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HAZARDOUS DUTY: Gambl i ng ADDICTION & t he Mil it ar y. NAADAC 2015 Annual Conference. October 11, 2015. Keith Whyte, Executive Director. National  ...
HAZARDOUS DUTY: Gamb l i n g ADDI CTI ON & t h e Mi l i t ar y NAADAC 2015 Annual Conference October 11, 2015

Keith Whyte, Executive Director National Council on Problem Gambling

ABOUT NCPG The national ADVOCATE for programs and services to assist problem gamblers and their families NEUTRAL on legalized gambling Founded in 1972 National grassroots non-profit with chapters in 35 of 50 states Work with government, gaming industry & community

CORE SERVI CES Helpline Number (800.522.4700) Nat’l Problem Gambling Awareness Month 30th National Conference on Problem Gambling (July 15-16, 2016 Tarrytown, NY) Public Awareness & Media Certification Administration ADVOCACY!


What Do We Know About Military Gambling & Problem Gambling? Demographics, Participation & Problems

II. Military Gambling Operations? Background, Policy & Issues

III. What Should We Do?

EXECUTI VE SUMMARY  Military personnel are likely to gamble and have substantial risk factors for problem gambling.  Problem gambling in the military is a serious health and policy issue that affects readiness  Active duty, dependents and veterans face significant barriers to treatment  DoD involvement in slot operations likely creates additional resistance to addressing this issue  We must raise awareness, build coalitions and develop programs

I . Wh at Do We Kn ow Ab ou t Mi l i t ar y Gamb l i n g & Pr ob l em Gamb l i n g? Demographics, Participation & Problems

DUNNE, J.  Military Chaplain, 1944-1953  Assigned to 82nd Airborne (Europe) and 187th Airborne Regimental Combat Team (Korea)  Severely wounded behind enemy lines at Munsani, Korea—medical discharge  Awarded Purple Heart, Bronze Star, Silver Star  NCPG co-founder, 1972  “Gambling harms the man like a self-inflicted wound”

GAMBLI NG I N MI LI TARY THROUGH THE AGES 1190: During the Third Crusade, King Richard & King Phillip II ban gambling for those below rank of Knight, 20 shilling a day above…but no limit for Kings! 1541: King Henry VIII of England prohibits several categories of gaming, including bowling, tennis, dicing, and carding…to encourage men to take up archery for defense

GEORGE WASHI NGTON “As few vices are attended with more pernicious consequences, in civil life; so there are none more fatal in a military one, than that of Gaming; which often brings disgrace and ruin upon officers, and injury and punishment upon the Soldiery.” General Orders, May 8, 1777

 “All officers, non-commissioned officers and soldiers are positively forbid [sic] playing at cards, and other forms of gaming at this time of public distress, men may find enough to do in the service of their God and our Country, without abandoning themselves to vice and immorality.” General Orders, February 26, 1776

THE BATTLE CONTI NUES  1862: Gen. Robert E. Lee is “pained to learn that the vice of gambling exists, and is becoming common in the army.”  1895: Gen. McCook prohibits gambling “in the vicinity” of his command.

Wh y SOLDI ERS gamb l e (MORE?) During deployment: Entertainment Stress Relieve boredom/social isolation Substitute/metaphor for war Belief in luck, superstition

When the soldiers return home: It is fun and exciting It fills a void

WHAT ARE THE ODDS? Winning a Powerball jackpot: 140,000,000 to 1 Struck by lightning: 576,000 to 1 Becoming a pro football player: 3,000 to 1 KIA or WIA in Iraq? 11 to 1

3 ON A MATCH I S BAD Lu ck  Superstition likely originated during Boer War.  When the first soldier lit his cigarette the enemy would see the light;  When the second soldier lit his cigarette from the same match the enemy would take aim;  When the third soldier lit his cigarette from the same match the enemy would fire.

