‘There’s something quite unique about behavioural addictions’

Dr Venetia Leonidaki (pictured, left) is a Consultant Clinical Psychologist at the National Gambling Clinic, and Dr Rebecca Lockwood is a Consultant Clinical Psychologist at the National Centre for Gaming Disorders.

How did you both become interested in treating behavioural addictions, and how did that evolve into treating gambling and gaming addictions? 

VL: I developed an interest in addiction early on in my career, when I had my first ever placement as a psychology student back in Greece in a methadone maintenance service which helped people who were suffering from heroin addiction. I was baffled by what was keeping people engaged in a habit that was so destructive. These people had had an addiction to heroin for most of their lives and they were willing to sacrifice absolutely everything, including their mental health, physical health and their lives to carry on with this habit. As a young psychology student I just wanted to understand what keeps people repeating a behaviour that is so harmful to them. I wanted to see how I could help people break away from that. 

I came to England to do a master's in addiction and moved onto studying clinical psychology working as a therapist in IAPT [Improving Access to Psychological Therapies] services in London. Eventually, it all came full circle when this opportunity came up in the gambling clinic where I joined as a consultant psychologist six years ago. There's something quite unique about behavioural addictions compared to substance use. While substance use services tend to emphasise a medical model, with behavioural addictions the first-line treatment is psychological and there's more space to think about the role psychosocial factors play in their development. 

RL: I came down a slightly different path – I'm from a background working in offender care in the prison system with women with complex trauma. As you might expect there was quite an overlap with addiction, particularly substance misuse. I really enjoy working with complex trauma and attachment issues, and I don't think people are always aware that when we're working with behavioural addiction there's lots of complexity around trauma, unmet childhood needs and broken or ruptured attachments. 

I'd worked in the prison for six years then there was a great opportunity for a consultant role setting up this new clinic to treat gaming disorder – which had just been recognised by the World Health Organisation. I came in really willing to learn on the job and I just found it fascinating. I've been here since then – which was five years ago. It's such an interesting and complex area and very different to what I expected. There's a lot of classic psychology in the service, CBT [Cognitive Behavioural Therapy] and lots of third-wave therapy, but we've also got a family therapy pathway and we work in a really different, intuitive way. 

Could you tell me about the impact of gaming addiction? 

RL: I have been really struck by the impact across the board. Not just the emotional and psychological impacts but the physical impact that gaming disorder has on the small number of people who have this diagnosis. The National Centre for Gaming Disorder, forming part of Central North West London (CNWL) Foundation Trust was set up in 2019. We work with people aged 13 and upwards and their families. Often we meet parents who have been through lots of different services and they're exhausted and anxious and at the end of their tether. We've also seen a huge amount of child-to-parent violence in relation to gaming disorder, often when parents are trying to intervene to reduce the amount of gaming. Nearly 50 per cent of our cases have commented on aggression or violence from the young person to the parent. 

I have been struck by the impact this addiction has on the minds and behaviours of the people that are doing it. We've seen people that haven't been to school for many years because they've been gaming throughout the night. We see people not engaging with everyday activities, not engaging with parents or families or friends. It has a huge physical impact too – we're seeing people who are very underweight because they're not eating meals, or they might be eating unhealthy, convenient food and becoming overweight. 

Venetia, could you tell me about some of the impacts of gambling addiction? 

VL: With gambling a distinct type of harm is debts. People might find themselves in serious debts which have, of course, consequences, not only for the gambler, but also for significant others, including spouses, children, parents and siblings. The thing about gambling is people can lose money, huge amounts of money very, very quickly, and it can then take them years to be able to pay back this money. This can impact mental health in all sorts of ways, including them feeling depressed, feeling anxious and feeling suicidal as well. I think death by suicide is the most tragic harm concerning gambling addiction, and unfortunately we know that those with pathological gambling are more likely to die by suicide as compared to the general population. 

Gambling addiction also puts pressure on families with relationships breaking down as a result. It's not unusual for some of our clients to come to us when their partner has given them an ultimatum because of their gambling. Those marriages breaking down might mean the person can't see their children or they can't provide for their families. There's also a lot of social isolation. Gambling, like gaming, can take up a lot of time. People are preoccupied with gambling, with placing the next bet, or spending hours and hours gambling, so there's no space for them to be involved in social relationships.  

Could you tell me about the treatments you use with people experiencing problem gambling and gaming? How effective are the treatments available?

VL: We're currently waiting for the NICE guidelines for the identification, assessment, and treatment of gambling harms to come out. However, the National Gambling Clinic, also forming part of CNWL, was founded in 2008 and we have developed a comprehensive treatment programme. The first-line treatment is psychological treatment and CBT is at the heart of the programme here – that's the core treatment. In our service we start by engaging clients; people who experience an addiction have a lot of mixed feelings about quitting their habit so we start with engagement and resolving ambivalence towards change. This is coupled with some practical measures that people can take to place some barriers between themselves and the gambling and money – for example using software that blocks gambling websites, certain banks also allow you to block gambling transactions, and people can also self-exclude from bookmakers, casinos and other forms of gambling. 

