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1 Introduction

The National Problem Gambling Clinic is the first and only National Health Service clinic (provider of free state medical treatment) designated to the treatment of pathological gamblers from all over the UK.

The current prevalence of problem gambling in Great Britain is 0.9 % according to the latest British Gambling Prevalence Survey (NatCen 2010). This showed a 50 % increase since the previous survey of 2007 reported a prevalence of 0.6 %.

Currently therefore, there are deemed to be at least half a million pathological gamblers in the country with as many more scoring on screening for at-risk behaviors in relation to gambling (Natcen 2010).

2 The Clinic Activities

Our clinic was set up by Dr. Henrietta Bowden-Jones as a direct result of the public concerns at a time when the British government was planning to allow the construction of several more casinos and when advertising gambling products had become legal.

The idea behind the project was to provide patients with a gold standard, evidence-based time-limited service providing specialist treatment delivered by psychologists and psychiatrists.

We have now had over 3,000 referrals and own the largest problem gambling database in Europe, and the amount of information collected has allowed us to reach in-depth understanding of the clinical subtypes presenting.

The types of gambling that patients are involved in are also recorded.

The most frequent activities are sports betting and electronic roulette machines, called fixed odds betting terminals in the UK. Internet gambling is increasing and about a third of our patients are now doing this regularly, sometimes to the exclusion of land-based gambling following a migration of habit.

Personal and psychiatric histories are also collected in an attempt to link activity and experience to outcomes; this is particularly relevant when we look at early adverse events in childhood and their predisposing negative impact on future illness.

Our patients tend to be male and aged between 30 and 40 years old, and most will be in either full-time or part-time employment.

Many, 84 %, have committed illegal acts to fund their gambling at some point in their lives.

Twenty percent have lost their jobs due to gambling, and 50 % have lost significant relationships such as their marriage due to gambling.

Many of the patients we see are depressed or anxious at the time of assessment and about a third have lifelong comorbid presentations, at times with severe and enduring mental illnesses such as schizophrenia.

Our approach is to treat everyone apart from the acutely psychotic patients, but even then, we advise on the best antipsychotic and agree to delay treatment temporarily so we do not turn people away as our strength is in understanding the complexities of dual diagnosis presentations.

The yearly funding for the treatment of what are now over 700 referrals a year comes in several ways, but the main bulk of the money, about £330,000, is received from the Responsible Gambling Trust, a government charity set up to distribute voluntary donations from the gambling industry to avoid a compulsory levy based on earnings.

Other funds come from government working parties attended by the Director of the clinic, court reports written by forensic psychiatrists trained at the clinic in pathological gambling expertise, industry training days, some Employee Assistance work, and lecturing fees. Further funds come via the successful research grant applications that may free up the clinical time of some researchers to contribute in clinical time for the access to problem gamblers in research projects of which there are many.

Although cognitive behavioral therapy is deemed to be a highly effective way of treating problem gamblers, we do offer other interventions such as a Money Management assistance service which in the UK is funded by the banking world to assist people with mental health issues. This service provides a session of psychoeducation around managing finances but also individual help with setting up repayment plans.

Another integral part of the clinic is the assistance we offer to relatives and carers of problem gamblers. Often, it will be an elderly mother who has read about us in the newspapers and has referred her son for treatment. At other times, spouses of gamblers are brought into clinic once the patient begins therapy. The support we offer to carers is also manualized and linked to psychological outcomes to determine the usefulness of the intervention, but we are more relaxed about our data collection as we really do want to help the individuals feel more supported in their suffering.

2.1 Treatment

Pathological gamblers who attend our clinic are offered a 90-min face-to-face assessment with a clinician. This assessment covers current and previous gambling history including first gambling experiences and emotional links to the gambling, for example, some patients only spent time with their father in childhood when they were gambling. This has important implications for the right treatment approach as we do offer some more psychodynamic treatment for some patients who need a more interpretative approach. A history of medical and psychiatric difficulties is also taken along with any history of parental gambling problems. A brief personal life history is also obtained. Clients also complete a comprehensive battery of questionnaires including gambling and mental health screens. All assessments are discussed in a weekly multidisciplinary team (MDT) meeting where decisions are made regarding treatment packages offered.

The basic treatment offered by the clinic is an eight-session cognitive behavioral therapy treatment developed from work conducted by Nancy Petry (2005; Petry et al. 2006). The treatment is manualized in the sense that there are a set number of sessions and each session topic is guided by a specific handout. Within this protocol, therapists are expected to deliver the treatment flexibly in order to best meet the client’s individual needs. Homework is an essential component of this treatment, with each session topic having comprehensive handouts including homework tasks. Clients are informed that homework is essential to change. Topics covered include stimulus control, rewards, coping with cravings, increasing pleasant activities, trigger management, understanding lapses, coping with gambling thoughts, and managing lapses. The treatment includes a strong psychoeducational component where clients are socialized to an addiction model of problem gambling, drawing on research from scanning studies to highlight commonalities with drug and alcohol addiction. This serves to “normalize” the problem and reduce confusion and the degree of personal guilt and judgment that clients often present with.

The service is guided by the “pathways model” of problem gambling (Blaszczynski and Nower 2002). This seminal paper suggested that three levels of severity of difficulties can be observed in problem gamblers. These levels relate to different etiological factors for problem gambling and increasing levels of associated and comorbid difficulties, with each level requiring more intensive treatment. In the MDT, a decision is made as to whether the individual assessed is of a “lower,” “moderate,” or “higher” severity, based on criteria derived from the pathways model and from internal audits of client characteristics.

