Introduction

Demand for gambling treatment began to rise in Italy only after 2010 (Pavarin et al., 2018), in parallel with the market’s exponential growth, after addiction to gambling was officially acknowledged with Law 220/2010. Since then, access to treatment has remained low and availability varies across the country. According to the National Research Council (Benedetti & Molinaro, 2020), 1.57% of Piedmont’s residents between the ages of 18 and 84 (approximately 50,000 people) are “problem gamblers”, defined on the basis of the CPGI (Canadian Problem Gambling Index) as being people who are at “moderate risk” or who report having gambling problems. However, only 1,155 people, or about 2% of the estimated target, turned to public addiction services to treat their gambling problems in 2018 (Diecidue et al., 2020). Though this percentage does not take into account those who turn to private services, it is even lower than the approximately 10-20% found by international studies (Ladouceur et al., 2001; Suurvali et al., 2008; Dąbrowska et al., 2017).

Furthermore, the often belated decision to turn to a service is chiefly driven by a crisis such as job loss, a separation, being caught stealing, etc., rather than by a personal decision based on the recognition of having a gambling problem (Evans & Delfabbro, 2005). Seeking help, in fact, is often a process imposed by the gambler’s family members when the economic and/or legal costs of gambling have made the problem clear and undeniable (Evans & Delfabbro, 2005; Suurvali et al., 2009; Dąbrowska & Wieczorek, 2020).

Identifying barriers that prevent or delay attempts to seek help is thus crucial to implementing effective measures for reducing the negative outcomes of problem gambling, which affect families and society as a whole as well as individuals (Suurvali et al., 2009; 2012). As Dąbrowska and colleagues (2017) note, the previous literature on barriers, most of which originates in the English-speaking countries, tends to classify barriers as either individual or structural. The main individual barriers are denial, belief that one can face the problem alone, shame, pride and the desire to keep the problem secret (ibidem; Suurvali et al., 2009). However, studies are generally based on surveys where respondents are asked to choose barriers from a closed-ended list, which limits the researcher’s ability to achieve a better understanding of the gamblers’ perspective (Dąbrowska et al., 2017). A study involving both help-seeking and non-help-seeking gamblers (Pulford et al., 2009) and using a mixed-method approach which also included open-ended answers reported pride, shame and denial as the barriers that are most frequently experienced—or, as the authors put it, “real”—and perceived by both targets.

Building on this reasoning from a sociological perspective, we argue that the main barriers generally regarded as individual actually originate from social and cultural representations. Indeed, stigma is a theoretical concept and it is not obvious that gamblers will recognize it as a factor that prevents them from seeking help, which is a limit when considering only barriers that are in fact perceived and recognized as such. Public stigma—defined as the reaction of society towards a group of people by defining them by their condition or problem using judgement and labeling (Dąbrowska & Wieczorek, 2020)—could thus play a larger role in blocking help-seeking than that found by previous studies, by increasing both shame and resistance to admitting the problem.

Public stigma attached to gambling has been confirmed by several studies showing that people with gambling problems are often depicted as “idiots”, immature, irresponsible individuals, who tend to lie and lack willpower ((Hing et al., 2015, 2016a; Horch & Hodgins, 2013; Dąbrowska & Wieczorek, 2020). Studies have also shown that hiding the problem is the main coping strategy used by people with gambling problems to manage stigma (Dąbrowska & Wieczorek, 2020; Carroll et al., 2013; Hing et al., 2014; Horch & Hodgins, 2015).

Public stigma obviously has a negative impact on the self-perceptions of people with gambling problems, who end up internalizing judgements and feeling stupid, weak and unable to manage their own lives (Dąbrowska & Wieczorek, 2020; (Hing et al., 2015, 2016a; (Hing & Russell, 2017a, b). Internalization of stigma, or self-stigmatization, is in turn devastating for self-esteem and self-efficacy ((Hing et al., 2016a; (Hing & Russell, 2017a, b; Dąbrowska & Wieczorek, 2020), which are key factors in successful recovery from gambling and other addiction problems (Yang et al., 2019; Toffanin, 2004; Vasiliadis & Thomas, 2016).

