someone else’s gambling. Further information on GamAnon can be found at www.gam-anon.org Gamblers Anonymous is a support group for people who have experienced harm from their own gambling. Further information on Gamblers Anonymous can be found at www.gamblersanonymous.org/ You may find that the strong medical nature of the 12-step model used by Gamblers Anonymous does not suit all of your clients. Gamblers Anonymous takes the view that ‘compulsive’ gambling is a disease for life and that controlled gambling is unacceptable and reflects a person’s denial of the risks and costs of their gambling. Some clients find the spiritual approach of Gamblers Anonymous of calling on a ‘higher power’ too religious (although it is less emphasised than in Alcoholics Anonymous). Other clients are uncomfortable disclosing their thoughts and behaviours in a group setting. However, Gamblers Anonymous does provide ongoing support and socialisation for often isolated problem gamblers, and GamAnon can provide understanding for family members who often have to be secretive about the problem gambling to others. Some gamblers do not adhere to Gamblers Anonymous 12-step process, attending the meetings just for support. However, other gamblers appear able to work with the Gamblers Anonymous abstinence model, while also following the common practitioner–client approach of harm reduction. You can access a list of current Gamblers Anonymous and GamAnon meetings from Gambling Helpline.

6.7.1.9 Involving family or support person in counselling Offer clients the opportunity to involve their family or a support person in their counselling. This can occur in two ways: the support person may attend some or all sessions at the election of the client, or the family/support person can be the person who is contacted in the follow-up sessions to independently confirm (or otherwise) the client’s progress (see also section 6.7.2.2).

6.7.1.10 Joining a group as well as individual counselling Although in the United States it is common for clients to attend group therapy then individual counselling, in New Zealand it is often the reverse. Many clients are averse to disclosing their issues to strangers, and behave in ways that isolate them from the group and show their discomfort, when numbers exceed more than one or two.


http://www.gam-anon.org/

http://www.gam-anon.org/

http://www.gamblersanonymous.org/

Group therapy can help to socialise gamblers and support family members (separately), but may be more attractive to family members. Gamblers may prefer to attend group therapy later in their treatment, especially if their practitioner is present as the facilitator. Group therapy can encourage honesty and allow the client to practise new behaviours, receive support not obtainable elsewhere, and take on board the experiences of others to assist their own learning and help them avoid negative incidents and experiences of their own.

6.7.2 Committing to goals Although clients may use a range of methods to represent their commitment to recovery, the two steps that have been found to be particularly useful in other addiction settings are: • having an agreed intervention plan • nominating someone else to be involved.

6.7.2.1 Having an agreed intervention plan The formalisation of goals is essentially the agreed intervention plan, which includes attending treatment sessions and following feedback from practitioners and strategies. In addition, both the client and practitioner sign the plan, indicating substance and structure, something gamblers have often lost in the past. The process is client-centred, with prompts provided about possible goals, but essentially it allows the client to elect their own goals. Regular reviews of these goals are set to acknowledge the client’s progress or to renew the client’s motivation when they have not achieved the goals. Two sample intervention plans are in the Appendix, one for clients seeking support for their own gambling and one for family/affected other clients (see Appendix 2).

6.7.2.2 Nominating someone else to be involved The option of nominating someone else to be involved is provided to enhance the assessment of the treatment outcome. This option is more applicable to gamblers, although family members can also benefit. The client chooses this person. Clients are often uncertain about the effectiveness of change, especially when many problems persist following treatment: creditors may still exist, depression may be slow to rise, and trust for the gambler may not be forthcoming. The opinion of someone who has some insight into the person’s behaviour or condition before treatment as well as after treatment can be positive for the client and the practitioner. The client may agree to this nomination and sign their consent on the intervention plan.


6.7.3 Reviewing progress and planning to end the episode It is important not only to discuss progress during the full intervention, but also to discuss ending the full intervention episode and when this should occur.

6.7.3.1 Review assessment When you end a client’s full intervention episode you should give the client an opportunity to briefly assess their own progress and the quality of the assistance that the service has provided to them. Use the feedback the client gives you to confirm you are providing a quality service or to identify aspects for improvement. This also provides, in part, evidence of treatment outcome. Services can establish processes to regularly review these findings for improvements and to confirm the effectiveness of their treatment goals. These findings are retained by the service. It is important for practitioners and clients to obtain an overall view of the client’s perspective about achieving their goals, and whether the treatment service is meeting the client’s needs. Ask about possible improvements to service delivery. Remember to provide feedback too, as many clients may under-describe their achievements. Ask the nominated person about their view of the client’s progress. Review forms are provided in Appendix 3 for: • clients presenting for their own gambling to reflect their progress (see Review tools:

The gambler • family/affected other clients to reflect their progress (see Review tools:

Family/affected other) • the practitioner to reflect on the clients progress (see Review tools: Practitioner) • any support people to reflect on the clients progress (see Review tools: Support

person).


7 Facilitation

7.1 What is facilitation? Facilitation: • is one or more sessions within a full intervention episode actively supporting people

experiencing harm to access specialist mental health, alcohol and other drug, or social services

• involves working with an agency or service other than the specialist problem gambling intervention service

• involves working one to one with people who have to some degree acknowledged the harms they are experiencing from their own or another’s gambling

• involves working with people who have made some commitment to seeking support from a specialist gambling service

• is not a valid session type for group therapy.

7.2 Summary of facilitation Facilitation is an opportunity to assist clients, both problem gamblers and affected others, to access other community services as part of their change process. A comprehensive assessment will most likely reveal other issues and needs that need to be addressed. Clients experiencing harm from their own or other people’s gambling often have other problems in their lives. Client’s mental health, alcohol and other drug, or social service needs may exist separately from the gambling or be a result of the gambling. Either way, the Ministry of Health believes significant health outcomes can be achieved by ensuring people receive support for any issues a health professional identifies. The key concept behind the facilitation service is that the problem gambling practitioner may not have the skills or capacity to provide ongoing support or the complex skills required to address co-existing issues. However, the practitioner should have the skills to support people to access other services. Clients often slip through the cracks between services during referrals. Therefore, the facilitation service is designed to actively support people to engage with other services, not just to advise them that another service is available. This may include: • supporting the client to make first contact with another agency • arranging for other services to be available within the problem gambling intervention

service venue • attending initial consultations and meetings with the allied service • discussing the client’s progress with addressing their other issues and providing

motivational support, if required, as a normal part of a full intervention episode.

Intervention Service Practice Requirements Handbook: Facilitation 79

The defining feature of a facilitation session is that it involves both the client and another agency. Activities that do not involve both these parties are not valid facilitation sessions, for example, writing court or probation reports or general practitioner reports. The Ministry believes that this type of work should be encompassed within the practitioner’s non-clinical workload. The Ministry also notes that some types of reports are paid for by other services or, in some instances, by clients. Providers should ensure that work funded by other services is not delivered as part of Ministry-funded problem gambling services.

7.2.1 Court sessions Supporting clients to attend court sessions is a form of facilitation that can be particularly time-consuming. Attending a court session with a client may use up a large portion of practitioners day (eg, if the client has a noon court session they need to present at 9 am). The Ministry of Health accepts that attending with the client can often involve a range of therapeutic work and support and can help build the relationship with the client. The Ministry accepts that facilitation is valid in situations where the court appearance is related to gambling (eg, gambling-motivated or -related theft, fraud or domestic violence). However, the Ministry will count only up to four hours per facilitation session in any one day against contracted provider targets.

7.2.2 Relationships with other services The facilitation service needs to have relationships with other services. The problem gambling service may need to develop memoranda of understanding or relationship agreements with other services that outline how they will engage, share information and develop joint client management protocols. The Ministry of Health is aware that sometimes clients may raise concerns about another agency’s service delivery when discussing barriers to their accessing services. The Ministry expects that for the most part these concerns can be addressed through relationship agreements with the services in question. Where ongoing and high-risk issues emerge, the Ministry should be advised directly.

7.3 Rationale for facilitation Many people put off seeking help for their gambling until they can no longer cope with their problems on their own. By the time someone does seek help they are often dealing with a range of other problems and issues. Section 6.4.5 discussed screening for a small range of co-existing issues. Section 6.7.1 discussed a range of other needs clients may have related to their gambling.


While practitioners can support clients with many of the issues they relating to their gambling, some problems will require specialist services, or may be unrelated to the client’s gambling. In many cases you will refer a client to an appropriate service, provide some motivation to attend and the client will successfully access the other service. However, the Ministry is aware that many clients drop out of the health system when they are referred to another service. The Ministry developed the facilitation service specification to recognise the importance of actively supporting clients to access other services they need for recovery. It is important to remember that facilitation may be required at any point in the client’s full intervention episode. You will likely identify some issues early on in the episode; others may only be identified towards the end of the episode or even later during follow-up. Although it seems logical that changing problem gambling behaviour should bring positive influences into other aspects of a person’s life, this is not always the case. Sometimes, addressing the initial presenting issues unexpectedly exacerbates or highlights the consequences of other problems. People often have few strategies to cope with these unexpected consequences. When this happens, clients become at risk of returning to their old ways of coping, which often means reverting to their problem gambling behaviours. Identifying these potential vulnerabilities during assessment and setting goals with the client during intervention and relapse prevention planning, to connect with other resources that will help minimise the risks. Some clients many need a facilitated referral to more intensive problem gambling interventions or the inclusion of additional social supports, such as the Gambling Helpline, Gamblers Anonymous or budgeting services.

