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.

 

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Addiction and Personal Responsibility

One of the hottest topics relating to addiction is the concept of personal responsibility.

Do addicts bring it on themselves? Are addicts morally weak? Do addicts repeatedly fail in recovery because they refuse to take on responsibility?

On the other hand, it can be rightly claimed that all this emphasis on the individual is distorting an understanding of addiction. If, as some claim, addiction is a ‘disease’ how can people be responsible for it? Why is there virtually no alcohol addiction in Saudi Arabia (where alcohol is prohibited by law)? What social factors play a part in addiction? Do some commercial products – tobacco is an example – ‘hook’ some people in the right circumstances?

There is no such thing as an addict; there are only individuals suffering with addiction. Everybody is different, but some groups seem more prone to addiction to others. In the professions journalists, the police, doctors, entertainers, sportspeople and politicians have high rates of addiction. So too do people with multiple and complex disadvantages such as homelessness, poverty, lack of educational and cultural capital, mental illness, criminal background, adverse childhood experiences, trauma – or just one of these.

And people from different social backgrounds seem to be treated very differently when their addictions come to light. Newspaper readers will weep over the death of a pop idol through drugs; a politician will be praised for his ‘brave struggle’ against alcohol. In popular culture – films, books and television – we have come to expect our flawed heroes often to have an addiction problem as one of their flaws, a lonewolf cop bucking the rules and knocking back malt whisky while meditating on a case, a singer in rehab, a public figure making public penance.

Less favourably are seen the ‘scagheads’, the ‘junkies’,  the street addicts, the working class addicts. Although victims all their lives of unequal and unjust social conditions, turning to drugs or drink or gambling to escape if only for a moment, it is they who are most harshly blamed and despised for their lack of responsibility – while those with a lifetime of advantages are treated with adulation and sympathy.

In his remarkable book, Good Cop Bad War, former undercover cop Neil Woods charts his journey of increasing knowledge through the ‘low life’ of desperate addicts (in contrast to the venomous gangster business cartels that bring drugs to market). He grow increasingly sympathetic to the friends he makes while pretending to be himself an addict. Apart from their addiction, most are essentially decent, often intelligent, kind and caring. One such friend , Cammy, tells him his heart-felt news that he has heard a good friend has died. Neil asks whether he will go to the funeral to say goodbye and Cammy replies, ‘I’m not going to the funeral. I wouldn’t do that to the family. The last thing they want is some dirty junkie turning up and ruining everything.’ As Woods observes, ‘No matter how society may condemn and look down on the addict, it is never, ever as low a view as he has of himself.’

That internalisation of social attitudes and stigma is something all addicts have to deal with. Part of them remains ‘clean’ and is a constant accusing voice; the addict hates themself. Guilt and shame alone can maintain an addiction – that belief of such utter worthlessness that there is no point in trying to stop, instead seeking that absurd temporary negation of inner torment with a fix.

Of course, those with a lot going for them tend to do better. Not everybody, of course: the nature of every individual addiction, while having common attributes, is unique in the complexities of an individual. It’s probably easier on the whole if you’re, say, a teacher to have three months leave on full pay to attend rehab, or just to get your life together, than if you are without any money, any support, any care, any love, surviving in brutal conditions. Though yes, many who seem to have well insulated lives with all the support in place do succumb, grow sick and die. And yes, too, some at the very bottom recover and flourish.

There are as many as 40% of addicts who recover spontaneously, relatively painlessly, without any intervention by ‘experts’ or support organisations. A well known example of this is ‘maturing out’ whereby young people who have addictive or risky tendencies literally grow out of them when they settle into employment, get married, start a family. Another famous example is how 80% of American soldiers deemed heroin addicted in Vietnam lost their addiction when they returned to the States and their families. Against this, many others in recovery are certain that addiction is a disease for life and that the only way to manage it is by faithfully following a programme such as a 12-steps one.

A word is needed here too about dependence versus addiction. Through force of habit, culture, lifestyle, many drinkers, for instance consume not only health-damaging amounts but quantities which make them physically dependent. The withdrawl from physical dependency can be life threatening and ideally requires medical supervision. Yet many heavy drinkers then go onto just stop or greatly limit consumption: they were heavy drinkers, not alcohol addicts. There is an additional dependence which is separate from addiction – psychological dependence. Partly this is just the force of habit, neural correlates in the brain ‘speaking’ loudly to perform an action when certain triggers arise. Usually one can become psychologically dependent on a substance or activity to avoid stress, negative feelings or often an undiagnosed mental disorder such as anxiety and depression. Dependence can, and often does, lead to addiction but it’s still possible to recognise a dependence and take responsibility for halting it with acceptance of necessary effort and suffering which will vary greatly in terms of time and intensity according to unique individuals in unique circumstances.