LI VE FOR THE DAY  “As a warrior you should be keenly aware of the frailty and randomness of life. You should know that death could find you at any time. Sometimes, you know there might not be a future for you beyond tomorrow. So you bloody well better live it up tonight just in case! ‘Work hard, play hard’ is the motto of many a soldier, and coincidentally, the main reason there are no rich soldiers.” • Faith & Steel: A Warriors Manifesto. Bergeron, S. (2003)

Mi l i t ar y PG Ri sk f act or s  Prone to risk taking/Highly impulsive/Discount the future  Highly competitive  Face extreme stressful situations/anxiety  Male  PTSD  Other mental health issues

Substance use & abuse Low SES Higher % of minorities Link to suicide Younger More athletic Loneliness & social isolation  Grief/loss       

Su b t ypes Action  More likely to be male  Prefer “skill” games  Narcissistic  Uses gambling to elevate mood

Escape  More likely to be female  Prefer “continuous” games  Uses gambling to withdraw “zone out”

POSSI BLE PROTECTI VE FACTORs ? 64% of officers identify as Republican; also higher % religious than civilian population. 65% of Americans believe gambling is morally acceptable (58% conservatives/73% of liberals).

WWSHRBAMP The Worldwide Survey of Health Risk Behaviors Among Military Personnel is a large-scale epidemiologic study that screened personnel for gambling-related problems in 1992, 1998 and 2002. Criteria and definitions changed considerably between surveys. Likely underreporting.

RATES of Gamb l i n g Pr ob l ems 1992















Gamb l i n g & Al coh ol 2002 WWSHB

1-4 Gam Prob

5+ Gam Prob

Abstain/Light Drinker Moderate/Heav y Drinker Serious Consq from Alcohol Dependence









VETS COMORBI D 2004-2006, 7% past year serious psychological distress 7% substance use disorder 1.5% both Iraq & Afghanistan vets 2001-2005 35% mental health, 20% had a substance use disorder

Female veterans had twice rate of serious psychological distress.

SA & PG I N TX  66% of PG in residential program had lifetime SA abuse or dependence.  58% using in year prior to admission.  Most SA preceded PG. • Patterns of SA Among Tx Seeking PG. Kausch, O. Jouanal of SA Tx (2003)

 33% of SA in Tx program met PG criteria.  Current alcohol consumption significantly higher in gamblers. • Pathological Gambling In Hospitalized SA Veterans. Daghestani, A. J. Clin. Psych (1996)

su i ci de 40% of PG in tx made lifetime attempt. 64% reported most recent attempt related to gambling. • Suicide Attempts Among Veterans Seeking Treatment. Kausch, O. J. Clinic Psych (2003)

 2008 suicide rate among Army personnel highest in three decades, surpasses civilian rate.

CASE STUDY: WALSH, A.  Decorated Army Apache helicopter pilot.  Developed severe gambling problem.  Unsuccessful treatment attempts.  AWOL, resigned 2005 before court martial.  Committed suicide 2006.

PTSD & PROBLEM GAMBLI NG  In a study of military veterans entering treatment for PTSD (Biddle et al., 2005), 17% met DSM-IV PG criteria.  Among 111 veterans entering a gambling treatment program, 64% reported a history of emotional trauma; 40% physical trauma; and 24.3% sexual trauma;  most trauma had occurred in childhood.

 History of trauma was associated with a greater frequency of suicide attempts and drug and alcohol dependence, more severe scores in measures of psychiatric distress, and limited effects on personality functioning. • Kausch et al. (2006)

Ci v i l i an PTSD Among treatment-seeking pathological gamblers, 34% had a high level of PTSD symptoms with the latter assessed by selfreport checklist (Ledgerwood & Petry, 2006). The common pattern appears to be greater pathology and worse functioning among pathological gamblers with a trauma history or PTSD.

RECRUI TS N=31,104 AF recruits 10.4% weekly gambling 6.2% current problem gambling 1.9% current pathological gambling Higher rates among minorities  Gambling & Health Risk Taking Behavior in a Military Sample. Steenbergh, et al, (2008) Military Medicine

ACTI VE DUTY N=584 Naval Outpatient Psychiatric Clinic 1.4% current pathological gambling Only 0.04% were diagnosed Lower rate of PG than expected, but only 25% response rate and more than ½ were female.  Prevalence & Epidemiology of Pathological Gambling

at Naval Medical Center Portsmouth Psychiatry Clinic.

