500,000 people or 0.9% of the UK population are estimated to be problem gamblers. An average patient at our clinic arrives £15,000 in debt, 51% have seen their marriage/relationship break down and 39% of our patients have a further mental illness.

Gambling Concern has been set up to educate the general public about issues related to problem gambling within contemporary society and to fundraise to extend the work of the National Problem Gambling Clinic, aiming to double the amount of patients in treatment at the clinic.

Through high quality, cutting edge clinical research, disseminating good practice methods and funding additional places at the clinic we aim to reduce the negative impact of problem gambling in society

Set up in 2008 by Dr Henrietta Bowden-Jones, the National Problem Gambling Clinic is the first and only NHS centre to treat pathological gamblers and support their families. The clinic is part of Central North West London NHS Foundation Trust and is based in Soho, London.

Problem Gambling in the UK

Problem gamblers represent 0.9% of the UK population, with the number fluctuating with different methods of screening. At NPGC females represent 5% of problem gamblers receiving treatment , although research suggests that this number is unreliable, with 20% of problem gamblers being women.

Age of onset is variable but usually adolescence for males, yet later on into adulthood for females. Research findings indicate a hereditary influence, with problem gamblers more likely to have a family history of problem gambling.

The clinic is open to anyone 16 years of age or above and is free. Individuals can refer themselves or be referred by their GP or another health care professional. All patients are then invited to the clinic for an initial assessment, which will enable clinicians to recommend the most appropriate program.

Defining Problem Gambling

Currently the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) classifies pathological gambling (also known as problem gambling) under disorders involving Impulse Control. In addition to the diagnostic criteria, DSM-IV describes pathological gamblers as those who may present with the following:

  • Behaviours: seeking “action” or euphoria more than money; seeking approval
  • Characteristics: competitiveness, restlessness, boredom, generosity
  • Cognitive distortions: denial, superstition, overconfidence, a sense of control/power
  • Comorbidities: depression; attention-deficit hyperactivity disorder; substance abuse or dependence; personality disorders; and physiological disorders as a result of stress.

In the forthcoming edition of the Diagnostic and Statistical Manual of Mental Disorders V (DSM-V), pathological gambling will be redefined. In DSM-V we shall find it grouped with addiction and related disorders and renamed Disordered Gambling. Current research suggests that a greater overlap exists between alcohol and substance abuse and pathological gambling than was previously found including symptoms of withdrawal and tolerance, two of the key criteria by which addiction is defined.

Motivational Interviewing

Motivational interviewing (MI) is a directive person-centred therapy that attempts to resolve ambivalence, in this case surrounding problem gambling. Ambivalence refers to an uncomfortable state of contention between denial and acceptance. This technique involves establishing rapport with the patient in order to encourage them through a process of change. Practitioners are trained to engage in a number of different strategies developed to elicit change talk from patients. Resolution of ambivalence must occur prior to the start of treatment with cognitive behavior therapy (CBT).

Cognitive Behavioural Therapy

Individual

CBT is structured and goal orientated, focusing on the interwoven nature of thinking patterns and behaviour. Working together the clinician and patient identify problematic behaviours and thoughts. Once examined, appropriate theoretical models are applied in order to heighten patient’s awareness. Clinicians assign ‘homework’, requiring patients to try new techniques, for example behavioural experiments (changing behaviour to see what happens). Another technique frequently used is a structured discussion (or thought record) which enables patients to breakdown cognition into more manageable parts in order to come up with more balanced thoughts.

At NPGC there are 8 sequential sessions with topics relating to problem gambling:

  • Stimulus control
  • Tracking and rewards
  • Increasing pleasant activities
  • Coping with cravings and urges to gamble
  • Triggers to gambling
  • A functional analysis of gambling
  • Challenging gambling thinking beliefs
  • Future planning

CBT has proven effective for anxiety disorders, depression, bulimia nervosa, psychosomatic disorders and addiction. The efficacy of CBT is, however, different for every individual: some notice residual symptoms (e.g. vulnerability towards relapse under stress) while others experience none. Problem gambling tends to manifest as a chronic disorder (a disorder that is long lasting and recurrent) but CBT reduces the likelihood of recurrence even if it does not entirely abolish the possibility. One aspect that many find useful is that this kind of therapy is practical with a focus on the ‘here and now’, helping patients to help themselves, giving them back a feeling of control.

Group Therapy

NPGC also offers CBT in a group setting, which proves beneficial for many patients in that it provides a motivational, supportive environment. The program again consists of 8 weekly sequential sessions, and involves one or two facilitating therapists, and up to twelve participants (but typically closer to eight). It is strongly advised that the course is fully attended. The sessions follow a similar format to that of the individual CBT sessions, and every member of the group is encouraged to engage in the presented material and offer their own insight.

Family Support

Frequently, in order for patients to get the most out of their personal treatment at the clinic support from family members is key and it is usually beneficial for them to be aware of the process. Family members and friends can be affected by a gambler’s problems and may benefit from help from NPGC too. Therapy sessions can take place with or without the gambler; as an individual or as a family unit. Families are provided with an informative self-help handbook, which outlines problem gambling and the therapeutic process used at NPGC, and explains the available support and tools for their own therapy.

Remote Treatment

As NPGC is the only NHS affiliated problem gambling clinic in the United Kingdom, and the only one that offers CBT, it is not possible for all patients to attend the clinic regularly. In these cases, practitioners offer remote CBT via telephone. Patients are provided with a handbook, which contains the same information that is presented in therapy sessions at the clinic. Families may also receive remote treatment in a similar way, accompanied by the handbook mentioned above.

Women’s Therapy

Recent research shows that women who present as problem gamblers have indicated difficulties within close personal relationships as a contributing factor to their gambling. With this in mind, the women’s group sessions provide the opportunity to practice assertiveness and emotional expression in a safe environment. Thus, these sessions are structured (slightly) differently from the group therapy above.

Aftercare

Upon completion of a program at NPGC there are a number of follow-up options available to patients:

  • Opportunity to review and discuss efficacy of treatment with a psychologist
  • Additional individual support with stopping gambling if the initial treatment has not achieved the desired outcome
  • Short-term treatment of residual symptoms and associated mental health difficulties, for example, anxiety and depression, which may later lead to relapse
  • Monthly drop-in support group open to individuals who have completed a course at NPGC.

These sessions take a more informal approach and are available for as long as patients are in need of guidance

Other

In addition to the programs above, the clinic provides specialized resources in the areas of:

  • Court report writing service for problem gamblers who are appearing in court
  • Employee assistance program for employers who may have employees who are problematic gamblers
  • Money management sessions for problem gamblers who require additional help organising their finances

Funding

The clinic is supported in the main part by the Responsible Gambling Trust, which funds the NHS to provide the treatment according to its protocols. The rest of the funding comes from CNWL NHS Foundation Trust, which has supported the clinic from the outset. Currently the clinic receives over 600 referrals a year.