Addiction by its very nature, the heart of addiction, disowns the individual’s core self. It disowns the possibility of being responsible for one’s destiny, for making deep choices. No addict will be able to understand what is going on. They are fully aware of the misery they leave in their wake, of their loss of pride, reputation, money, health, relationships, status, children. They desperately want to stop. But they can’t. In the old days people spoke of a demon inside that controlled them. The demon took them over. This degree of inner torment varies from individual to individual. It’s certainly true that there are many ‘highly functioning addicts’ in all walks of life, folk nobody begins to suspect as being an addict, and, of, course, another core attribute of addiction is the addict’s propensity to deny their addiction. It’s for this reason that common wisdom has it that people must ‘hit rock bottom’ before they can start to recover. This is, fortunately, a myth. It may be true that a secret gambler’s addiction only comes to light when the bailiffs arrive to take the family home and he or she spirals into heavy debt, bankruptcy, prison or failed suicide attempts. But in many cases – often in consort with worried others – many are lucky enough to address their addiction before absolute calamity.

The foregoing suggests just a few of the strands in the complexity of an individual’s addiction. If there is a common attribute of addiction it is that to take responsibility for recovery one must already have made a vital move. This vital move, this perception that one is not only the addicted self, is the precursor of recovery. For some, this vital move is totally unconscious and involves little pain and effort, for others it is a lifelong process.

To conclude, to return to the topic of addiction and responsibility. All of us are a product of our environments, probably more so than products of our genes. Children have been sold drugs from icecream vans (dealers do not ask for age verification or advise responsible use of their products) so 12 year olds have become heroin addicts. The vans are part of the environment, behind the vans are networks of the drugs business, also part of the environment. People continue to smoke cigarettes but on the packets is written ‘smoking kills’, and tobacco is more and more restricted by government policies: it’s recognised that tobacco addiction is not the result of weak responsibility in individuals. Campaigns to restrict and limit junk food (itself  addictive), sugar, salt, fat are not controversial. People argue about minimum pricing for alcohol, but the argument is not see as being around any bizarre claims. In short, government and industry are seen as having a major role in addressing the damage that harmful products may do to individuals and society, including addictive products.

Current debate about addiction is skewed towards a focus on individual responsibility. Just as a parent is deemed responsisible for feeding their children high doses of sugar and fat (these being by far the cheapest foods to buy for those in poverty), so the addict is held reponsible for choosing their addiction (even if this was motivated by a need to escape misery and despair into 20 minutes of artificial paradise). There are no jackpots, magic fixes that will ever beat the scourge of addiction but government and industry have to stop denying their role and play their part in attenuating it.

(An academic, nuanced discussion of responsibility and addiction is in The Journal of Gambling Issues)

 

Addiction’s a Jingle Jangle

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.

 

 

 

Anxiety and Time

Anxiety is a normal and essential part of life. It acts as a motivator. It is a function of the ancient need for vigilance, an evolutionary ‘must have’. As a part of the full spectrum of our lives we feel anxious much of the time. We worry about our children, about having to gave a talk in public, about a job interview. Wemay have lef the house then worry that we have not locked doors and windows, or that we have left the oven on.

However, anxiety goes beyond the normal range for millions of people. Anxiety is one of the commonest mental health conditions. Depression often accompanies anxiety. Anxiety is not simply a ‘mental’ state: it affects, and is affected by, the body and all its organs. . A hangover – which is a temporary illness – often brings severe anxiety to join its unwelcome symptoms. Severe anxiety, apprehension of doom or death, accompanies some heart attacks.

Among clinical anxiety orders is included a diagnosis of generalised anxiety disorder, a chronic unease and state of worry. Anxiety can directly affect the body with digestive disorders, ‘butterflies in the stomach’, irregular heart beat. A very intense and unpleasant experience of anxiety is in panic attacks. In panic disorders one may feel that one is about to die, that something dreadful is about to happen, even that one is abou to die. Obsessive compulsive disorder is classed as a severe anxiety disorder.

There is no neat line between ‘ordinary’ and ‘clinical’ anxiety. Mental ‘disorders’ are best seen as extremes on a spectrum of normal human experience, exremes which have a significant impact upon quality of life and funcioning. Such extremes are treated by medication, counselling and ‘talking therapies’ such as cognitive behavioural therapy.

