Forensic Psychiatry_ Clinical, Legal and Ethical Issues Book 1

Other substance misuse

with significant others is the key to bringing about Treatment Outcome Research Study (NTORS), has been
change and achieving goals. underway since 1995 (Gossop et al., 2003). In this study, 1,075
4. Family therapy involves trying to understand and interpret drug  m­ isusers are being followed-up through and beyond
family dynamics in order to change the psychopathol- two types of residential services (inpatient and residential
ogy. Substance use is perceived as a symptom of family units) and two kinds of community services (methadone
dysfunction and, therefore, altering the family dynamics reduction and methadone maintenance). Their age range
will bring about change in the substance misuse. Family was 16–58. Half of them were responsible for caring for
members are viewed as contributing to the problem. children. There was a history of treatment for psychiatric
Behavioural and psychodynamic techniques may be used. disorder in the 2 years prior to programme entry; in the 3
5. Group therapies and 12-step programmes. Participation months prior to entry, 30% had had suicidal ideation. Over
in self-help groups is an important feature of many 27,000 acquisitive criminal offences were reported by people
treatment programmes, in which participants receive in the cohort, also during the 3 months prior to starting
support from recovering members who often go back treatment (Stewart et  al., 2000), with shoplifting the most
over the negative consequences of substance misuse. common. Ten per cent of the sample was responsible for
The 12-step approach is one form of this. Central to the three-quarters of crimes committed. Higher frequency of
12-step philosophy is the idea that recovery from ad- illicit drug use was associated with higher levels of criminal
diction is possible only when the individual recognizes behaviour. High-rate offenders were more likely to be regu-
his/her problem and admits that s/he is unable to use lar users of heroin and were three times more likely to have
substances in moderation. Alcoholics Anonymous used cocaine regularly.
(AA) and Narcotics Anonymous (NA) are examples of
this; users have to abstain completely. There is an important difficulty with this study in
6. Motivational interviewing. The most influential and pop- that the specifics of the treatment modalities have not
ular form of treatment currently has been motivational been described in detail, so, from the study reports, it
interviewing, a ‘brief ’, ‘minimal’, ‘non-judgmental’ in- would be difficult to replicate the complex mix of treat-
tervention, the aim of which is to build motivation for ments and services delivered within each main group.
change and alter the decisional balance so that users Outcome measures, however, are strong and various.
themselves can direct the process of change (Rollnick Opiates, amphetamines, cocaine, non-prescription benzo-
et al., 2008). The focus is on the user’s own concerns about, diazepines and alcohol levels have been assessed, as has
and choices regarding, future drug use. Motivational en- the impact of treatment on psychological health, suicide,
hancement supports motivation for change through other mortality and crime. After 5 years, 62 people had
empathic feedback, advice and information. Significant died, alcohol use remained at a constantly high level,
people in the user’s social group may have a treatment with 25% still drinking above safe limits; 80 people were
role, but not a major one; the individual’s motivation is long-term users of two or more illicit drugs. Nevertheless,
seen as central. The key characteristics are best described there was significant progress. Also after 5 years, a third
by the acronym FRAMES (Miller and Sanchez, 1993): of users achieved abstinence in the community as did half
●● personalized feedback or assessment results of those in residential services. Although 20% of the study
sample continued to use daily and 40% about once a week,
detailing the target behaviour and associated effects this had reduced from 66% at intake in the residential
and consequences on the individual; services group and 80% in the community services group.
●● emphasizing the individual’s personal responsibility Likewise, injecting reduced from 60% to 40%, criminal
for change; activity halved. This is encouraging, despite the limita-
●● giving advice on how to change; tions in study design noted above, suggesting that adults
●● providing a menu of options for change; have a reasonable prospect of benefitting from current UK
●● expressing empathy through behaviours conveying treatment programmes.
caring, understanding and warmth;
●● emphasizing self-efficacy for change and instilling hope Despite the high rate of mental illness histories in the
that change is not only possible, but also within reach. NTORS study, and advances in the effectiveness of phar-
There is growing evidence for the benefits and cost effec- macological and psychological treatments for substance
tiveness of this type of intervention (Dunn et  al., 2001; misuse (Lingford-Hughes et  al., 2004; Project MATCH
Project MATCH Research Group, 1998). Research Group, 1998; UKATT Research Team, 2005a,b), it
is not clear that more positive outcomes will generalize to
Treatment effectiveness among comorbid cases (Cornelius et al., 2004; Haddock et al., 2003).
adult drug misusers Evaluations of combined treatments (pharmacological and
The first longitudinal, prospective, observational study psychological or two types of pharmacological treatments)
on outcome in drug misusers in the UK, the National have only just begun with people with substance misuse
disorders and mental illness. Nunes and Levin (2004), in a
systematic review and meta-analysis of treatment of people

© 2014 by Taylor & Francis Group, LLC 459

Addictions and dependencies: their association with offending

with standardized diagnoses of unipolar depression and sentences with a drug treatment element were started
alcohol or other drug dependence, found just 14 double- in England in 2006/7. Investment in prison treatment
blind, randomized controlled trials (RCTs) of antidepres- increased tenfold, from £7 million in 1997/8 to £80 million
sant medication with recorded effects on depression and in 2007/8. In the 12 years 1996–2007 there was an increase
substance use (8 alcohol, 4 opioids, 2 cocaine). There was from 14,000 prisoners on maintenance or detoxification to
a modest beneficial effect on the depression and, where 51,000 (UKDPC, 2008). The NTA has described a series of
effect sizes for depression were largest, on quantity of sub- key elements which should be in place in criminal justice
stance misuse, but rates of abstinence were low. Additional settings, as shown in box 18.4.
specific targeting of the substance misuse disorders was
recommended. Even ‘effective’ treatments are not effective A Cochrane review of the effectiveness of commu-
for all who seek help and not all who need help will seek it. nity and prison based interventions to reduce offending
behaviour in drug users concluded that the evidence from
In the most comprehensive review to date, Tiet and the 24 RCTs selected was equivocal (Perry et  al., 2006).
Mausbach (2007) considered both psychological and phar- This was mainly due to the broad range of studies and lack
macological treatments for substance misuse associated of standardization in the outcome measures, although the
with depression, anxiety, schizophrenia, bipolar disorder or authors did comment that the use of therapeutic com-
other severe mental illness. Fifty-nine studies met stand- munities combined with an aftercare programme showed
ards for inclusion, of which 36 were RCTs. Although there ‘promising results for the reduction of drug use and
was no clear evidence of superiority of any one interven- criminal activity in drug using offenders’. The evidence
tion over the comparison treatment for either psychiatric reviewed, though, generally excludes important popula-
disorder or substance misuse, and treatments had not tions, such as women and young offenders, who have not
been replicated, the review did demonstrate that effective been participants in any major evaluations of interven-
treatments for psychiatric conditions tended to reduce tion effectiveness.
psychiatric symptomatology and effective treatments for
substance misuse tended to reduce substance use, even in A more recent review of the evidence for the effec-
the presence of comorbidity. The value of integrated treat- tiveness of a variety of interventions for the UKDPC
ment was not, however, substantiated. (McSweeney et  al., 2008) concluded that, whilst there is
strong evidence that individual criminal behaviour can be
Evidence in general is, therefore, scant, but data more modified by drug interventions, the evidence for the effec-
specific to people in the criminal justice system (CJS) tiveness of some interventions is not strong. The findings
even more so; such people are rarely represented in treat- are summarized in table 18.6.
ment trials. Furthermore, treatments and services are not
as accessible or available as is required, for these and other Community provisions for drug
especially vulnerable groups. Some principles of treatment, misusing offenders
however, are filtering through into the CJS. Both mental The range of community-based CJS provisions for England
health and substance problems are likely to be chronic and Wales was summarized in a review of the evidence
conditions, so treatment cannot be conceptualized or supporting current drug-related interventions (UKDPC,
presented as a ‘cure’, but rather as support and care, which 2008). Programmes listed include testing for drugs
can improve some substance, health and psychosocial on arrest, mandatory assessment following a positive
outcomes. Emphasis is on engagement of the service user,
and, where possible, carers in the community rather than Box 18.4 Key elements in treatment delivery for
in an institutional setting, with continuity, responsiveness, drug misusing offenders (NTA, 2006b)
and flexibility in care, and in attempting to integrate edu- ●● Drug-misusing offenders should have quick access and
cational and employment options and accommodation
needs as well as special relationships within the treatment entry into drug treatment.
framework. ●● They should be retained in continuous drug treatment

