There has been and remains an implicit separation of ‘addiction services’ and ‘mental health services’. In practice this has led to individuals being directed from one place to another without ideal integraation of treatment. Yet why is there this separation? Addiction is surely a severe mental illness, and a very pervasive one with some estimates suggesting that one in ten of the UK population are addicted to something. People with existing conditions such as depression and anxiety, and more serious ones such as bipolar disorder, are far more likely to become addicted. Addiction itself worsens such conditions or may give rise to them.
There are, it’s true, good reasons for having expert support with addiction just as people need expert treatment for cancer, but all health conditions in an ideal world would best be understood as aspects of health. Mental health and physical health are inseparable, but in practice the latter receives more resources than the former. Addiction is a mental health disorder but often receives less attention than other forms of mental and emotional distress. Gambling addiction receives less attention than other addictions.
Like any health condition, treatment is often far from enough. A range of factors need addressing according to an individual’s life circumstances. With regard to mental health, it’s long been recognised that health is inseparable from personal factors such as debt, homelessness and relationship breakdown, and the wider impacts of poverty, inequality, exlusion and discrimination, unemployment, poor education and low cultural capital.
Professionals and support providers do what they can, but many of the influences on poor health require political action. Services try hard to integrate social care with medical care. and this can improve life for people. Hopefully, with specific focus here upon gambling as a health problem, further efforts towards integrating support will continue to grow positively.
We examine some aspects of addiction and psychology at HABIT OR ADDICTION? on our site, The Machine Zone. This provides an overview of how we can form habits or become addicted. Gambling addiction shares common features with any addiction.
David A.Porter outlines how the diagnostic ‘bible’ used by psychiatrists has come to include compulsive gambling as an addiciton:
The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition) has recognized gambling as a potential behavioral addiction. Addiction or dependency is typically viewed as the physiological and psychological dependence on a chemical substance. Dependence is defined as needing progressively larger amounts of a substance to acquire the same effect that used to be experienced, a characteristic physiological and/or psychological syndrome that emerges in response to cessation of use, and compulsive use despite consequences. The concept of dependence is being increasingly applied to, or considered for, behaviors such as gambling, as well as shopping, sex, exercise, eating, and using electronic media. The DSM-5 notes that gambling is the only behavior that is currently included as a behavioral addiction (American Psychiatric Association, 2013). In the DSM-IV, (Diagnostic and Statistical Manual of Mental Disorders, fourth Edition), pathological gambling was classified as an Impulse Control Disorder NOS (Not Otherwise Specified). In response to a growing knowledge base of the neurological basis of problem gambling, which has commonalities with addiction; pathological gambling was moved to the Addictive Disorder category (Reilly & Smith, 2013).
The DSM (5th and most recent edition) characterises someone suffering from gambling disorder thus:
Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period:
- Needs to gamble with increasing amounts of money in order to achieve the desired excitement.
- Is restless or irritable when attempting to cut down or stop gambling.
- Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
- Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).
- Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed).
- After losing money gambling, often returns another day to get even (“chasing” one’s losses).
- Lies to conceal the extent of involvement with gambling.
- Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling.
- Relies on others to provide money to relieve desperate financial situations caused by gambling.
There are many examples on this site of personal experiences of gambling addiction. We’d like to just make some points here:
- Gambling addiction is NOT a character flaw, a failure of will or morality. It is a serious mental disorder and recognised as such by psychiatrists and doctors. One of the many, often seemingly insurmountable, problems gambling addicts face is that they are so often stigmatised as ‘bad’ even by those closest to them. They cannot explain to themselves or others why they act as they do. They feel a complete sense of isolation.
- Gambling addicts are usually convulsed with shame and guilt. They understand deeply the harm they are doing to others such as their family.
- Unlike substance addiction which attracts at least some sympathy and support from individuals and society at large, gambling addicts have much fewer sources of support.
