Mental Health – The Machine Zone

Digital Health: Gambling

If you were recovering from drinking alcohol too much, it wouldn’t be a good idea to carry a bottle of booze around with you. These days, even carrying a mobile phone would be risky as in most cities you can order drink to be delivered 24/7 – for a lot of cash true, but when you’ve ‘got a habit’ any financial sense is the last thing that will protect you.

With gambling the problem is much worse. Unless you get rid of your phone and every other digital device you constantly have a casino in your pocket or near at hand on your other devices, 24/7 – in bed, at work, driving, on the bus or train, watching sports on television. And you’ll be assailed by precisely designed marketing to ‘enjoy’ playing ‘games’ precisely and scientifically designed to be potential instruments of addiction. Or instruments of torture.

You have choices with alcohol. Pour it down the sink. Avoid socialising with drinkers, at least early on in your recovery. Don’t carry it with you. Obviously.

But with gambling, unless you completely cut yourself off from the digital world, the supply is there by default. It follows you wherever you go. Younger people are ‘digital natives’. To them gambling is a completely normal and fun activity, especially associate with sport and sporting heroes. Loot boxes and other ‘games’ blur the boundary between childhood behaviour and adult ‘fun’. Every kid wants to grow up and act like the adults. Immersed in constant usage of digital devices – for good or ill – the ease of quick-thrill access to gambling, pornography and drugs (the latter just a text message away for quick delivery) puts many – not all – young people in harm’s way. What age checks may officially exist are easily circumnavigated. In the digital world you are not a thirteen-year-old you are a bundle of data. Very profitable data.

On our main site, The Machine Zone, we have begun to examine the huge area of what is known as Digital Health. This phrase is riding like a juggernaut through health services including the NHS and is already a multi-trillion dollar corporate industry. It is heavily promoted as A.Very.Good.Thing. In many ways it is and will be: there can be no doubt about that. But we’ll be looking at some more precautionary views. While data sharing can speed up and enhance healthcare, for instance, there are concerns about privacy. There’s also the question of whether a consultation with a human doctor may be more beneficial than diagnosis and treatment via remote apps and algorithms.

Well, it’s also the case that digital health should, in the interests of prevention, consider the digital causes of illness and ill-being. There are, in the case of gambling, many apps which prevent digital bank transactions – and credit card transactions are now illegal. One may ask, and be certain to be fiercely argued against, whether a truly effective preventive method may see the complete banning of all digital online gambling and hence marketing. Such a radical move, even the proposal, is enmeshed in the fundamental political questions around business and personal freedom, business and personal responsibility, loss in tax revenue, and – of course – the deprivation for millions who enjoy a little flutter responsibly and safely. Even tobacco regulation hasn’t gone nearly so far, and surely tobacco causes far more illness and death than gambling. All true.

It is hard to see where treatment for people with gambling-related distress may develop. ‘Addiction services’ in the UK have been decimated since the government transferred responsibility to local councils reeling under budget cuts. Stigmatising attitudes in all mental health care are institutionalised. Medical professionals, through no fault, do not have the knowledge and experience to help. Stigma prevents many people admitting to problems and seeking what help there may be. That help is there in some geographical regions (although in Scotland there are no dedicated gambling services). Anti-stigma projects around mental health are proving of some success: people generally are willing to identify their own issues, such as depression, and seek help. Perhaps one way forward to destigmatising gambling issues is to launch an ongoing social media campaign – the very social media that have proved their weight in gold to businesses of every shade. Funding for such a campaign is unlikely; less so a willingness to see the need for such a campaign.

The weight of prevention of gambling harms has been given over to schools and social enterprises funded ultimately by voluntary donations from the gambling industry. There is much good work being done – along with some not so good work. The big problem is that educational initiatives have behind them a paucity of evidence, research and effectiveness evaluation. Whether by design or not, the weight given to education repeats the dominant ideology of modern capitalism: individuals are responsible for their choices and behaviour; individuals identified as ‘pathological’ or ‘failing’ should be given support but ultimately everything is down to them. The responsibility of industry is thereby de-emphasised – in the case of gambling, the industry’s social responsibility to ensure harm minimisation by discontinuing harmful products, marketing and willingness to reduce profits in the name of rigorous procedures to monitor and prevent individual disasters. Not everybody will agree with this; some will vigorously disagree. That’s life, that’s politics, and no one anywhere can press a magic button to produce a win-win. The savage legal restrictions faced by the tobacco industry, the negative social perception of tobacco, emerged after more than 50 years of furious debate. While it’s true that the comparison between gambling and tobacco is often too heavily simplified and overstated, from a health perspective there remains a good deal to learn good lessons.