Treatment Delivery Models for Drug for at least 3 months.
Misusers in the Criminal Justice ●● They should have the option of methadone
System (CJS) in England and Wales
maintenance (and not rely on detoxification alone).
In 2008, the UK Drugs Policy Commission (UKDPC) ●● Comprehensive care management techniques are
reported some startling statistics. The budget for adult drug
interventions within the CJS in England and Wales was needed to deal with an individual’s multiple needs.
over £330 million in 2006/7. By January 2008, 3750 offend- ●● There needs to be close co-ordination between
ers a month were entering treatment through the Drug
Interventions Programme (DIP), while 15,799 community specialist and generic services across a range of
interventions.

460 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

test, restrictions on bail (including compulsory drug police stations to screen arrivals, triage and guide on safe
treatment) following a positive test, and conditional management (see also chapter 25).
cautioning by a police officer. Failure to comply may
result in prosecution for the original offence. Legislative Substance abusers detained by the police may need
f­ramework for community-based coerced treatments is to be transferred to hospital, sometimes to the A&E
under Drug Testing and Treatment Orders (DTTOs) or department, particularly if they are intoxicated or
Drug Rehabilitation Requirement Orders (DRROs). There suffering drug-related injuries. Following treatment, a
are a number of accredited treatment programmes that patient may be well enough to be discharged from hos-
may be attached to community orders, including Offender pital but may not be fit enough for detention in a police
Substance Abuse Programmes (OSAPs) and Addressing cell. The hospital doctor should take this into account
Substance Related Offending (ASRO). when assessing the patient’s fitness for discharge and,
The Drug Interventions Programme (DIP) if necessary, recommend reassessment by the forensic
The Drug Interventions programme provides a framework physician at the police station (Crome and Ghodse,
for interaction between CJS workers, providers of drug 2007).
treatment services and other related services to provide an
individualized package of care for a drug user in the CJS. The police may ask doctors for their opinion about the
It is delivered through Criminal Justice Integrated Teams patient’s fitness for interview. Before providing this, it must
(CJITs) and is designed to provide a service from first point be established whether the patient is currently under the
of contact with the CJS to discharge and beyond. influence of drugs or alcohol, whether there is evidence of
the abstinence syndrome or whether the detainee is fully
Safe and ethical management of aware of his/her surroundings and is able to understand
drug users in police custody potentially stressful questioning, cope with the interview
The assessment and treatment of drug users in police and, if necessary, instruct a solicitor. The timing and dura-
custody poses particular management problems, as unrec- tion of the interview will help to inform this advice, which
ognized withdrawal states or injuries masked by intoxica- is important because of questions about the admissibility
tion can result in death. Advice on this is available from a of confessions obtained if the individual’s mental state is
number of sources (Association of Forensic Physicians and impaired or s/he is in withdrawal and desperate for a ‘fix’.
Royal College of Psychiatrists, 2006; Royal Pharmaceutical If an individual is obviously intoxicated, it is customary
Society of Great Britain, 2007). At present there is no to wait for the effects of the drug to wear off; however,
national policy on best management, and management is the mental state may fluctuate markedly following hal-
subject to considerable regional variation. Newer models lucinogenic drugs, making it difficult to ascertain when
here involve community psychiatric nurse location at the patient is fit for interview (Association of Forensic
Physicians and Royal College of Psychiatrists, 2006).

An intimate search for drugs must be carried out at a
hospital or other medical premises, by a registered medical

Table 18.6   Summary of evidence base for interventions for illicit drug misusing offenders (UKDPC,
2008)

Intervention Reasonable evidence Mixed evidence No effectiveness
evaluations
Drug courts ✓
Community sentences ✓ ✓
Prison-based therapeutic communities ✓ ✓
Opioid detoxification and methadone maintenance ✓ ✓
RAPt 12-step programme ✓ ✓
CJIT ✓
Restriction on bail ✓ ✓
Drug testing in addition to a community order ✓
Counselling Assessment Referral Advice and Throughcare ✓
(CARAT) interventions
CBT based interventions
Addressing Substance Related Offending order (ASRO)
Conditional cautions
Diversion from prosecution schemes
Intervention orders

© 2014 by Taylor & Francis Group, LLC 461

Addictions and dependencies: their association with offending

practitioner or registered nurse, but responsibility for it lies apply to PMMT. The key ideas are that methadone doses
with the forensic physician, not the hospital doctor. should be sufficiently high (>60 mg daily) and treatment
duration of sufficient length (probably that of the prison
Treatment for drug misusers in prisons sentence) to reduce drug use and injection in prisons as
The poor general health of prisoners is often related well as improving retention in treatment and reducing ille-
to substance abuse, and has ramifications, both during gal drug use and criminal behaviour on release.
imprisonment and after it. Tuberculosis and HIV may start Counselling, Assessment, Referral, Advice and
or worsen whilst in prison, but there is also an opportunity Throughcare (CARAT)
to improve health generally, and coincidentally reduce the The CARAT service was set up in every prison in England
likelihood of re-offending and negative impact on public and Wales in 1999. CARAT workers offer counselling and
health (European Monitoring Centre for Drugs and Drug support to prisoners about drug misuse and act as link
Addiction (EMCDDA), 2007). workers to other services, both in custody and on release
from prison. A review of findings from the research data-
Efficient management of drug problems in prisons is base was published in 2005, which covered 2 years of the
central to reducing drug-related harm there. The two main service from 2002 (May, 2005). This review concentrated
high-risk periods are just after reception and at discharge on descriptions of the population engaged by CARAT
from prison. There is a correlation between drug with- rather than on outcomes, and showed that 40% of the
drawal symptoms and suicide in the first week of custody prison population accessed the CARAT service during the
(Shaw et  al., 2004) and a seven- to nine-fold increase in study period.
overdose deaths in the weeks after release from prison Other prison-based services for drug users
(Bird and Hutchinson, 2003; Farrell and Marsden, 2008); Additional measures for prisoners who have drug problems
some are accidental but there is also an increased risk of include:
intent to die just after release (Pratt et al., 2006). ●● drug-free wings and voluntary testing programmes;
●● Short Duration Programmes (SDPs) (4 weeks) based on
Interventions available range from simple prison-based
detoxification, methadone maintenance and placement cognitive behavioural therapy;
on drug-free prison wings through to more structured ●● Prison-Addressing Substance Related Offending
multi-method programmes, such as the Integrated Drug
Treatment System (IDTS) and/or Counselling, Assessment, (P-ASRO) – a behaviour programme of low to medium
Referral, Advice and Throughcare (CARAT) service activi- intensity targeting offending behaviours connected
ties. Prison in-reach services have also been used to deliver with drug use;
a comprehensive mental healthcare package, including ●● therapeutic communities providing treatment based
management of patients with co-existing addiction and on social learning.
mental illness. These services have, however, not been
standardized and are described as variable and idiosyn- Comprehensive treatment programmes
cratic in their delivery methods (Steel et al., 2007). A number of initiatives have been funded within the UK to
The Integrated Drug Treatment System (IDTS) provide integrated care for those in the CJS who have drug-
The IDTS is designed to expand the range of clinical related problems. These initiatives focus on the concepts of
interventions available within prisons, with a particu- throughcare and aftercare, the former describing arrange-
lar emphasis on improvement in prescribing substitute ments for managing the continuity of care provided to a
medications and provision of a range of psychosocial
interventions. The aims of the IDTS are summarized in an Box 18.5 Aims of the Integrated Drug Treatment
overview produced by the NTA, one of the bodies respon- System (IDTS) in prisons (NTA, 2001–2008)
sible for the roll-out of the service across the UK (see box ●● Increasing the range of treatment options available to
18.5) (NTA, 2001–2008). The components of the IDTS have
not yet been rigorously evaluated within a prison setting, those in prison, notably substitute prescribing.
but there is evidence for the effectiveness of some compo- ●● Integrating clinical and psychological treatment in prison
nents in other settings.
into one system that works to the standards of Models
Substitute prescribing is a well-recognized treatment of Care and the Treatment Effectiveness Strategy, and
for opiate dependence, supported by several studies, par- according to one care plan.
ticularly in its impact on social outcomes such as reduced ●● Integrating prison and community treatment to prevent
debt and crime (Seivewright and Iqbal, 2002). The effective- damaging interruptions either on reception into
ness of prison-based methadone maintenance treatment custody or on release back home.
(PMMT) has been reviewed by Stallwitz and Stöver (2007),
who concluded that findings from other settings broadly