Structural barriers include lack of awareness/knowledge of services and treatment options, accessibility, costs and other practical issues (Dąbrowska et al., 2017). The existence of a range of differentiated services—such as self-help groups; financial, legal and relational consultancy; assistance at the gaming venue; online support desks—seems to be almost ignored (Suurvali et al., 2009; Gainsbury et al., 2014). Furthermore, even if problem gamblers are aware that treatment services exist, perceptions of their low quality and effectiveness can also pose barriers (ibidem), as can concerns about their cost (Rockloff & Schofield, 2004; Gainsbury et al., 2014). Some barriers relate to specific contextual and organizational aspects, like where treatment takes place. For instance, whether treatment is offered in separate, specialized services, by more general addiction services, or by psychiatric facilities also affects stigmatization processes (Dąbrowska et al., 2017). Other studies have found that to facilitate undertaking treatment and its success it is important to address gamblers’ motivation and their expectations about treatment (Pfund et al., 2020), which in turn can be influenced by public opinion about general or specific types of treatment service.

Though a full understanding of the barriers to help-seeking is crucial in designing actions that can encourage problem gamblers to engage with treatment (Gainsbury et al., 2014), to the best of our knowledge no studies on the topic have yet been carried out in Italy. However, an earlier qualitative study focusing on gambling trajectories in Piedmont (Rolando et al., 2019) found several barriers concerning local public addiction services in particular, viz.: (1) a general lack of knowledge about these services; (2) the belief that they only treat addition to illegal substances and the resulting stigma; (3) the conviction that treatment is necessarily aimed at total abstinence rather than at controlled gambling.

To address the gaps in methodological and geographical knowledge mentioned above, the present study aimed to gain insights into the cultural and social barriers to help-seeking in an Italian region, using qualitative methods to explore the gamblers’ point of view (Suurvali et al., 2009; Baxter et al., 2016).

Methodology

Recruitment

The study sought to include both gamblers under treatment and people who were not being treated. Interviewees were recruited in three provinces in Piedmont (northwestern Italy), viz., Cuneo, Torino and Verbanio-Cusio-Ossola. Part of the sample was then recruited among gamblers under treatment at a local addiction unit, with the help of the staff members. By agreement with the researchers, they presented the study to all gambler clients and proposed that they participate. Another part of the sample, whom we will call “externals” for brevity, was approached by the interviewers either directly outside gambling venues or through informal channels (acquaintances, word of mouth, Facebook groups, private psychological/ psychotherapy groups, Gamblers Anonymous groups). The only eligibility criterion was the declared awareness of having/having had a problem with gambling and having tried to solve it. Both sub-groups of the sample (public service clients and externals) were constructed to assure a minimum level of demographic heterogeneity.

Sample

The final sample consists of 30 participants equally divided between clients and externals, both including interviewees of different gender, age, educational level and game of choice. In line with the typical problem gambler’s profile (Cerrai et al., 2018), most interviewees are male, aged between 40 and 60 years and attracted mainly by AWPs, or slot-machines. Among the externals, 8 out of 15 were not in treatment at the time of the interview, 5 belonged to Gamblers Anonymous groups, and one was being treated privately by a psychologist and by a naturopath. Even among those who were not in treatment at the time of the interview, 3 had previous treatment experiences (see Table 1).

Table 1 Participants’ sociodemographic data
Full size table

Data Collection

Interviews were conducted between December 2020 and January 2021 by trained interviewers, and took place either in rooms made available by the addiction units or in other locations agreed on with the interviewees. Because of the pandemic, most participants chose to be interviewed online, using the Zoom or Skype platforms. We adopted a narrative approach, using semi-structured interview guides designed to allow participants to follow their train of thought so that their experiences and beliefs could emerge as freely as possible. Interview guides covered several key topics, focusing in particular on the process which led to the awareness of the problem and the need for help, the factors that led to or hindered help-seeking and entry into treatment, and representations of gambling and services available for gamblers.

