MIDWEST CONFERENCE ON PROBLEM GAMBLING AND SUBSTANCE ABUSE

14TH ANNUAL CONFERENCE “EVOLUTION THROUGH INNOVATION”

JUNE 21-23, 2017 KANSAS CITY, MO

GLENN OSOWSKI, ICGC-II

MILITARY CULTURE AND DISORDERED GAMBLING IN MILITARY AND VETERAN

POPULATIONS

Glenn Osowski, ICGC-II

Veterans Administration Ann Arbor Healthcare System

Healthcare for Homeless Veterans Team

2215 Fuller Road

Ann Arbor, Michigan

419-360-5022

glenn.osowski@va.gov

DISCLAIMERThe views and opinions expressed in the following PPT slides are

those of the individual presenter and should not be attributed to the Department of Veteran Affairs.All information is publicly available and the author declares no

conflict of interest with regard to the content of this presentation.The opinions and views expressed in this presentation are the

sole responsibility of the author.

OBJECTIVES Understand American military culture in society Comprehend the impact of military experiences Understand military structure and processes Describe the demographics of todays military Cultural and behavioral norms for military personnel Dispel myths about military service and deployment related

to physical and mental health issues Understand signs and symptoms of gambling addiction

OBJECTIVES Understand the impact of gambling expansion Gambling and Substance Addiction Develop skills to build rapport and a therapeutic

relationship with the military or Veteran and his or her family

Clinical implications for providers to include access and availability of services for Veterans

Review best practices in treatment of Disordered Gambling

WHY UNDERSTAND MILITARY CULTURE

Veterans will identify with military culture after their service Values and identities continue to be critical and important Each Veteran will have their unique story – context of the Veteran’s

experience Develop therapeutic alliance Understanding the perspective and context of Veteran mental health

conditions Improved treatment planning Appreciation for military service Learning military structure, differences of branches, rank, values and ideals

WHAT IS THE MILITARY• Not just a job, a way of life• Not a union or fraternal organization• Tradition• Each service has its own culture• Shaped by national cultures including: geography,

demographics, history and politics• Governed by civilians• Purpose

WHY JOIN• Personal and Social Values • Friends • Education Benefits• Economic • Sense of adventure• Escape Home• Challenge• Service• Sacrifice

OATH OF ENLISTMENT• The Oath of Enlistment:

"I, _____, do solemnly swear (or affirm) that I will support and defend the Constitution of the United States against all enemies, foreign and domestic; that I will bear true faith and allegiance to the same; and that I will obey the orders of the President of the United States and the orders of the officers appointed over me, according to regulations and the Uniform Code of Military Justice. So help me God."

DEMOGRAPHICS• All Volunteer force last 38 years

• 0.8 % of US population (309m) wears military uniform today 14% WWII

• 1948 Racial Integration

• Overall today minorities represent nearly 1/3 (30.7%) of all active duty personnel

• Women make up nearly 15% of all active duty personnel officially integrated in 1976 however been serving since WWI

• Since 1983 decrease of African Americans and increase in Hispanics serving in the military

• Average age older

• Education level higher

• Marital status higher than civilian

MILITARY STRUCTURE• Military Rank: Officer, Warrant Officer, Enlisted/NCO• Chain of Command• Duties: MOS, AFSC, Navy Ratings• Identifiers• Customs and Courtesies

ENLISTED USA AND USMC

ENLISTED USAF

ENLISTED USN AND USCG

MILITARY PAY (ENLISTED)

OFFICER INSIGNIA

WARRANT OFFICER INSIGNIA

MILTARY PAY (OFFICER)

RATIO OFFICERS TO ENLISTED(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

MAKE UP OF ACTIVE DUTYArmy 465,056

Navy 322,368

Marine Corps 183,866

Air Force 319,707

Coast Guard 40,919

AGE OF ACTIVE DUTY(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

MAKE UP OF RESERVES

Army National

GuardArmy Reserve

Navy Reserve

Marine Corps

ReserveAir

NationalGuard

Air Force Reserve

Total DoD

Coast GuardReserv

e

TOTAL

TOTAL OFFICER 45,193 37,940 14,240 4,434 15,116 13,677 130,600 1,087 131,687

TOTAL ENLISTED 296,645 161,054 43,793 34,002 89,724 54,490 679,708 5,310 685,018

GRAND TOTAL 341,838 198,994 58,033 38,436 104,840 68,167 810,308 6,397 816,705

AGE OF RESERVES(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL

• Each Armed Service has a Reserve• The National Guard is a state agency

unless it is federalized• Deployments part of a planned cycle• Smaller force yet similar numbers of