462 © 2014 by Taylor & Francis Group, LLC

Other substance misuse

drug user from the point of arrest through sentencing and are using to alleviate psychological distress (Chatham et al.,
linking seamlessly with aftercare, this being the package 1999).
of support planned for when the user reaches the end of a
prison or community based treatment programme within Two large community studies in Europe have recently
sentence. These programmes often include basic drug supported this. Both the Netherlands Mental Health
treatment supplemented by support packages including Survey and Incidence Study (Bilj et  al., 1998) and the UK
housing, financial management, basic educational skills, Psychiatric Morbidity Study among adults living in private
family and relationship problem solving and employment households (Singleton et al., 2003) showed that, while anxi-
skills development. ety and mood disorders rates were higher among women,
drug use and dependence were higher among men. In the
Medicinal support for relapse prevention Dutch study, substance use disorder was more likely to be
Naltrexone is an opioid antagonist without euphoric effects comorbid with a mood disorder among the women than
which blocks the effects of opiates. It can be provided prior among the men (de Graaf et al., 2003).
to release for abstinent users as a support to psychosocial
treatment. This is only recommended in association with Studies of people in treatment provide further evidence
psychosocial treatment; there is evidence that drop-out that women are more likely to have mental illness in con-
from treatment is associated with increased mortality junction with substance abuse. Among people newly enter-
(Minozzi et al., 2011). ing treatment in NTORS in England, women were twice
as likely as men to report anxiety (32%:17%), depression
The Evidence Base for (30%:15%), paranoia (27%:17%) or psychoticism (33%:20%)
Treatment of Drug Users in the previous 90 days (Marsden et al., 2000). In Germany,
the 6-month prevalence of such psychiatric disorders was
Evaluation of these programmes is beginning to suggest greater among female (46%) than male (31%) opiate users
progress (UKDPC, 2008). One-third of new drug treat- in regular contact with treatment services for 1 year
ment episodes in England are referrals from the criminal (Krausz et  al., 1998). Furthermore, female drug users met
justice system. Half of all offenders in contact with the the criteria for significantly more diagnoses than their male
DIP reduced offending, while only a quarter increased it. peers. A Norwegian study examined gender differences in
Successful completion of a DRRO or DTTO almost doubled poly-substance users attending clinics (85% heroin users)
between 2003 and 2008; re-conviction rates of completers compared with people dependent exclusively on alcohol.
are about half those of non-completers. Nevertheless, 1 in All groups had high rates of mental illness and/or person-
200 injecting heroin users may still die from heroin over- ality disorders (93%), but the female poly-substance users
dose within 2 weeks of leaving prison. differed significantly from all other groups due to their
high levels of major depression, simple phobia and border-
Some Special Groups of Drug Misusers line personality disorder, while the male poly-substance
abusers were distinguished by their higher rate of antiso-
Women who misuse drugs cial personality disorder (Landheim et  al., 2003). A small
There is great variability in the prevalence of substance Portuguese study found that 65% of 231 pregnant drug mis-
misuse among women in different countries and regions users in community treatment had other mental disorders
of countries, and in different ethnic groups (Crome and (28.5% personality disorders, 22.5% neurotic/somatoform
Kumar, 2007). This may be explained in part by differences disorders, 10% schizophrenia) (Flores, 2002).
in definitions, in patterns and modes of use, in screening,
assessment and diagnostic tools, the time window during The one study with slightly different findings was of
which use is being measured (e.g. lifetime, previous year consecutive admissions to a clinical detoxification centre
or previous month usage), and study settings, as well as in in the Netherlands (Hendriks, 1990). Whilst a significantly
wider environmental influences such as availability, price, higher proportion of female (73%) than male (45%) opiate
social acceptability, seizure and arrest policies. Regardless users met criteria for non-substance-related Axis I disor-
of the methods used to assess psychiatric disorder among ders, the men were 11 times more likely to have both an
opiate users, however, or stage of treatment, female opiate anxiety disorder and a depressive disorder, while women
users meet criteria for psychiatric disorders and symptoms were only twice as likely to have the two.
more frequently than do male users. In Ireland, for example,
48% of men and 75% of women in prison were found to be Abuse histories, particularly sexual abuse histories
mentally ill, while 72% and 83% respectively reported life- tend to be more common among female than male drug
time experience of drug use (Hannon et al., 2000). Women misusers. A study by Gilchrist (2002) of female drug users
who use drugs are more likely than men to say that they attending a crisis centre, a drop in centre and a methadone
clinic in Scotland (Glasgow), found that 71% had a lifetime
experience of emotional abuse, 65% had been physically
abused, and 20% had a history of sexual abuse. Brown et al.
(1995), in an English sample, found that female drug users
were more likely than male users to report lifetime physical

© 2014 by Taylor & Francis Group, LLC 463

Addictions and dependencies: their association with offending

abuse (30%:6%) or sexual abuse (25%:4%), this is echoed (National Institute on Drug Abuse (NIDA), 1996). figures
in the study by Grice et  al. (1995) (60%:17%). Drug users were similar (5.2%) in Australia according to a study using
who have experienced abuse have poorer psychological birth certificate report of substance misuse (Slutsker et al.,
functioning and are significantly more likely to have anxiety 1993) and the Australian National Drug Strategy Household
disorders, suicide attempts, self-harming behaviours, and Survey (6%) of women who stated that they were or had
eating disorders (Grice et  al., 1995; Jarvis and Copeland, been pregnant and/or breastfeeding in the previous 12
1997; Kang et  al., 1999), as well as depression or PTSD months (Australian Institute of Health and Welfare, 2004).
(Plotzker et al., 2007). ●● Opiates/opioids: Reported prevalence of their use dur-