Weis, D, et al (2007) Military Medicine

COMMON FI NDI NGS Male military at higher risk Significant association with: Smoking Alcohol abuse/dependence

No significant association with rank

Maj or Cor r el at es of Pr o b l e m Ga mb l i n g Divorce Poor health Other mental health problems Job loss and lost wages from unemployment Bankruptcy Arrest and incarceration

Gamb l i n g Ef f ect s on Se r v i c e Me mb e r a n d Fa mi l y  Letters of indebtedness  Bounced checks  Misuse of government credit cards  Security risk  Forgery  Embezzlement

 Loss of rank  Divorce  Lost work time/ productivity  Forced retirements  Bad conduct discharges  Suicidal risks

(Source: Substance Abuse Rehabilitation Department, Naval Hospital Camp Pendleton)

BARRI ERS  Doesn’t fit comfortably with existing structure— is it addiction, mental health, financial, discipline or moral (chaplain) issue?  Concerns about confidentiality.  Military uses stricter definition of insanity.  Lack of resources, particularly gambling.  Problem gambling often accompanied by crimes–risk of courts martial/DD  Stigma.

CASE STUDY: FOSTER, A. Chaplains Assistant, 8th Army, Korea. “He went to Army Community Services; they said they couldn’t help and sent him to Mental Health Services. There, they said, ‘No, we can’t help you-go to your chaplain.’ So he goes to his chaplain, who says he’s not qualified to help with addiction and refers him to…Army Community Services.”

PG TREAT PROG N=35 SARP Naval Hospital Average 10 yrs active duty service Significant concerns about confidentiality 20% of referrals for female spouses Preliminary results effective  Review of the First Year of an Overseas Military Gambling Treatment Program. Poole, et al. Military Medicine (2005)

I I . DoD Sl ot Op e r a t i o n s Background, Policy & Issues



Gamb l i n g i n t h e U.S. Mi l i t a r y…  US service members may legally engage in slot machine gambling at the age of 18.  It is estimated that at least 36,000-48,000 active duty US service members may have a gambling problem.  None of the gaming revenue is dedicated to fund problem gambling prevention, education or treatment services.

Hi st or y  Slot machines have been on some military bases since the 1930s.  The machines were banned from domestic military bases in 1951 but enjoyed a resurgence in the 1960s.  They were removed from Army and Air Force bases in 1972, after a cash skimming scandal.  Fifteen hundred machines remained on Navy and Marine Corps bases overseas, and in 1980 the Army and Air Force began restoring machines at overseas bases.

SCOPE OF PROGRAM  5,000, 7,000, 10,000?  Each service runs its own program  Located OCONUS  On-base at MWR facilities—O clubs, bowling alleys, etc…

PROGRAM RESULTS 2005 slots: $2 billion handle, $120 million revenue. Revenue goes back to MWR. Military claims high payout percentage provides greater entertainment—in most jurisdictions it is a marketing tactic.

NOT JUST SLOTS Army bingo, 2005: $45 million. 11 of the largest games average more than $100,000/month.

Casinos in close proximity to bases: Nellis AFB-Las Vegas, Camp PendletonPechanga, Kessler AFB-Biloxi

Poker & social gambling in barracks. Military lottery?

UCMJ  Article 134 - (Gambling with subordinate)

 (1) That the accused gambled with a certain servicemember;  (2) That the accused was then a noncommissioned or petty officer;  (3) That the servicemember was not then a non-commissioned or petty officer and was subordinate to the accused;  (4) That the accused knew that the servicemember was not then a noncommissioned or petty officer and was subordinate to the accused; and  (5) That, under the circumstances, the conduct of the accused was to the prejudice of good order and discipline in the armed forces or was of a nature to bring discredit upon the armed forces.