7.4 Summary of the facilitation service specification To count a facilitation activity, a service provider needs to have had at least a 15 minute or more phone call or face-to-face contact with the client and another provider or external agency as specified in the client’s agreed referral plan. Facilitation and support access can be to relevant life-skills programmes, cultural activities and services, social and budgeting services, relationship counselling and other problem gambling services including the Gambling Helpline. In some cases assisting with a formal referral process on behalf of the client may be required. Problem gambling services providing facilitation services should continue to review and support problem gambling clients for referred or facilitated issues for 12 months following their last full intervention episode as part of follow-up services. If a client does not have a positive score on a gambling screen, but does have a positive screen on a co-existing issues question, the Ministry of Health expects the problem gambling service to facilitate the client’s access to an appropriate service. This should be carried out within one or two facilitation sessions under a full intervention episode. No follow-up support or responsibility for care should be provided once the full intervention episode has been closed.


Note that the Data Management Manual criteria for sessions and episodes do not allow sessions to be recorded when the individual does not have a primary problem gambling mode. Providers should record and report facilitation sessions with clients who do not have a primary problem gambling mode in their six-monthly narrative report to the Ministry. The service specification for facilitation is outlined in Table 7.1. A flowchart of typical client pathways to and from facilitation services in Figure 6.2. Table 7.1: Facilitation service specification description (purchase unit PGCS-04)

Outcome All people identified as experiencing gambling related harm (from their own gambling or from the gambling of a significant other) are able to access relevant services that assist them to reduce the gambling related and associated harms occurring to them and their family.

Objective To minimise gambling related harm to individuals and their families/significant others through facilitation to health and social services

Activities Provision of facilitation services will include the development of a referral plan that addresses the problems identified during brief or comprehensive assessment and ongoing review, by facilitating access to a range of allied health and social services and problem gambling psychosocial intervention services. Facilitation services will maintain responsibility for client care until 12 months following service exit. Facilitation services will include, but are not limited to, the following activities: •

•

•

•

•

establishment of formal referral and relationship protocols with those services being utilised (including accountability for access, case management, exit processes, follow-up and information sharing). development of referral plans. facilitate and support access to relevant life skills programmes, including self-help or support groups, cultural activities/services, budgeting services, relationship counselling or other follow-up services as negotiated with the service user facilitate and support access to problem gambling full intervention services including the Helpline. education in relation to early intervention, maintenance of health, relapse prevention, problem prevention and promotion of health.

Key processes

Services users will be able to, as a minimum, access all of the following processes described in the ‘Process Descriptions’: support, service handover, case management, discharge planning, liaison and consultation, referral

Reporting Six monthly narrative reports to the Ministry will use the provided report template and summarise: •

•

•

•

barriers and successes over the last six month period (ie, issues with referral processes) trends and patterns in client presentations FTE employed to deliver this service over the last six month period (noting variances and any periods of unemployment) any other relevant information.

Provided by

Services will be provided by a team or person with appropriate qualifications, competencies, skills and experience in working with people with gambling problems and/or other behavioural addictions, as outlined in the revised practitioners manual.


Access Access will be from brief or full intervention services. The service will be community-based with the delivery setting reflecting the needs of the particular community. The service should be flexible in its hours to accommodate the needs of the service users (eg, evenings or weekends).

Minimum delivery

One FTE will deliver a minimum of 60 facilitation sessions (average 60 minutes each) per month.

7.5 Examples of facilitation

7.5.1 Case 7: Gambling client Louise came to the service for support after her marriage broke up following financial problems and the loss of her job. She had been playing the pokies over a nine-month period. Louise stopped gambling completely about two weeks before her first appointment. As part of the comprehensive assessment you consider Louise’s financial debts and mental health status, especially as she has lost her job and her marriage has ended due to the gambling. Louise acknowledges that she is having financial problems and is feeling down about her circumstances even though she is feeling confident that she won’t go back to gambling. As part of intervention and referral planning, you speak to Louise about considering contact with a budgeting service that other clients have had good outcomes with. You tell her you know one of the budgeters well and that that person has a good understanding of problem gambling issues. You also say you think it might be a good idea for her to see her doctor, with whom she says she has a good relationship, to discuss the levels of depression that you pick up from the screening. Louise agrees to contact budgeting services to make an appointment to see a budgeter. Louise also agrees to see her doctor. Louise meets with her doctor who then asks if you could meet with him and Louise together. You attend a half-hour session with Louise and her doctor and discuss Louise’s gambling and other issues. Louise agrees to your sharing her case notes with her doctor and for her doctor to discuss issues related to her depression with you. You spend time signing consent forms for this purpose. At your next session with Louise, you ask her how the appointment with the budgeting service went. Louise tells you she had made the appointment but felt silly telling someone she couldn’t manage her money, so she didn’t go. You discuss Louise’s feelings and agree that she will make another appointment with the budgeting service and you will attend with her for support. You and Louise go to the budgeting service and spend an hour with the budgeter and Louise.


Later, Louise’s doctor calls you with an update on Louise’s depression and the treatment he has recommended. You discuss Louise’s case with the doctor for about 20 minutes.

7.5.1.1 Questions After reading case 7, answer the following question. • How would we account for the contact details with Louise in the statistical

requirements?

7.5.1.2 Answers How would we account for the contact details with Louise in the statistical requirements? Louise is registered as a client under a full intervention episode. The time you spend completing assessment and intervention requirements is designated as assessment. The time you spend talking to Louise about referral planning and making contact with external agents on her behalf is still part of the full intervention. Record this time in the same way as you would record any other counselling session. Facilitation is recorded when you spend time with the client and a third party agency. Therefore, you: • count all of the time you spend with Louise on her own as full intervention sessions • count the half hour you spent with Louise and her doctor and the one hour with

Louise and the budgeting service as facilitation sessions • do not count the 20 minutes you spent talking with Louise’s doctor, as it is not

counted against clinical targets.

7.5.1.3 Guiding principles Facilitation is a different activity to assessment in a full intervention episode. It requires that a referral plan has been generated as a result of discussions with the client, consents have been signed, and the service provider is actively engaged in the referral with both the external agents and the client. Facilitation plans should be monitored and reviewed in the same way as the intervention plan is.

7.5.2 Case 8: Suzie (from case 6) revisited Suzie was one of the women who showed up with a group member to sit in on the group in case 6 (see section 6.5.4). She filled out a brief gambler screen and scored zero, but pointed out she was always arguing about money with her family.


Suzie’s concerns were financial problems and strained relationships because of her high spending and the lies she told to keep her family from finding out her true financial situation. She said all her problems were the same as those of others in the group, and she wanted counselling with you as well as group sessions, because she felt desperate. Suzie did not identify a primary problem gambling mode.

7.5.2.1 Questions After reading case 8, answer the following questions. • How would you account for the contact with Suzie in the statistical requirements? • What could we do for Suzie in the way of interventions?

7.5.2.2 Answers How would you account for the contact with Suzie in the statistical requirements? What could we do for Suzie in the way of interventions? When Suzie was screened using the Brief Gambler Screen you could have counted for her contact under a brief intervention. Because she had a nil score she does not qualify for ongoing problem gambling intervention. However, you identified that Suzie was experiencing high levels of stress and anxiety. As a result of Suzie’s discussion with you that focused on co-existing issues, in which her finances were causing her many problems, you felt that facilitation services should be provided. Suzie said she was feeling desperate, so screening for depression and suicidality may also be appropriate. Suzie said she was keen to be seen by you individually and be part of the group, so she would most likely be willing to come back for an appointment with you so you could further assess the co-existing issues. The time at group might not be appropriate to screen those concerns thoroughly. At that appointment you would assess co-existing issues, get the minimum data required to count against contract targets (see the Data Management Manual) and plan appropriate referrals, which might include referrals to a budgeting service and possibly a general practitioner or mental health service. When Suzie is unsure about a service or unwilling to make contact on her own, you can offer to support her to make contact until she has established a relationship with the other agency. You should try and complete this within one or two sessions. As Suzie does not have a primary problem gambling mode you cannot record your work with her in CLIC. You should report on your work with Suzie in your six-monthly narrative report to the Ministry.

7.5.2.3 Guiding principles A person scoring zero on a problem gambling harm screen still provides a service provider with an opportunity to work with the individual by assessing them for co-existing issues and doing referral planning to support the client to access appropriate community, health or social services. As the person is not experiencing gambling harm facilitation should be completed within one or two sessions.


People you work with who do not have a primary problem gambling mode cannot be recorded in CLIC. You should report on your work with these people in your six monthly narrative report to the Ministry. Not all clients need facilitation to other services, sometimes you will only need to make a referral. Facilitation is designed for people who need additional support. People may not always select the right service when reach out for help, but they should never be made to feel they have made a mistake by trying to get help. It is the service provider’s responsibility to ensure staff have the skills to appropriately screen, acknowledge the concerns presented and facilitate the individual to the right services for help.

7.6 Recommendations for facilitation planning Facilitation most commonly occurs after a comprehensive assessment and additional areas of support have been identified. Sometimes practitioners will be engaging in a brief screen and become aware of safety or other risk issues for the client or their family. In these instances, the practitioner should directly support the client or their family to access the relevant services, regardless of the client’s brief gambling screen score. Note that the criteria in the Data Management Manual for a session and an episode do not allow for sessions to be recorded when the individual does not have a primary problem gambling mode. Providers should record and report on facilitation sessions with clients who do not have a primary problem gambling mode in their six-monthly narrative report to the Ministry of Health. Note that the Ministry regards ongoing support for individuals who have not met the criteria for a positive screen as unusual. While the Ministry accepts that sometimes services are provided to such clients, the Ministry believes such clients will be the minority of clients seeking help. The Ministry will seek clarification of such practices (ie, multiple facilitation sessions for clients who have not had a positive brief or full intervention screen), if they become a significant portion of a service’s client load. Facilitation does not require any specific minimum screens. However, facilitation is just as vital a component of the full intervention process as is screening, conducting a comprehensive assessment and intervention planning. Due to the potential benefits from offering facilitation services to a client, it is important that a service provider engages in a negotiated intervention planning process with a client as part of the assessment so referral planning can be considered. It is important for problem gambling service providers to be well acquainted with the variety of community services available in their area, so that the referral process is as seamless as possible for the client. Service providers should become familiar with key staff in community agencies who can be contacted directly if a referral is needed. In doing so, clients are more likely to buy in to the referral, especially those who are reluctant to consider support outside the problem gambling service. Clients are more


likely to consider other agencies as part of their interventions if their service provider’s recommendation is based on familiarity with the external agency. When considering contact with external agencies on a client’s behalf, ensure clients sign service consents to clearly give their approval for you to give their name and circumstances to an external party as part of a formal referral.


