On March 24, the second Change Talks webinar took place. The event, which was free to attend, featured an accessible, clear, and responsible discussion of two issues currently affecting everyday life in our society: alcohol dependence and pathological gambling.
Without ever losing sight of The Clinic of Change’s primary mission—to care for and preserve mental health—the conversation addressed such pertinent topics as the symptoms of both addictions, the hope brought by scientific advances in the field of psychedelics, the importance of psychotherapy in conjunction with this type of treatment, and the importance of professional and specialized care.
The discussion therefore featured three speakers, all members of the clinical team at The Clinic of Change: Dr. Magda Carvalho, a clinical psychologist, Dr. Guilherme Bastos Martins, and Dr. Miguel Esteves Carneiro, both psychiatrists. Throughout the discussion, these experts answered several questions related to the topics at hand, some of which were posed by members of the audience.
The conversation began with a discussion of alcohol dependence, painting a picture of a country where alcohol consumption—often on a daily basis—is deeply rooted in its culture. Alcohol is currently the most widely consumed psychoactive substance in Portugal.
What are the characteristics of alcohol consumption in Portugal, and what is its impact on health and social life?
“The great danger lies precisely in this deep cultural entrenchment. Alcohol is ubiquitous in many celebrations. And the data show that first use occurs at an early age. The average age of first use is 14, which is problematic from a neurobiological standpoint. We are introducing a substance that will negatively affect the prefrontal cortex,” begins Dr. Miguel Esteves Carneiro.
This idea was reinforced by Dr. Magda Carvalho. “It has a significant physical impact. There are many diseases—liver and cardiovascular diseases—and it is the cause of many traffic accidents, as well as accidents in the home. In the long term, it causes many difficulties for families, in terms of productivity at work, and in terms of mental health, and we see this in the clinic. In our daily clinical practice, we truly realize the devastating impacts that alcohol has,” she summarizes.
Does the fact that Generation Z consumes less alcohol make it a mentally healthier generation?
“We are a country where a pattern of drinking characterized by primary alcoholism used to prevail—that is, people who had been drinking since childhood. In addition to the normalization of drinking, there was also an even earlier impact on the brain. I think there has been progress. As a result, younger generations have shifted to a drinking pattern more similar to that of central and northern Europe, specifically with lower daily consumption. Today, we have an overall trend in which alcohol consumption here appears to be declining. And this may be related to various factors—not all of which are necessarily positive. In the sense that young people are more distant from one another in terms of relationships, I’d say that the decline in alcohol consumption is part of the downside. If it’s also related to a model of social or health “hygiene”—something somewhat moralized—I’d say it’s not exactly a positive development. “Perhaps we’re talking about the generation that consumes the least alcohol, but on the other hand, these are the young people who score the highest on anxiety questionnaires. And are they replacing alcohol, for example, with endless scrolling platforms, which also provide very immediate dopamine hits?” reflects Dr. Guilherme Bastos Martins.
What are the main treatment options, and what are their advantages and limitations?
“At The Clinic of Change, we’ve realized that there’s a need here for a different kind of approach—one that can yield a different set of results. Ketamine has already been extensively studied in the context of alcohol use. The most recent studies are those conducted in a more controlled manner, and they provide figures that I would describe as promising. The protocol we use has an 86% success rate at six months. The results we’ve seen so far are quite interesting, giving us reason to believe that, in the future, when we’re able to expand treatment to other groups of people, we’ll have a therapeutic tool that’s more accessible to the general population,” explains Dr. Guilherme Bastos Martins.
“Traditional psychiatry relies heavily on the idea of detoxification—locking the person away, isolating them from their environment, and then referring them to a treatment community or prescribing aversive medications or those that reduce alcohol cravings. This approach does, in fact, work for many of our patients, but it doesn’t work for everyone. We must not treat alcohol as an isolated problem, because it rarely is. There is a lot of work that needs to be done beneath the surface of this problem, and this is where the program—as well as psychotherapy—comes in,” explains Dr. Miguel Esteves Carneiro.
Dr. Guilherme Bastos Martins adds: “We always view addictive behaviors—regardless of the substance—as the root of the problem. Of course, they aren’t. Ultimately, they exponentially amplify the problems the individual was already experiencing. Typically, addictive behavior emerges as a counterproductive response to something that was already happening—psychological distress or anguish. It’s a history of trauma that persists over time. If, when we plan a treatment, we don’t take this for granted, we’ll always be missing the mark.”
How is each patient monitored during psychedelic-assisted therapy?
“At the clinic, we have the KARE program, which is designed for people with alcohol-related problems. In the first phase, they undergo an initial medical evaluation to determine whether they are abstinent or not. In other words, abstinence is one of the conditions for starting treatment. Once abstinence is achieved—either through outpatient medication or inpatient treatment—we can begin the program. There are preparatory sessions designed to establish a trusting and safe relationship with the patient. They also serve to compile a medical history covering life events, previous treatments, what has already been tried, and the impact alcohol has had on various areas of the patient’s life, including family relationships,” explains Dr. Magda Carvalho.
He continues: “Then we have the administration sessions. During these, I work with the patient, always with the support of the nursing staff and a doctor. The integration takes place the next day, or 48 hours later at the latest. During the session, material may surface—sometimes even unconscious material, repressed memories, emotions, sensations—which is worked through in the integration sessions. Based on that material, we explore other narratives. And ketamine helps by promoting neuroplasticity, which is an extremely important opportunity. It allows us to see ourselves in a different light, to feel a sense of freedom. Substances, particularly alcohol, are a prison. Therefore, we begin to feel lighter, more liberated—all of this with the support of psychotherapy.”