In Europe, drug use is highly prevalent among female ing pregnancy ranges from 1.6–8.5% (Bauer et al., 2002;
prostitutes (Bretteville-Jensen and Sutton, 1996; Church Pichini et al., 2005). The Maternal Lifestyle Study in the
et  al., 2001; Gossop et  al., 1994). In the UK, it has been USA, based on meconium analysis (Lester et al., 2001),
estimated that about 80% of women engaged in street found a prevalence of 2.3%, but a wide range (1.6–7.2%)
prostitution are working there to finance a serious drug according to self-report.
habit (Hester and Westmarland, 2004), with at least three- ●● Cocaine: Again, reported prevalence varies, from 0.3%
quarters of their income being spent on the drugs (May (Buchi et  al., 2003) to 9.5% (Lester et  al., 2001). In the
et  al., 1999). These women commonly experience physi- UK, cocaine exposure is probably less than 1.1% among
cal and sexual violence from their clients (Barnard 1993; pregnant women (Farkas et  al., 1995; Sherwood et  al.,
el-Bassel et  al., 1997; Gilchrist et  al., 2001). A UK study 1999; Williamson et al., 2003b). Based on maternal self-
found that 81% of street prostitutes reported physical report and meconium analysis, one American study
violence from clients (Church et al., 2001). Despite these reported 9.5% exposure to cocaine (Lester et al., 2001),
findings, and knowledge of the impact of abuse on psychi- but the NIDA (1996) study found only 1.1%.
atric morbidity, the mental health of drug users involved ●● Cannabis: Since cannabis was used by 16.6% of women
in prostitution has not been widely examined. Female aged 16–24 years and 5.9% of those aged 16–59 years
drug users are more likely to be involved in prostitution during 1 year in the UK (2005; Roe and Mann, 2006),
than male drug users (Chatham et al., 1999; Grella, 2003), the potential impact on the fetus must be considered.
but may well be supporting the habit of their male part- Prevalence of use in UK urban communities is between
ners too. Indeed one of the barriers to treatment for such 8.5% and 14.5% at 12 weeks gestation (Farkas et  al.,
women may be the lack of provision for couples therapy in 1995; Sherwood et  al., 1999). In the Glasgow perina-
these circumstances (Smith and Marshall, 2007). tal sample, meconium analysis showed that 15% of
mothers had used it in the second or third trimester
The difference in prevalence of drug use and psychiatric (Williamson et  al., 2003b). US figures are from 1.8%
morbidity between female drug users with lifetime involve- (Buchi et al., 2003), through 7.2% (Lester et al., 2001) to
ment (n = 176) and no involvement in prostitution (n = 89) 15% (Williamson et al., 2003b). In Australia, 5% of those
was examined among female drug users recruited from women who stated that they were pregnant and/or
three services in Glasgow (Gilchrist et al., 2005). Two-thirds breastfeeding in the last 12 months had used cannabis
of the prostitutes had experienced emotional abuse, 57% (Australian Institute of Health and Welfare, 2004).
physical abuse and 33% sexual abuse during adulthood Substance misusers are poor candidates for pregnancy.
alone; 53% of them had attempted suicide in their lifetime They are frequently underweight, anaemic and socially
and 72% had depressive symptoms at interview. disadvantaged. They are often poor attendees at antena-
tal clinics, and young users tend to present late in their
In a US study of 33 male and 97 female prostitutes, 68% pregnancies. Substance misuse also increases the risk for
of them met criteria for post-traumatic stress disorder other conditions, for example sexually transmitted dis-
(PTSD). The severity of PTSD was not only related to physi- eases, hepatitis B, hepatitis C, HIV and domestic violence.
cal abuse in childhood but also to being raped in the course These associated problems can, in themselves, present a
of work as a prostitute, the likelihood rising with number significant risk to the pregnant mother and her unborn
of rapes as an adult. Experience of physical assault while a child. Intravenous drug users have the extra increased risks
prostitute did not have the same effect, nor was duration of cellulitis, phlebitis, thrombosis, endocarditis, septicae-
of involvement in prostitution a factor (Farley and Barkan, mia, septic osteomyelitis and, importantly, difficult intrave-
1998). In Edinburgh, Scotland, Nelson (2001) showed the nous access (Crome and Ismail, 2010).
impact of childhood sexual abuse on the development of Substances may affect the growth and maturation of
both addiction and mental health problems among female the fetus (Scher et al., 1998, 2000). The long-term develop-
prostitutes. mental neurocognitive, physical and psychosocial effects
Pregnancy and drug misuse resulting from in-utero exposure to opioids and other
The American National Pregnancy Health Survey found
that 5.5% of pregnant women were using at least one illicit
drug (including non-medical use of prescribed medication)

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Other substance misuse

drugs are poorly understood, and difficult to study because Drug-using parents and child protection
of the complexities of the situation. It is increasingly com- This is a complicated, emotional area (Ghodse, 2002). In
mon that substance misusers take a combination of differ- England and Wales, the needs of the child are paramount
ent drugs at different times during pregnancy. Child and (Children Act 1989), but every effort is made to consider
adolescent mental health services report that a parent’s the rights and needs of the parents too. A thorough assess-
longstanding drug and/or alcohol misuse is a substantial ment includes the ability of the parents (and perhaps the
risk factor for poor mental health in children (Mountenay, extended family) to provide shelter, food, safety and emo-
1998) and, particularly with respect to alcohol, for offend- tional security. The nature and extent of the substance mis-
ing in later life (Popova et al., 2011). Children may also be use, its impact on the child, the social circumstances and
at high risk of maltreatment, emotional or physical neglect wider support network have to be taken into consideration.
or abuse, family conflict, and inappropriate parental behav- The preference of most clinicians and allied professionals
iour (Barlow, 1996; Famularo et  al., 1992; Wasserman and is to work together to retain the integrity of the family if
Leventhal, 1993). Children may be exposed to, and involved at all feasible, by engaging them in treatment and support.
in, drug-related activities and associated crimes (Hogan, The situation may be monitored regularly under the Child
1998). They are more likely to display behavioural problems Protection Register. In some countries it is routine for chil-
(Wilens et al., 1995), experience social isolation and stigma dren of addicts to be placed on a child protection register.
(Kumpfer and DeMarsh, 1986), misuse substances them- Fear that this might happen is a strong force in pregnant
selves when older (McIntosh et  al., 2003), and/or develop women and mothers not seeking treatment early on, so it is
problem drug use (Hoffman and Su, 1998). necessary to encourage an atmosphere that appeals to their
needs (Crome and Ghodse, 2007). Nevertheless, there are
Parents with chronic drug addiction spend considera- occasions when the child is considered to be at immediate
ble time and attention on accessing and using drugs, which risk and it is in his/her best interests to live away from his/
reduces their emotional and actual availability for their her birth parents. An initial step is generally an Emergency
children. Conflicting pressures may be especially acute Protection Order under Section 44 of the Children Act 1989,
in economically deprived, lone-parent households and but permanent removal might follow. Psychiatric evidence
where there is little support from relatives or neighbours may be requested by the Court in such circumstances. A
(Rosenbaum, 1979). In the long term, children of substance promising intervention of intensive social work attendance
misusing parents may have severe social difficulties, includ- has been trialed in Wales for families where child removal
ing strong reactions to change, isolation, difficulty in learn- in such circumstances was imminent (Emlyn-Jones, 2007).
ing to have fun, and estrangement from family and peers
(Barlow, 1996). Physical treatment during pregnancy
●● Detoxification from opiates/opioids should be avoided
Despite this, substance misusers should not automati-
cally be stereotyped as poor parents. Pregnancy may motivate in the first trimester and carried out very cautiously in
individuals to modify their behaviours spontaneously or to the third (Luty et al., 2003). The risks must be explained.
be susceptible to advice for the health of the baby (McBride ●● Substitution and maintenance: Methadone is the main-
et  al., 2003). Indeed, about two-thirds of American women stay of the management of opioid abuse in pregnancy.
who drank prior to conceiving, and up to 40% of those who It has been used safely for many years, although this
smoked, stopped spontaneously during pregnancy (Durham use is unlicensed in the UK. Methadone maintenance
et  al., 1997). A telephone survey of pregnant women, also treatment decreases illicit opioid use, maternal mortal-
in the USA, yielded similar findings: 65.6% were drinking ity and morbidity, criminality, drug-seeking behaviour,
before pregnancy compared with 5.2% during pregnancy prostitution, sexually transmitted diseases and inci-
(Pirie et al., 2000). Hispanic ethnicity and younger age were dence of obstetric complications. It increases foetal
significantly associated with spontaneous alcohol abstinence. stability and ensures improved compliance with obstet-
The Australian Institute of Health and Welfare study (2004) ric care (Burns et  al., 2006). Since buprenorphine has
showed that women who were pregnant either abstained become available, a number of small-scale studies have
from alcohol (38%) or drank less (59%); only 3% continued to been undertaken (Fischer et  al., 2006, 2000; Johnson
drink at the same levels after becoming pregnant. et  al., 2003; Jones et  al., 2005; Lacroix et  al., 2004). At
this stage it is not clear whether there is any advan-
Since the prevalence of substance misuse among teen- tage over methadone. In the USA, it is an advantage
agers increased in the 10 years since the mid-1990s, this that buprenorphine may be dispensed by prescription,
group is of great immediate and future concern (Crome rather than at federally certified methadone clinics
et al., 2004). Many studies described above have noted the (Nocon, 2006).
vulnerability of young and disadvantaged women who are ●● A comprehensive care plan: Despite considerable pro-
increased risk of substance use and imprisonment as a gress in engaging and retaining pregnant substance
result of activities associated with their use. They also risk
premature death and the possibility of leaving bereaved
children.