7.7.1 Can I count a facilitation activity with no assessment? It is possible to count a facilitation activity before a comprehensive assessment is complete. Depending on the priority of the issues a client presents with, it may be important to act on a referral plan immediately, especially for mental health issues. Under normal circumstances, it is still considered important to complete a comprehensive assessment within the first three sessions. If a client has not provided a primary problem gambling mode you will not be able to record your work with them in CLIC.

7.7.2 What if a client does not need any facilitation services? A full intervention activity does not have to include facilitation to be counted against contract requirements. However, under normal circumstances, your file reporting client contact should show that assessment and intervention planning considered referral planning, but no facilitation services were required by or agreed to with the client.

7.7.3 Can I still count a facilitation activity if a person scores zero for gambling harm?

The Ministry of Health recognises facilitation activity as being warranted even if the person has been screened as not having any specific concerns with problem gambling harm, but has been assessed as having other social or health issues. For such clients, facilitation should be completed within one or two sessions and no follow-up support is provided once the full intervention episode has been closed. The circumstance of this contact should be as well documented in this client’s file as with any other client.

7.7.4 Does supporting clients to attend venues to self-exclude count as facilitation?

The Ministry of Health believes that supporting clients to attend venues to self-exclude themselves from further gambling is a good example of a valid facilitation session. However, writing a self-exclusion letter for a client does not count as facilitation.


8 Follow-up

8.1 What is follow-up? Follow-up: • is a series of scheduled one-to-one sessions (or contacts) with a client who has

finished a full intervention episode with a specialist problem gambling intervention service

• involves providing periodic support to people as they transition from the support of full intervention services to independence from gambling harm

• not provided for clients who are not experiencing harm from gambling but who are facilitated to other social or health services by a problem gambling intervention service.

Follow-up is an opportunity to re-engage with clients throughout the year after full intervention and facilitation services. This service applies to problem gamblers and affected others who have been previously registered as receiving full interventions. Seek the client’s agreement to a follow-up plan early, for example, when agreeing the intervention plan (see section 6.7). Ideally, clients who have had a full intervention episode closed should receive four follow-up sessions. These sessions should be at: • one month from the last full session • three months from the last full session (about 60 days from the last follow-up) • six months from last full session (about 90 days from the last follow-up) • 12 months from the last full session (about 180 days from the last follow-up). See section 6.2.5 for details on the pathways clients take to follow-up services without fully completing a full intervention episode.

8.2 Rationale for follow-up The rationale for follow-up includes that it: • optimises the opportunity for clients to reconnect with the service at an earlier stage

than might otherwise have happened, if at all • allows clients to receive updates on their progress and reinforces their positive

changes • gives you a change to provide motivational support • offers support for the client to review relapse prevention plans (including

reassessment) • enables you to advise the client about, and refer them to, other social and health

services as appropriate, and encourages ongoing liaison between the service user and referral services


• reinforces to the client their ability to achieve and maintain long-lasting change • increases our knowledge about client outcomes following treatment • increases our knowledge about what works with clients and provides opportunities for

us to reflect on training needs and processes • enables clients to give feedback to practitioners (eg, to affirm their clinical and

engagement skills) • enables counsellors, teams and agencies to benefit by knowing their clients have

improved • is best practice for health professionals.

8.3 Obstacles to client follow-up Follow-up may be difficult because: • clients may be mobile (ie, address and phone contacts change and clients fail to

advise us of changes) • clients’ needs may change and they may not want to continue the process • clients may be uncertain about the rationale for follow-up and not understand what

the follow-up process entails • clients may not want to be reminded of old behaviours after periods of remission • clients may be concerned about their privacy and be wary of future contact or

messages left • clients may have relapsed and not want to re-engage with the service at that time • clients may be concerned about engaging with another service and new practitioners

if they use the Gambling Helpline, Integrated Continuing Care system • practitioners may feel overloaded and reluctant to take on additional work. The advantages of client follow-up outweigh the disadvantages for clients, practitioners and treatment agencies. As well as supporting clients to manage their recovery and contributing to outcome data, the knowledge gained through follow-up assists us all to improve the supports and services available to clients. The importance of follow-up is signalled by the fact it is a significant part of funding. The Ministry of Health has reduced the targets required for other purchase units (such as brief intervention, full intervention and facilitation) and contracted for the follow-up service targets as a separate purchase unit.

Intervention Service Practice Requirements Handbook: Follow-up 89

8.4 Summary of follow-up intervention service specification The Ministry expects that follow-up services will include the collection of results from standard screening tools that are detailed in this section. The follow-up episode is a scheduled review session by phone or face to face, but not in a group, with a client who has previously had a full intervention episode. The service provider usually initiates the contact with the client one month, three months, six months and 12 months after the full intervention services. The service should be flexible in its hours to accommodate service users’ needs. At the three-month, six-month and 12-month follow-ups, reassessment screens are used with the problem gambler and affected others. A follow-up session is usually about 15–30 minutes in length and usually consists of one session per scheduled follow-up. If the follow-up episode session identifies that the client needs further counselling, assessment or facilitation services, the follow-up episode is ended and the subsequent sessions are recorded as a full intervention episode. If the client reconnects with the service provider because they are concerned about relapse and the call is not directly related to a scheduled follow-up, the session is recorded under a new full intervention episode. The service specification for follow-up is outlined in Table 8.1. A flowchart of typical client pathways and practitioner decisions for follow-up is in Figure 8.1.


Table 8.1: Follow-up service specification description (purchase unit PGCS-05)

Outcome All people identified as experiencing gambling related harm (from their own gambling or from the gambling of a significant other) continue to receive support to minimise any gambling related harm occurring to them and their family.

Objective To provide follow-up and motivational support to clients for 12 months after their discharge from problem gambling intervention services (Facilitation or Full Intervention).

Activities Provision of follow-up services will include follow-up and motivational support at one month, three months, six month, and 12 months from after discharge from problem gambling intervention services. This will include: •

•

•

•

advice and referral to other social and health services as appropriate motivational support review of relapse prevention plans (including re-assessment) ongoing liaison between service user and referral services.

The service may be mobile and will be provided to service users at a place that they prefer (unless safety or inaccessibility are an issue). The service will be flexible in its hours to accommodate the needs of the service user (and within parameters that ensures safe practice for the service deliverer).

Key processes

Services users will be able to, as a minimum, access all of the following processes described in the ‘Process Descriptions’: support, service handover, assessment, management of risk, case management, discharge planning, early identification, liaison and consultation, referral, screening.

Reporting Six-monthly narrative reports to the Ministry will use the provided report template and summarise: •

•

•

•

barriers and successes over the last six-month period (ie, issues with referral processes, contacting clients for follow-up) trends and patterns in client presentations FTE employed to deliver this service over the last six-month period (noting variances and any periods of unemployment) any other relevant information.

Provided by

Services will be provided by a team or person with appropriate qualifications, competencies, skills and experience in working with people with gambling problems and/or other behavioural addictions, as outlined in the Intervention Service Practice Requirements Handbook.

Access Access is from full intervention and facilitation services.

Minimum delivery

A full-time equivalent will deliver a minimum of 120 follow-up sessions per month each month (for an average 15–30 minutes each).


Figure 8.1: Typical client pathways and practitioner decisions for follow-up



8.5 Follow-up procedure As part of the comprehensive assessment process, clients are assured of confidentiality under the Privacy Act 1993, and consents to contact other services, including the Helpline, can be obtained at that time. This is an ideal opportunity to explain the follow-up process and the benefits to the client and to services (ie, improved client outcomes). Unless client distress or a lack of opportunity precludes this, it is preferable to offer this service to clients at the first contact to ensure follow-through. Use a follow-up agreement to encourage the client to commit to the follow-up process. It also offers certainty for the service provider about how to reconnect with clients at the scheduled follow-up times. An example follow-up agreement is provided in Appendix 2. Ensure there is a name or client ID on the follow-up agreement. Ask the client what type of follow-up they would prefer (ie, telephone or face to face) to complete the follow-up screens. Ensure the client signs and dates the relevant section of the follow-up agreement.

8.6 Closing a follow-up episode Follow-up episodes are an important part of empowering clients and supporting their independent recovery. Follow-up episodes are different from every other episode type as they always involve only one session. While every follow-up episode opens and closes each session, several outcomes are possible. The appropriate discharge code for each outcome is listed in Table 8.2. Table 8.2: Ending follow-up episodes


Client could not be contacted over a period of one week (see Figure 8.3.2).

Administrative Do not schedule further follow-up sessions

Client contacted, discussion indicates a need (and willingness) to renew specialist support (full intervention).

Treatment complete Schedule full intervention session Do not schedule further follow-up sessions

Client contacted, discussion indicates the client is maintaining or improving their progress to independent recovery.

Treatment complete Schedule next follow-up session

Client contacted but indicated they no longer agree to follow-up support.