Interviewees were informed of the study’s aims and that their anonymity would be guaranteed in accordance with current privacy legislation. Interviews lasted 45/50 minutes on average, while those with externals were generally shorter. Interviewees were allowed to interrupt the interview at any time and/or resume it on a later occasion if desired. This was sometimes the case, for example, in online interviews, when the interviewee was not at home alone and was afraid of being overheard by family members.

Data Analysis

Each interview was recorded and transcribed verbatim. The audio files were then deleted and the transcriptions were identified with an alphanumeric code, and all personally identifying information was deleted. The alphanumeric code for each interview indicated the number of the interviewee, gender, age and condition (in treatment or external).

As suggested by the literature (Wickham & Woods, 2005), coding was conducted with the help of Atlas.ti, a computer-assisted qualitative data analysis software package, which guarantees data traceability and makes it possible to return to the primary documents at any time throughout the analysis process. Coding followed an abductive approach (Timmermans & Tavory, 2012), based on both research questions and emerging findings. The coding scheme was thus based on a list of “family codes” corresponding to the main topics covered by the interview guidelines (gambling habits, key moments in the gambling career, others’ representations of gambling/gamblers, the gambler’s own representation of the problem, motives/factors related to the decision to ask for help, motives/factors related to the decision not to ask for help, opinions on treatment). Each family code was then developed in the coding process by creating a list of (sub)codes, assigned to similar sub-arguments emerging from the data (e.g., for factors related to the decision to ask for help: internal reasons, external reasons, facilitating factors, hindering factors, expectations, access channels).

In line with the theoretical background, in-depth analysis considered several family codes, i.e., not only perceived factors related to the decision to ask/not to ask for help, but also others’ and the participants’ own representations of gambling and gamblers, which interviewees may not perceive as barriers, and key moments in gambling careers.

Results

The main types of reasons gamblers tend to be reluctant to seek help despite having gambling-related problems are summarized below. Some were explicitly identified as barriers to treatment by interviewees, while others such as stigmatization processes were consciously recognized as barriers less frequently, though their role in hindering access to services was clear from the narratives. We will start with stigma, since it provides a useful background for understanding the other factors—(mis)representation of gambling issues and treatment services—with which it is also intertwined.

Stigma

The vast majority of interviewees reported feeling or having felt strongly judged for being involved in gambling, both by their family members and friends and by society in general. In their narratives, episodes in which they were insulted and belittled were recurrent, and the opinion that non-gamblers regard those who gamble as having weak or dubious morals was common among the interviewees. According to them, gamblers are commonly represented as “people without dignity and willpower”, “inept”, capable only of “wasting their lives”, destroying and ruining family affections and “squandering money” in a socially inappropriate activity. As the interviewees’ words show, the gamblers are likened to deviants, variously portrayed as “drug addicts”, “junkies” or “mad”. Social stigma is often internalized by the gamblers themselves, to the point of self-loathing, as can be seen from the following quotations where gamblers agree with others’ insults, ending in self-stigmatization (Dąbrowska & Wieczorek, 2020).

[Society thinks that gamblers] are fools. Yes, I’m a fool, because I gambled too… I think so! Fool is the only word for it! (8_M_58_U)Footnote 1

[People Think that] you’re a good-for-nothing, and that’s all. […] Right, Because it’s true! (19_VB_M_50_E)

People think a gambler’s depraved […]. A gambler’s somebody you shouldn’t have anything to do with, because he’ll drag you down into vice and so on and so forth, certainly he’s not well regarded by people. And rightly so! (24_M_43_E)

Like other addictions (Beccaria et al. 2015), gambling is thus still seen as a “vice”, a morally repugnant habit. The following quote highlights how the road to full acceptance of problem gambling as a health problem is a long one, and how this acceptance is not taken for granted even among gamblers themselves, who have bought into the dominant social representations.