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Addictions and dependencies: their association with offending

users in treatment, illicit use and its subsequent com- Table 18.7   2007/08 Estimates of proportions
plications should not be downplayed (Tuten and Jones, of young people taking Class A drugs (Hoare and
2003) and therefore, the use of contingency manage- Flatley, 2008)
ment as an adjunct has been described (Jones et  al.,
2001). Currently, ‘good practice’ must encompass pre- Class A Lifetime 16–19 9.3%
scribing within a comprehensive care plan. Class A Lifetime 20–24 22.3%
●● Stimulants and cannabis: As there is no evidence to Class A Last year 16–19 5.4%
suggest that substitution is effective and safe for stimu- Class A Last year 20–24 10.4%
lants, and there is no pharmacotherapy for cannabis, Class A Last month 16–19 2.9%
psychosocial support is fundamental. Class A Last month 20–24 5.5%

Young people and drug misuse and most are from the USA. There are many unanswered
Sixteen to 24 year olds form one-sixth of the p­ opulation questions around what the appropriate goals and outcomes
(in England and Wales, about 6.8 million people). Overall are for adolescents, how services can best be integrated for
mortality of adolescent addicts is 16 times that of the them, and which specialist teams and agencies should lead
g­eneral adolescent population. Adolescents become and co-ordinate the pathways. There is recognition that the
dependent much more quickly than do adults. The latest situation is dynamic for all parties. Offending is common-
data from the NHS Information Centre on 11–15 year olds place among the most severely affected young drug users,
have demonstrated a fall in those who have tried drugs often in the context of parental substance misuse and/
at least once, from 29% in 2001 to 25% in 2007, but 10% or mental illness, family conflict, school exclusion, mental
(300,000) were likely to have taken drugs in the past week illness in the young, self-harming, poor housing and social
(Fuller, 2008). service involvement. For this reason, the Pathways into
Problems report (ACMD, 2006) recommended that
People aged 20–24 use approximately twice as many
illicit drugs as 16–19 year olds (see table 18.7). In those who …the NTA should continue to promote and monitor the
attend specialist services there is considerable comorbid- development of accessible services for young people with
ity – about 75% have an additional psychiatric illness and serious tobacco, alcohol or drug-related problems, and
many also suffer physical ill health. to take active steps that these services are coordinated
with other initiatives that engage with vulnerable young
Outcome research in young people shows that, while people.
only a small minority will achieve and maintain abstinence
at 1–4 years after treatment, about two-thirds reduce Policy directions for younger drug users
substance use and improve in other areas, for example A number of initiatives have a direct or indirect posi-
in offending, education and employment as a result of tive bearing on young people. For England, these include
improved confidence, self-esteem, academic attainment, the establishment of national governmental bodies such
mental health and family relationships (Chung and Maisto, as NICE and the NTA, which aim to improve outcomes
2006; Chung et al., 2004). Evidence for effective treatment through the collation of up-to-date evidence and conse-
is mainly from the USA, where there is emphasis on brief quently improved services.
motivational work, cognitive behavioural therapy and mul-
tisystemic therapies (Dennis et  al., 2004; Henggeler et  al., The new drugs strategy (HM Government, 2012) focuses
2006). Some of these packages have been tested specifically on families and communities. In the UK, a series of policy
with young offenders. The involvement of the family may initiatives has evolved, including Hidden Harm (ACMD,
be necessary for consent for treatment, and is generally 2003); Hidden Harm: Three Years On (ACMD, 2007b); Every
desirable for support, information and advice, and enhanc- Child Matters (HM Government, 2003); the National Service
ing coping skills. In the UK, there is also emphasis on Framework for Children, Young People and Maternity
harm reduction, including needle exchange, prevention of Services (DoH and Department for Education and Skills,
drug-related deaths and treatment for physical illness and 2004); Every Child Matters: Change for Children, Young
injury. There is little provision or evidence for residential People and Drugs (HM Government, 2005); the updated
treatment, but it may be needed for those with chronic, Working Together to Safeguard Children (HM Government,
relapsing states. 2013; with its updated and revised models of care for drug
treatment (National Treatment Agency, 2006); Pathways
NICE guidance for buprenorphine and methadone is to Problems and the implementation of its recommenda-
aimed at those over the age of 18, but their opioid detoxi- tions (ACMD, 2006) and the report of the most recent
fication guidance covers those aged 16 and over, while that Confidential Inquiry into Maternal and Child Health (2007),
on community-based interventions in vulnerable disadvan- Saving Mothers’ Lives.
taged young people is for under 25 year olds. There are very
few studies on pharmacological treatments in adolescents, Greater involvement of users and carers is encouraged
in this process. This is sometimes accompanied not only by