Treatment partially complete Do not schedule further follow-up sessions


8.7 Follow-up screens

8.7.1 Gambler screens for follow-up For people who received support for their own gambling the following screens will be used for Follow-up services at 3, 6 and 12 month follow-up sessions. (See section 6.4.1 for how to score and interpret theses screens.) Gambler Harm Screen (record the total score) The Gambler Harm screen is nearly the same as the Gambler Harm Screen used for full intervention. When you use the Gambler Harm Screen for follow-up you ask the client to think about the time since you last talked. The Gambler Harm Screen is scored by the client’s response to each question (never = 0, sometimes = 1, most of the time = 2, almost always = 3). • Since we last talked, how often have you bet more than you could really afford to

lose? • Since we last talked, how often have you needed to gamble with larger amounts of

money to get the same feeling of excitement? • Since we last talked, how often have you gone back another day to try to win back

the money you lost? • Since we last talked, how often have you borrowed money or sold anything to get

money to gamble? • Since we last talked, how often have you felt that you might have a problem with

gambling? • Since we last talked, how often have people criticised your betting or told you that

you had a gambling problem, regardless of whether or not you thought it was true? • Since we last talked, how often have you felt guilty about the way you gamble, or

what happens when you gamble? • Since we last talked, how often has your gambling caused you any health problems,

including stress or anxiety? • Since we last talked, how often has your gambling caused any financial problems for

you or your household?

8.7.2 Outcome measures screens As part of the follow-up assessment, ask your clients who receive support for their own gambling about: • their control over their gambling (section 6.7.2.1) • the amount of money they have lost (‘dollars lost’) (section 6.7.2.2) • their annual household income (section 6.7.2.3).


8.7.2.1 Control over gambling The CLIC system calls this question ‘Gambler: Outcome-Control’. Control over gambling (record the number of the response ie, 1, 2, 3, or 4) During the past month: (1) I have had complete control over my gambling Or (2) I have had some control over my gambling Or (3) I have had little control over my gambling Or (4) I have had no control over my gambling

8.7.2.2 Dollars lost The CLIC system calls this question ‘Gambler: Outcome-Dollars lost’. Dollars lost (record the response ie, $5,000) In the last month when you were gambling, roughly what amount of money did you spend on gambling? This is the total amount of money in dollars that you used on your gambling activity or activities (ie, money you took to gamble with and any additional money you obtained and gambled with such as from cash machines or eftpos). Ignore any money you won during your gambling sessions. Dollars spent on gambling: $...............

8.7.2.3 Annual household income screen The CLIC system calls this question ‘Gambler: Outcome-Household income’. Approximate annual household income (record the number of the response ie, 1, 2, ... 6, or 7) (1) < $20,000 (2) $20,000–$30,000 (3) $31,000–$50,000 (4) $51,000–$100,000 (5) $101,000–$200,000 (6) $201,000–$500,000 (7) $501,000+

8.8 Family/affected other screens for follow-up For people re-screening for the impact someone else’s gambling has had on them use the family/affected other screens for at the three-month, six-month and 12-month follow-up sessions. (See section 6 for how to score and interpret this screen.)


8.8.1 Family/affected other harm screen For assessing the impact another person’s gambling problem is having on your client, after they have received a full intervention, the variation of the Full Family/Affected Other Screen below should be used for follow-up. The Family/Affected Other Harm Screen is made up of two questions. You will see that the CLIC system calls these questions: • Family/Other: Harm-Awareness • Family/Other: Harm-Effect Introduction/opening statement: When you were seeing our service regularly you described your awareness of the effect of their gambling on you and a range of effects that the person’s gambling was having on you and your family. I would like to ask you some similar questions to see how your awareness and feelings about the other person’s gambling has changed.

1. Awareness of the Effect of the Gambler’s Gambling (record the number of the response ie, 1, 2, or 3) Do you still think you are being affected by someone else’s gambling? (1) I don’t know for sure if their gambling affects me (2) Yes, in the past (3) Yes, that is still happening to me now





(1-5)

8.8.2 Family/whānau outcome measures screens As part of the follow-up assessment, ask clients seeking support for someone else’s gambling about: • the gambler’s gambling frequency (section 8.8.2.1) • how they are coping with the gamblers gambling (section 8.8.2.2). The client or you may fill in the outcomes screens.

8.8.2.1 Gambler’s gambling frequency screen The CLIC system calls this question ‘Family/Other: Outcome-Gambling Frequency’.


The statements below are about the person who was gambling at the time you sought help and about you. Gambler’s gambling frequency (record the number of the response ie, 0, 1, 2, or 3) Which of these four statements is true about the person’s gambling over the past three months? (Tick ONE box only.) (0) The gambler in my life has not been gambling during the last three months. (1) The gambler in my life has been gambling less during the last three months. (2) The gambler in my life has been gambling about the same as usual during

the last three months. (3) The gambler in my life has been gambling more than usual during the last

three months.

8.8.2.2 Coping with the gambler’s gambling The CLIC system calls this question ‘Family/Other: Outcome-Coping’. You can ask this screen during normal discussion with the client or over the phone, or the client can complete the screen on their own. Coping with the gambler’s gambling (record the number of the response ie, 1, 2 or 3) Which of these three statements is true about your ability to cope with the person’s gambling over the last three months? (Tick ONE box only.) (1) I am coping better with the gambler’s gambling than I have in the past. (2) I am coping about the same with the gambler’s gambling as I have in the

past. (3) I am coping worse with the gambler’s gambling than I have in the past.

8.9 Examples of follow-up

8.9.1 Case 9: Follow-up services for a couple Roger came to the service four months ago with a problem gambling concern relating to the pokies primarily and the track secondarily. This gambling behaviour was significantly affecting his marriage, so he included his wife, Helen, in the treatment process. Over a three-month period, you saw Roger almost weekly under a full intervention episode for assessment and agreed interventions. Helen became so involved in the intervention process, for mostly couple work, that you registered her as a client too, and conducted an assessment over the course of contact. At the end of a three-month intervention experience, Roger and Helen both felt they had made great progress and were ready to exit full intervention services.


At an early point in the assessment process, you had explained follow-up contact to Roger and Helen, and they both agreed to telephone contact past the point of full intervention for follow-up purposes.

8.9.1.1 Questions After reading case 9, answer the following questions. • What did you do statistically after the full intervention services were completed last

month? • What is your next step one month after seeing Roger and Helen for full intervention

services? • What will you do as part of the second follow-up contact?

8.9.1.2 Answers What did you do statistically after the full intervention services were completed last month? Roger and Helen had each completed a full intervention episode with your service. They both were registered clients, so you have to close the full intervention episode for each person. As they both felt the service was complete, both receive a discharge code of ‘treatment completed’ on their client form with the full intervention episode end date being their last session. What is your next step one month after seeing Roger and Helen for full intervention services? The first follow-up is to occur one month after the last full intervention contact, and you plan to reconnect with Roger and Helen to see how the last month has been for each of them. You prepared them both during the assessment and received their agreement to phone contact as part of the follow-up process, so you now call them to see how they are each doing. What will you do as part of the second follow-up contact? When speaking individually with Roger and Helen, you receive feedback from both that they are still doing well. On the client form you now enter them both into a follow-up episode. At the end of that call, you let them know that you plan to touch base again in two months’ time. At the three-month contact, you will ask Roger to answer the follow-up screens for a gambler and Helen the questions from the follow-up screen for an affected other. Document these screen scores for each on their client form for their next session details as part of the follow-up episode.

8.9.1.3 Guiding principles It is always good practice to get agreement to follow-up as early in the full intervention episode as possible, because it is difficult to predict how long your full intervention contact will be, especially if there is an ‘administrative’ or a ‘treatment partially completed’ discharge (see section 6.2.6 for more detail).


It is important to end the client’s full intervention episode before starting a follow-up episode for them. Usually, attempt the one-month follow-up one month after the last session in the full intervention episode. Even if a client does not attend the last session scheduled in a full intervention and efforts to reschedule have been unsuccessful, closing the full intervention episode as soon as possible and still attempting, at the one-month mark, a follow-up contact may be the best plan. A new full intervention episode can be started after a client’s full intervention episode has been closed if they renew contact. Proceeding in this manner also helps prevent inactive files being kept open indefinitely. The one-month follow-up contact does not require the follow-up screens to be done. Do the follow-up screens at the three-, six- and 12-month follow-up contacts.

8.9.2 Case 10: Reopening a full intervention after a scheduled follow-up Three months ago you ended Fred’s full intervention episode after working with him for three months. Fred had made good progress clinically, and you mutually agreed that no further sessions were required. At the one-month contact, Fred seemed consistently well since his last full intervention session. It is now time for your second scheduled follow-up contact with Fred at the three-month mark. You contact Fred and discover during your conversation and by redoing the problem gambling screens that he has not been doing very well in the past six weeks. He has been struggling with his finances, which has put pressure on his relationship and he has started punting on the horses again. You encourage Fred to come in for an appointment, which he agrees to do.

8.9.2.1 Questions After reading case 10, answer the following questions. • How would you account for the types of contact you have had with Fred using the

CLIC data information system? • What next steps might you take?

8.9.2.2 Answers How would you account for the types of contact you have had with Fred using the CLIC data information system? Initially, Fred would have been seen under a full intervention episode, so all his contacts during that episode would have been entered accordingly in the session details. At the last full intervention session three months ago, you would have ended his full intervention episode. When you re-engaged for his one-month follow-up contact, you would have started a follow-up episode, had one session of about 30 minutes, and closed the follow-up episode.


On re-engaging with Fred for the three-month follow-up, the problem gambling screen scores as part of his reassessment would be entered on the client multiple session form along with session details. At this point he is still in a follow-up episode, but because of his increased scores and risk of relapse, you close the follow-up episode and re-open a full intervention episode when he comes in for his agreed appointment. What next steps might you take? At the agreed appointment, you open a new full intervention episode for Fred, review relapse prevention and referral planning with Fred as part of the reassessment and intervention process. Fred may now see the need to engage with a budgeting service, which you could facilitate and identify under facilitation activity within the new full intervention episode.

