The link between trauma and addiction

Cognitive behavioural therapist Paul Dent discusses the importance of tackling past trauma in the treatment of gambling addiction.

With the 50th anniversary of the first residential treatment programme for gambling addicts coming in 2021, the Gordon Moody Association (GMA) has gone from strength to strength in the intervening period, now offering five distinct programmes.

The male residential treatment programme offers two unique specialist centres providing an intensive treatment for gamblers most at risk. Previous research has shown that this group often demonstrate psychopathological and psychosocial problems with 80-95% never having obtained formal support for their problems.

Treatment is only sought when they have failed outpatient programmes or require a greater level of care than can be provided in the community. With this in mind, GMA has collaborated with the University of East London and University of Lincoln, key research institutions in the field of gambling and addiction. A number of joint studies have been undertaken to investigate the characteristics of those entering and leaving the programme over a 15-year period.

The most recent study (Roberts et al, 2019) set out to identify any significant predictors and evaluate any differences between voluntary and enforced withdrawal. One of the key findings was that those suffering from a high incidence of childhood maltreatment, trauma or abuse were more likely to leave the programme prematurely.

These early experiences may affect the ability to sustain trusting relationships with other individuals, possibly in this case the therapist. This is in keeping with other previous research (Melville et al 2007) which highlighted a need to tailor treatment that specifically targets the effects of stress and early trauma.

This could have wider implications for treatment providers and operators, as early identification could lead to different strategies in how to interact with disordered gamblers.

In response to these findings, therapists at GMA attended a workshop on complex trauma. They were introduced to the stages and implementation of the Tri-Phasic Trauma Recovery Model (Herman, 1992). This has a natural resonance with the programme at GMA where the residents first undergo stabilisation to regain internal and external control.

The programme is psycho-educative in nature and is designed to teach the client about their symptoms: how to recognise and anticipate them, what they mean and how to manage them. It also deals with decreasing the client’s shame and confusion, as well as normalising certain behaviours, especially if the language used is empathic and empowering.

Victim to survivor The importance of decreasing shame cannot be emphasised enough – a significant factor in stabilisation is the gradual redefining of the client’s role from that of victim to that of survivor.

There then follows the more difficult phase of addressing past traumas, reconstructing and processing memories so they no longer disrupt normal life. As was indicated in research by Sharman et al (2019) on 768 gamblers attending GMA between 2000 and 2015, early-age onset was an indicator of gambling severity.

Early-age onset gamblers were more likely to have committed unreported crimes, abused drugs and solvents and to have a parent with a gambling problem. They were more likely to be verbally aggressive and less likely to report a positive childhood experience.

This type of work needs to be addressed with care and by staff qualified and experienced in trauma. Long-buried memories can resurface which can present as PTSD that the client may have spent many years compartmentalising. Indeed, gambling may well be just the coping mechanism to deal with previous negative experiences. This has to be dealt with in a sensitive, timely and considerate manner, particularly in a group setting.

The final phase is about reconnecting and reintegrating with society, redefining oneself in the context of meaningful relationships. This final stage cannot be underestimated as many who attend the programme will be returning to relationships and hopefully some form of employment.

This is supported by Abbott (2020) who in advocating a public health and policy approach, thereby questioning the effectiveness of responsible gambling, highlights that the burden of harm is mainly due to financial problems and damage to relationships.

Abbott advocates a strong focus on reducing exposure to more toxic forms of gambling as well as increasing the availability of interventions to assist at-risk and disordered gamblers to prevent relapses. GMA, in continuing the reintegration through its outreach support, provides an invaluable stepping-stone, not only back into the community and familial home, but providing support in the many months and years afterwards when relapse is always possible.

While there is a growing number of studies linking trauma, addiction and gambling, there is scope for further research to test the validity of this specific model, particularly with a new approach. Abbott (2019) highlights the importance of well-designed studies to increase the understanding of therapeutic mechanisms, to enhance client retention and meet individual patient needs. Comparisons could assist in developing cost-effective stepped care services with further attention to long-term follow-up and assessing ways to prevent and manage relapse.

Indeed, novel coronavirus (Covid-19), changes in regulation and the ongoing shift to online gambling has forced everyone to reflect on how they deliver, operate and manage their staff.

Early on, GMA recognised that the current crisis would hit the client base hard. Being some of the most vulnerable in society, the decision was taken to expand support and make a shift from reactive to proactive when it came to contact with the extended service user community.

Additional groups have been added to outreach support using both VOIP and text-based interventions with more people than ever engaging with GMA. Regular remote support for people waiting to access treatment but unable to do so has been set up, and interventions weekly via phone, email and VOIP now number in the hundreds.

Although the number of requests to take in new residents has been stable, there has been an increase in contact with ex-residents, friends and family during this difficult time, with experienced therapists on hand to offer both practical and emotional support.

With these measures in place, GMA has made sure that everyone in need of support has been able to access the services they require.

Perfect storm Covid-19 has created the perfect storm of boredom, financial constraint and isolation that many have predicted will cause a surge in global online gambling. This presents an opportunity for operators but also a new global responsibility to culturally diverse gamblers who will often be using their services across international borders.

Many countries have little or no support available for disordered gamblers, leaving vulnerable people with few places to turn for help if they begin to struggle. GMA, through its online provision, may well be the only service available for these people. Therefore, the medium-term goal is to move towards providing 24-hour multilingual support in line with global nature of the industry.

GMA will continue to be part of the conversation as to how and when to provide effective interventions to those who may be struggling. A pilot project has already been completed looking at how clinical skills and knowledge can be shared, particularly in the area of complex calls such as suicide. Among other things, the project examined the effectiveness of the responsible gambling message. Is it just a smokescreen? Should a more public health approach be taken, looking to intervene at a higher level where ultimately the costs are borne?

Looking to the future, GMA has an excellent track record and legacy of supporting people, which it will continue to build on. At the heart of this, residential support will be offered in more places. This will be driven by continuing to raise awareness of the charity, as well as through partnerships and property purchases where appropriate.

The retreat and counselling programme demonstrates how it is possible to combine a model of one-to-one with virtual support and will continue to develop to reach those who need it. A new centre of excellence will be created to provide thought leadership to the therapy sector and to help develop the workforce of the future.

This cannot be done in isolation. There will continue to be collaboration with the gambling and addiction sector to create a system that can help those most requiring help, at the time of demand, in the right place, with the support that’s right for them.

Paul Dent is clinical manager for gambling therapy at the Gordon Moody Association. He supervises the remote team who provide global online support to problem gamblers and affected others. Paul is an experienced trauma and addiction psychodynamic and CBT therapist.