466 © 2014 by Taylor & Francis Group, LLC

Pathological gambling

an increasing focus on the regulation of clinical and profes- into society. Areas for improvement include: screening
sional issues and service and resource management, but and assessments, with reviews and re-assessments; train-
also on research and publication governance. Some of this ing and supervision for staff; simplification of funding,
regulation impacts on the training and education methods, management and commissioning systems; and reorienta-
with a far greater weight now given to competencies than tion of treatment to a positive, problem-solving approach
knowledge alone. There are university-accredited courses rather than a punitive one. This report explicitly encour-
on addiction and mental health. These may be used as ages improvements in prison service standards, including
opportunities to enhance and develop the multiple skills adherence to clinical guidelines, performance management
that practitioners require when faced on a regular basis and clinical governance and a safe and seamless transition
with patients with multiple problems. Comorbid popula- between prison and community services.
tions are still seriously excluded in terms of availability and
accessibility of services (NCISH, 2006; Hodges et al., 2006) Some of the areas highlighted for research include inde-
and are generally excluded from NICE guidance (NICE pendent evaluation of the DIP, conditional cautions, diver-
2007a,b,c, 2008a). Accessibility, social acceptability and the sion from prosecution schemes and prison interventions.
legal framework not only influence substance use but also The need for comparative evaluation of DTTOs/DRROs
treatment options. Differences across national and interna- and drug courts, and of the costs and benefits of commu-
tional boundaries must be considered when devising policy. nity and prison services was noted. The report raises strik-
ingly similar issues to those raised by Kastelic et al. (2008)
The main themes of these policies involve strong lead- in a practical guide to opioid substitution in custodial set-
ership to build bridges between child and adult health and tings. Recurring themes include that:
social care and the CJS, through collaborative working by
integrated multidisciplinary and multi-agency teams, train- drugs and prisons have to be seen in the wider social
ing, and practical resources such as checklists, protocols, context, that imprisonment should not mean more
and briefings. punishment than the deprivation of liberty; that pris-
ons must be safe, secure and decent places (WHO
Older people and drug misuse Health in Prisons Project and Pompidou Group, 2001a).
The number of older people is projected to increase, so that It is vital to capitalise research, which has identified
people over the age of 65 will comprise 23% of the popula- gaps in the evidence and so directs practice and policy
tion by 2020. Older people are at risk of substance misuse (Copeland et al., 2007; Dolan et al., 2003; London et al., 2003;
for many reasons, including the development of multiple MacDonald  et  al., 2008; Melnick et  al., 2001; Nace et  al.,
chronic physical and psychiatric illnesses, for which they 2007; Reuter and Stevens, 2007; Sullivan et al., 2008).
receive prescription medication. There is also the continu-
ation of substance use into older age by users who began Pathological gambling
their substance use in the 1960s, the initiation of substance
use in older age due to isolation, losses and/or illness, and Gambling as a social phenomenon
the relapse into substance use of older people coping with
disability, pain, anxiety and/or insomnia. Gambling is ubiquitous in Western society, reaching the
point in Britain where it merited a major investigation
While there is some information on good practice and a by a Royal Commission (1978) (Rothschild), then fur-
limited evidence base for treatment of older substance mis- ther review, in 2001, by a specially constituted gambling
users, raising awareness about the problems and potential review body, which produced the Budd Report (Gambling
solutions, it has not been the focus for training health and Review Body,  Department for Culture, Media and Sport,
social care professionals, treatment providers and the pol- 2001). In the USA, gambling was reviewed by a con-
icy establishment in the UK that it has been, for example, gressionally mandated commission (Commission on the
in the USA (Crome, 2005; Crome and Bloor, 2006a,b, 2007). Review of the National Policy toward Gambling, 1976).
Some evidence from studies with younger adults may, with KPMG  (2000),  a  firm of advisors and accountants, gave
caution, be extrapolated to older people. Appropriate help the gambling industry an estimate that the total amount
can only be offered if relatives and professionals can detect wagered in the UK in 1998 was over £41 billion, producing a
problems. profit for the industry of £867 million; the annual per capita
spend, net of winnings, on all gambling activities was £100–
Illicit Drug Use and Offending: £150, putting the UK among the high gambling nations of
conclusions the world along with the USA, Australia, and New Zealand.
The most profitable sectors were off-course bookmaking,
The 2008 UKDPC report called for a strengthening of the gaming machines, and the National Lottery.
evidence base in this field, but also highlighted the need for
comprehensive services, which will promote reintegration Gambling is, then, an important entertainment indus-
try, but the constant attention from official bodies indi-
cates that this is an entertainment industry which gives

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Addictions and dependencies: their association with offending

concern. Besides providing pleasure, jobs and revenue for a compulsion in its strict psychiatric definition, is a repet-
the Exchequer, gambling also produces considerable mis- itive act performed by a patient against his will, which he
ery for a large number of people. The USA Commission is unable to suppress.
estimated that nearly 1% of the adult population of the S/he preferred the man to be called:
USA were ‘probable compulsive gamblers’. The more an excessive gambler
recent UK gambling review report estimated that there and said
are 275,000–370,000 problem gamblers in the UK, a num-
ber that is likely to increase if their recommendations for the gambler’s behaviour is a source of pleasure in which
decreasing the controls on gambling are implemented, as he indulges irrespective of cost; the compulsive’s is a
most have been. They drew immediate attention to the burden which makes him anxious and depressed.
paucity of research into problem gambling, even though
the Rothschild Commission’s first recommendation was According to the writer, the motivation of an excessive
that a gambling research unit should be established. gambler is no different to that of the ordinary gambler
The Budd Report went on to note that it is not part of
the standard school curriculum to advise children of the every man in the street can imagine himself in his place,
dangers of gambling, unlike the situation with regard to which alone puts him outside the pale of psychiatry.
tobacco, drugs, alcohol and irresponsible sex. This is in The author then returned to the mantra that
spite of evidence that there is a higher incidence of prob- antisocial behaviour must not be confused with mental
lem gamblers among adolescents than among adults and illness, and psychiatrists must beware of having forced
that, in general, the younger a person starts gambling, the on them the role of controlling misfits or regarding it as
more likely s/he is to become a problem gambler. Budd their function to normalize them, the abnormal and non-
further notes: conforming.
Would this leader writer now eat his/her words in sight of
Gambling does not come with a health warning, and the the Academy of Medical Sciences (2008) review?
incidence and nature of problem gambling, and the exist-
ence of facilities for problem gamblers, are not widely The article provoked a flurry of responses in the let-
known. ter pages. Moran (1968) agreed that the term compulsive
should not be used in the context of excessive gambling and
Gambling Terminology urged the term ‘pathological gambling’ as an all-embracing
term, which could include different types of excessive gam-
Some of the terminological confusion about gambling will bling which require assistance; he was the only correspond-
already be apparent. Problem gambling is the term used in ent to question the wisdom of leucotomy here. One of us
the Budd Report, but the US Commission wrote of com- (Gunn, 1968) drew attention to the inconsistency within
pulsive gamblers. Orford (1985) prefers the term ‘excessive the BMJ, which only 3 years before had published a leading
appetite’ as a conceptual means to understanding five article describing the plight of the pathological gambler in
forms of addiction – alcohol, drugs, food, gambling and terms of personality deterioration.
sexuality. Add to this the general debate in psychiatry as to
whether and when unwanted behaviours can be regarded In some ways the terminological argument is sterile,
as ‘illness’ or ‘pathological’ and we have a mini Tower of but it does lead to differences in response, which are very
Babel. important to the individual concerned, and perhaps wider
society too. Blaszczynski and McConaghy (1989) argue that
To some extent, this confusion is a product of the diffi- a dimensional model of gambling may allow controlled
culty in conceptualizing abnormal behaviours and, to some gambling as a treatment goal, but disease model propo-
extent, an attitudinal statement about how we believe we nents argue that complete abstinence is the only accept-
should respond to individuals presenting themselves with able aim. These tensions pervade addictions work. The only
behavioural difficulties. In 1968, for example, a spat broke valid test of such a distinction is an empirical one, and this
out in the British Medical Journal (BMJ), after an article is not yet forthcoming.
in The Times reported that a thief appearing in court was
referred to a psychiatrist and then a brain surgeon for a Orford’s review of the psychology of addictions (1985)
leucotomy to cure ‘a compulsive urge to gamble’. A leader may be the best available way of reconciling the differ-
writer in the BMJ took umbrage about this terminology – ent approaches and embracing a therapeutic approach. He
although made no comment on the proposed treatment! acknowledged the important benefits of a disease model:
The writer asked:
How else could… the wife of an excessive gambler, be per-
Where does social misdemeanour end and mental illness suaded that her husband’s beastliness was attributable to
begin? his modifiable gambling rather than to his unmodifiable
S/he suggested that character, without recourse to some notion of sickness?
He also, however, pointed out that disease models can
retard understanding in over-emphasizing the role of