8.9.2.3 Guiding principles When the screens are redone at the three-, six- and 12-month follow-ups, review them against previous scores with a client. See this as an opportunity to increase the client’s motivation for maintaining or reconnecting with relapse prevention skills. If full intervention support is to be resumed, based on follow-up contact, use this opportunity to revisit assessment and intervention planning. Even though facilitation might not have been necessary at the original assessment, reassessing Fred offers another opportunity to consider options and revisit co-existing issues questions.

8.10 Recommendations for follow-up Follow-up services represent a significant component in the therapeutic process with clients. As problem gamblers are at high risk of relapse, a structured follow-up plan allows you to motivate the client and encourage them to maintain their changes and to address concerns before they appear insurmountable. This is a standard process all clients are encouraged to be part of, so it normalises the experience and does not set clients up to think they have little chance of succeeding in their recovery. Introducing the concept of follow-up early in the full intervention episode reassures clients of an extended connection with the service and allows full intervention to be completed without clients feeling support has been taken away. Clients need to feel that support is available if they need it again. It is important not to lose track of when clients need to be contacted at the one-, three-, six- and 12-month times, so service providers should work towards a system within their service that reminds them to complete these follow-up contacts in a timely fashion.



8.11.1 What if I can’t contact my client for follow-up purposes? Not all clients will be available for follow-up purposes, as it depends on what else is going on in their lives. However, service providers are expected to be able to make contact with most of their clients. The first follow-up is about one month after last contact, which should ensure most clients are still available. The more invested clients are in seeing the follow-up process as part of their treatment, the more agreeable they will be to receiving follow-up support and being proactive to ensure you have their up-to-date contact details. It is the service provider’s responsibility to build the client’s awareness of the role of follow-up in their recovery. It is also their responsibility to be flexible in the hours they offer to accommodate the service user’s needs. If a client does not attend or was not available for a scheduled follow-up contact, the Ministry of Health expects providers to make three to five contact attempts on two occasions about a week apart. If the client can still not be contacted, note that no further follow-up attempts will be made. Document attempts to contact the client in the client’s clinical notes. If you could not contact your client for follow-up, but they recontact the service within a short space of time, use your judgement to decide whether the client is seeking to resume full intervention support or whether they could benefit from resuming follow-up. Record the clinical time spent engaging with the client and assessing their progress as the missed follow-up. If follow-up is resumed, the next session is the same as if the client had been contacted. For example, James misses his three-month follow-up session. He recontacts the service two weeks later. He had been on holiday and forgot about his appointment. The practitioner spends half an hour with James discussing his progress. James gives the practitioner a new cellphone number for contacting him, and they agree a date for the next follow-up session – the six-month follow-up (90 days after the three-month session (the recontact) was held).

8.11.2 When does follow-up start? How does the discharge code used when closing a full intervention episode influence the follow-up process?

Ideally, service providers should aim for a full intervention episode to end with a ‘treatment completion’ discharge code. This is when the treatment ends with the client’s successful completion of agreed the interventions. With the full intervention episode end clear, a follow-up episode can commence one month after the last session. However, many discharges are not clear, and often service providers are attempting to connect with clients, by phone or mail, who have not attended previously scheduled appointments.


The Ministry of Health expects that when clients do not attend a session, practitioners will attempt to contact the client to reschedule (multiple attempts should be made). The three possible outcomes from these attempts to recontact the client are as follows.

• No contact is made: Start a 90-day countdown for an administrative discharge; attempt to recontact the client in 90 days if the client makes no contact; and, if the client cannot be contacted do not schedule a follow-up.

• Contact is made, and one of the following occurs. – The client agrees to recommence intervention, so a new appointment is made,

and contact is recorded as a full intervention session. – The client does not agree to recommence intervention, but does agree to engage

in follow-up. The full intervention episode is ended, due to a treatment partially complete discharge, a follow-up episode is started, and the contact is recorded as a one-month follow-up. Start a 60-day countdown to the three-month follow-up.

– The client does not agree to recommence intervention and does not agree to engage in follow-up. The full intervention episode is ended due to a treatment partially complete discharge, a follow-up episode is started, and the contact is recorded as a one-month follow-up. The follow-up episode is ended, and the provider notes that no further follow-up is required.

You should remember that opening and closing episodes is an administration task and can be carried out once the session is over. See section 6.2.5 for further discussion of contacting and recontacting clients during full intervention episodes.


9 Public Health

9.1 Introduction Intervention services and public health services are funded separately by the Ministry of Health. However, a provider may be delivering both intervention and public health services. Even if no one in your organisation is involved in public health directly, you should have links with organisations that deliver problem gambling public health activities in your area. Section 9 outlines the public health services the Ministry purchases and ways that this work may relate or support intervention services and complement the work you do. Note that intervention service targets and contractual requirements do not include public health activity. It is important clinical staff ensure they are delivering against the contract their organisation has with the Ministry.

9.2 Problem gambling public health services Problem gambling public health services (and their purchase unit codes) include: • policy development and implementation (PGPH-01) (section 9.2.1) • safe gambling environments (PGPH-02) (section 9.2.2) • supportive communities (PGPH-03) (section 9.2.3) • aware communities (PGPH-04) (section 9.2.4) • effective screening environments (PGPH-05) (section 9.2.5).

9.2.1 Policy development and implementation (PGPH-01) The objective of policy development and implementation services is to increase the adoption of organisational policies that support the reduction of gambling-related harm for employees and organisation’s client groups (eg, employee assistance policies and organisational positions on accepting gambling funding, relationships with gambling venues, and permitting gambling promotions in internal and external media). What does this mean for me? Public health practitioners work with a range of organisations to support the adoption of healthy public policies. If, as a practitioner, you are aware that many of your clients come from a single organisation – say a large company that uses the casino for its social functions, consider raising this with your local public health service. The pubic health service can engage with the company to consider policy or structural changes that the organisation could implement to create a safer environment for its employees. You may also notice that many of your clients are struggling to receive assistance or support from a government agency. It may be that the agency does not have a good understanding of how gambling affects its clients. Again, your local public health service can follow up this kind of issue.

Intervention Service Practice Requirements Handbook: Public Health 103

9.2.2 Safe gambling environments (PGPH-02) The objective of safe gambling services is to ensure gambling environments are safe and provide effective and appropriate harm minimisation activities. What does this mean for me? Intervention practitioners can add a lot of value to informing public health initiatives by noticing trends in their clients. For example, if, as a practitioner, you become aware that many of your clients are having trouble with self-exclusion at a certain venue, you could raise this with your local public health service.

9.2.3 Supportive communities (PGPH-03) The objective of supportive communities services is to ensure communities have access to services that provide strong protective factors and build community, family and individual resiliency. What does this mean for me? Many activities intervention practitioners do with their clients, such as encouraging social networking, reducing isolation, encouraging alternative activities and informing of the impacts of gambling harm, contribute to this work at an individual level. It is useful for practitioners to be aware of the activities public health practitioners are doing in their area and support them by informing clients of opportunities to participate, when appropriate, and ensuring public health initiatives have accurate and defensible local information.

9.2.4 Aware communities (PGPH-04) The objective of aware communities services are social marketing campaigns that are delivered consistently at national, regional and community levels to improve community awareness and understanding of the range of harms that can arise from gambling. What does this mean for me? Many practitioners support these services by contributing stories and advice to a national social marketing campaign. It is useful for practitioners to ensure they are aware of the messages being promoted nationally and to support clients to engage in opportunities to participate in local social marketing activities, when appropriate.

9.2.5 Effective screening environments (PGPH-05) The objective of effective screening environments services is making relevant organisations, groups and sectors aware of the potential harms that can arise from gambling and to actively screen and refer individuals to appropriate gambling intervention services. What does this mean for me? A key dimension of public health is to improve the responsiveness of other health and social services to problem gambling. This means public health practitioners are out in the community educating other agencies and organisations about the effects of gambling and encouraging them to develop systems to screen their own clients for gambling harm and refer people to problem gambling intervention services when appropriate. This means more organisations will want to engage with your service to develop referral protocols and relationships, similar to the


agreements described for brief intervention and facilitation services. While it is the responsibility of the public health services to raise awareness, provide education and support the development of any new systems, the intervention service needs to be involved in discussions about developing a local relationship.

Intervention Service Practice Requirements Handbook: Public Health 105

10 Infrastructure Services

10.1 Introduction Section 10 describes the Infrastructure services the Ministry of Health has funded as part of each problem gambling service contract. The infrastructure services represent the services that providers deliver that are not directly related to working with clients.

10.2 Infrastructure services Infrastructure services (and their purchase unit codes) include: • kaumātua consultation and liaison (PGA-01) (section 10.2.1) • workforce development (PGA-02) (section 10.2.2) • participation in research and evaluation (PGA-03) (section 10.2.3).

10.2.1 Kaumātua consultation and liaison (PGA-01) The objective of kaumātua consultation and liaison services is service providers offer an environment that is culturally safe for Māori service users and their family/whānau and significant others, as well as for those delivering the services. What does this mean? For dedicated Māori providers these services typically represent an acknowledgement of the existing cultural infrastructure, resources and capacity that have been established and need maintaining within the organisation. For general and other dedicated services, these services represent the Ministry of Heath’s commitment to building this capacity within their organisation.

10.2.2 Workforce development (PGA-02) The objective of workforce development services is problem gambling staff are supported to access appropriate training and workforce development opportunities and attend national and regional hui and conferences. What does this mean? The Ministry of Health is funding all problem gambling practitioners to attend and travel to training opportunities and national and regional conferences and hui. This means it is part of each service’s contractual requirements to ensure staff attend these events. The Ministry has reduced each service’s clinical targets to ensure practitioners are not penalised for the time they take away from their clients.