Understanding the difference between a vice and an illness is something that… it’s very difficult, isn’t it, but it’s very difficult for the gambler himself, not just for the people around him. Usually the people around you, starting from the closest relatives: mother, father, wives, kids; they’re little but they already judge you. They judge you because you did this, you did that, you’re unreliable, you’re worthless, all that stuff, right? They judge you because you’re a moral weakling, essentially. […] A dissolute person, somebody that’s unlikely to be thought of as a sick person. Somebody… that’s thought of as dissolute because he throws his money away […]. I think a gambler is seen a bit as … a bad person, essentially. (24_M_43_E)

Though representations and self-representations of the gambler as dissolute, helpless in the face of gambling’s addictive power, were more frequent among the participants we classified as “externals”, some addiction unit clients also expressed this concept. Such representations also imply a lack of confidence in one’s self-control and, consequently, the idea that abstinence is the only possible way recovery can take place. This can be seen, for example, from an interviewee’s reasoning about mechanisms of self-exclusion from gambling, introduced in Italy—as in other countries—as a harm reduction measure envisaged by “responsible gambling” policies.

When they tell you that you can self-exclude for a while: somebody who’s caught up in this vortex can never get out, if they don’t quit entirely. So either you don’t let them get in touch with gambling any more so that you ban them forever or…[it’s useless] because people who gamble so much are like drunkards who stop drinking but the minute they have a couple of beers again they’re right back where they started. And unfortunately gambling is OK [only] for people who don’t fall into the vice, I mean… it’s OK to gamble… I don’t think gambling’s a disease. (15_M_41_U)

Some interviewees reported that, after entering treatment, they were relieved to be recognized as “‘sick’ people in need of treatment on a par with those suffering from Parkinson’s or Alzheimer’s” (18_M_52_E), since this freed them, at least in part, from feeling “guilty” about their condition. However, even representing gamblers as sick people addicted to gaming and unable to control themselves can weigh on gamblers’ self-esteem, as can the “pity” that this condition arouses.

Maybe the first thing people feel when they see a situation like this is exactly a kind of pity about the fact that a person isn’t able to control themselves and fell into this trap so easily. Isn’t that right? Like maybe when somebody comes to your door to sell you something and then it’s clearly a scam, but you let them in, you let them string you along, and they manage to make you fall for their pitch. (25_M_34_E)

Even when gamblers were not openly criticized, they were still conscious of a prejudice against them, as one interviewee reported while maintaining that this is to some extent unavoidable and therefore to be accepted.

Maybe behind my back a lot [of people criticize me] I think […] not openly, but behind my back certainly, […] I’ve learnt: some [criticism] I just let roll off me, because you can’t live like that, with somebody pointing their finger at you, can you? Let’s say, no, you can’t, because at the end you have to accept that too […] that’s just the way it is, it can go on behind my back. (16_M_72_E)

Some interviewees associated the social stigma with widespread ignorance of the question among non-gamblers, and specifically to their lack of understanding of gambling dynamics and related problems. According to the interviewees, few people are able to go beyond a stigmatizing and simplistic representation of gamblers and fully understand the “dramas” that can lie behind a problematic relationship with gambling.

Oh, well, certainly there are people who think differently, some people think [that the gambler is] a criminal, a failure, worthless, just wants easy money, and there’s the more intelligent person who says, who knows, who knows what drama, maybe, or what kind of situation this person is living with at home to throw himself into gambling like that. (15_M_41_U)

It is easy to understand from the interviewees’ accounts why shame and self-depreciation are recurrent among gamblers. However, alongside internalizations, some interviewees also reported more “explosive” externalizing reactions such as real outbursts of anger.