One of the dangers around ‘digital health’ is that it is embedded in wider ideological worship of data and algorithms. Buzz-words are efficiency, cost-saving, productivity. Unsurprisingly, the same words are almost holy icons in business. It can tend to work at a population level, seeking to insert a living human individual into a categorised ‘box’. It was the philosopher Kierkegaard who said, ‘To label me is to dehumanise me’. Sadly, in our ordinary lives we do tend to label people: ‘waster’, ‘junkies’, ‘alkies’. Big Data takes labelling into the realms of a high art, an ethereal cloud of digital bits totally disunited from the hearts and souls of a whole, living individual with all that means. The word ‘whole’ is where we get the word ‘health’ from. In seeking and recognising the unique wholeness of a person we have to go beyond statistics, data and ‘evidence’. That’s why it’s greatly to be welcomed that far below the data clouds the voices of individuals are being heard more and more. In health generally, perhaps most visibly, ‘Experts by Experience’ are coming to the fore. In what relatively little gambling research there is, there is a turn away from quantitative data-crunching towards qualitative research focused on individual human experiences, the voices of whole individuals. Such approaches may, of course, be appropriated by powerful stake-holders, including the researchers themselves, to ultimately hide those voices. Yet it cannot be denied that the gathered voices of ordinary people have been successful in so many ways in ‘bottom-up’ challenges to policy making so often driven drom the ‘top-down’.

We live in a digital world, breathe it, an air as invisible and taken-for-granted as the sea is by the fish that swim there. But we aren’t bits of cork bobbing about and carried this way and that by environments over which we have no control. We are not bits of data, we are human beings rich with the powers of solidarity and more power than we sometimes realise to make a better world just by being who we are.

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.

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Mental Health and Education are ubiquitous topics for discussion. ‘Users’, front line providers, parents, academic research, government, media, politicians, campaigners, charities, myriad social media comments are all apparent.

I’ll bring the two topics together later, but for now point out two separate commonalities to each. Firstly, a great deal, perhaps the majority, of discussion involves finance and resourcing.

Secondly, a less obvious but significant point, the impact of technology on each area. In education, the use of digital devices as an aid to learning is highlighted; less so educational preparation for the rapidly changing digital worlds that will succeed each other education anticipating great flexibility, genuinely transferable technical and critical skills, and engagement with the political and cultural dimensions of new digital environments. In mental health, there is also some movement towards using digital devices as remote devices to support users and provide diagnosis and feedback; there are also growing concerns that some aspects of digital device usage have negative and deleterious effects on mental health.

Returning to the first point, money. It goes without saying that exiting education and mental health services have worked very well for millions of people, and would be able to do even more with extra cash. Equally obvious, many people have not been reached or adequately supported by state provided services. Purpose built schools with the best of technology and architecture have sometimes not provided better education; some have closed a few years after opening. Despite a conveyor belt of government reports, mental health, even with a modest input of extra money, is still inadequately funded or recognised as on a parity with other health services.

But money is not the only issue. The quality of workers and curtailing their leaving jobs through stress, overload and poor pay are others. But the quality of each worker is important too in ‘delivery’. Undertraining, inadequate training programmes and general personal development are factors; more important are the qualities of each worker in terms of dedication, self-development, caring and endurance: these cannot be programmed.

Confounding everything are the myriad competing ‘theories’ of education and mental health. These relate to questions such as what is education for? What constitutes mental health? How best to promote mental health and education? Debates are largely academic rarifications, and are often not debates at all since adherents to this or that body of beliefs may be more interested in promotion than discussion, though this is the worst case scenario.

What is, or should be, clear is that whatever the conceptual muddles and inadequacies of historical and contemporary theoretical underpinnings, the huge impact of technological development with implications for every aspect of life has to be factored into debate over the design of services and allocation of resources.