10.2.3 Participation in research and evaluation (PGA-03) The objective of participation in research and evaluation services is that problem gambling providers participate in and support Ministry of Health–approved research and evaluation.


What does this mean? The Ministry is funding all problem gambling practitioners to participate in the Ministry’s research programme. The Ministry has reduced each service’s clinical targets to ensure practitioners are not penalised for the time they take away from their clients or for the extra effort that may be required. This service does not mean the Ministry has agreed your organisation can do its own problem gambling research or participate in someone else’s research. Discuss any such proposal with your contract manager.

Intervention Service Practice Requirements Handbook: Infrastructure Services 107

11 Glossary Terms used in this document have the meanings as stated below. Term Definition

bankruptcy Bankruptcy is a legal process that enables the client to get relief from the burden of debt that they cannot repay, despite their best efforts. See www.insolvency.govt.nz

comprehensive assessment

A comprehensive assessment is a thorough assessment of a client for a range of health and social problems. The minimum screening tools required by the Ministry of Health for assessing clients form a starting point for a comprehensive assessment. However, practitioners should discuss screen results with clients and obtain relevant clinical information when appropriate.

episode, treatment episode

An episode (or treatment episode) is a set of actions and requirements intended to achieve a specific outcome for a client. An episode is delivered through one or more sessions, with the associated actions and requirements depending on the type of episode. An episode is a series of sessions within a specific purchase unit. Sessions are not valid if they occur within an episode of a different type. The three types of episode are a: •

•

•

brief episode, which contains only brief sessions full intervention episode, which contains only full or facilitation sessions follow-up episode, which contains only follow-up sessions.

An old episode must always be closed and a new episode opened before a new session type can be started for a client (ie, a full intervention episode must be closed and a follow-up episode opened before a follow-up session can be recorded).

family/affected other (family/ other)

The Ministry recognises that people can be negatively affected by someone else’s gambling in many ways. The problem gambling sector uses family members, whānau, significant others or affected others to describe the broad range of relationships between a person affected by gambling and a gambler. The Ministry has used the term family/affected other in the handbook to emphasise that people can be affected by the gambling of someone outside their immediate family. Family/other is used as an abbreviation of family/affected other.

full-time equivalent

See the definition in the service specification in Ministry of Health service provider contracts.

gambling Gambling has the meaning set out in the Gambling Act 2003. Gambling means: paying or staking consideration, directly or indirectly, on the outcome of something seeking to win money when the outcome depends wholly or partly on chance

Gambling includes all forms of gambling and financial risk-taking, both present and future (eg, existing class four (pokies) and emerging Internet modes linked to an increased incidence of harm).


Term Definition

gambling harm Gambling harm has the meaning set out in the Gambling Act 2003. It means harm or distress of any kind arising from, or caused or exacerbated by, a person’s gambling, and includes personal, social or economic harm suffered by the person, their spouse, partner, family, whānau and wider community, or in their workplace or society at large.

group therapy Group therapy is a clinical counselling session where multiple clients (gamblers or their significant others) not previously known to each other, meet to share their experience of gambling harm and support each other. Client’s should have had at least one full intervention session and completed a comprehensive assessment before they start group therapy.

insolvency Insolvency is when a person is unable to pay their debts as they fall due.

practitioner A person with the necessary skills and competencies to diagnose, screen, assess, and provide psychosocial and culturally based interventions to people experiencing harm from gambling.

provider, service provider

A provider (or service provider) contracts with the Ministry of Health to provide services. Providers include individuals and organisations that act as a nominee, an agent or a subcontracted provider to a provider.

purchase unit A purchase unit is a category of problem gambling services the Ministry of Health funds. The four purchase units (and codes) addressed in detail in this handbook are: •

•

•

•

•

•

brief intervention (PGCS-02) full intervention (PGCS-03) facilitation (PGCS-04) follow-up (PGCS-05).

Other purchase units (and codes) are: infrastructure services (see section 10) – kaumātua consultation and liaison (PGA-01) – workforce development (PGA-02) – participation in research and evaluation (PGA-03) public health services (see section 9) – policy development and implementation (PGPH-01) – safe gambling environments (PGPH-02) – supportive communities (PGPH-03) – aware communities (PGPH-04) – effective screening environments (PGPH-05).

screening Screening involves asking a client questions from a formal questionnaire. Many screens are developed so clients can read and answer them on their own. The screens required by the Ministry of Health have been chosen for simplicity, to allow national and international comparisons, and to provide clients and practitioners with feedback on client progress.

session A session is a single interaction with a client (or clients) related to a brief, full or follow-up episode. Each purchase unit (brief, full, facilitation or follow-up) has specific rules for a valid session. These rules are described in this handbook and Data Management Manual. It is important service providers are familiar with the most up-to-date rules.

Intervention Service Practice Requirements Handbook: Glossary 109

11.1 Flowchart symbols The symbols used in the flowcharts in the Handbook are detailed in Figure 11.1. Figure 11.1: Guide to flowchart symbols


12 Version History Section 12 records the main changes to this document from the previous version. Version Release date Changes 1.1 9 July 2008 Method of recording screen responses and scores into

the CLIC system simplified based on provider feedback. 1.0 30 June 2008 First release

Intervention Service Practice Requirements Handbook: Version History 111

Appendix 1: Screens The Ministry has identified the following screens for use in problem gambling services. The screens are listed below, along with the name used in CLIC and the section of the handbook that describes how to use and score the screen. Table A.1 List of screens

Screen Category

Handbook Reference

Screen Name CLIC Title

Brief gambler section 5.7.1 Brief Gambler Screen Brief Gambler

Awareness of the Effect of the Gambler’s Gambling

Brief Family/Other-Awareness

Brie

f Int

erve

ntio

n (s

ectio

n 5.

0) Brief

family/affected other

section 5.7.2

Effect of Gambler’s Gambling

Brief Family/Other-Effect

Gambler harm section 6.4.1 Gambler Harm Screen Gambler: Harm

Control Over Gambling Gambler: Outcome-Control

Dollars Lost Gambler: Outcome-Dollars Lost

Gambler outcome

section 6.4.2

Approximate total annual household

Gambler: Outcome-Household Income


Family/Other: Harm-Awareness

Family/affected other harm

section 6.4.3


Family/Other: Harm-Effect

Gambler’s Gambling Frequency

Family/Other Outcome-Frequency

Family/affected other outcome

section 6.4.4

Coping with the Gambler’s Gambling

Family/Other: Outcome-Coping

Alcohol Use (AUDIT-C) Coexisting-Alcohol

Drug use Coexisting-Drug Use

Depression Coexisting-Depression

Suicidality Coexisting-Suicidality

Full

Inte

rven

tion

(sec

tion

6.0)

Co-existing issue (gambler or family/affected other)

section 6.4.5

Family/whānau concern Coexisting-Family/other concern


Screen

Category Handbook Reference

Screen Name CLIC Title

Gambler harm section 8.7.1 Gambler Harm Screen Gambler: Harm

Control Over Gambling Gambler: Outcome-Control

Dollars Lost Gambler: Outcome-Dollars Lost

Gambler outcome

section 8.7.2

Approximate total annual household

Gambler: Outcome-Household Income


Family/Other: Harm-Awareness

Family/affected other harm

section 8.8.1


Family/Other: Harm-Effect

Gambler’s Gambling Frequency

Family/Other Outcome-Frequency

Family/affected other outcome

section 8.8.2

Coping with the Gambler’s Gambling

Family/Other: Outcome-Coping

Alcohol Use (AUDIT-C) Coexisting-Alcohol

Drug use Coexisting-Drug Use

Depression Coexisting-Depression

Suicidality Coexisting-Suicidality

Follo

w-u

p (s

ectio

n 8.

0)

Co-existing issue (gambler or family/affected other)

section 6.4.5

Family/whānau concern Coexisting-Family/other concern

Intervention Service Practice Requirements Handbook: Appendix 1 113

Brief Gambler Screen For people screening for their own gambling behaviours the following screens are used for brief interventions (see section 5.7.1). Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Introduction/opening statement: Most people in New Zealand enjoy gambling, whether it’s Lotto, track racing, the pokies or at the casino.

Sometimes however it can affect our health.

To help us to check your wellbeing, please answer the questions below as truthfully as you are able from your own experience. A ‘no’ answer can also mean that ‘I don’t gamble at all’.

Brief Gambler Screen (record the number of positive responses to questions 1 to 4. If there are no positive responses, then record a zero “0”) 1. Do you feel you have ever had a problem with gambling? (Only ask if not obvious)

2. If the answer to Q1 is yes, ask: And do you feel you currently have a problem with gambling?

3. Have you ever felt the need to bet more and more money? 4. Have you ever had to lie to people about how much you gambled? If you answered yes to any of the above, what would help? (response not recorded)



Brief Family/Affected Other Screen For screening people for the impact another person’s gambling problem has had on them, use the Brief Family/Affected Other Screen (see section 5.7.2). Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Introduction/opening statement: Sometimes someone else’s gambling can affect the health and wellbeing of others who may be concerned. The gambling behaviour is often hidden and unexpected, while its effects can be confusing, stressful and long-lasting. To help us identify if this is affecting your own wellbeing could you answer the questions below to the best of your ability.