468 © 2014 by Taylor & Francis Group, LLC

Pathological gambling

medicine and, in particular, physical features of the prob- 2. ‘Psychopathic’ gambling, as part of a generalized anti-
lem to the neglect of psychological mechanisms. Orford social response to life, mixed with stealing and other
was at pains to identify similarities between a range of criminal activities (not only related to gambling) and
‘excessive appetitive’ activities, including drinking and poor social adjustment in terms of work and personal
drug taking, postulating that some of their strongest deter- relationships.
minants are social, both in terms of restraints and encour-
agements. In turn, these appetitive activities come to serve 3. Neurotic gambling, as a response to stress such as a
personal functions for different individuals, such as mood disturbed marriage. One partner in such a marriage
modification and tension reduction. All this, he suggested, may use the gambling as a means of punishing the
is subject to lifelong social and psychological changes. other. Adolescent stress is another possible cause of
gambling.
He imported the law of proportionate effect from oper-
ant learning theory into his model; this generates increasing 4. Impulsive gambling, characterized by loss of control
attachment to the behaviour, such that it becomes auto- which cannot readily be accounted for by illness, or the
matic and functionally autonomous. An altered biological environment and is not part of an antisocial response
response can then occur, so that the individual experiences to life. Sometimes it is controlled when the money runs
a feeling of less control, greater desire and craving. At this out. It is usually feared by the gambler who is aware that
point the costs or harm from the behaviour may amplify an s/he loses control to his/her own detriment, but it also
increasing attachment, for example by encouraging altera- brings relief from craving.
tions of role and social group, and weakening relationships
with sources of social control and restraint. He noted that 5. Subcultural or socially acceptable heavy gambling.
supporting agencies have often taken a religious form and These clinical descriptions have stood the test of time and
suggested that change in appetitive behaviour constitutes are probably the best available; however, modern practition-
a kind of moral passage. He concluded that, besides these ers seem uneasy unless they can invoke the official interna-
naturally occurring processes, expert treatment plays only tional or US classifications (ICD or DSM). The definition in
a modest part in appetitive behaviour change but this is ICD-10 (WHO, 1992a) seems in part to be based on Moran’s
not to suggest it is ineffective. The common factors in indi- definition; the slight differences may detract somewhat
vidual treatment and self-help groups are engagement, the from its clinical usefulness. F63.0 asserts that
feeling of being listened to, involvement of family and the
expectation of change. This means that professional and The disorder consists of frequent, repeated episodes of
traditional religious moral agencies and ideas can co-exist. gambling which dominate the individual’s life to the
detriment of social, occupational, material, and family
Clinical Features of values and commitments.
Pathological Gambling
Those who suffer from this disorder may put their
According to Moran (1970), recognition of pathological jobs at risk, acquire large debts, and lie or break the
gambling depends on four features: law to obtain money or evade payment of debts. They
1. concern on the part of the gambler and/or the family describe an intense urge to gamble, which is difficult
to control, together with preoccupation with ideas and
about the amount of gambling; images of the act of gambling and the circumstanc-
2. the presence of an overpowering urge to gamble so that es that surround the act. These preoccupations and
urges often increase at times when life is stressful.
the individual may be intermittently or continuously This disorder is also called ‘compulsive gambling’
preoccupied with thoughts of gambling, usually associ- but this term is less appropriate because the behav-
ated with the subjective experience of tension relieved iour is not compulsive in the technical sense, nor is
only by further gambling; the order related to obsessive-compulsive neurosis.
3. the subjective experience of an inability to control the In the differential diagnosis, however, we are told that path-
amount of gambling; ological gambling should be distinguished from (a) frequent
4. economic and/or social and/or psychological and/or gambling for excitement; (b) excessive gambling by manic
family disturbances which result from the gambling. patients; and (c) gambling by people with sociopathic per-
After reviewing 50 patients, Moran suggested five subtypes sonalities in which there is a wider persistent disturbance
of pathological gambling. of social behaviour.
1. Symptomatic gambling associated with mental ill-
ness, for example a depressive illness, giving rise to The American DSM-IV (APA, 1994) is only slightly dif-
guilt feelings which are then expiated by gambling. It is ferent and includes the same differential diagnostic advice.
sometimes difficult to distinguish depression causing None of this is of great significance provided the clinical
the gambling from depression which is reactive to the understanding of the patient’s problem is clear, although
gambling. those undertaking research may want the aid to reliability

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Addictions and dependencies: their association with offending

provided by such operational definitions. Perhaps even bet- expiate guilt, what Freud called ‘moral masochism’. Bergler
ter for such circumstances, in spite of some criticisms (see (1958), building on the idea of the masochistic neurosis,
Orford et al., 2003), the South Oaks Gambling Screen (SOGS) postulated that the ‘classical gambler’ has never relin-
(Lesieur and Blume, 1987) is widely used; it is a sensitive quished the omnipotent phase of childhood – but, with his
rather than specific clinical aid – over-predicting problem alcoholic violent father could Dostoevsky ever have had an
gambling. omnipotent childhood phase? Bergler wrote of 60 gamblers
he treated by psychoanalysis; 25% gave up treatment after
The exclusion of mania-related behaviour from the a 4–6 week trial period but he implied that the other 44
diagnosis of pathological gambling in the official classifica- patients all gave up gambling. These apparently remarkable
tions could divert attention from an association between results need replication.
gambling and affective disorders, which has been consist-
ently identified (e.g. Moran, 1970; Taber et  al., 1987a,b). Management of Pathological Gamblers
McCormick et al. (1984) reported that, in a group of 50 men,
highly selected by virtue of their admission to an inpatient The prognosis in many cases of excessive gambling is poor.
treatment unit for gamblers, 76% had a major depressive There is ambivalence on the part of the gambler, social
disorder, 38% hypomanic disorder and 8% manic disorder, pressure to continue gambling, psychological dependence
while 36% had at least one important cross-addiction to intermittently reinforced, and perhaps powerful uncon-
alcohol or drugs. The men also showed a very high rate scious destructive drives. Psychiatric and psychological
of suicidal behaviours, all but 10 having shown at least treatments have limited success. Punishments, however,
one in the year prior to admission; nearly half had shown such as fines or imprisonment are also unlikely to yield
at least moderately severe suicidal behaviour, for exam- positive change, and may even make the gambler worse.
ple having thought of a specific plan. Six men had made The pathological gambler is quite likely to try and win his/
a lethal attempt. Linden et  al. (1986), studying people her fine on a racehorse! Prisons are ideal places in which
attending Gamblers Anonymous meetings, found that over to gamble, since boredom is excessive, everybody is short
70% of their sample had had a major depressive illness at of money, tobacco, and other desirables, and important
some time in their lives. Findings of abnormalities on the support systems such as employment, wife, family are
dexamethazone suppression test (Ramirez, 1988) and in removed, maybe permanently.
monoamine levels and peptides in the cerebrospinal fluid,
plasma and urine of gamblers (Roy et al., 1988) have added The efficacy of treatment for gamblers may be as much
weight to these associations. affected by the quality and extent of the service delivery
as the treatment itself. Volberg and Steadman’s (1988) tel-
A more recent review of the clinical features of ephone survey of the prevalence of pathological gambling
­pathological gambling emphasises DSM criteria for in New York illustrated how one service delivery seemed
pathological gambling and draws attention to the simi- to be failing. Thirty-six per cent of problem gamblers were
larities between gambling addiction and other forms of women, but only 7% of those coming into one of the three
addiction, including the notion of withdrawal symptoms treatment programmes in New York State were women;
(Lesieur and Rosenthal, 1991). The losing phase or what 43% of the surveyed gamblers were non-white, but 91% of
gamblers call ‘chasing’ (trying to get money back that treatment places were taken up by a white clientele; only
was lost gambling), to the extent that this becomes an half the expected group of young people presented for
obsession, is, however, unique to gambling. They also treatment. All the differences were significant. A dispropor-
draw attention to the possibility of multiple addictions tionate number of women, non-white people and young
and to the misery and problems suffered by relatives, folk were thus failing to connect with services.
especially the wives of male gamblers, and their children.
A wide range of criminal behaviour has been detected The importance of extended assessment
among such gamblers, from forgery and embezzlement People who gamble excessively are difficult to assess briefly;
to armed robbery and fencing stolen goods. The review a detailed knowledge of the person’s background, current
includes some of the psychoanalytic literature, which social environment and psychopathology before a manage-
begins with Freud’s (1928) essay on Dostoevsky, a man ment programme is necessary. Particular care should be
who wrote not only perceptively about the problem from taken not to miss depressive disorder or suicidal ideation.
his own first hand experience but also often to a deadline It is almost never possible to treat gamblers successfully
in order to pay off his gambling debts (e.g. his 1867 novel, without involving the spouse or close contacts, as the
The Gambler). behaviour and the treatment will profoundly affect their life
also. This is especially true in Moran’s type (c) cases, where
According to Freud (and Dostoevsky), the gambler does family stress may be the main pressure to gamble.
not necessarily gamble for money, but for the gambling
itself. In fact, Freud suggested that the gambler may gam-
ble in order to lose. Losing is a form of self-punishment, to

