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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
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