1. Awareness of the Effect of the Gambler’s Gambling (record the number of the

response)

Do you think you have ever been affected by someone else’s gambling? (0) No, never (you need not continue further) (1) I don’t know for sure if their gambling affected me (2) Yes, in the past (3) Yes, that’s happening to me now





(1-5)

3. Support Requested (response not recorded)

What would you like to happen? (Tick one or more.) I would like some information I would like to talk about it in confidence with someone I would like some support or help Nothing at this stage


Gambler full intervention screens The gambler full intervention screens are made of the: • gambler harm screens (see section 6.4.1) • gambling outcomes screens (see section 6.4.2) • co-existing issue screens (these questions are the same for gamblers and

family/affected others) (see section 6.4.5). Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Gambler harm screen 1. Gambler Harm (record the total score)

The Gambler Harm Full Screen is scored by the client’s response to each question (never = 0, sometimes = 1, most of the time = 2, almost always = 3) • Thinking about the past 12 months, how often have you bet more than you

could really afford to lose? • Thinking about the past 12 months, how often have you needed to gamble with

larger amounts of money to get the same feeling of excitement? • Thinking about the past 12 months, how often have you gone back another day

to try to win back the money you lost? • Thinking about the past 12 months, how often have you borrowed money or

sold anything to get money to gamble? • Thinking about the past 12 months, how often have you felt that you might have

a problem with gambling? • Thinking about the past 12 months, how often have people criticised your

betting or told you that you had a gambling problem, regardless of whether or not you thought it was true?

• Thinking about the past 12 months, how often have you felt guilty about the way you gamble, or what happens when you gamble?

• Thinking about the past 12 months, how often has your gambling caused you any health problems, including stress or anxiety?

• Thinking about the past 12 months, how often has your gambling caused any financial problems for you or your household?


Gambler outcome screens 2. Control over Gambling (record the number of the response)

During the past month: (1) I have had complete control over my gambling Or (2) I have had some control over my gambling Or (3) I have had little control over my gambling Or (4) I have had no control over my gambling

3. Dollars Lost (record the response ie. $50,000)

In the last month when you were gambling, roughly what amount of money did you spend on gambling? This is the total amount of money in dollars that you used on your gambling activity/ies (ie, money you took to gamble with PLUS any additional money you obtained and gambled with such as from cash machines, eftpos etc). Ignore any money you won during your gambling sessions. Dollars spent on gambling: $...............

4. Approximate total annual household income (record the number of the

response ie. 1-7)

(1) $20,000 (2) $20,000–$30,000 (3) $31,000–$50,000 (4) $51,000–$100,000 (5) $101,000–$200,000 (6) $201,000–$500,000 (7) $501,000+


Co-existing issue screens 1. Alcohol Use (AUDIT-C) (record the total score)

One standard drink is 30 ml straight spirits (two nips/shots, one double), 330 ml can of beer or 100 ml glass of wine. • How often did you have a drink containing alcohol in the past year?


• How many drinks did you have on a typical day when you were drinking in the past year? (1 or 2 drinks = 0, 3 or 4 drinks = 1, 5 or 6 drinks = 2, 7 to 9 = 3, 10 or more drinks = 4)


2. Drug use (record the code for the response No = 0, Yes = 1)

In the past 12 months, have you ever felt the need to cut down on your use of prescription or other drugs?

3. Depression (record the total number of positive responses (0 = no to both, 1 or 2))

• In the past 12 months, have you often felt down, depressed or hopeless? • In the past 12 months, have you often had little interest or pleasure in doing

things? 4. Suicidality (record the number of the response that best fits)

Within the last 12 months: Have you had thoughts of self-harm or suicide (0) No thoughts in the last 12 months (1) Just thoughts (2) Not only thoughts, I have also had a plan (3) I have tried to harm myself in the past 12 months

5. Family/whānau concern (record the code for the response No = 0, Yes = 1)

In the past 12 months, has anyone in your family/whānau worried about your health or wellbeing (including spiritual health)?


Family/affected other full intervention screens The family/affected other full intervention screens are made up of the: • Family/Affected Other Harm Screen (see section 6.4.3) • gambling outcomes screens (see section 6.4.4) • co-existing issue screens (these questions are the same for gamblers and affected

others) (see section 6.4.5). Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Family/affected other harm screen For screening people for the impact another person’s gambling problem has had on them, use the Full Family/Affected Other Screen.

Introduction/opening statement: Sometimes someone else’s gambling can affect the health and wellbeing of others who may be concerned. The gambling behaviour is often hidden and unexpected, while its effects can be confusing, stressful and long-lasting. To help us identify if this is affecting your own wellbeing could you answer the questions below to the best of your ability.

1. Awareness of the Effect of the Gambler’s Gambling (record the number of the

response) Do you think you have ever been affected by someone else’s gambling? (0) No, never (you need not continue further) (1) I don’t know for sure if their gambling affected me (2) Yes, in the past (3) Yes, that’s happening to me now





(1-5)


3. Support requested (response not recorded) What would you like to happen? (Tick one or more.) I would like some information I would like to talk about it in confidence with someone I would like some support or help Nothing at this stage

Family/affected other outcome screens This form can be filled in by the client or with the practitioner. The statements below are about the person who was gambling at the time you sought help, and about you. 4. Gambler’s Gambling Frequency (record the number of the response)

Which of these four statements is true about the person’s gambling over the past three months ? (Tick ONE box only.) (0) The gambler in my life has not been gambling during the last three

months. (1) The gambler in my life has been gambling less during the last three

months. (2) The gambler in my life has been gambling about the same as usual

during the last three months. (3) The gambler in my life has been gambling more than usual during the

last three months. 5. Coping with the Gambler’s Gambling (record the number of the response)

Which of these three statements is true about your ability to cope with the person’s gambling over the last three months ? (Tick ONE box only.) (1) I am coping better with the Gambler’s gambling than I have in the past. (2) I am coping about the same with the Gambler’s gambling as I have in

the past. (3) I am coping worse with the gambler’s gambling than I have in the past.


Co-existing issues screens 1. Alcohol Use (AUDIT-C) (record the total score)

One standard drink is 30 ml straight spirits (two nips/shots, one double), 330 ml can of beer or 100 ml glass of wine • How often did you have a drink containing alcohol in the past year?


• How many drinks did you have on a typical day when you were drinking in the past year? (1 or 2 drinks = 0, 3 or 4 drinks = 1, 5 or 6 drinks = 2, 7 to 9 = 3, 10 or more drinks = 4)







Within the last 12 months: Have you had thoughts of self-harm or suicide (0) No thoughts in the last 12 months (1) Just thoughts (2) Not only thoughts, I have also had a plan (3) I have tried to harm myself in the past 12 months




Follow-up gambler screens The gambler follow-up screens are made of the: • Gambler Harm Screen (see section 8.7.1) • gambling outcomes screens (see section 8.7.2) • co-existing issue screens (these questions are the same for gamblers and affected

others) (see section 6.4.5). Practitioners should use their judgement about whether these screens are required.

Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Gambler harm screen 1. Gambler Harm (record the total score)

The Gambler Harm Full Screen is scored by the client’s response to each question (never = 0, sometimes = 1, most of the time = 2, almost always = 3) • Since we last talked, how often have you bet more than you could really afford

to lose? • Since we last talked, how often have you needed to gamble with larger amounts

of money to get the same feeling of excitement? • Since we last talked, how often have you gone back another day to try to win

back the money you lost? • Since we last talked, how often have you borrowed money or sold anything to

get money to gamble? • Since we last talked, how often have you felt that you might have a problem

with gambling? • Since we last talked, how often have people criticised your betting or told you

that you had a gambling problem, regardless of whether or not you thought it was true?

• Since we last talked, how often have you felt guilty about the way you gamble, or what happens when you gamble?

• Since we last talked, how often has your gambling caused you any health problems, including stress or anxiety?

• Since we last talked, how often has your gambling caused any financial problems for you or your household?


Gambler outcome screens 2. Control over gambling (record the number of the response)

During the past month: (1) I have had complete control over my gambling Or (2) I have had some control over my gambling Or (3) I have had little control over my gambling Or (4) I have had no control over my gambling

3. Dollars lost (record the response)

In the last month when you were gambling, roughly what amount of money did you spend on gambling? This is the total amount of money in dollars that you used on your gambling activity/ies (ie, money you took to gamble with PLUS any additional money you obtained and gambled with such as from cash machines, eftpos etc). Ignore any money you won during your gambling sessions. Dollars spent on gambling: $...............

4. Approximate total annual household income (record the number of the

response) (1) < $20,000 (2) $20,000–$30,000 (3) $31,000–$50,000 (4) $51,000–$100,000 (5) $101,000–$200,000 (6) $201,000–$500,000 (7) $501,000+


Co-existing issue screens The practitioner may deem it appropriate to reassess the client for co-existing issues during follow-up. 1. Alcohol Use (AUDIT-C) (record the total score)


(Never = 0 / Monthly or less = 1 / Two to four times a month = 2 / Two to three times per week = 3 / Four or more times a week = 4)

• How many drinks did you have on a typical day when you were drinking in the past year? (1 or 2 drinks = 0 / 3 or 4 drinks = 1 / 5 or 6 drinks = 2 / 7 to 9 = 3 / 10 or more drinks = 4)

• How often did you have six or more drinks on one occasion in the past year? (Never = 0 / Less than monthly = 1 / Monthly = 2 / Weekly = 3 / Daily or almost daily = 4)






Within the last 12 months: Have you had thoughts of self-harm or suicide? (0) No thoughts in the last 12 months (1) Just thoughts (2) Not only thoughts, I have also had a plan (3) I have tried to harm myself in the past 12 months




Follow-up family/affected other screens The family/affected other full intervention screens are made of three sets of questions: • Family/Affected Other Screen (see section 8.8.1) • Family/Affected Other outcomes screens (see section 8.8.2) • Co-existing issue screens (these questions are the same for gamblers and affected

others) (see section 6.4.5). Instructions for what information should be entered into CLIC for each screen is in bold italics ie. (record the total score).

Family/affected other harm screen For assessing the impact another person’s gambling problem is having on your client, after they have received a full intervention, use this variation of the Full Family/Affected Other Screen for follow-up.