470 © 2014 by Taylor & Francis Group, LLC

Pathological gambling

Building a supportive network for control group; who received no specific treatment, showed
gamblers and their families considerable improvement at 6 months on most of the
The two vital elements of management are support and gambling variables, doing as well as the combined treat-
counselling. The necessary qualities of support include ment group; the authors considered the individual work a
accepting the individual without accepting his/her behav- cost-effective therapy.
iour, making and keeping to a long-term commitment,
refusing to reject the person when others do as the prob- Sylvain et al. (1997) compared the efficacy of CBT with
lem seems hopeless. In addition, where the gambler has a waiting list control group. There were 29 participants,
retained family and friends, support should be extended, most of whom were video poker players and racetrack gam-
as far as possible, to them too, whether directly or through blers. The treatment group did better than the controls.
other professional or voluntary bodies. Counselling will Ladouceur et al. (2001) conducted a randomized controlled
include a discussion about the patient’s behaviour and its trial of individual cognitive therapy with 66 slot machine
consequences, may involve advice about restructuring his/ and video gamblers. On measures of clinically significant
her life, but is likely to follow a motivational approach (see change and end-stage functioning virtually all the treated
above). sample and none of the waiting list controls improved,
which was similar to their earlier study (Sylvain et al., 1997).
Specific treatments for pathological gambling There is, thus, some evidence for the efficacy of cognitive
Toneatto and Ladouceur (2003) reviewed the literature on therapy for problem gamblers.
treatment for pathological gambling and point out the pau-
city of information about it, especially given its high preva- Several approaches to group work have been tried but,
lence (1–2% of the population). McConaghy et  al. (1983) again, there have been very few evaluations. An interesting
did a number of studies on imaginal desensitization. For idea, in view of the prominent marital problems in some
this, the key to intervention is the instruction to relax in the cases, was reported by Boyd and Bolen (1970) who treated
presence of several imagined gambling-related episodes. In husband and wife pairs; of nine pathological gamblers
their hands, this proved to be superior in outcome to aver- and their wives, one pair dropped out, leaving four pairs
sion therapy, using electric shocks. They also reported that in each of two groups. All improved, five nearly stopped
imaginal desensitization was superior to imaginal relaxa- gambling, three actually stopped, all the marriages were
tion, a similar treatment but one that does not instruct reported as improved. These are promising results, but
the individual to visualize gambling situations; instead the need replication.
participants are asked to remain in the presence of visual-
ized relaxing scenes. There were no group differences at Perhaps the most important form of group treatment
follow-up, with 30% of both groups reporting abstinence or for gamblers is that run by the gamblers themselves. As for
controlled gambling. McConaghy et al. (1991) reported on alcoholism, a self-help group Gamblers Anonymous (http://
the long-term follow-up (an average of 5½ years) of 120 par- www.gamblersanonymous.org.uk/) has gained a prominent
ticipants who were randomly assigned to five treatments. place in treatment and should always be considered as one
Again, in their estimation, imaginal desensitization proved option a patient may take. A description of the California
to be superior to the other treatments but as Toneatto and branch where it all began is given by Scodel (1964). Again
Ladouceur (2003) point out, there are serious problems following the lead of the sufferers from alcoholism, another
with the outcome variable of ‘ceased’ gambling; although self-help group has sprung up for spouses of gamblers –
30% of the imaginal desensitization participants were said Gam-Anon (http://www.gamanon.org.uk/).
to have stopped gambling, 27% of the participants who
received combined behavioural treatments also ceased. Although Toneatto and Ladouceur (2003) are gener-
ally critical of research to date, they conclude that the
Echeburua et  al. (1996) compared three active treat- cognitive behavioural spectrum of treatments does have
ments with a waiting list control group. Treatments con- some empirical support as being superior to other forms
sisted of individual exposure response prevention, group of specific treatment, and give guidance on how meth-
cognitive restructuring, and combined treatment. In expo- odological flaws can be eliminated from future research.
sure response prevention, participants are trained to man- Another review focuses on pharmacological treatments
age money better, avoid gambling situations, and remain (Grant et  al., 2003). Again, the first point is the disparity
in the presence of high-risk gambling situations but resist between the prevalence of pathological gambling and the
gambling. The cognitive treatment challenges the ‘illu- attention paid to it in well-designed research. At the end
sion of control’; the combined treatment included both of their review, Grant and colleagues conclude:
treatments. All three treatments were administered over 6
weeks, with a goal of abstinence. The 64 participants were emerging data from short-term controlled clinical
all slot machine gamblers. Of interest is the finding that the trials suggests that pathological gambling frequently
responds to pharmacological intervention. Mounting
evidence suggests that SSRIs represent an efficacious
and well-tolerated short-term treatment for patho-
logical gambling. Treatment of pathological gambling

© 2014 by Taylor & Francis Group, LLC 471

Addictions and dependencies: their association with offending

appears to require doses of SSRIs that are comparable criteria, but four were excluded as treatment outcome
to those used in the treatment of obsessive compulsive studies and four for methodological reasons. One Dutch
disorder and higher than those required for the treat- study (DeFuentes-Merillas et  al., 2004), one Australian
ment of major depressive disorder. Whether subgroups study (Abbott et  al., 2004), and three US studies (Shaffer
of pathological gambling (e.g. those with depression or and Hall, 2002; Slutske et  al., 2003; Winters et  al., 2002)
strong urge symptoms) respond better or worse to collectively followed 1289 people ranging from college
SSRI treatment is not known at this time. Preliminary freshmen to acknowledged problem gamblers over periods
evidence also suggests that opioid antagonists are ranging between 2 and 16 years. Using these data, they
effective in the treatment of pathological gambling, tested three hypotheses. The first was that pathological
especially for those who have strong urge symptoms. gambling (reaching threshold on the measure, typically the
Among the studies to have examined the use of selec- Oaks Gambling Screen) is persistent; in fact, as a group, the
tive serotonin reuptake inhibitors (SSRIs), Hollander et al. pathological gamblers showed the least stable behaviour
(2000) conducted a double-blind cross-over trial with patterns in this respect. The second hypothesis was that
pathological gamblers using fluvoxamine against placebo. more severe gambling problems are less likely to improve
Both groups improved rapidly within 1–2 weeks of medica- than less severe ones – evidence did not support this; the
tion and remained relatively stable thereafter. Studies with third test was that individuals with some gambling prob-
naltrexone have also been shown to benefit pathological lems are more likely to progress to pathological gambling
gamblers, though it is not clear whether this is a specific than those without – they were not.
effect or not. Grant et al. (2008), in a double-blind placebo-
controlled trial showed that, although not dose related, In challenging received beliefs, LaPlante and colleagues
people on naltrexone had significantly greater reduction perhaps open renewed hope for treatment in the field, but
in rating scale scores, gambling urges and actual gambling also underscore the importance of randomized controlled
than those taking placebo. trials conducted over substantial periods to test the effec-
tiveness of any given treatment. Perhaps too, their findings
LaPlante and colleagues (2008) have conducted the open routes to refining subgroups of people with different
most recent systematic review on the stability of gambling needs. Are the truly persistent more likely to show the brain
behaviours over time. The results may go some way to differences outlined by Reuter et  al. (2005)? Could this
explaining why treatment outcome studies seem so equivo- mean that treatment approaches for them would be more
cal. Their focus was on longitudinal, prospective, empirical likely to need to incorporate of physical treatments as part
studies of ‘disordered gambling’. Of 92 peer reviewed arti- of the package, whereas the psychosocial treatments alone
cles published up to October 2006, 13 met initial inclusion may suffice for the others? Clearly these are among areas
for future research.

472 © 2014 by Taylor & Francis Group, LLC