Reino Unido: No interior da única unidade do Serviço Nacional de Saúde especializada em jogos de fortuna ou azar

The Friday morning discussion of new referrals to the National Problem Gambling clinic provides a sharp picture of why pathological gambling is such a catastrophe for those who become...

The Friday morning discussion of new referrals to the National Problem Gambling clinic provides a sharp picture of why pathological gambling is such a catastrophe for those who become addicted and their families. Medical staff gather in an airy upstairs room of the Fulham, south-west London clinic and take an hour to fill each other in on the profiles of their new referrals.

The first new patient, a man in his 60s, decided to contact the clinic himself, motivated by a sense of self-loathing after being caught stealing from his wife’s purse; he recently punched his daughter when she confronted him over his gambling, and neither is now speaking to him. He thinks he has probably lost around £150,000 over the past decade, and is about £3,000 in debt; somehow he has managed to keep hold of his job, but his shift patterns make it difficult to attend the clinic’s group treatment sessions. He is feeling suicidal.

The next man, in his 40s, a sometime mechanic, is living in temporary homelessness accommodation because he gambles away all his money every week. He has lost £50,000 over his gambling career, and says the only time he doesn’t gamble is when he is in hospital (which is relatively frequently because of a complicated mental health condition). He is particularly drawn to the roulette machines that have in the last few years become a lucrative – for the bookmaker – feature of every high street betting shop. Until recently he thought he was smarter than the machines, although he now concedes he probably isn’t, given how much he is losing. He too is very depressed.

“He has no job, no family, lives in a room somewhere. No one cares about him. He has reasons to be depressed. The only place he ever sees anyone is in a gambling shop,” the clinic’s founder, psychiatrist Henrietta Bowden-Jones, notes.

The next new patient is – like 20% of the clinic’s patients – a City trader, who finds it difficult to navigate the line between his gambling (he places bets on the currency market) and the risks he is required to take as part of his job. He has lost £200,000 of his own money in three years and continues to gamble in an attempt to recoup his losses. The stress at home has become so intense he describes it as “like living in a pressure cooker”. During a preliminary assessment at the clinic, he berated the financial markets at length for not behaving more predictably.

‘There is a lot of guilt, when they look at the negative consequences on their employers, spouse, children, employers’ … Henrietta Bowden-Jones. Photograph: David Levene for the Guardian

“It is harder for traders to acknowledge the extent of their illness because financial risk is part of their everyday business. He has a lack of insight into his own behaviour,” Dr Bowden-Jones says, recommending that he is signed up for a programme of group cognitive behavioural therapy (CBT). “We need to make him realise he is just like everyone else, that he is not special. I don’t think he should go back to work as a trader. It’s not a good place to be, not in that environment.”

Around 15 problem gamblers are referred to the clinic every week from across the country; every year between 750 and 900 people start treatment here. Most are male, and in their 30s and 40s; about 70% are working. “Yet, by the time we see them, they have lost jobs or lost opportunities professionally because of their gambling and they have often compromised important relationships,” Bowden-Jones says. “They are usually highly stressed and there is a lot of guilt, when they look at the negative consequences on their employers, spouse, children, employers.”

Most patients are spending their money on the high street roulette machines – known as fixed odds betting terminals (often described as the crack cocaine of gambling, because of the speed with which large sums can be staked, and lost), and on sports betting, usually done online at home. The easy availability of online, in-game betting has made sports betting increasingly popular over the past decade. While 15 years ago people might only have been able to bet on the result of a game, at the bookmakers, now they can bet online, on a variety of scenarios within the game, making watching the sport highly stressful for gamblers.

Bowden-Jones, who previously specialised in alcohol and drug addiction, founded the NHS’s first and only specialist gambling clinic, funded by the Central and North West London NHS Foundation Trust, in 2008. It had become obvious, amid rising concern about the growing presence of super-casinos and new easy access to betting shops, that there was a desperate need for it. She has been innovative and experimental, trialling the use of a cravings-suppressing drug, naltrexone, more commonly prescribed to alcoholics and heroin addicts. It is a last-resort treatment for gamblers whose addiction has persisted despite the clinic’s interventions.