“What we’ve observed in our clinical practice is that psychotherapy enables a leap forward—not only in terms of the duration of abstinence, but also in terms of the potential for change—a change that isn’t so much related to alcohol itself, but rather to exploring issues that predate alcohol use,” emphasizes Dr. Guilherme Bastos Martins.
How has gambling addiction resurfaced as a result of new technologies?
In a session divided between two key themes, the second part was dedicated to pathological gambling. The context of this issue within the current discussion on mental health was presented by Dr. Miguel Esteves Carneiro. “We are facing a pocket-sized epidemic. The problem of gambling is not new. The excitement associated with gambling has been around for hundreds of years, but it has changed. There have been changes—even in the last decade—that have completely transformed gambling. In the past, a person had to physically go to a location to gamble; they had to be seen there; there was even a kind of prejudice and stigma surrounding gambling that often prevented people from gambling. It was possible for that person to self-exclude from casinos. “Now, with the advent of online gambling, we’re seeing a transition that has been a real challenge for people working in the field of addiction,” he explains.
The introduction continues: “Many online casinos are, in fact, regulated, and it is possible to self-exclude. But in recent years—and particularly among younger generations, who make up a very significant percentage of players in Portugal—many casinos have emerged that we can consider illegal and that end up luring these people in with free spins and free game entries, which often don’t materialize. Now, the casino is at young people’s fingertips 24 hours a day.”
From sports betting to the sometimes fraudulent schemes promoted by YouTubers and content creators, the panel agrees on one point: gambling is entering young people’s daily lives at an increasingly early age. “One of the issues has to do with the very way these casinos and these forms of gambling are advertised. There’s a youthful vibe to the advertising itself. It’s all very appealing,” adds Dr. Guilherme Bastos Martins.
And when does it stop being just for fun and become a problem?
“People experience emotional distress and seek to relieve that distress by gambling,” notes Dr. Magda Carvalho. “Then all the negative consequences set in—the time spent gambling, the money they spend—but they keep gambling. So breaking this cycle is difficult. As with alcohol, gambling is also closely linked to each person’s psychological vulnerabilities. In the case of gambling, there’s also a strong connection to the concept of reward. Every gambler always believes that this time is the one—this time they’ll win back the money they’ve lost.”
“In fact, it starts to become a problem when you get caught up in something called ‘chasing losses’—that is, when you start trying to recoup what you’ve lost. In counseling sessions, we hear many stories of people who are lucky at first. Just like when you first use substances, there’s a transformative and very pleasurable moment. Then people chase after that moment, but it rarely happens again—and if it does, a lot of money has already been lost. It’s one of the most complicated phases of the disease: the fallacious belief that you’ll recover what you’ve lost,” adds Dr. Miguel Esteves Carneiro.
“And here begins a phase marked by a few innocent lies, deliberate concealments, and some prolonged absences. Some people start resorting to lines of credit, and debts pile up. Families rarely catch this early on; by the time they realize it, the problem has already become too big to handle. Often, we’re dealing with a person who is completely desperate, with suicidal thoughts, because they don’t know what to do about their debts and because they’ve blatantly lied to several people. It is, in fact, one of the deadliest addictions,” concludes Dr. Miguel Esteves Carneiro.
“Based on our clinical experience, we’ve realized that gambling is a problem that often goes unnoticed. These are patients who come to us at very late stages of the problem, when the financial consequences are sometimes irreversible. They have very low retention rates in the healthcare system, in addition to the problem of co-occurring addictions. Alcohol and gambling, for example, often go hand in hand,” adds Dr. Guilherme Bastos Martins.
What is the clinical approach for someone with a gambling addiction?
“First and foremost, the first step is to identify the problem and seek help. Treatment is individualized; there is no one-size-fits-all solution. But during the first consultation, we have to be pragmatic and take immediate action to curb the problem. Often, this involves self-exclusion. We know full well that self-exclusion is possible at brick-and-mortar casinos and regulated online casinos, but it’s harder to do so at illegal casinos—just as it’s harder to live without a smartphone. In some cases, it may make sense to share some banking information with trusted individuals. Treatment does not involve moralistic lectures or authoritarian prohibitions. Often, that only leads to more resistance. It may also involve pharmacological approaches if there is anxiety, depression, or a hyperactivity or attention deficit disorder. Just as with alcohol, getting to the root of the problem ultimately yields the best results,” responds Dr. Miguel Esteves Carneiro.
Young people addicted to video games Are they more vulnerable to developing pathological gaming?
“Many video games are disguised as games. They don’t involve money, but we see that the neurobiological underpinnings—the activated areas of the reward mechanisms—are comparable to putting money in without knowing what will happen and in the hope of receiving something in return. And video games increasingly feature add-ons—so-called ‘loot boxes’—which are little boxes that open up and may contain a skin or a piece of armor for this or that. Many video games also involve real money. It’s not gambling in the strict sense, but it ends up, unconsciously, taking root in the minds of many of these young people who have a problematic relationship with video games. I’d say that, in adulthood, only the age, the money, and the platforms change. The underlying mechanism is still there. I’d say yes, that connection exists.
Learn more about our psychedelic-assisted programs and treatments HERE.