- Like all addictions gambling addiction can strike anybody, from whatever part of society. It has recently been estimated that online gambling addiction is associated very strongly with richer people. But, although amounts wagred may be much less, there is also strong evidence that people living with multiple deprivation suffer disproportionally from gambling harms. As an example of high spending, here a former army major talks about how he lost £750,000 through online gambling. He warns of an oncoming ‘catastrophe’ for young people if action is not taken. Although our focus is upon FOBTs, the online betting experiences can be identical. The UK government is currently looking at advertising, particularly on television, which leads people to online gambling opportunities.
Let’s face it. Millions upon millions of words about mental health and addiction, and indeed health in general, have been written. Everybody has their own ideas. These together are contradictory and don’t provide simple ‘answers’.
(For those interested in reading as part of their recovery, the above book is very popular). The experience of trying to make sense of things does indeed resemble shaking a kaleidoscope and finding new patterns, as much for the individual in distress as for service providers. Note that Maté includes a ‘spiritual’ dimension. This reference to the spiritual may conjure up all sorts of negative ideas but for many people, not only the religious and the ‘spiritual but not religious’, the word may point to something important. Atheists can be ‘spiritual’. In recent years, large organisations such as the World Health Organisation, the NHS and Royal College of Psychiatry have recognised the importance of spirituality. The RCP has a page about it here.
What a topic like spirituality does bring to the table, even if you reject the word, is the importance to an individual of having deep meanings to life. For an addict meaning is centred upon the object of addiction. Everything else fades and disappears. Deep meanings can include things like family, friendship, work. They may be a cause such as a political cause, or the value of giving to others. They may involve a close attachment to hobbies and activities such as photography or sport.
The psychiatrist Viktor Frankl survived most of the second world war in concentration camps because he was used as a doctor. He wrote a book (Man’s Search for Meaning) in which his central insight is that the dreadful conditions of the camps brought people to their kneees, physically, mentally and spiritually Yet some died very quickly. Others in identical circumstances survived. Those who survived, he said, had deep within them some core meanng to their lives; for some it was religion, for others it was their family outside the camps, for some it was music or literature or writing, for some it was helping others. This idea of having a deep meaning for being (or reasons to be alive) is seen as crucial to surviving the sufferings life throws our way.
For that third of people with an addiction who recover without help or expert support, perhaps it’s because a deep meaning entered their life to push aside the attachment to destructive behaviour, such as starting a family or getting involved with community activities. There is a recognition in mental health services that such finding of meaningful activities is a tremendous boost. Many mental health recovery services (which includes addiction) recognise this by providing a range of activities from horticulture to drama, from writing groups to sports and outdoor activities. Sadly, with regard to specifically ‘addiction services’ financial cuts in recent years have seen many such opportunities lose funding. This is an example of the political and economic dimensions of mental health.
Another area of economics and politics regarding gambling and health attends to the roles of industry, regulation and legislation in preventing or minimising harms. Attention is paid, for instance to the effects of advertising and marketing, the design of gambling products which may exploit basic psychological vulnerabilities, the fitness of regulation and gambling laws, the funding of treatment, research and education.
Mental health, addiction, disability and many other campaigners have long fought to challenge the status quo of poor recognition and funding for resources and services. Such campaigning has been about raising awareness and challenging stigma. There does appear to be an institutional stigma against addiction in relation to mental health. Common conditions such as anxiety and depression seem to receive most attention (which also serves to deflect attention from the most serious disorders such as schizophrenia, one of the most highly stigmatised of all health conditions). Such institutionalised stigma is largely unconscious, and it is not applicable to the many excellent initiatives and working practices of so many working within institutional settings such as the NHS or public health bodies. There are many positive signs of change and we need to keep the momentum going.
It is helpful for some to understand a little about the basic psychology behind addiction. To others it is not appropriate. In the midst of mental and emotional turmoil the last thing you need is more reading. Also, it is possible that some may use reading about addiction as a distraction from doing something about it. A bit like studying menus and never getting down to the meal. With that in mind this link will take you to some very basic psychology. It may help you deepen your understanding that addiction is an illness, not a moral failure.
Frontline Health and Social Care, Academics and Students
This link will take you to content relevant to your work. It may be of general interest to anybody interested in the field of gambling addiction.