My family especially launched really bad insults, things that really weren’t nice at all […], to tell the truth, sometimes I got really upset, maybe punching the wall or the table, sometimes, unfortunately, without wanting to, I even laid hands on my mother. But since my mother was somebody who once she started off talking had a pretty sharp tongue, and then I just couldn’t stand that, maybe by laying hands on her I mean a shove or maybe sometimes I maybe even gave her a couple of slaps, yes, I have to be honest, because the insults hit so close to home that I just couldn’t hold myself back. (15_M_41_U)

Though others’ criticism may have had a constructive effect for some interviewees and perhaps led them to cut back on their gambling, the most common way to avoid being judged was found to be hiding one’s gambling. This is why some interviewees reported that they gamble far from their homes.

If I stayed in town there’d certainly be judgement because it’s a small town and people talk. There’d be judging by the people who live here, by my neighbors… but I never gave anybody a reason to talk about… about this thing here. (11_M_58_U)

Misperception of Gambling Problems

As we have explained, being aware of having a problem does not necessarily lead the gambler to seek treatment, but it is undoubtedly one of the most important prerequisites (Evans & Delfabbro, 2005). Among the interviewees, denial of the problem was most common in the subgroup of “externals”. As the following quote shows, sometimes the mistaken ideas about the odds of winning lead people to believe that they do not have a problem.

The fact is, I think—I’m convinced, or at least I was convinced a long time ago—there’s a way to win, and that’s what made me rule out the fact that I might have a problem of some kind, because in a way, part of me is still convinced, that there’s a way to win. And this thing doesn’t let me, um… I mean, to think that I’m entirely out [of the gambling habit]. (25_M_34_E)

In other cases, the issue consists mainly in recognizing the nature of the problem. Some interviewees’ narratives revealed that the representation of gambling as a bad habit rather than a disease makes gaining awareness slower and more difficult, because of the idea that solving the problem is a matter of individual willpower, rather than of professional help.

To me, it was just a vice and nothing more, I mean I didn’t see it as a problem, for me it wasn’t a mental problem, I didn’t consider it an illness, I considered it a bad habit and so let’s say, yes, at the end when I say enough is enough, I only need to have more willpower to say myself “Don’t gamble”. But in the last ten years, when I started […] looking for psychological help, I started to think that maybe there was a problem that I couldn’t get out from under on my own. (15_M_41_U)

Because you always think you can quit [gambling] on your own, you have this thought that in the future, you always put it off to the future… telling yourself: “Yes, later I’ll quit, it’s just momentary, I’ll be able to get clear of it on my own, it’s useless to tell other people about it.” (29_ M_30_E).

In all cases, the perception of having a problem did not come suddenly, but developed in a slow process of reflection unfolding over several months (6 or 7 on average in the interviewees’ accounts), in which gamblers gradually recognized signals that help them focus on their feelings and actions. The first “alarm bell” was often the enormous amount of money spent, the guilt felt after losing and the stress and anxiety, including panic attacks.

In past years I realized it but went ahead anyway, then bit by bit it started to come home to me, in fact […] for example I had these attacks where my heart would start racing, it happened especially—and always—in the worst moments when maybe I had spent more. And so it happened… I knew I was doing the wrong thing, I was doing it, and in that instant I’d have these attacks. (10_M_53_U)

Other alarm bells that eventually rang for the interviewees were social isolation, i.e., the gradual abandonment of acquaintances and interactions with one’s family and friends, changes in the sleep-wake rhythm or in self-care (e.g., irregular eating habits), or even suicidal ideation.

I could tell I needed help […] I felt really down, I felt as if I didn’t have the will to live any more, thinking awful thoughts, thinking even… about suicide [cries]. (14_F_61_U).

In other cases, the interviewees reported that the impetus for change came when they “hit rock bottom.” From this standpoint, the most effective motivator for quitting gambling comes with having reached a maximum level of problematic consequences and feeling “contempt” for oneself and for gambling.