Mental health is currently heavily involved with the prevention of disorders, the promotion of ‘wellbeing’. Health and illness correlate strongly with poverty, deprivation, housing, cultural capital, employment and educational level, although it is vital to remember that ill health is often apparently endogenous or correlated with lifestyle factors and choices among the more privileged sectors of society. Schools, colleges and universities report increasing instances of mental health disorders among students. Education and mental health are linked in complex but definite ways.

There are more general social and cultural factors that are involved with increases in sadness, unhappiness and misery – often treated now as mental disease, perhaps inappropriately – among relatively comfortable classes of society. These factors, it is variously argued, are caused by things like the consumerist ethic, 27/7 lifestyles, the impact of digital technology and the blurring of work and leisure, even capitalism itself. To these may be added financial precarity, the huge challenges facing young people to even begin to reach the security of their elders, and the rapidly shifting political and global surfaces. Whether imagined or real, people in the past generally had ‘a ground of being’, yet these days there is no ground at all; for many there are no central meanings and values. It is not an exaggeration to integrate all this into the identifying of an existential crisis.

There are many discussions and even celebrations of ‘The Future’, a brave new world of exciting technology. Much of this is well warranted. Advances in health care, cleaner environments, colonisation of foreign planets (actually vital, according to Stephen Hawking, if the human race is to survive). Equally, a cursory glance suggests obvious downsides. Advances in war machines, increased wealth divides as technological benefits are for the rich only, the fate of the unskilled and uneducated, and the law of unintended consequences – emergent factors from autopoetic complexity in development.

To conclude, yes more money is needed for everything. But it is foolish and one-dimensional to imagine mental health or education as discrete entities. Not only are these two connected, they are connected with myriad other issues in dynamic ways which cannot be simply modelled or mapped. Whether Artificial Intelligence improves our cognitive skills, we presently have to acknowledge that to a large extent we are making progress – as we also have – largely in the dark, quite crude in our conception of the landscape. Nevertheless, let’s not kid ourselves that money is the answer to everything. We need to factor in urgently not some distant future, but the one that’s already here in many ways. We need to imagine forward our humanity. This can be done by asking the deeper questions about what we mean by health and education.

Ade Johnston

Image: Gerd Leonhard, Licence CC BY-SA 2.0

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:

Researching and acknowledging the scale of the issue as a whole rather than by reference to particular addictions.
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.
Raising awareness among professionals and ancillaries; ensuring destigmatisation among support providers and workers.
Not allowing loss of government revenues to be used as an excuse to prevent public harm.
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.
Roll out public health promotion and advertising.
Rethink drugs policy. Seek best practices globally for decriminalisation or legalisation. Emphasise treatment over punishment.
Immediately produce policies and strategies to support the many people who suffer dual diagnosis disorders.

What treatment for gambling addiction?

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There are many profit making facilities for recovery from every kind of addiction – substances, alcohol, increasingly ‘digital addiction’. Some offer expensive promises for recovery from gambling addiction. There’s Gamblers Anonymous too, a 12-step programme which may or may not work for some people, but many don’t like the approach. Figures suggest only 5% of problem gamblers seek help and only 1% receive it.

What’s available on the NHS? Gambling addiction is recognised as a psychiatric disorder and described in detail in the DSM, one of the psychiatrists’ ‘bibles’. So if you go say to your GP what’ll happen? A lot will depend on your GP but she may recommend cognitive behavioural therapy (though you may have to wait a long time before you get it). Truth to tell, CBT has not been proven to be universally effective. A GP may offer meds for concurrent depression or anxiety. Very rarely will you be referred to a NHS psychiatrist.

I was talking to a psychiatrist today and asked what treatment was available. He said possibly CBT but the condition is under-researched. It’s true though that some medication trials and research are promising, but the overall situation is very thin and patchy.

Given that gambling addiction carries with it a much higher suicide risk than the general population, various mental ailments such as anxiety, depression or obsessive compulsive disorder, and in 70% of cases parallel substance abuse disorders, you’d think research and treatment would be much more advanced by now.

There are hundreds of thousands of gambling addicts just in the UK, an dtheir addiction has a ripple effect on families and society as a whole. Gambling addiction is a case of awful individual suffering. And it’s likely to become a greater problem as gambling seeps into the DNA of our culture where even children are becoming problem gamblers.