OEF/OIF Veterans coming to VA• Suicide rate continues to climb• May deploy individually• Family not necessarily entrenched in

military culture• Less access to health services

• Always on Active Duty

• Always Federal

• Lives on or near military base

• Medical care through Military

• Deploys as a unit

• Family deeply entrenched in military culture

• Suicide rate leveling off

THE RESERVE COMPONENT

ACTIVE RESERVE

GROWTH OR LOSS SINCE 1995 (BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

ENLISTMENT BY STATE (BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

FEMALE MEMBERS(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

FEMALE MEMBERS(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

MILITARY BY RACE(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

RAPID INCREASE OF MINORITY OFFICERS

(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

USA AND USMC DECREASE IN MINORITIES

ENLISTED EDUCATION(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

MARRIAGE IN THE MILITARY(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

MARRIAGE BY BRANCH(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

43.6% ACTIVE DUTY HAVE CHILDREN

(BUSINESS INSIDER FROM WWW.MILITARYONESOURCE.MIL)

DEFINING THE PROBLEM Over 2.7 M Service members have been deployed to fight in Iraq and

Afghanistan since 2001 over half deployed multiple times 99% of US counties have deployed a Reserve Component member in support of

OIF OEF and Operation New Dawn 1M Veterans have officially recognized disability 40% of the OEF/OIF/OND Veterans dx with a MH issue upon return from

deployment 50% of returning Veterans register with the US Department of Veteran Affairs 90% of service members quit school….majority are reasons other than financial Deployments significantly impact families who are often ineligible or w/o services Suicide

SUICIDE Veterans have a suicide rate 50% higher than those who did not serve in the

military

Veterans serving during the Iraq and Afghanistan wars between 2001–2007

Deployed: 317,581 total Veterans 1,650 total deaths 21.3% death by suicide.

Deployed Veterans showed a lower risk of suicide compared to non-deployed Veterans.

Suicide rate of female Veterans: 11.2 out of 100,000 Veterans. Suicide rate of male Veterans: 33.4 out of 100,000 Veterans.

Regardless of deployment status, the suicide risk was higher among younger, male, white, unmarried, enlisted, and Army/Marine Veterans; however, predictors of suicide were similar between male and female Veterans

MILITARY CULTURE

UNIQUENESS OF MILITARY CULTURE• Military career places stress on members and families

• For most folks their job is what they do, military deeply defines who they are

• Military life offers a sense of community with clearly defined rules and expectations

• Share a unique bond, professional ethic, ethos and value system

• Sense of community and camaraderie unlike any other profession

• Fosters a warrior ethos that frowns upon any weakness and timidity

• Military defends the constitution but does not emulate it = There are very strict rules limiting freedom of speech and association

• Commanders responsibility for subordinates behavior

DEFINING UNIQUENESS• Leave and liberty

• Subject to performing your duty 24 hours a day

• Told what to wear, where to live, and who you can socialize with. Not long ago you even needed your commander’s permission to marry

• Meds & vitamins, restrictions on seeing a counselor, having medical procedures

• Family members are subject to restrictions and their actions directly reflect upon their service member

• Definition of the military family has changed

TENENTS OF MILITARY CULTURE

• Recruiting

• Testing

• Training

• Core Values

• Fitness

• Joint Service

• Some Language

• Rank is Great Equalizer

• Mission

• Service Culture

• Leadership Development

• Uniforms

• Rank Insignia

• Language

• Acronyms

SIMILARITIES AND DIFFERENCES

WOMEN VETERANS• Women Veterans are younger

• Among women Veterans returning from OEF/OIF:

58% between 20-29

• Leave service early in their military careers:

Balancing career and family

Perceived lack of advancement opportunity

Sexual assault and harassment

40% of military women on active duty have children

Twice as likely to be a single parent (14.7%)

Divorce rate 3 times higher for women

U.S. VETERANS IN 2010

VALOR OR GUILT

CombatCombat has major impact one ones psyche and changes

perceptions • I witnessed my friend or someone in my unit get killed 50%

• I saw dead or seriously wounded non combatants 45%

• I saw serious death or severe injury 45%

• I smelled seriously decomposing bodies 37%

• I was seriously knocked over or moved by an explosion 23%

• I was injured but was not hospitalized 23%

• I received a blow to the head in an accident, combat or injury 18%

• I was injured and hospitalized 11%

WOMEN IN COMBAT• 112K women have served in OEF/OIF• 32% of all women currently serving have deployed to combat zones

203K Active Duty 146K National Guard and Reserves

• Deployment rates highest and longest for Army personnel and Marines followed by Navy and Air Force

• Strengths of Women Veterans disciplined, courageous, self motivated, loyal, team players, leaders,

understand diversity, resilient, humble Women fared worse in PTSD 2x as likely to have SMI and SA issues

