Stopping people ruining their lives is what gives Dr Henrietta Bowden-Jones the energy to go to work every day.

"It gets me up in the morning. I love treating addicts," she said at TEDMEDLive Imperial College in April.

It is estimated that 500,000 people in England today have a gambling problem, about 0.9 per cent of the population. It’s called the "hidden addiction", because it can be kept secret even from those closest. Perhaps that’s why there was no NHS centre dedicated to problem gambling until 2008. "It was a real adventure. I had to start from the beginning."

Dr Bowden-Jones is a consultant psychiatrist and an honorary clinical senior lecturer at Imperial College London. She founded the National Problem Gambling Clinic (NPGC) with £250,000 she raised herself and for two years she treated every patient who walked through the door. Now, the clinic has 12 staff, gets 700 referrals a year, and is involved in several research projects. Her ultimate ambitions are for the clinic to become the hub of a national strategy against problem gambling, and to ally psychology and neuroscience to find out what leads her patients down a path that hurts them so much.

Technically, to be a problem gambler means to be on the verge of addiction. A problem gambler experiences three or four of the symptoms listed in the American Psychiatric Association’s diagnostic manual, the DSM-5. These could include thinking about gambling all the time, trying and failing to stop, and getting angry at anyone who suggests cutting back; or gambling to escape when you feel low, lying about it to those around you, and stealing their money to play with. Someone with five or more symptoms is a pathological gambler, and medically considered an addict. Problem gambling is the commoner term, but most of Dr Bowden-Jones’ patients are actually pathological gamblers.

Despite the number of people with a problem, which has increased considerably during the last decade, gambling is not widely recognised as an addiction. Pathological gambling was only moved into the addictions category of the DSM this year. Those working in the field hope this will lead to increased recognition for what they believe is a life-ruining medical illness. "It is an addiction," Dr Bowden-Jones assures me. "The negative impact all round is just as serious as any other addiction."

She explained at TEDMED Live what sets gambling apart from other addictions: "Pathological gamblers don’t have track marks on their arms. They’re not walking around with an unsteady gait. They’re not shaking while they’re talking to you. It’s very hard to know one". This may be why, when gamblers do confront a problem, it’s often only after getting into serious trouble. At the clinic, the average patient has lost over £150,000, half have lost a partner, and 84 per cent of them have committed some illegal act to support their gambling. "And in terms of impact on family and children, gamblers tend to do worse because of their financial losses, often losing the family home, for example."

The National Problem Gambling Clinic

Only 5 per cent of England’s problem gamblers ask for help. Most of these get support from charities around the country that provide counselling, psychotherapy and other services. The NPGC, in central London, is the first and still only NHS service dedicated to treating them. "When I started it was really very much just me. I thought I would do this in a special session one afternoon a week. I didn’t think many people would show up."

The clinic’s main treatment is a cognitive behavioural therapy (CBT) programme. In CBT, a psychotherapist aims to help a client develop strategies to replace or avoid thoughts and behaviours that cause them problems. The clinic’s programme was adapted from one for drug addictions. "The focus is very much on stimulus control, relapse prevention, and getting people to modify their behaviours; replacing the negative with positive things that enhance their lives and fill the void left by gambling." It also offers money management help and family therapy.

The clinic has now treated over 3,000 people. "It tends to work, even with people who are very unwell with other conditions – depression, anxiety, schizophrenia." The success rate is 80 per cent, outperforming the template CBT programme. "That’s because we are a designated problem gambling clinic, and I think people feel that everyone here is putting their lives into this work." Since those hectic first two years, Dr Bowden-Jones has moved into a more managerial and ambassadorial role – hence engagements like the TEDMED Live talk. "I spend a lot more time promoting the clinic, doing interviews, and linking the clinic up with all sorts of organisations that can provide support or staff, or that need teaching about the subject." She raises funds for the clinic through the charity Gambling Concern; the NPGC remains primarily funded by the NHS and the industry-supported Responsible Gambling Trust.

Dr Bowden-Jones’ overall ambition is for the clinic to become the centre in an NHS strategy to tackle problem gambling nationwide. "I had always envisaged a hub and spoke model, with small NHS units around the country taking care of the most severe cases and others being left to charities with expertise in treating addictions. The clinic would keep the clinical governance and risk management responsibility." This hasn’t yet come to pass, which disappoints her, though she remains hopeful.

Fighting addiction

It’s all part of a quest that began when Dr Bowden-Jones was growing up in Milan in the 1960s in the midst of a heroin epidemic. By age 10 she was used to seeing addicts shooting up in the streets, bloodstains in public toilets,  and syringes scattered in grassy parks. She couldn’t understand what these people were doing and why no one seemed to be helping them. "I wanted to be a psychiatrist before I knew what a psychiatrist was", she says.

After studying medicine, she trained in psychiatry and specialised in addictions. She spent years running clinics for homeless addicts and running the central London NHS alcohol and drugs inpatient detoxification unit. She found both heartbreaking and uplifting stories in her patients. "It was while running that ward that I became overwhelmingly aware of the damage a bad start in life can give a person." Yet she saw too that unlikely recoveries could be made.