And then you have to have a motivation, you have to be disgusted by the business, you have to look at the bottom from below and after you’ve looked at it from below then [you can do something] […] When you’re a bit down either you stop or … you’re at a crossroads: either you become a complete wreck or… […]. [You have to feel] disgust and even repugnance! […] it’s the first step, if you’re not disgusted with yourself, you can’t stop. (22_M_45_E)

“Hitting rock bottom” often coincides with critical events, such as bankruptcy or frauds, that bring the problem out into the open, precipitating the situation and spurring others—in most cases family members—to give the gambler an ultimatum.

I remember one time, I had the credit card and I gambled money I shouldn’t have gambled. Winning money, I thought I was going to win money and then to make up for my losses I doubled down and kept on playing and getting my wife to give me money and I lost it all. That’s when my wife goes: Enough! (23_M_55_E)

So, this strong message I got from my father, who’s the authority figure here […] in the sense that… he scared me: either you quit or otherwise you’re not going to get anything from me at all. (18_M_51_E)

With the desire not to lose, disappoint or alienate one’s family or friends, thinking about their well-being and their needs thus becomes the main motive for seeking treatment.

I was upset because […] I could see my son, my wife who were… getting further and further away: we got the point where it was just “hello” in the morning and “good night” in the evening, there wasn’t anything anymore, there wasn’t any dialog any more. Yeah, I was there, I slept on the sofa for six months, so… […]. When I understood that I was about to lose everything, I said: “Chill, you’d better chill, because otherwise…”, I went into a therapeutic community. (7_M_64_U)

Maybe it [the decision to go into treatment] has to do with the fact of being afraid for the family, of ruining the family… (11_M_58_U).

It was mostly my partner, she gave me an ultimatum […]. Either you quit or you lose me and I’m not going to help you anymore. One day she came right out and said: I’m not sure any more that I’m going to stay with you anymore, and I was afraid. (15_M_41_U)

Representation of Addiction Services

The interviewees’ narratives suggest that seeking help of any kind is usually the result of pressure from family or friends. What form of treatment is chosen depends on the interviewees’ information resources. Often, the decision is not based on comparing the available options, but simply follows the suggestion of some authoritative voice who is part of the gambler’s network. This means that people do not consciously choose the aims of their treatment path. The following excerpt, for instance, shows how a man joined Gamblers Anonymous without even knowing what its methods and goals were.

Where my wife worked, […] there was a lady and she told her: “Look, I’m doing so-so…” and [the lady] gave her the number of Gamblers Anonymous; and so my wife came home and said, “Look, I found this number, for Gamblers Anonymous”, ok… (16_M_72_E).

Interviewees were unfamiliar with both private and public addiction services before entering treatment. In addition, they had had mistaken ideas about what the public services did. Most interviewees stated that they used to associate local addiction units only with drug addiction, which contributed to discouraging them from seeking help. According to the interviewees, gamblers tend not to turn to the local addiction units because they think of them as the “methadone places […], for junkies (11_VB_M_58_U)” and therefore to be avoided, in order not to be labeled as deviant or dissolute. Accordingly, they believe, the public addiction service needs to work on improving its image.

Maybe it’s also a bit because of what people go around saying about this kind of agency. In the sense that if you hear that somebody’s ended up there, it’s something like… “Ah! They got him with that [illegal substance] and he ended up in the addiction unit”, I mean it’s something maybe a bit… socially unacceptable. Probably if they changed the service’s name and ran some ads on TV […] where they said you can call this number and then you can come to this new office, probably some people would do it. (1_M_36_E)

In some cases, scepticism about the addiction unit surfaces and is linked to a lack of confidence in the efficiency and effectiveness of public services in general. In most cases, however, prejudices about these services disappeared once the interviewees got to know them.