WARRIOR MOTHER• Women are expected to “bounce back” from combat as the “perfect mom”

• Possible impacts of combat/trauma on family relationships

Attachment issues with children

Bonding with adult relationship partners

Modeling of (in)appropriate emotional controls

• Sense of confidence/self-reliance either enhanced or diminished by the military experience

COMBAT VETERANS

WHAT IS GAMBLING

• Gambling is risking something of value on an event that is 

determined by chance

• Gambling is an activity in which something of value is risked on 

the outcome of an event when the probability of winning and 

losing is less than certain (Korn and Shaffer 1999)

• A person is actively gambling if:

- he or she puts up something of value (money, property)

- outcome has element of chance beyond the person’s  control

- once the bet is made it cannot be undone or reversed

EXPANSION OF GAMBLING

• All but 2 states have some form of legalized gambling

• Pari-mutual racetrack betting in 40 states

• Lottery in 43 states

• 28 states have legalized casinos

• 100’s of riverboat/dockside casinos

• Indian gaming started in 1988

• Internet Gambling

• Televised poker/blackjack tournaments

• 15 percent of Americans gamble at least once per week

CATEGORIES OF GAMBLERS

• Social Gambler – occasionally for fun sticks to limits

• Serious Social Gambler – Gambles regularly, hobby, still does not spend more than they can afford

• Professional Gambler – Gambles as a way to make a living

• Problem gambler- Beginning to have problems due to gambling

• Pathological Gambler – Major life problems due to gambling

• Anti-Social Personality – sometimes mistaken for a pathological gambler hitting bottom

• Bungler – Incompetent bets on favorite color, name number

PROBLEM GAMBLING 

DEFINITION

• Gambling is a problem when it disrupt or damages your:

-Physical Health

-work, school or other activities

-relationships

-finances

-reputation

PROBLEM GAMBLING • Approximately two to three percent of Americans meet the criteria

for problem gambling. That's around 6 million adults and about a half

million teens

• About 40 percent of people with a gambling problem started

gambling before the age of 17

• Youth risk developing a gambling problem at a rate of about two to

three times that of adults, and approximately 6 percent of college

students in America have a gambling problem

• Nevada has the highest prevalence of problem gambling in the

country, at about 6.4 percent

(DSM-IV)• Impulse control disorders not otherwise classified

• Preoccupation

• Gamble more money for desired excitement level

• Unsuccessful attempts at stopping or cutting back

• Restless or Irritable when cutting down or stopping

• Escaping problems

• Chasing

• Lies

• Illegal acts

• Risked or lost something or someone important

PATHOLOGICAL GAMBLER 

(DSM-5)• New name – Disordered Gambling

• New classification – Addiction and related disorders

• Gambling disorder is the only Behavioral (Process) addiction

• 9 criteria – eliminate illegal acts

• Why change? Reward Center research – Similar to Substance Use Disorders (cravings, highs, hereditary nature)

• Similar treatment (12 step, CBT, MI, MET)

• Assumes cannot recover

• Severe cases less likely to improve

TYPES OF GAMBLERS• Action - Escape/relief 

• Pathway Model Emotionally vulnerable – Impulsive –

Behavioral conditioned (2002 Blaszczynski Nower) 

(2006 Ledgerwood Petry)

• Emotionally vulnerable – Alexithymia and depression –

low on sensation seeking

• Impulsive – high sensation seeking and alexithymia

• Behavioral conditioned – convinced they have a 

system/strategies/illusion of control 

SIMILARITIES OF CD AND 

GAMBLERS• Preoccupation

• Lack of Control

• Ambivalence (rather than denial or resistance)

• SA

• Depression

• Escape

• Family Dysfunction

• Intolerance

• Chasing

• Immediate gratification

• Shame

• Co-morbidity

DIFFERENCES OF CD AND 

GAMBLERS

• Not easily detected

• Fantasy/Dream Life

• Not self-limiting (can’t OD)

• Job Family functional

• Suicidality

• Hopelessness

• Financial (extreme debt)

• Social perception

• Few resources

• Solitary 

WHY GAMBLE?