If the results are positive, she wants the NHS to fund a clinical trial of the drug urgently. “Every day we delay, families break up. People lose their family homes, experience domestic violence, turn to crime. Every day in gambling is an important day because lives get ruined fast.”

Despite heightened awareness of the devastating effects of problem gambling, there is some uncertainty over whether the numbers of pathological gamblers are rising. The British gambling prevalence survey indicates that there are around 450,000 pathological gamblers in the country – about 0.9% of the population. Although industry revenues have risen dramatically, this figure has for the moment remained stable; the results of a new Health Survey for England, expected in the summer, may shed clearer light on whether the problem is growing. The charity GamCare, which operates the National Gambling Helpline, says it handled an 18% increase in calls from problem gamblers in 2014-15 and saw a 39% rise in clients in treatment.

The clinic also helps family members (usually women), struggling to cope with the fallout from gambling. A woman has come in search of advice, hoping to help her husband who has been gambling for most of his adult life, but had successfully concealed it from her until a few years ago. “The home environment is very charged and tense,” the psychologist who carried out the assessment reports. “They won’t say a word to each other in the evenings. He is sleeping in another room. She wants to stay with him for the sake of the children. He spends most of his time playing on computer games and watching football.”

Online betting can make watching sport a stressful experience for problem gamblers

Bowden-Jones contrasts this urge to conceal a gambling problem with a growing openness about alcohol addiction. “People tend not to tell someone new about their gambling history when they meet. We want to remove the stigma. If people were able to say ‘I am a problem gambler’ in the same way that they say ‘I am an alcoholic’ then it would protect them – people wouldn’t put them in charge of the money,” she says. “Families suffer terribly from gambling. They lose homes, the kids become depressed. This is not the worst case by any means.”

A second woman has requested help. Although she was dimly aware of her husband’s gambling before they married, she says her understanding was very naive, and it is only recently that she has realised he has amassed huge debts. A few weeks ago he was caught shoplifting shoes, and confessed to her that he shoplifts regularly to fund his gambling. “She says he has not accepted responsibility and makes her feel it is her job to stop him from gambling. She finds it hard to cope. She feels anxious all the time,” the psychologist says.

Most people accepted by the clinic join a group programme of CBT, where they talk about their experiences and are given strategies for avoiding temptation. If their families agree, they are also signed up for family therapy, which is also a powerful tool. Around 60-70% of the clinic’s patients are abstinent at treatment end and are still not gambling six months later.

But the psychological treatment doesn’t always work. During her afternoon session, Bowden-Jones meets a man in his early 30s who has had success with the group therapy in the past, but has had a dramatic relapse and is anxious to try the drug treatment. He started gambling again after cashing a cheque last week, and taking the money to play on fruit machines in an arcade.

“I cashed a cheque because I needed the money. I was feeling pretty hungover. My decision-making wasn’t great. Access to £200 was enough to trigger it,” he says. He says he is feeling suicidal as a result of his return to gambling. “I went through quite a bad patch last week after the relapse. My ability to cope has not been great,” he tell Bowden-Jones. He has taken a coach from a town 50 miles from London to get the specialist help here. Although some charities offer gambling treatment, Bowden-Jones says the NHS is a brand people trust.

He is prescribed a half-dose of the drug, to be taken after breakfast each day. “It acts on your reward pathways; it blocks your feelings when you start thinking about gambling,” she tells him. “If you see a bookmaker’s or a machine, it excites you. This medication will block the pleasure pathway so you will not feel it. It will dampen all the pleasure of this activity and allow you to focus on other things.”

