Gambling in the Context of All Addictions

There are several reasons to include other addictions when thinking about gambling addiction:

  • While the nature of addiction varies between types (as well as between unique individuals) much of the research in substance and other behavioural addictions can throw a good light on the nature of addiction generally.
  • It seems, in particular, that neuroscience points to common factors across addictions, involving specific neurotransmitters and learned neural pathways.
  • Many with gambling addiction suffer one or more other addictions.
  • Addictions of all types are strongly related to specific diagnoses of mental disorders which precede or follow addiction, or which accompany addiction, or all three.
  • Research into gambling, medical and other professional knowledge and expertise, and public awareness of gambling addiction are relatively sparse compared with more well known addictions. What has been learned and known about the latter can inform ways of seeing gambling addiction.
  • Debates about alcohol, substance and some behavioural addictions have been ongoing in most cases much longer than current gambling debates. Much disagreement exists beteen professionals, lawmakers, industry, people affected by addiction and the general public. Overviewing these controversies helps place gambling in context as many of the issues are identical. Of particular interest is the extent to which focus has been upon individual ‘pathology’ with lesser attention piad to wider factors which contribute to addiction. In some ways, these debates reflect those in the field of general mental health where an individual is seen as the centre of attention to the detriment of studying social, economic and other wider contributors to mental distress.
  • The presence of stigma against addiction is best looked at with a broad view of all addictions.
  • The relative underfunding and research around gambling, and a lack of support services is best understood by examining addictions generally. This will suggest that gambling addiction is particularly under-resourced.
  • Evidence about what works and what does not work in addiction education – in formal education and public health campaigns – is available for substance addiction, and this can inform developments in gambling education. Although alcohol and drugs education has been around for a long time, there has been no uniform approach to implementing it. Some emerging evidence suggests what doesn’t work – for instance, one’off ‘lecturing’, ‘thou shalt not’ approaches – there is relatively litle evaluation and pointers to good practice. We’ll be discussing this more on our site.
  • The questions around industry funded research and education have been highlighted with alcohol. For instance, it is claimed that industry funded initiatives may avoid discussion of subjects which cause discomfort to the funders.
  • Local councils have responsibility for commissioning addiction services (including NHS and Third Sector*) and may be likely to treat addiction generically rather than by type of addiction.
  • While it is true that addiction can afflict anybody, whatever their socioeconomic background and status, there are strong correlations between different sub-populations. For instance, adults who had adverse childhood experiences are more prone to mental health disorders including addiction. Poverty and other disdvantages also correlate with the likelihood of addiction. Studies across the field of addiction can examine such correlations more fruitfully than framing addiction as simply an individual pathology.
  • There are no neat divisions between harmful habits, compulsive behaviour, things called addictions metaphorically (e.g. shopping addiction), psychological dependence on behaviours or substances (without addiction), repeated deep modes of distraction (such as immersion in television or other screen activities). Clinically diagnosed addiction develops over time (gambling addiction has only relatively recently been admitted to clinical definitions; some psychologists include ‘internet addiction’). Many ‘normal’ behaviours such as immersion in social media offer distractions from the world. Psychological relief and life patterns provide both escape and security, so perhaps extreme addiction can be formulated as part of ordinary everyday behaviour.

Addiction’s a Jingle Jangle

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Coffee and biscuits in the atrium then the delegates move into the large lecure theatre.Professor McEwan welcomes them, expresses her pleasure that so many experts are assembled in the same venue. She is delighted to introduce the world famous Emeritus Professor Nathan Bronowski, acknowledged as one of the world’s leading authority on addiction. Fulsome applause accompanies his walk to the podium. Then follows an avuncular  talk interspersed with good humour which brings ripples of appreciate chuckling from the audience. Beautiful slides on the big screen bring images of complex neural activity, statistics and the chemical structures of the latest pharmaceutical medications which evidence has shown to be efficacious. He is humble enough in his lecture to acknowledge the work of others in the field, but he deftly dismisses their theories almost with sadness.

The day proceeds with further lectures and workshops in which various experts gather by speciality. A delicious banquet is provided in the university’s great hall in the evening, then delegates retire to the several bars. Somewhat ironically, some of them fail to hide their hopeless addiction to alcohol and make fools of themselves. Others, more fortunate, bond in pairs that find their way to the bedroom.