Patients who present at the “lower” end of the severity spectrum are offered a brief intervention. This comprises the provision of an 85-page self-help workbook, with four individual sessions with a therapist. The workbook contains all handouts from the eight-session CBT treatment, with guided self-help exercises included.

Clients assessed as being of “moderate” severity are invited to attend the eight-session manualized treatment delivered in a group format. These sessions are of 90 min length and up to 20 individuals are invited to each group. Sessions involve group feedback of progress and homework and delivery of session topic content and finish with reflections on the session and homework for the coming week. Groups are strongly encouraged by the service; gathering with other individuals has the effect of normalizing a problem that often presents in highly isolated individuals.

Clients assessed as being of “higher” severity will receive the eight-session group CBT program plus additional individual CBT sessions with a therapist. Each of these types of additional intervention is designed to prevent relapse and provide a solution for the problem of the “revolving door” in addiction services where clients with more severe difficulties often represent multiple times. These sessions may be offered for three reasons: additional support for gambling problems, provision of support for related comorbidity, and cognitive formulation work. Additional support for gambling is offered if individuals have not achieved control over their gambling by the end of the eight-session program or the clinicians are concerned that abstinence may only be temporary. The provision of support for related comorbid difficulties focuses on obvious comorbid, and often premorbid, psychological difficulties such as anxiety or depression that may hinder ongoing recovery. In the case of more severe comorbid difficulties, care planning for referral onto specialist mental health services will take place. The cognitive formulation is an intervention that provides an understanding for the client as to why gambling has become problematic for them. It may also help with other difficulties in the client’s life that hinder recovery. The cognitive formulation follows methods pioneered by Aaron Beck of establishing how childhood experiences may contribute to negative core beliefs and the development of subsequent dysfunctional rules and strategies in adult life. In clients with gambling problems, it is very common to observe adverse upbringings leading to the development of core beliefs of “failure” or “defectiveness.” These can leave an individual vulnerable to addiction if exposed to gambling. Understanding these core beliefs and challenging them are often an essential part of treatment.

The core eight-session manualized CBT treatment may be delivered by individual therapists instead of in a group format under one of the following three conditions: language difficulties, risk issues to self or others, and low intellectual functioning. Individuals who are anxious about group working are encouraged to try out groups prior to opting for an individual CBT treatment.

We also offer a brief Motivational Enhancement Intervention for individuals who may be unsure as to whether they have a gambling problem. This comprises a four-session treatment with a therapist using motivational enhancement principles to guide discussions about the gambling behavior. If, as often happens, during these sessions the individual decides they do have a problem and wish to change, then the therapist delivers the manualized CBT treatment.

As not all individuals can be grouped together in the main CBT program due to different levels of cognitive functioning, special group programs for the following distinct populations have been established: a women’s group for emotionally vulnerable women who present with significantly low mood and anxiety and a reticence to attend the predominantly male groups, a homeless persons group held either at the clinic or in a homeless hostel and funded by the homeless national services, and a mental health group. All follow a modified version of the core CBT program.

Following the completion of treatment, each individual has a discussion with their therapist as to whether they feel they have received a sufficient intervention to help them combat gambling difficulties. With the group program, this is delivered by telephone following the end of the eight group sessions. If individuals are happy with the treatment they received, they are invited to attend the Aftercare Group. This is held once a month and patients who complete treatment can attend for as long as they wish. The Aftercare Group is an open-forum group; facilitators start by setting an agenda of topics that the attendees wish to discuss. These topics may involve positive or negative experiences of recovery. The conversations are then steered by the facilitators to cover the topics in the manualized treatment. The group serves as a reminder for individuals of techniques and strategies learned in the CBT sessions they attended. Members are invited to support each other within this group, but preferably by suggesting techniques from the manualized intervention.

2.2 Education and Prevention

Because the clinic is the only one, it has a significant role in British society that goes far beyond its remit to treat problem gamblers.

Here is a list of activities we believe a National Clinic needs to attend to as well as deliver high-quality treatment:

  • Any time a newspaper article or other media program is planned, the clinic will be asked to contribute to it in light of its expertise and perspective.

  • The aim for us is to remain as politically neutral as possible while still enforcing what we believe are fundamental societal needs to protect gamblers, such as adequate self-exclusion policies, the protection of children and young people from the proliferation of gambling products, the need for more stringent laws around advertising gambling activities, and ensuring enough attention is paid to the quality of treatment services at a national level when they fall outside the remit of the NHS.

  • Peer-reviewing journals.

  • Training the next generations of psychiatrists and psychologists.

  • Maintaining links both nationally and internationally in the field writing articles on case studies and disseminating knowledge about problem gambling to professional groups (Bowden-Jones and Clark 2011).

  • Lecturing to medical students and other mental health professionals on the topic of problem gambling.

  • Teaching the general public about the issues via open lectures and invited talks.

  • Facilitating the work of the neurobiological research group currently neuroimaging the gamblers.

All of the above need to be addressed and constantly updated if we are to continue leading the way in the UK.

Our hope is that in the future, the State will recognize the need to fund problem gambling treatment throughout the UK and include pathological gambling in the illnesses it recognizes. The need for smaller clinics set up to be linked up to our central “hub” is a cost-effective one that we will be working on for years to come.