Honestly, I thought I would find the classic government thing that’s absolutely worthless, you know what I mean? The classic thing where they bounce you back and forth like a tennis ball, but for everything, you know? Where you have to struggle with all the bureaucratic stuff in order to get anywhere, you know? (9_M_38_U)

Let’s say that the addiction unit […] I’d heard it mentioned for drug problems, so for me it was always a service that: “I don’t take drugs!” […]. And then I discovered that they don’t do just that, but also these gambling treatments and I have to say that it’s been very positive for me. (13_M_24_U)

A further barrier is the perception of the addiction unit as “far” from gamblers; according to interviews, the services should not wait for gamblers to come to their facilities once the problem is out in the open, but should adopt outreach strategies to contact people in gambling venues. As one interviewee pointed out, this would be more effective than the information and warnings that gambling providers are required by law to post in venues and on electronic gaming machines, which also include the telephone number of treatment services.

I wish that people who maybe don’t have my character, but who really need a hand to get out of this, had some help from the addiction unit staff, but they don’t have to wait for gamblers to come to them, because nobody’s going to come, are they? It’s true that going to point a finger at somebody “You’ve got problems, come with me and I’ll help you” isn’t easy. But a phone number in front of a slot machine doesn’t do any good. (9_M_38_U)

The cost of treatment can also be an obstacle to seeking help, since not everyone knows that treatment provided by public services is free. Conversely, private psychotherapists’ fees are sometimes seen as creating a conflict of interest incompatible with a genuine concern for the patient.

[There’s] also a question of cost because at the end I imagine it costs money. So let’s say that could be an obstacle for a lot of people. (29_M_30_E)

In Milano it wouldn’t be possible to find somebody like that… partly because she [the private therapist], once she closes her studio in the evening… you think she gives a fuck about me? What she gives a fuck about is her 150-euro bill that I pay. (11_M_58_U)

Discussion

The study sought to add to the understanding of the cultural and social barriers that prevent problem gamblers from entering treatment in a northwestern Italian region, where a huge proportion of the need for help remains unexpressed.

First, the study found that, in Italy as in more extensively investigated countries, gambling is still socially conceived as a “bad habit” and thus a question of individual responsibility, while the concept of gambling as a health problem struggles to gain ground. As reported by international studies, the conception of gambling as a moral problem and not as a disease has an impact on social acceptance and leads people to be ashamed of their discomfort, thus making it more difficult to ask for help ((Hing et al., 2014, 2016a, b; Petry & Blanco, 2013). In line with previous literature, interviewees’ narratives showed that gamblers introject the moral disapproval they perceive at the social level, and thus end up thinking of themselves as guilty and intrinsically weak (Dąbrowska & Wieczorek, 2020; Wöhr & Wuketich, 2021). Self-stigmatization, however, can undermine the sense of self-efficacy which is recognized as necessary for motivation and for treatment to succeed (Toffanin, 2004; Vasiliadis & Thomas, 2016). Also, the idea that “hitting rock bottom” is the first essential step on the road to recovery, which was embraced by treatment communities in the ‘90s (Coletti & Grosso, 2012) and is still present in people’s representations of addiction, may actually contribute to delaying help-seeking, making treatment more challenging.

Stigma and moral disapproval appear to be directed towards local addiction units as well as to gamblers. This is a longstanding problem in Italy, where it is even more deeply entrenched than in other European countries because of the specific history of addiction treatment and the larger role the Catholic Church has had in framing the issue (Beccaria & Rolando, 2013; Beccaria et al., 2015). Though they were introduced earlier, local addiction units spread during the 90’s to cope with the AIDS epidemic among people who used heroin by injection, thereby entering into competition with the therapeutic communities which at the time were almost all faith-based and took a moralistic approach (Beccaria & Rolando, 2013). People using heroin were represented by mass media as criminals and considered a “social scourge”, while local addiction units were accused by therapeutic communities—detractors of methadone substitution treatment—of being “state pushers” (Beccaria et al. 2015). Even today, though a range of addiction services (local addiction units, communities, anonymous support groups, etc.) have evolved in parallel to adapt to the needs of an increasingly diversified target, the public services were seen by some interviewees as exclusively dedicated to treating drug addiction and associated with a stereotypical and stigmatizing image of the “junkie” (Rolando et al., 2019).

