Complex Needs Require Expertise
Gambling often comes with other ‘fun’ activities such as smoking and drinking. The strong risks that smoking and drinking may kill you or make life misery don’t deter people. Even gamblers who should know a thing or two about risks don’t stop when the fun brings horrific hangovers or lung disease. Dependence and addiction are sly. Couple them with underlying depression and anxiety which they amplify, and deteriorating physical health, and we begin to see how support and treatment need expert unravelling of all the factors – which may include debt, unemployment, poverty, relationship breakdown. In ongoing distress people may drink more, use drugs, smoke more and gamble more.
Smoking, drinking, drugs and gambling
It is usual for health providers to separate alcohol from ‘drugs’ despite alcohol’s being a hard drug which globally represents by far the most damaging harms to a person’s health, wellbeing and life itself. Modern research increasingly shows that even ‘modest’ drinking is implicated in serious illnesses. It’s estimated that one in eight Americans meet the diagnostic criteria for alcohol dependence syndrome. Add to that the role of alcohol in violence, murder, domestic abuse, suicide and widespread mental and emotional distress to drinkers and those around them. Most drinkers do so ‘responsibly’ though as said there is a growing scientific consensus that there is no safe level of drinking. The UK guidelines for ‘low risk’ drinking limit intake to 14 units a week, about six pints of beer, not to be repeated every week, and not to exceed 4.5 units on any day, about two pints.
Unfortunately, many people, mainly men, who experience gambling harms also have a tendency to drink far too much for their own good, smoke, or take other drugs. As people tend towards degrees of addiction and dependence a shared characteristic across behaviours is denial to self and others. Taking tobacco as an example not all the facts and figures, statistics, even the horrifying images on cigarette cartons of corpses or diseased lungs will deter some smokers. Something else is going on. We are not, though we like to think we are, rational creatures all the time. Something deeper is driving us. It is probably a universal experience of people with or nearing addiction that a war goes on in their heads: I desperately want to stop doing this. I desperately want to continue doing this.
Cross-Addictions and Comorbidity
Comorbidity refers to the existence of two or more ‘disorders’ which run together. It may refer, for example, to compulsive gambling and alcohol dependence. It often refers to the co-occurrence of mental health conditions and addictive tendencies. Depression and anxiety (and these two commonly occur together) may be the root states that drive a person to seek relief whatever the consequences. Or the use of drugs and gambling may cause such disorders and amplify them. Some of the rarer and most severe disorders carry with them a high risk of developing substance and behavioural painful consequences: people with bipolar condition, for instance, are 50% more likely than the general population to suffer from such consequences.
Another phrase used for comorbidity is ‘dual diagnosis’. In practice this often means that because ‘addiction services’ are set apart from ‘mental health services’ a person may be denied treatment for depression, for instance, until ‘addiction services’ have sorted out their substance or behavioural problems. We have tried to explain our unhappiness with the word addiction . It is encouraging that the word ‘alcoholic’ is slowly being replaced with ‘alcohol dependence syndrome’, a step in the right direction to reduce stigma. But no such new words spring to mind for gambling addiction and it remains a word, unpleasant as it is, that continues to point people to what is meant. Many gamblers will refer to themselves as having or having had an addiction and, of course, the NHS and third sector organisations headline their ‘addiction services’. What the word points to is a devastating mental health condition, and we hope that before long it is fully integrated into health and social services.
Unique Individual, Tailored Treatment/Support
We hear a lot about ‘person centred support’ and ‘holistic treatment and support’, these taking into account the unique circumstances of each individual. In practice unfortunately, there can be a one-size-fits-all approach coupled with an often arbitrary provision of services and pathways – where appropriate services are available at all. A person with gambling difficulties may have serious underlying health conditions including mental health issues, serious stressors particularly debt, relationship breakdowns and unemployment. Another gambler may face only serious debts, while another may find themselves in prison arising from desperate measures to combat debt. Not every gambler with major problems is an addict but every addict will have major problems arising from the addiction. As mentioned above, some people wit one addiction will have another, or may replace one addiction with another. Suffering from negative gambling consequences while harming body and mind with alcohol or other drugs, almost invariably with accompanying mental and emotional distress, sometimes with suicidal ideation, complicates the picture greatly. Denial and stigma are obstacles to seeking help, but when help and support are sought, for many they prove inadequate and unsatisfactory. And when a recovery process does begin it is far more the case than not that a person will suffer ‘relapses’. One person may be lucky enough to have family, spouse or friends support; others may face harsh judgment and ostracisation. The ‘legacy’ period after active addictions or heavy dependence will include factors such as money and debt stressors, regaining trust, finding employment and coping with stigma. These will impact on states of depression and anxiety. A sense of boredom and emptiness is common and may trigger a return to unhealthy behaviours. Such is the mental and physical damage incurred by years of alcohol dependence that a long period of post acute withdrawal syndrome (PAWS) may last as long as seven years while the body and mind repair. Couple drinking with gambling, which has its own ‘withdrawal syndrome’, and it can be a very long road characterised by troughs of depression and anxiety.
That’s the bad news but most people have a better time of it. The luckier oness are able to recover well quite easily with minimal help, and many recover with no expert clinical support. One=to-one peer support, 12-steps and SMART Recovery benefit lots of people. And remember not to be dismayed by worst cases. Up to 30% of people stop spontaneously with no support; they decide to stop and stop. The main point is that there is no typical ‘addict’ because there is no typical individual. Services that provide support, often beginning with a GP, have to be especially sensistive to achieve as far as is possible an understanding of all the factors involved in an individual’s distress, and know that long term help may be required, and that the spectrum of pains cannot be eased with prescriptions for medication important as these may be when used appropriately to meet individual needs.
There are national third sector services offering support online and by telephone but the advice given is often (as reported by users) ‘generic’, as if the ‘problem’ fits into a neat box and can be addressed by a neat set of bullet point stages (which often include referral elsewhere). While NHS gambling clinics are learning as they grow and not magic bullets with 100% success rates, they do provide professional expertise, experience and knowledge of worthwhile support such as peer aid networks. Scotland should keep pushing for such expertise.