The second day, a little less enjoyable for those nursing hangovers or guilt, ends with Professor McEwan’s rapturous celebration of how successful her conference has been. The delegates disperse. Journalists from the BBC and the world’s leading media send their stories through the ether to sub-editors who will headline them with claims that huge advances in the treatment of addiction have been discovered. Within a week, everybody will have forgotten the conference and the media stories – except for Professor McEwan who will already be thinking about her next big event as she continues her ruthless climb towards the top of the academic tree. So it goes.

The proceedings of the conference are made available in a publication which, like most academic publications, costs a great deal of money to compensate for the fact that there will be very few buyers and even less readers. Perhaps a PhD student will discover it in a few years’ time and refer copiously to it safe in the knowledge that neither his supervisors nor the world at large will have the slightest inclination to examine the primary material. The said student may with equal safety discover and refer to perhaps a hundred or two such dusty tomes in a university library, and go on to produce a thesis which does indeed add ‘an original contribution’ to the field of research, a remarkable tapestry of totally random material made whole and coherent through the application of academic discourse. Such tapestries – and there are very many of them – reveal great skills of weaving and stitching  If the successful PhD candidate  is lucky and possesses rudimentary knowledge of self-promotion the thesis may be the basis of a reputation such that other academics and journalists will regard him or her as an authority. So it goes.

Those of us who are not academics and who lack the humility to look up to them, are not lacking in access to experts on addiction. Since most people are addicted to something or other these days, not surprisingly there is money to be made. Anybody can set themselves up as a private therapist, for instance. With some capital you can establish a recovery retreat centred around holistic principles and involving a diet almost totally of watercress: you could charge, say, £2000 a week. In publishing, there are so many magazine and newspaper articles, so many books that will cure you in a week, so much drivel on social media (a place people go to when they have lost the capacity to live in the world), so much of it all that I lack the will to say more (although doubtless a different kind of person may find it a rich area for PhD enhancement). Suffice it to say you could end your life still addicted having spent it reading about how to beat addiction or paying a fortune to people to beat addiction for you. Or eating watercress.

 

But addiction isn’t funny. And though it’s fine to be lighthearted about academia, we acknowledge too that getting a PhD, doing research are not easy. Most are doing their best to add a drop to the ocean of knowledge, most are passionate about their work, many are deeply motivated by wanting to make the world a better place. Like addicts, academics, are human beings first. An addict or an academic may be a murderer or a saint. Anyway, addiction isn’t something to be treated lightly. It’s certainly unlikely too that all the academic research in the world has made or is likely to make any immediate difference to an actual addict, a unique human addict. ‘Expert’ theorists of addiction argue wih other, often vehemently, defending their position and attacking their ‘opponents’. The situation is as bad or worse for us ordinary mortals who equally support this idea and strongly oppose that idea. 12 steps enthusiasts can be unshakeable in their belief of the power of the programme; others have a strong aversion to it. ‘Born again’ ex-addicts can be evangelistic: for them it’s not enough to have recovered, they have a mission to convert those left behind with ‘the indusputable truth of the way’.

In fact, addiction is a messy concept. We can get rid of the cases where it’s used metaphorically such that people say they are addicted to Game of Thrones or chocolate. We can be left with a clear idea of devestating addiction where life is slowly destroyed at many levels, but it’s still a pretty tangled concept. A jingle-jangle as Bob Dylan refers to in Hey, Mr Tambourine Man. The experience, the being, of addiction can’t be categorised neatly, objectively. Like severe depression (which often precedes, accompanies or follows addiction) the experience is different for every person. Even a gifted writer has trouble explaining what it is or was like for her or him, but there are some excellent addiction memoirs which demonstrate the uniqueness of the experience for each unique person. (There are also many more dreadful memoirs. Not everybody has the gift of writing well).

Nevertheless, there are some commonalities which most addicts would recognise. Some of these factors are overlooked, ignored or counted as unimportant in therapy and research. It is much more straightforward to categorise addiction as ‘impuse control disorder’ or to concentrate on the neural pathways involved in orbitofrontal cortical mediation: such precise ‘scientific’ approaches are neat and can be investigated, and do add something to understanding addiction. But they’re not the complete picture by any means. Many of the factors overlooked are subjective feelings which cannot be seen by the scientific gaze.