Some people are more anxious than others because of their constitution, the genetic factors: they are in higher states of arousal, classically the condition of introverts who are uncomfortable with too much social interaction; shyness is a form of anxiety. Others are made anxious by experience. Adverse childhood experience is a key factor: abuse, inadequate parenting, trauma in a young child who lacks all the adult defences may scar permanently. Such childhood experiences can lead to a range of other problems later in life including addiction.

One of the commonest reasons for addiction taking root is given by the self-medication hypothesis. This essential states that a mood of distress such as anxiety is found to be relieved by a substance or behaviour such as gambling. Not all addiction follows this course, but where it does, recovery must take account of the underlying factors.

There are other ways of looking at anxiety than through  medical or therapeutic perspectives. For instance, it’s interesting to note that the word itself has its roots in the same Latin word which means anger, and that Latin root itself came from a meaning of choking or strangling. Anger itself is one of our basic emotions, a response to danger which is often immediate and without thought. It’s not hard to feel how some forms of anxiety are experienced as an angry turmoil. Anger is strongly related to fear. Anxiety has been likened to fear ‘without an object’, a vague but very uneasy feeling of fear that something very dangerous but ubknown is very near. When a person is anxious, having no object to be fearful of, they may ease their anxiety by turning it into fear of a specific object. Hatred and social evils such as racism are related to this process wherein a deeply anxious, fearful person projects anger towards an object.

In those many parts of the world where chronic absolute poverty, starvation, war and other horrors exist, everyday life is largely fearful of specifics. Where is the next mouthful of food coming from? Will the soldiers come tonight? But in rich nations here basic material needs are largely satisfied, for many who have everything there remains a deep underlying unease. hen all the material needs are satisfied what is the person left with? Many people prosper and live satisfying lives; many with similar material security do not. A chronic anxiety fills the days. The poet W.H.Auden coined the term ‘The Age of Anxiety’ for a long poem in the 1930s.

The sense of this sort of anxiety – unexplained fear – is accompanied by a sense of emptiness. The experience can be one of racing thoughts all going nowhere, restlessness, inability to be at peace with oneself and the world. One reason that such unease occurs in rich countries is that we have the luxury or horror of facing fundamental human problems. We spend a lot of mental energy, for instance, pushing down the fact that not only are we going to die but e may die in the next moment. We learn to block feelings of dread when people close to us suffer and die. Alone, we seek distractions to stop thinking deeply. Much – much more! – has been written around such cheerful points by philosophers and others, but the essential point is that everyone faces these questions or, more commonly, refuses to face them.

Addicts are no different. When you label someone an addict you often disguise the fact that they are as much a human being as anyone else. If you label someone a doctor, you can forget that more importantly they are a human being. In some ways people who are addicts are extreme examples of individuals who have sought and found a means of escaping a world that is ultimately meaningless. The world escaped from is full of anxiety, suffering, death – and the hard, hard work of getting along with other people (‘Hell is other people,’ the philosopher Sartre wrote). The addictive moment, when an addict engages with the drink or the gambling machine, is also an escape from time. Time is the demon at the heart of anxiety. It is the fear that the future, the next hour, the next minute, the next second will bring something overwhelmingly dreadful. The worst anxiety is Dread.

Starting in the United States, the phrase ‘the machine zone’ was employed to refer to the unique state of being between gambling machine and user. The zone is a time one more than a place one, or rather a timeless zone. All the Dread and anxiety associated with time dissolves. The ‘zone’ is a double whammy. It removes the deep negative anxiety of time and provides a positive experience of intense power, independence from the flow of time, and something akin to those ecstatic moments produced by drugs and some religious rites. The latter themselves may be deemed a form of addiction. To a lesser extent, the ‘ordinary punter’ may escape anxiety by shopping, bargain hunting, social media, internet addiction, hoarding, proud housekeeping, fooball, reading, climbing, exercise, over-eating… Addiction seen this way is an extreme example, a very harmful one, of ordinary human behaviour. Most people have a range of distractions, some healthy and some not, but addicts centre their lives around one major objec of desire.