The drug has been used in Australia and the US for some years, but fewer than 10 people have been prescribed it so far in London. “You are a pioneer in this country in relation to naltrexone. If you could, keep a diary – write down if it is impacting your enjoyment of cakes or sexual things; in theory it could,” she says. “I am very excited about the medication for you. It could be that your DNA is the right one to stop feeling the urge and cravings.”

Her next patient reports that he is delighted to have stopped gambling entirely after just one session at the clinic. He is putting all his energy into antique repairs and has taken the bus from Bristol for his appointment, eager to volunteer his services to other patients. “I haven’t gambled for seven or eight weeks. I know it is 100%. It is unbelievable. I have had residential treatment in the past and gamblers’ anonymous therapy. Nothing ever worked,” he says, effusive with excitement. But when he tells her he is saving for a holiday it triggers concern; she warns him not to relax or assume he is cured.

“The more money you save up, the riskier it is for you,” she tells him firmly. “I will not be reassured by this; I have been doing this for decades. Gambling addiction is insidious; you can never relax around money. Those faulty circuits in your brain have been around for so many years; they are well-trodden paths. You have now blocked them, but if a heroin addict said, ‘I am abstinent but there is heroin hidden at home,’ it is a risk. It’s the same with money.”

She recommends that he contact his bank to request they delay any significant payment to him for three days, to prevent any spontaneous return to gambling. This notion of “stimulus control” is a key element of the clinic’s strategy – helping patients, with very practical techniques, to make it harder for them to access the funds and find the opportunity to gamble. “I am just saying, protect yourself. The risk remains.”

In the past year Bowden-Jones’ interest in helping gamblers has spread to internet addicts, and she is seeking funding to set up another clinic that will allow her to help people whose internet use has reached unhealthy extremes. Relatives frequently call the clinic on behalf of a family member they believe has become addicted to the internet – gaming addiction is the most prevalent, but also porn, compulsive shopping or excessive social media use. “The gamers are the most extreme. They put most at stake in terms of giving up on their everyday lives,” she says. “Pathological gamers are playing 12-14 hours a day, forgetting to eat, dropping out of university, dropping out of work – we are not talking about someone spending a little time on the internet. Particularly problematic are games that bring people together across countries and timezones, because that makes it hard to stop at any one time.

“The more of these requests there were, the more I was thinking about another clinic. Internet disorder is recognised as an illness just as pathological gambling is.” At the moment she is unable to help. “It is quite heartbreaking to have to say no. I know that CBT would work very well for this.”

Raising funds will be difficult. In a climate of NHS cuts there is little money available for this kind of venture. When the clinic opened in 2008 it was a “golden era for addiction”, she says. “The NHS is seriously impaired in its ability to address new pathologies because it is having to spend all its money on drugs and alcohol treatment.”

Her final patient of the day is – unusually – a woman in her mid-40s who has been gambling for 25 years, and has lost £10,000 this year. This week she took £10 to the betting shop and lost that too. “Oh poor you!” Bowden-Jones tells her with genuine sympathy, offering no judgment.

The patient wonders if she could start on the naltrexone, which she says sound like a miracle, but it seems unlikely because it may clash with other drugs she is taking for a medical condition.

“The last four months have been so out of control. I do it to distract from the other problems that are there,” the patient says. She says her earliest memory is of playing poker with her father for pocket money, and she associates gambling with a warm, happy time in her childhood.

Somehow she is cheered by the session and leaves heartened by the prospect of a women-only group session.

“When you hear the stories, you realise this is never a blank canvas on which gambling happens. These are people who have often grown up in households where there was already significant gambling; these are people who have often inherited a genetic predisposition to gambling, people who have experienced sexual, physical or emotional abuse. You see a picture of a person who has ended up gambling pathologically but nearly always on a background of other things that make that excessive behaviour understandable from a psychiatric perspective,” Bowden-Jones says.

“I love my patients. I never get tired or burnt out. I love spending time with them.”

Source: The Guardian