She became focused on one question: why do some people make decisions that ultimately end up ruining their lives while other people don’t, even when they have the same opportunities to do so? Deciding to find out more about what goes on inside the head of an addict, she took on a PhD in neuroscience at Imperial. There she investigated how dysfunction in a specific brain region makes relapse more likely in alcoholics. It was during that time that she realised the significance of decision-making and risk-taking in addictions.

"One of the things I loved doing during my doctorate was putting together a battery of psychological tests to determine who was going to do well in treatment – who was not going to relapse following detoxification. And I did manage to predict it, but it took eight hours of tests, which is not clinically viable."

However, the project revealed to her the relation between certain behavioural traits and addiction. "Impulsivity" is a famous example. Psychologists define impulsivity as a tendency to do things immediately, without thinking them through, and to take fast rewards over ones you have to wait for. Long-term studies have shown that impulsivity is associated with a higher risk of becoming an addict of any sort – an impulsive child is more likely to become an addicted adult. 

This seemed like it might be an answer to Dr Bowden-Jones’ question. But something else made an even bigger impact on her. One of her tests was the Cambridge Gamble Task. You can see what it looks like on the right and play a demo here. It is essentially a game in which, every round, one of the ten squares at the top hides a yellow square. Your task is to bet on whether the yellow square will be under a red or blue square. You start off with 100 points, and you must bet some of them on each guess. The odds don‘t multiply with the bet – if you bet 10, you win 10 or lose 10, no more or less. You choose the amount you gamble by clicking the black box on the right. If you want to bet 75, you have to wait for it to show that number; sometimes it will count up (5, 25, 50, 75) and sometimes down (95, 75). Each step takes several seconds and waiting for a particular number is pretty boring.
What’s important is this: if you want to win, you might as well always bet on the colour with the most squares (here blue), because you win the same amount either way. And sometimes you have to be patient to make big bets, because the number on the right goes up only very slowly.The test identifies both impulsive people, who tend to bet quite quickly whatever the amount, and people who like to take risks, who bet against the odds or wait for the big numbers. Dr Bowden-Jones found that alcoholics tend to be more impulsive than most people, which was expected. But she also found that alcoholics who later relapsed tended to play faster, yet at the same time bet more points, even though sometimes that forces them to wait. So the worst addicts seemed to have a natural hunger for risky rewards.

"This was incredibly inspiring for me because it went to the core of what it means to be someone who can’t make the right decisions. To have a tool that identifies these people was very exciting because, well, now I knew who they were." The test inspired her to spend six months reading up on gambling, decision-making and risk-taking. It was then that she realised there was no dedicated NHS service in the country for treating problem gambling, and decided to set one up herself.

Searching for causes

She and her patients are now involved in studies aiming to find out what neurological and psychological processes are behind gambling addiction. She is trying to bring together her interests in early life experiences, impulsivity and risk-taking with other scientific insights, such as modern brain imaging techniques, for this purpose.

"We know that about one third of our patients have had very difficult early life experiences. We see a lot of people who have been separated from parents at birth, through death, divorce or because they spent long periods in hospital. We see people who have had some form of abuse in childhood – physical, emotional, or sexual – or who have been badly bullied at school. We see these things over and over again, and if they hadn’t happened, these people probably wouldn’t have ended up gambling." She is interested in working out statistics for how much these experiences actually increase a person’s risk of becoming a problem gambler.

On the other hand, she knows from experience that many people’s addictions are quite independent of such experiences. "The more patients I see, the more I have to subdivide them into different categories." She identifies about another quarter as being impulsive, led into gambling addiction by a tendency to seek stimulation and push boundaries. Another group enjoys the feeling of being about to win or lose everything.

The other major set of causes is the inherited factor. There is probably some degree of genetic predisposition to gambling addiction, an affinity in the blood. But this is extremely difficult to separate from the effect of having been brought up by parents or grandparents with gambling problems. Many gamblers have had formative experiences associated with familial gambling that will never leave them, and which have nothing to do with their DNA.

Recently, Dr Bowden-Jones ran a large study combining accounts of early life experiences, brain scan data, psychological assessments and treatment outcomes to try to find correlations. Unfortunately, it didn’t find any clear relationships. "At the moment, we’re lumping everyone together as pathological gamblers, and when we try to break down this group into smaller chunks using any neurobiological classification, we’re failing.

"We have to go back to the beginning now. The prognostic bit is really our focus." The clinic is in the early stages of a study that will aim to link various traits to patients’ chances of relapsing after quitting gambling. It’s similar to her doctoral project predicting relapse in alcoholics, and she hopes to replicate that success, though preferably more expediently. "The ultimate dream is to find a prognostic test that’s one page long and tells you who needs more input for which treatment to help them succeed. The minute we know who’s doing well and who’s doing badly, in relation to what treatment, we can then look in-depth at their experiences, and spend money and time neuroimaging specific groups."

Dr Bowden-Jones left the TEDMED Live audience with this remark: "It is a medical illness and it can be cured." Explaining what makes us who we are is never an easy task, but she is one person who is committed to finding out what makes a person an addict.