After this we move onto CBT and use similar strategies that you find in other treatments for tackling substance use, such as coping with craving, dealing with triggers, preventing relapse, but also some unique features when it comes to CBT for gambling – for example, helping people learn to reward themselves for non-gambling days. Another distinct element is gambling-related beliefs. People may think that they can make money from gambling which is why they gamble, and in therapy we can help them come to a more balanced belief – professional gamblers may make money but for most people gambling is not a good way to make money and can lead to debts. As well as CBT we might offer couples and family therapy, psychodynamic therapy, medication to help with cravings, consultation to teams, and we have a pathway for affected people in a client's family. 

RL: There's quite a lot of overlap in gaming – we use CBT to help with managing urges, cravings and challenging thoughts. But our goal is more to develop a healthy relationship with gaming rather than abstinence, unless that's someone's specific goal in therapy. Initially we help people develop specific goals then we move on to using third-wave therapy such as DBT [Dialectical Behaviour Therapy], ACT [Acceptance and Commitment Therapy], CFT [Compassion-Focused Therapy], and CBT, and think about changing that pattern of addiction and exploring why the addiction has developed in the first place. We also do a lot of work with families and run workshops for parents of young people with gaming disorder. 

This is a new clinic so we're learning and beginning to profile presentations of people and why they use gaming as a coping mechanism. Interestingly, what we've seen is there is quite an overlap with neurodiversity – one fifth of our patients have a diagnosis and many more are awaiting assessment, so we're mindful of this in our treatment. A lot of what we think about is why this person is gaming, what function it serves, what need is it meeting for them? We think about the individual, what their goals might be more generally in life, we think about self-esteem and value development because that helps increase engagement with treatment. 

Did the Covid pandemic impact on the number of people you were seeing?

RL: In one way it helped us to get working online and running and designing our programmes to be Zoom-based, so it was great we could still connect with people. During Covid most people were using more screens but it's actually post-Covid that we saw people struggle to stop engaging in compulsive behaviours like gaming. That's when people noticed their children were refusing to go back to school or had lost their confidence in interacting with people. We noticed a sudden influx of referrals after the lockdowns stopped because people were struggling to get back to normal or had developed addictions. 

VL: With gambling we saw two things happening. One was that some gamblers stopped gambling completely, and this was because during Covid there were no sports to bet on, people couldn't access bookmakers, the pandemic acted as a form of natural stimulus control which meant people didn't have their usual access to gambling. However, for some people their gambling became worse. Our clients who preferred online gambling had more access to this than ever before, and these gamblers were severely affected by the pandemic. We also had people whose gambling changed and they started to look for other forms of gambling that were accessible during the pandemic such as online gambling which was not their usual way of gambling. 

Can you tell me what change you would most like to see in your areas?

RL: I think we need to promote a better understanding of gaming and screen use. I think it's increasing awareness and thinking about education of families so they can identify what is healthy gaming compared to problematic gaming. A lot of that is done with open communication – keeping the dialogue open between parents and children. As a nation we have a responsibility to think about supporting particularly young people to develop a healthy, limited, boundaried engagement with gaming. It's worth thinking about protecting screen time, potentially having tech-free zones in the house, not using your phone at the table, having a time to stop using screens before bedtime, also thinking about playing offline games which are far less addictive than playing online with other people. 

VL: Pathological gambling is increasingly recognised as a public health issue, which is good. There is still more work to be done in terms of the government actively implementing tighter regulation. As professionals we need to be identifying people who are at risk of gambling harm and need treatment. I'd like to see any frontline professionals doing mental health assessments to include questions about gambling – just as we ask about people's alcohol or drug use. If people do have problems with gambling help is available and it'd be great if we could encourage more people to come forward and ask for help – as with any addiction there's stigma attached. 

Can you tell me about the work you're doing to increase awareness of these behavioural addictions?

VL: We're running webinars for healthcare and psychological professionals looking at some of the key challenges that our client groups face, increasing awareness so clinicians know what to ask to identify whether someone is being affected by gambling and gaming addiction, and recommending some low-key interventions that they can use to help them and know where to signpost. 

We also offer a comprehensive overview of the treatment programme for gambling– and our CBT protocol in particular. The key treatment principles and techniques of our CBT protocol can also be found in a self-help book called Breaking Free: How to Stop Gambling. This is written by clinicians and academics connected to the clinic and was published by Cambridge University Press two years ago.

• Leonidaki and Lockwood are hosting a webinar to provide an introduction to gambling and gaming disorders on Wednesday 27 November. Leonidaki will also host a webinar in February providing an introduction to behavioural addiction and treatment for gambling harms. Full details of these will be published here.