Keeping it Simple
While it’s a great example of primary health care establishing a dedicated gambling programme, the Primary Care Gambling Service in South London is not a model that most primary care health services could follow. Supporting people with issues arising from behavioural or substance disorders requires expertise – though medical experise will be part of the support, dealing with physical and arising mental and emotional issues.
Ideally, a localised community-centred integration of health, social care and specialist services would allow for a move towards holistic support and reduce obstacles encountered on pahways to treatment.
There are specialist doctors, nurses, social workers and others but the competence level of the sorely pressed frontline worker needs basically to require awareness of gambling arms and health and wellbeing, and knowledge about referral networks. Many health and social care professionals continue to urge colleagues to be aware of the issue and, where an individual does not volunteer information, sensitively screen very simply for distress related to gambling.
Between basic awareness and knowledge levels, itself of immense value, and specialist staff such as found in the South London example, there are opportunities for frontline staff to develop competences. Here, as with so much, as well as individual staff influence, much will be guided by the specific service’s response to identified community needs.
Understanding and responding to gambling-related harm: A brief guide for professionals
This free online learning course from the Roayal Society for Public Health has been developed in collaboration GambleAware. Our online course will provide useful guidance for people who want to provide brief interventions to address risks and harms related to gambling disorders.
The course is split into five key sections – with interactive elements to maintain your attention and make learning easier. At the end of each section, you’ll find a Revision Quiz to help boost your learning.
Topic 1: Introduction to Gambling Disorder
- What gambling is
- Gambling statistics
- What Gambling Disorder is and the impact it can have
- The possible signs of Gambling Disorder to look out for
Topic 2: What is a brief intervention?
- Definitions of brief intervention
- Information about brief interventions
- Why we should offer brief interventions
- Research into the effectiveness of brief interventions
Topic 3: How to Provide a Brief Intervention
- Screening as a basis for intervention
- Preparing for brief intervention
- The knowledge base supporting brief intervention
- Elements of a brief intervention
Topic 4: Important Considerations and Responding to Affected Others
- Cultural considerations and brief intervention
- Overcoming potential barriers
- Resources for family and affected others
Topic 5: Getting your Organisation Ready (optional)
- Project initiation
- Consulting within the organisation
- Project planning
- Ongoing improvement
Screening and Referral
Magdalena Boo, Health Improvement Principal, Sheffield City Council recommends the simple Lie/Bet screen. Have you ever lied about yor gambling? Have you ever bet more than you can afford to lose?
She provides a flowchart for screening and referral, noting:
This (embedded PDF) flow chart guides affected individuals or clinicians through the screening process and enables them to identify which support is most appropriate for them at that time. Clinicians can help engagement in support services by completing online referral forms for patients and booking follow up GP appointments to check progress and engagement. There is low engagement in help-seeking and help is often only sought in a crisis such as a mental health or financial crisis, so if someone does present for help it is likely that they are at a very low point. There are emerging links between problem gambling and suicide so it is important to assess whether there is any immediate risk and follow suicide prevention protocols.
Co-morbidity or Dual Diagnosis
Is someone drinking because they’re depressed or depressed because they’re drinking, or both? That’s a classic example of difficulties faced by GPs. In the case of gambling, there is plenty of evidence to demonstrate not only that gambling is often seen with heavy drinking, for instance, but that it also causes intense emotional and mental distress, and further to this there is much evidence that the activity of gambling is for many a coping mechanism, a ‘self-medication’ to escape distress. There is also a great deal of evidence to show that gambling disorders, addictions and other serious mental health disorders share a common source in adverse childhood experiences. Such complex interplays are often emedded in contexts of negative social, cultural, economic and educational inequalities. As ever, the borders between ‘personal health’ and environment are very thin if they exist at all. Add to this that a dispassionate, not overly-cynical, perspective on mental health and addiction services would have to see the need for urgent improvement, something true of all public services.