The wealth of modern rich economies is built less on coal and steel than on consumer products. Businesses that provide these products to a large extent reach the need of customers to chase distractions from the pressures of life, and to fill what would otherwise be a terrible emptiness. Business practice is as much a reflection as a driver of culture, its own practice dependent upon and informed by the culture(s) we all live in. Some business, however, also sets out to exploit vulnerable consumers, and this can be seen in financial products including respectable high street names credit offers. The worst cases are exorbitant interest fees for loans and cheating old people of their savings and homes. In he case of gambling and drinks industries it appears that those most vulnerable to harm are exploited. Cheap high strength alcohol is made available for pocket money prices.

Moving towards a conclusion now, i can be argued that states like anxiety and depression are common experiences and we seek ways to escape them. Some ways are relativelt harmless but addiction brings with it not only severe life and health problems but an increase in both anxiety and depression. Addictive engagement seems to bring about a quick way of switching moods very quickly, that switch is the attraction. This isn’t the case for everybody: addiction is a complex condition dependent on many factors peculiar to the individual. But it’s certainly true that many people have felt ‘lost’, anxious, depressed, unable to concentrate as thoughts race. These feelings are not uncommon in society as a whole. Many who are a long way from clinical anxiety and addiction nevertheless live a life permeated by unease, a vague pervading anxiety. In the case of full blown addiction, this unease is intensely powerful and negative, and the only sure ‘way out’ seems to be the ‘fix’ which will lead, of course, to deeper anxiety, guilt, shame, all the impossible attributes of feeling helpless, powerless in the drive to do the one thing one desperately does not want to do.

Those of us who have known addiction or are struggling with it may acknowledge that we have not learned the coping strategies of facing everyday unease. The psychiatrist Sigmund Freud said that his therapy was designed simply to move people from ‘neurosis’ to ‘common unhappiness’. Even the happiest, most contented people have periods and episodes of unhappiness and unease, but they have found positive things in life against the negative background – family, music, donkey racing, clmbing, music, reading, exercise, volunteering, whatever. Recovered or recovering addicts lapse often because the negative unease persists, and perhaps it’s here that medication or other therapies are most important. But when people do recover they don’t become saints or bundles of joy: they slowly come to terms with the anxiety and unease that is part of the package that all humans have to live with to be alive.

12% of UK Doctors are Addicts

According to this site for sick doctors, 10% of the general population are estimated to be addicts. The figure rises to 12% for doctors in the UK. These figures refer to drug and alcohol addiction and do not include other addictions such a s gambling addiction. Both figures are probably highly surprising to most people. Addiction is certainly one of the most pervasive of all mental illnesses. The costs to individuals and those near them is huge in terms of grief and suffering; the cost to the nation runs into may billions of pounds.

Doctors and other front line health workers generally work under very stressful circumastances. One stressor must surely be that those they are helping or trying to help often turn against them, blame them, may be even physically violent. This may be true especially among addicts who ahve a tendency before they start on recovery to externalise their pain,  and blame whatever or whoever comes to hand. Doctors are often in a position where they can do little for a patient except refer them elsewhere. Often, when recovery from addiction has begun and the patient has gained some ownership of their own recovery, doctors can help with things like depression and anxiety.

However, going back to the figures at the top, if doctors themselves have such a high rate of addiction it seems reasonable to suggest that there is no easy medical ‘cure’ for addiction, no magic pill. If doctors cannot heal themselves, or not easily by use of medication, it follows they cannot offer easy solutions to anybody else. Doctors have to embark on recovery in the same ways as anyone else.

It’s the case that ‘addiction’ is classed as a ‘mental illness’, yet perhaps it’s true also that there is no straightforward and medication based treatment.

It may be that recovery is not a medical matter. Although medicine can help with the complexities of addiction on an individual case basis such as whether a comorbid mental health disorder needs treating initially or during recovery, by and large recovery takes place in non-medical contexts. 12 step programmes (AA,GA,NA etc.) is an obvious example (although as is well known, while some swear by the programme, some evidence regarding its efficacy suggests low success rates, and many people find it is not for them). Psychological therapies are used too, but accessing them can be very difficult, involving a long wait for treatment which is not necessarily successful.

A large number of people – in cases of alcohol addiction, for instance, maybe as many as a third of people – recover with no recourse to doctors, psychologists, 12-steps or any other agency. A well known example is that when soldiers became addicted to heroin fighting in Vietnam, 805 of them recovered without intervention on returning home to America where they were in the environment of family, home and friends. Inversely, studies show that drug addicts who stop using while in prison, sometimes for many years, resume upon release when they return to their old social networks. Environment in its broadest sense seems to play a big part in recovery.

How prevalent is addiction?

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:

• 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?

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.