Co-morbidity

when gambling illness comes with other conditions

We saw in the previous page how drinking or using other hard drugs may make an individual’s distress more complex as an experience, and more complex to treat. On this page we explore forthe rthe concept of co-morbidity.

Distress caused by gambling and alcohol or other hard drugs often comes with psychological states such as depression or anxiety. This is known clinically as comorbidity

It is very common for addiction not be considered as a mental disorder. It is conceptually separated from ‘mental illness’. In practice we see Mental Health AND addiction services. This can mean in practice that an individual is shuttled between two different forms of support service. Added to this the individual will be referred to debt services, legal services, housing services and so on.

A little reflection may result in accepting that addiction must be seen as inside mental health, not as something separate. Besides the social and personal consequences of addiction such as deterioration  of mental and physical health, debt, unemployment, relationships breakdown etc., the subjective experience of addiction is one of great emotional distress. Addiction may result from existing emotional distress. It will certainly amplify pre-existing suffering. A person may suffer from two or more addictions such as gambling and alcohol dependence. Additionally they may have had underlying but unrecognised mood disorders such as depression or anxiety. Depression itself, to take one example, manifests in many different ways. Like all emotional distress it can’t be put into a neat box containing other neat boxes that someone can tick. It’s more like a tangle, difficult to express. The point is that a unique individual will have a unique whirlwind of negative experiences. Hence the call for a person-centred approach to treatment, Rather than fitting an individual into neat boxes, what needs attending to is the deeply human individual experiences.

For many decades the issues around comorbidity have been recognised. There have been projects which address the problems arising. There are clinics and other services which do treat the whole person rather than addressing, for instance, depression and addiction separately. One issue that emerges generally though is that doctors and other health staff don’t feel qualified to understand addiction. This is reflected in the bizarre lack of reference to addiction by mental health charities. Where it is mentioned it is often in passing and seen as something separate to ‘mental health’. Some organisations ignore it entirely. On the other hand, many addiction specialists and organisations similarly focus on ‘a person with an addiction’ rather than just a person with unique emotional experiences.

Much confusion arises because we have all been medicalised. Clinicians, including psychiatrists, tend  to like things ‘scientific’. They work with neat diagnoses with no fuzzy edges. They split human experience into ‘disorders’ such as schizophrenia, depression or borderline personality disorder. Then they fit an individual into their boxes. Not all clinicians, of course, but this is the dominant tendency. problem here is that the symptoms of one ‘disorder’ are also found in a different one: for instance, the psychotic experiences such as hallucinations occur in many conditions (and  hallucinating or hearing voices are possible in ‘healthy’ people).  Another big issue is that three different psychiatrists may arrive at three different diagnoses. And across the world different cultures have differing conceptions of  ‘mental illness’, diagnosis and treatment. Evidence also shows that cultures with less reliance on medication than the USA and Europe have vastly superior outcomes for people with severe emotional distress  than those seen in London or New York.  In the context of ‘mental’ or mind ‘disorders’ such neat classification systems are usually followed by neat prescriptions – such as medications coupled with twelve sessions of cognitive behavioural therapy. Ignoring the fact that access to the latter may involve a long wait, for many people CBT is inappropriate, despite its success elsewhere. As for medications such as ‘antidepressants’, unfortunately for almost half of people who take them they provide little or no benefit, coupled with the fact that withdrawal from such medication can entail severe distress for some.

To all this must be added the massive negative effect on our understanding of mental health that a dominant clinical approach can have. At worst it can imply that addiction or some other emotional distress is a ‘disease’, or brain chemicals gone wrong, isolated in the brain of an unfortunate individual. It ignores the entire context of our emotional well being and ill being. It is demonstrated time after time that we are affected by our environments which include our relationships, our work, our housing, income, employment, and our position in the social ‘pecking order’. The values and norms we adopt from society can be toxic if aspects of those norms and values are toxic. None of us escape this. There is no perfect ‘mental health’. Our well being fluctuates. We all have good days and bad days. Some may be barely functioning and the final straw can bring breakdown.

Some of us eat too much, drink too much, smoke too much, take drugs to sedate or make us high, or engage in a large number of unhealthy behaviours despite ‘knowing’ they are bad for us. A little imagination shows how easy and understandable it is that some take things too far, bit by bit slipping down unconsciously into danger zones. What does it say about our society that in lockdown restriction off-licences were allowed to say open as ‘vital services’? Or that we added billions of pounds of profit to the gambling industry using our digital devices? Indeed, using those same devices what does our frenetic shopping activity say about us?

There are, and probably never will be, any neat answers to all this, though millions of words have been spilt discussing the issues. In practice, if somebody is addicted to gambling and/or alcohol they need immediate support now, today, this minute. The rest is clearing ground for the future to provide greater understanding, new ideas motivated more by imagination than data, better treatment. As well as a ‘whole person’ approach we need to develop a ‘whole systems’ approach which sees health as arising not only from individual factors but from all the social and cultural factors that go towards the making of the individual.

Maybe we should abolish the concept of comorbidity which implies two or more neatly separated ‘conditions’. In fact some psychologists want to abolish the notion of ‘mental health’ itself, replacing it with ’emotional well being’. The word ‘mental’ is itself full of stigma. ‘Health’ means wholeness, what we used to call hale and hearty. It is much more than a bundle of symptoms and neat diagnoses which only are ever used when a person is deemed to be unhealthy. There are great examples from the very many people who live relatively healthy lives. There are so many things we recognise that need to be removed for people at population level to move towards health. These things all fall under headings such as injustice, exploitation and inequality. While we need to fight fires today we can look to extinguish them in the future. Rather than intense focus on states such as addiction we can encourage a broader view of human potential. To encourage means to give heart. Instead of backward looking concentration on sickness, we can restore health as that which is hale and hearty.