To fully understand the interviewees’ discourses about people with substance use disorders, it should be borne in mind that this can be interpreted as a strategy for coping with stigmatization, consisting in cognitive distancing from another, even more stigmatized group, as it has been observed in Poland (Dąbrowska & Wieczorek, 2020; Dąbrowska et al., 2017).

Beyond the internal and external stigmatization processes (Dąbrowska et al., 2017), lack of knowledge of the services and types of treatment available for problem gamblers, as well as the perception of their low quality and efficacy (Suurvali et al., 2009; Gainsbury et al., 2014) were found to be significant barriers, especially for public services. Furthermore, interviewees were generally ill-informed about the diverse types of treatment available for them, and many stated that they were not aware of their treatment path’s goals when they embarked on it. The fact that gamblers do not consciously choose the goal of their path is a risk factor for continuing with treatment (Dowling et al., 2009). Among other misrepresentations, the belief that treatment is necessarily aimed at total abstinence rather than controlled gambling—a barrier also found in other parts of the world (Blaszczynski, 1998; Robson et al., 2002)—may be even more persistent in Italy because of the predominance of Catholic therapeutic communities until the recent past.

This study’s findings may have practical applications in increasing the rates of help-seeking. The first and most straightforward implication is that public and private treatment services should provide more information about the treatment they offer, making its goals and methods clearer. For instance, Gamblers Anonymous groups—like most therapeutic communities—are oriented towards total abstinence, while public services generally contemplate self-regulation and harm reduction as possible aims. This would make it possible to disambiguate the different services, as well as to combine them as needed for the patient. Furthermore, the message that public addiction services are free of charge should be more effectively conveyed, since lack of money is itself a barrier for many gamblers (Rockloff & Schofield, 2004). As other authors (Dąbrowska et al., 2017) have suggested, setting up separate facilities specifically for gamblers could increase help-seeking because of stigmatization that may attach to other addictions and/or psychiatric problems. Other options might include developing outreach services or online counseling (Rodda et al., 2013) which would help attract people who, for many reasons, do not want to access onsite services.

However, to encourage help-seeking, it would be even more important—and difficult—to try to modify the stigmatizing social representations of gambling problems and gamblers. De-stigmatization of gambling and increased information at community level would also help problem gamblers’ relatives and friends be better able to offer emotional, informational and material support, which is recognized as crucial for entering and remaining on a treatment path (Wieczorek & Dąbrowska, 2018). We do not believe that this can be achieved through informational and educational interventions alone: what Brown and Russell (2020) call “advocacy actions” are crucial. The latter authors use this term to mean interventions aimed at reframing the problem, shifting the focus from the individual to the collective level. This type of action will necessarily involve multiple targets, not only gamblers and their families, but also communities, services, stakeholders and policy makers. Furthermore, specific attention should be given to media narratives and the rhetoric adopted by the industry and policy makers (Rolando et al., 2020). For instance, the “responsible gambling” message, endorsed by the gaming industries themselves, reinforces the idea that people are responsible for their own gambling problems (Hing et al., 2016a; Miller & Thomas, 2017), sidelining the fact that games and gambling venues are specifically designed to attract gamblers and keep them hooked on gaming. Advocacy interventions should thus seek to expose the gambling industry’s tactics and the “addictive” properties of games, thus shifting the responsibility—and blame—from gamblers to the industry and policy makers, who should protect the population from the damage caused by gambling (Thomas et al., 2016; Yücel et al., 2018; Miller & Thomas, 2017).

Conclusions

The present qualitative study investigated social and cultural barriers to seeking help and access to services for problem gamblers in Piedmont, a region in northwestern Italy, where the number of gamblers in treatment is even lower than international estimates. Based on interviewees’ opinions and experiences, we argue that stigmatization of gambling and the treatment services—public local addiction units in particular—is the most significant barrier to accessing treatment. It is thus crucial to take action to reduce the stigma associated with both gamblers and the services assigned to their care, with a combination of informational and advocacy interventions.