• Win money

• Social activity

• Excitement

• Competition

• Fantasy

• Family members

PARKINSON'S & RESTLESS LEG 

SYNDROME

• PD higher rates of PG

• Statistically significant findings from multiple studies 

suggest 3-7% individuals with PD had PG

• Dopamine agonists (Mirapex, Requip) utilized to treat PD 

has been shown to increase PG

• Dopamine Agonists also associated with:

• Binge eating, Hoarding, Compulsive buying, hyper sexuality

CIGARETTE SMOKING AND PG• Gamble on more days and spend more money gambling (several 

studies)

• Crave gambling more

• Perceive no control over gambling

• More likely to take psychiatric meds (especially anxiety sx) on more 

days than non-smoking gamblers

• Same patterns found with history of SUD. However treatment 

outcomes not effected

• fMRI study (Goudriaan et al, 2010) indicated heavy smoking 

activates same reward centers in the brain as PG and positive 

correlation b/w heavy smoking and gambling relapse

ONE STORY

BEST PRACTICES IN TREATMENT• Motivational Interviewing

Arranging conversations so people talk themselves into change based on their own values

and interests

Addressing ambivalence

Reasons to change and reasons not to change (change process)

Therapy is not case management

• CBT

Irrational beliefs

Cognitive distortions (triggers, randomness)

Behavioral structure (leisure activities)

Relapse prevention

• Imaginal desensitization

• Attend GA

BEST PRACTICES IN TREATMENT

• Self exclusion

• Psychopharmacology- Naltrexone

• Family Involvement (GAM-ANON)

• Financial planning (fiduciary)

• Aftercare treatment

BARRIERS TO TREATMENT

• Military Belief Systems – Shared set of beliefs, thinking, and behavior based on the shared understanding of the mission

• 65% fear the perception of being seen as week

• 63% fear leadership will treat them differently

• 59% fear others would have less confidence in them

• Threatens position, promotion and retention

• Treatment beliefs not addressed

• Fears of failure and fears of success

• Labels and stereotypes

BARRIERS TO TREATMENT• Avoidance

• Realistic concerns

• TBI - 75% of all injuries are from blasts

• Suicide rate passes general US population for the first time

• For every Veteran killed by enemy combatants, 25 Veterans take their own life

• Key triggering issues:

- Relationship issues

- Financial Problems

- Number and length of deployments

- Legal issues

BARRIERS TO TREATMENT• MST – Military Sexual Trauma

- 30% of female Veterans of all eras say they were assaulted or raped while in service

- Only 8% of offenders are prosecuted

- More than 70% of women Veterans experienced sexual harassment in service

- Major health problems from MST: Depression, Miscarriages, Eating Disorders

• Homelessness

• History

• Eligibility/Referral

• Assessment/Phone Screening

• Admission Screening Committee

• Travel/Arrival

• Testing

• Length of stay

• Housing

• Multi – Disciplinary Team

• Treatment Plan – Updates

• Group Psychotherapy

• Individual Psychotherapy

• CBT/MET/MI/Mindfulness

BRECKSVILLE GAMBLING 

TREATMENT PROGRAM

BRECKSVILLE GAMBLING TREATMENT PROGRAM

• Recreational Therapy

• GA Meetings

• Spirituality

• Relapse Prevention Plan

• Graduation/Coining out

• Aftercare

• Therapeutic Passes

ADDITIONAL RESOURCES• OIF/OEF case management coordination

• On site service officers to assist w/ C&P claims

• VJO- Veterans Justice Outreach

• Vocational Rehabilitation Program

• CWT (Compensative Work Therapy Programs)

• Homeless Veteran Coordination Team

PROVIDER BIAS• “No one goes unaffected by the aftereffects of war. How we embrace this truth shall determine

our path into the future.” Lawrence Winters• Pictures - Do you have a picture of a flag or a person in uniform? While these may be eye

catching and create a quick visual cue for Veterans it may also be a reminder of a negative experience while in the military, especially if she has experienced service-related trauma.

• What language do we use – female or woman Veteran? Victim or warrior?• Provide clear steps for accessing care• Family pictures• MST in the military is not a “woman’s issue.”• Feeling safe (door, noise)• Welcome children• Active duty or Veteran• “You don’t get it.”

DO’S AND DONT’SDO:• Thank them for their service• Listen nonjudgmentally with empathy and acceptance• Be aware of the likelihood Veteran maybe working through adjustment issues and

treat him or her with “respect, dignity and privacy”• Ensure Veterans and their families are aware of available services and potential

benefits for themDON’T:• Try to “talk the talk,” Nothing will discredit you more.• Give your armchair general or political analysis of the war• Press for trauma details (but be prepared to listen when they are offered)• Tell them they were “lucky” or “fortunate” or “I understand” • Tell them what to do – how has that worked so far

MYTHS AND BIAS• A Veteran with PTSD is violent

• Another human being killing another has moral issues

• More patriotic then those that do not serve

• Uneducated or criminals join the military

• Can not think on their own

• War Crimes

• Not justified

• Cannot be independent

• Cannot be trusted with weapons

HEALING AND MOVING FORWARD

“Things do not change: We change.” 

Thoreau

QUESTIONS