 

We could call these factors ‘the human factors’ since they appear in everybody, not only people suffering with addiction (and incidentally, ‘addict’ is a word loaded with negative connotations which is when used here is simply for brevity. The language of mental health is a serious topic in its own right).

In everyday language we are familiar with the word ‘shame’ which refers to a fear of what other people think of our wrong actions The word ‘guilt’ refers to our conscience, it’s a negative feeling brought on by judging ourselves. In addiction, both of these factors are greatly amplified, partly because of the damage caused to self and others, partly because the addicted person’s mind will be hyper-vigilant, in extreme anxiety which over-arouses negative feelings. And partly because of stigma – related to shame, the shame that society stigmatises, ‘casts out’ the class of people with addictions, and related to guilt because of self-stigmatisation. The addicted person as a member of society has internalised the norms and values of the culture, and is then in the terrible situation of ‘casting out’ themselves as worthless, not fit to be in public. It is not unusual to hear of people in such extreme states talk of hating themselves. Yet how can one ‘recover’ if one feels deeply that one is worthless? And, unsurprisingly, it is to be expected that people then feel ashamed of being ashamed like this, ashamed of feeling worthless – so they have to put on some sort of front, a mask just to survive in the family, in public, in the doctor’s office.

In many cases, especially in connection with gambling addiction, it will not be only the guilt, the shame, the loss of dignity and self-respect that goes with addiction. The person may well have done things that anybody would feel ashamed or guilty about. especially theft, conning people, perhaps violence.

Clinically the person will suffer to varying degrees from depression and anxiety. There may be complex underlying mental health issues that have never been diagnosed. Mental distress such as chronic depression may have been what led a person into addiction in the first place, a means of relieving pain through self-medication. Adverse childhood experiences are known to be particularly strongly correlated with not only addiction but other adult problems, and often the person may suffer from addiction as well as developmental problems. In the case of gambling addiction there is an extremely high correlation with alcohol dependence and/or other drug dependence.

People with addictions often present with what are called ‘multiple and complex problems’. Some are mentioned above. Others include imprisonment, homelessness, severe debt and long term unemployment.

We’re a long way from the lecture theatre and the academic research. In each individual any or all of the above factors may ‘cross cut’ through the central problem of addiction. It’s a reasonable supposition to claim that there are many who face a much harder road to ‘recovery’ than others. Reasonable but not always the case. Experience demonstrates that some facing the most severe obstacles not only beat addiction but turn their lives around. On the other hand, some who seem to ‘have everything going for them’ find it impossible to overcome their addiction. Sadly, not everybody does recover. But the majority do, and of that majority most do it ‘on their own’ with little or no help from doctors, support groups, books or social media gurus.

To label somebody an ‘addict’ is wrong not only because it carries a lot of negative stigma but because it misses the point that somebody suffering with an addiction is a unique person first and foremost, with a complex and singular individuality. There are therapists, doctors, psychologists, psychiatrists and others who can relate to the human factors, and through their art (as opposed to their science) provide some help. Help but not a magic wand. Maybe medication is a necessary help. Maybe being housed or helped with money worries. Maybe just being treated with respect and loved.

 

 

 

How prevalent is addiction?

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Following on from the previous post, our coffee discussion turned to the prevalence of addiction in the UK. We were both coming from a belief that it reveals an astonishingly large number of people in trouble. We believe it is a massive social problem that is not getting the attention it requires.

Later reflection considers the following:

  • There is a problem understanding what may be referred to as addiction. There is a very large number of people whose addictions have resulted in actual or potential life ruin involving finance, employment, social status, relationship breakdowns, a range of severe physical and metal health problems, and death.
  • However, there are many more cases where people are nearing these severe states. There are many whose drinking or other substance dependence are working slowly to take years off their lives. Nicotine addiction is an an obvious case. This applies to behavioural addictions such as gambling also, and statistics for these groups are hard to achieve if at all.
  • Unknown numbers of people are addicted to over the counter painkillers or prescribed medicines. Unknown again is the number of people illegally ordering prescription only addictive medication online.
  • There is a range of other addictions which are now taken seriously by researchers and treatment providers such as eating disorders, sex addiction and internet addictions.
  • Many ‘normal’ behaviours share characteristically common features of addictions. Compulsive shopping, perfectionism, workaholism for instance have similar neural substrates to all addictions.
  • A research paper has suggested that 47% of Americans are addicts in some sense.
  • Statistics for all addictions taken together in the UK are hard to come by. Limited statistics are available separately, e.g. for alcohol, opiates, marijuana (usually treated as psychological dependence),  gambling, amphetamines, heroin, cocaine.
  • It is extremely difficult to gather statistics. Since many addictions are to illegal substances and do not get reflected in medical interventions for instance, the true scale of actual addictions to a substance or behaviour can only be estimated.
  • Nevertheless, what figures there are contribute to an understanding of the prevalence of addiction. 9% of men and 4% of women are dependent upon alcohol. In Scotland there are 50% higher rates. The Gambling Commission also reflects geographical variation:

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  • Such figures cannot disclose current trends nor the breakdown of specifics of for instance, types of alcohol behaviour, methods of gambling. As for gambling, since it is increasingly done at home using online technology, only sources such as publicised personal catastrophes, some suicides, treatment statistics are available. The stigma associated with addiction is that even many severe cases will be attributed to financial ruin or depression etc.
  • For every addict at the extreme negative end of the spectrum, many more people will be affected, especially children and families. The problems of addiction therefore affect very large swathes of the population.
  • Besides the immense personal costs and suffering, society as a whole spends many billions of pounds because of addiction. These costs relate to health, crime, lost productivity and the welfare bill.
  • We aren’t remotely expert or knowledgeable but believe the true rate of addiction is extremely high. It needs much more urgent focus by policy makers across government services and within government, especially:
  1. Researching and acknowledging the scale of the issue as a whole rather than by reference to particular addictions.
  2. Identifying social, environmental, business contributions to addiction and curtailing them. For instance, prohibiting products designed to entice vulnerable people or induce people towards addictive behaviour, such as fixed odds betting terminals, advertising, online design; minimum unit pricing for alcohol.
  3. Raising awareness among professionals and ancillaries; ensuring destigmatisation among support providers and workers.
  4. Not allowing loss of government revenues to be used as an excuse to prevent public harm.
  5. Acknowledge once and for all that addictions represent one of the nation’s main mental health disorders. Integrate metal health services, educate staff, resource much greater treatment provision.
  6. Roll out public health promotion and advertising.
  7. Rethink drugs policy. Seek best practices globally for decriminalisation or legalisation. Emphasise treatment over punishment.
  8. Immediately produce policies and strategies to support the many people who suffer dual diagnosis disorders.

Addiction. Mental Health. Which?

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We were enjoying cappuccino and chatting about the somewhat ambiguous relationship between ‘mental health’ and ‘addiction’. Not being experts, the questions we raised only represent the view from the bottom – or, more precisely, they only represent our own coffee time discussion.

  • Why do campaign groups big support organisations, medical and government sources seem very reluctant to include addiction as a mental health issue? Certainly they all mention addiction but it seems to us that it is put in a box of its own and not given anything like the prominence of, for instance, depression and anxiety.
  • This seems odd especially because it is well known that depression and anxiety alone are very closely related with substance and behavioural addictions. They may lead to addictions via ‘self medication’ or the impulse to escape intolerable pain; both are likely consequences of addiction. It’s a cycle.
  • We are aware of the concept of  ‘dual diagnosis’ or ‘comorbidity’ where addiction is often accompanied by another mental health disorder. We are aware too that this is well known among professionals and has been researched and discussed for decades. There are organisations dedicated to researching and promoting discussion around dual diagnosis, such as Progress and many others but in practice we believe on the ground support and awareness is patchy geographically or non-existent.
  • Give that some mental health disorders such as gambling addiction and bipolar have high rates of comorbid substance abuse we find it odd that publicity around the issue is very feeble.
  • Anti-stigma campaigns around mental health issues are to be celebrated if they are evidenced as effective. Stigma is a huge barrier to recovery, seeking treatment and engaging socially. Yet we are not aware of any ongoing, well-resourced anti-stigma campaigns relating to addiction.
  • In our next post we consider the prevalence of addiction in the UK. We are concerned that a great deal of suffering is not being as adequately addressed as it could and should be.