Against any pessimism arising from considerations of complexity it can’t be said often enough that the best quality of human interaction can rise above constraints (and the ‘best’ service design will be useless without that prime quality). Cliches exist because they are true, and it is an historical record of individuals in all walks of life reporting thatt their lives changed for the better because of meeting somebody with that quality. It is equally true that an individual in the greatest of distress and hardship owns powers to endure and overcome. Similarly, communities in ‘data zones’ showing dreadful indicators of health, poverty, all-round deprivation are made of individuals and each is as much a unique individual as one in a leafy suburb: there can’t be one-size-fits-all solutions to the unique individual’s needs.
Also against pessimism, we should remember that many people ‘recover’ with little or modest intervention. Often their needs are more straightforward, and perhaps they are supported by family and other close people, with employer support, good levels of social and cultural capital. We need to remember too that a third of people with behavioural disorders recover spontaneously with no support: this is most prominently seen in young adults who ‘mature out’ of harmful behaviours as they start a family.
Finally, having mentioned the leafy suburbs it is crucial to remember that people of any background can develop dosorders on the addiction spectrum. Priests, teachers, doctors, politicians all share one thing with us: they are human. It’s important to identify that gambling disorders are more likely in individuals from communities impacted by inequality but we need to be wary of stereotyping and stigmatising ‘addiction’ as located only in communities already heavily stigmatised by all the markers of deprivation.
The details below show the possibilities arising with comorbidity:
Comorbidities and Gambling Disorder
Nurses and healthcare personnel working in any setting should be aware of the comorbidities that may accompany a patient’s problem gambling: alcohol/substance abuse (Black & Shaw, 2008; Lorains et al., 2011; Rash et al., 2016; Rodda et al., 2012, 2016; Streich et al., 2020; Wareham & Potenza, 2010); anxiety (Black & Shaw, 2008; Lorains et al., 2011; Rodda et al., 2012); ADHD (Black & Shaw, 2008); depression (Black & Shaw, 2008; Lorains et al., 2011; Quigley et al., 2015; Rodda et al., 2012); panic attacks (Lorains et al., 2011); severe legal and financial issues, such as job loss, lost time and lost productivity, theft, fraud and embezzlement, bankruptcy, divorce, healthcare problems due to high stress, prison time and homelessness (National Endowment for Financial Education & National Council on Problem Gambling, 2000); suicidal ideation/attempts (Goldman, 2013; Hills, 2010; NorthStar Problem Gambling Alliance, 2013; Russel, 2014); obesity (Streich et al., 2020); nicotine dependence (Lorains et al., 2011; Rodda et al., 2012; Streich et al., 2020); binge eating disorder (Yip et al., 2011); ACES or adverse childhood experiences (Sharma & Sacco, 2015); manic depressive disorder (Black & Shaw, 2008); homelessness (Stein & Stinchfield, 2020), using or taking dopamine for Parkinson’s Disease which may increase the incidence of GD (Stein & Stinchfield, 2020); domestic violence (NorthStar Problem Gambling Alliance, n.d.) and PTSD (Najavits et al., 2011).
Genetics definitely play a role in gambling disorder, with some twins studies elucidating exactly how genetics and GD relate. Studies show that there is considerable evidence for the influence of genetic factors on GD, along with complex interactions with both environmental factors as well as other psychiatric disorders. Lobo and Kennedy (2009) argue for the further study of genetic and biological factors and their impact on GD in order to develop more specific and finely targeted prevention and treatment strategies.
Taylor and Francis Online Volume 40, 2021
Two Useful Resources: Dual Diagnosis
Dual Diagnosis can sometimes be a misleading term since many will have more than two diagnoses. Multiple diagnoses or comorbidity are more accurate terms in this case. Turning Point have produced two thorough resources for healthcare professionals, Dual Diagnosis Good Practice Handbook and Dual Diagnosis Toolkit. The focus is on mental health and substance disorders (which may well relate to a person with gambling difficulties) but the general principles carry over.
Materials for Staff and Patients
It is useful to promote services which support gambling harms. This could be done with leaflets and poster in community spaces. In health and similar settings more focused displays are beneficial such as leaflets and posters in waiting rooms which encourage people to speak with staff, for instance the GP, about their gambling.
We’re in the process of designing basic materials which will appear here shortly.