Introduction/opening statement: When you were seeing our service regularly you described your awareness of the effect of their gambling on you and a range of effects that the person’s gambling was having on you and your family. I would like to ask you some similar questions to see how your awareness and feelings about the other person’s gambling has changed.

1. Awareness of the effect of the gambler’s gambling (record the number of the

response) Do you still think you are being affected by someone else’s gambling? (1) I don’t know for sure if their gambling affects me (2) Yes, in the past (3) Yes, that is still happening to me now





(1-5)


Family/affected other outcome screens This form can be filled in by the client or with the practitioner. The statements below are about the person who was gambling at the time you sought help, and about you. 3. Gambler’s gambling frequency (record the number of the response)

Which of these four statements is true about the person’s gambling over the past three months? (Tick ONE box only.) (0) The gambler in my life has not been gambling during the last three

months. (1) The gambler in my life has been gambling less during the last three

months. (2) The gambler in my life has been gambling about the same as usual

during the last three months. (3) The gambler in my life has been gambling more than usual during the

last three months.

4. Coping with the gambler’s gambling (record the number of the response)

Which of these three statements is true about your ability to cope with the person’s gambling over the last three months? (Tick ONE box only.) (1) I am coping better with the Gambler’s gambling than I have in the past. (2) I am coping about the same with the Gambler’s gambling as I have in

the past (3) I am coping worse with the gambler’s gambling than I have in the past.


Co-existing issue screens Use your discretion to determine whether it is appropriate to reassess the client for co-existing issues during follow-up. 1. Alcohol use (AUDIT-C) (record the total score)


(Never = 0 / Monthly or less = 1 / Two to four times a month = 2 / Two to three times per week = 3 / Four or more times a week = 4)

• How many drinks did you have on a typical day when you were drinking in the past year? (1 or 2 drinks = 0 / 3 or 4 drinks = 1 / 5 or 6 drinks = 2 / 7 to 9 = 3 / 10 or more drinks = 4)

• How often did you have six or more drinks on one occasion in the past year? (Never = 0 / Less than monthly = 1 / Monthly = 2 / Weekly = 3 / Daily or almost daily = 4)






Within the last 12 months: Have you had thoughts of self-harm or suicide? (0) No thoughts in the last 12 months (1) Just thoughts (2) Not only thoughts, I have also had a plan (3) I have tried to harm myself in the past 12 months




Appendix 2: Intervention Planning Tools

Agreed intervention plan (gambler) A possible intervention plan for a gambler is as follows. Name/ref ........................................................................................................................... My goal(s) (write down your initial goals or tick from the list below): 1 .................................................................................................................................. .................................................................................................................................. 2 .................................................................................................................................. .................................................................................................................................. 3 .................................................................................................................................. .................................................................................................................................. Possible goals

I will attend our agreed sessions – initially this will be .......... sessions. I will ask my partner/husband/wife to participate by .................................................

(eg, authorising you to confirm I am attending sessions; inviting them to attend a session with me in the future)

Start a budgeting plan Exclude myself from ................................. by ..........................................................

or Reduce my gambling to............................................................................................. Ready myself to get work Start an exercise plan and carry it out Improve my social life by (eg, rejoining a club I used to belong to) Reduce risk by...........................................................................................................

(eg, telling my gambling friends I’ve stopped; having a break to see what stopping is like; staying away from gambling venues even if just going out for a drink)

Reduce risk by listing all the triggers that set me off gambling (and adding to the list on a regular basis, their times when most powerful, and people I may be around)

Avoiding these situations that can trigger the gambling (and developing ways to ensure I act straight away to avoid them)

Contact a support group if available and attend Use the Gambling Helpline as another support (both during and after treatment

has been completed) Appoint a support person who could provide an independent opinion of my

progress following treatment

Name ................................................................. Phone/contact......................................


Practitioner I (or the treatment provider) agree to: • provide help and counselling to assist you to achieve your goal/s • will endeavour to return your calls promptly • provide you with follow-up information and advice about your progress following

treatment.

Planned review dates of goals and progress once monthly two-monthly Other ............................................

(use new sheet for updating or renewing goals) Agreed: (client)...............................................................................................................

(practitioner) ..................................................................................................... Date...................................................................................................................................

Agreed intervention plan (family/affected other) A possible intervention plan for a family member is as follows. Name/ref ........................................................................................................................... My goal(s) (write down your initial goals or tick from the list below): 1 .................................................................................................................................. .................................................................................................................................. 2 .................................................................................................................................. .................................................................................................................................. 3 .................................................................................................................................. .................................................................................................................................. Possible goals

I will attend our agreed sessions – initially this will be .......... sessions. I will ask my partner/husband/wife to participate by .................................................

(eg, authorising you to confirm I am attending sessions; inviting them to attend a session with me in the future)

Start a budgeting plan Ready myself to get work Start an exercise plan and carry it out Improve my social life by (eg, recontacting friends) Appoint a support person who could provide an independent opinion of my

progress following treatment Name.................................................................. Phone/contact......................................


Practitioner I agree to: • provide help and counselling to assist you to achieve your goal(s) • will endeavour to return your calls promptly • provide you with follow-up information and advice about your progress following

treatment.

Planned review dates of goals and progress once monthly two-monthly Other ............................................

(use new sheet for updating or renewing goals) Agreed: (client) ...............................................................................................................

(practitioner)...................................................................................................... Date ...................................................................................................................................


Follow-up agreement A sample follow-up agreement is reproduced below. Client ID:............................................................................................................................ We would like to reconnect with you one, three, six and 12 months after our contact finishes. We greatly appreciate you completing this follow-up as we like to know how you are. It also helps us to plan better services. I agree to receive a telephone call to complete the follow-up screen questions and discuss my progress with a staff member. YES / NO (circle one) Name:................................................................................................................................ Signed: .............................................................................................................................. Date: .................................................................................................................................. The best telephone number to use to contact me is: .................................................................. or ............................................................... Instructions: .......................................................................................................................................... .......................................................................................................................................... I would prefer an appointment to complete the questionnaire and discuss my progress with a staff member. YES / NO (circle one) Name:................................................................................................................................ Signed: .............................................................................................................................. Date: .................................................................................................................................. Please contact me by phone: ............................................................................................ OR Address: ............................................................................................................................ Please keep in touch and let us know if you change your address. Thank you.


Appendix 3: Review and Assessment Tools The following tools are examples of review assessment forms you may use as part of your review with a client before closing a full intervention episode.

Review tools: The gambler A sample review assessment form for a problem gambling client.

Name/ref:

Overall

1. Your progress How well would you consider you have achieved your goal/s?

Very well Quite well Average Not well

2. Our performance for you How well did our service meet your needs when you attended?


How could we improve?

Thank you – please hand this to your practitioner.


Review tools: Family/affected other A sample review assessment form for a family member.

Name/ref:

Overall

1. Your progress How well would you consider you have achieved your goal/s?


2. Our performance for you How well did our service meet your needs when you attended?


How could we improve?

Thank you – please hand this to your practitioner.


Review tools: Practitioner Your sample review assessment form follows.

Client’s name:

Practitioner’s name:

Practitioner’s review assessments How well do you think your client has progressed? (Complete periodic reviews.)

a) Review Excellent progress Good progress Some progress Little progress

Comments (brief): ............................................................................................................. ........................................................................................................................................... ........................................................................................................................................... ...........................................................................................................................................

b) Review Excellent progress Good progress Some progress Little progress

Comments (brief): ............................................................................................................. ........................................................................................................................................... ........................................................................................................................................... ...........................................................................................................................................

c) Review Excellent progress Good progress Some progress Little progress

Comments (brief): ............................................................................................................. ........................................................................................................................................... ........................................................................................................................................... ...........................................................................................................................................

Final review on completion therapy or exiting service Excellent progress Good progress Some progress Little progress

Comments (brief): ............................................................................................................. ........................................................................................................................................... ...........................................................................................................................................


Review tools: Support person A sample review assessment form for a support person follows.

Support person’s response at final review (if nominated by the client) How well do they think the client has progressed since............ (date accessing service)?

Excellent progress Good progress Some progress Little progress Comments (brief):............................................................................................................. .......................................................................................................................................... .......................................................................................................................................... ..........................................................................................................................................


References Durie M. 1994. Whaiora Māori: Health development. Oxford University Press.

Durie M. 1999. Te Pae Mahutonga: A model for Māori health promotion. Unpublished paper. Palmerston North. School of Māori Studies, Massey University.

Minister of Health, Associate Minister of Health. 2002a. He Korowai Oranga: Māori Health Strategy. Wellington: Ministry of Health.

Minister of Health, Associate Minister of Health. 2002b. Whakatātaka: Māori Health Action Plan 2002–2005. Wellington: Ministry of Health.

Ministry of Health. 2005. Preventing and Minimising Gambling Harm: Strategic Plan 2004–2010. Wellington: Ministry of Health.

Ministry of Health. 2008. Data Collection and Submission Manual. Wellington: Ministry of Health. URL: http://www2.moh.govt.nz/problemgambling. Updated 1 July 2008.

Ministry of Health. 2008. Data Management Manual. Wellington: Ministry of Health. URL: http://www2.moh.govt.nz/problemgambling. Updated 1 July 2008.

Paton-Simpson & Associates Ltd. 2005. CLIC Database Manual (v14). URL: http://www.p-s.co.nz/CLIC_manual.php. Updated 25 June 2008.

Pere R. 1984. Te Oranga o Te Whānau: the Health of the family in hui Whakaoranga Māori Health planning workshop, Hoani Waititi Marae, 19–22 March 1984.


http://www2.moh.govt.nz/problemgambling

http://www2.moh.govt.nz/problemgambling

http://www.p%1Es.co.nz/CLIC_manual.php

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