 Ex planation. This offense can only be committed by a noncommissioned or petty officer gambling with an enlisted person of less than noncommissioned or petty officer rank. Gambling by an officer with an enlisted person may be a violation of Article 133. See also paragraph 83.  Lesser included offenses. Article 80—attempts  M ax im um punishm ent. Confinement for 3 months and forfeiture of two-thirds pay per month for 3 months.

DOD Pu b l i c COMMENTS:  Undersecretary of Defense Leslye Arsht said that machines on bases and posts provide "a controlled alternative to unmonitored host-nation gambling venues and offer a higher payment percentage, making it more entertainment oriented than at typical casinos. DoD policy authorizes the military services to operate gaming and/or other amusement machines in overseas locations only, unless prohibited by host-country laws or agreements.”

DoD  Slot machines are "a very profitable operation," said Peter Isaacs, chief operating officer of the Army’s Community and Family Support Center, which runs the largest slot machine program. "But we do not operate them strictly to extract profit. Our soldiers have told us they want access to the same games and gambling opportunities available to the civilians they are defending."

I I I . Wh at Sh ou l d We Do Ab o u t It ?

ULTI MATELY, MI LI TARY MUST SEE AS HEALTH PROBLEM “It seems that taking drugs is considered a health problem that requires understanding and treatment. There has been far less tolerance for gambling offenses, even through they correspond to a behavioral addiction that may also need to be treated as a health problem. The professional sports authorities seem to make a distinction in which an athlete is considered to have a choice about compulsive gambling, where as drug abuse is seen as a sickness. In truth, such a distinction is blurred by the common ground of addiction. Self destructive behavior among athletes can be expressed through many pathways.” • Stanley Titelbaum, Ph.D., Sports Heros; Fallen Idols (2005)

NCPG/ARMP RG POSTER  NCPG Helpline now available directly from: Germany, Japan, Korea, Italy, United Kingdom  Routes to 24/7 call center in Louisiana

Mi x ed messages

SO…WHAT DO WE DO? Do not delay action even though current knowledge is imperfect Do not accept the status quo Devise creative solutions Work with all stakeholders Language, evaluation & cost benefit is critical Public/private partnerships may be cheaper, faster, better

APPROACHES Legislative (DoD & VA) advocacy Coordinated policy chaplains, MWR, surgeon general, counselor training, financial services Tricare?

Continuum of care to reserves & VA. (trendy) Outreach (MN NG, others)

FY 2016 NDAA Study of gambling and problem gambling in military, including: # of slots, participation & revenue Prevalence of PG among military personnel Assessment of capacity of treatment services

Report to Congress in one year Builds foundation for future efforts

Dod/VA I ssu es Disconnect between DoD & VA; between services and Guard, between Guard and Reserve. Reserve forces only get DoD health benefits 6 months pre- and post-deployment.

Complex eligibility system for VA. No uniform records across systems.

PETERRR  Move towards comprehensive policy  Long term initiatives  Holistic, multi-faceted approach with all stakeholders

 Prevention  Education  Treatment  Enforcement  Research  Responsible Gambling  Recovery

Pr ev en t i on Life Skills & Help for Families programs. Financial guides, especially for low ranking enlisted. Ensure programs include family. Dependents are a major factor.

Edu cat i on Implicit harm reduction approach, given 85%+ lifetime gambling. Responsible gaming strategies if individuals choose to gamble. Education that problem gambling is a real disorder, and help is available.

Tr eat men t Highly co-morbid—must screen for PG in all health care settings. Need continuum of care: BRIEF INTERVENTION→Therapy→hospital

Safe harbor to seek help? Most who seek & complete treatment generally improve.

En f or cemen t Of all laws and regulations, including regarding social gambling Harmonization between policy and practice Ensure safe harbor for help seekers

Resear ch Links together all previous sections. Outcome & evaluation Determine benchmarks/best practices Includes survey research, longitudinal & cohort, natural studies

ResPONSI BLE g AMBLING Providing gambling in a manner that reduces the risks Standards based Self exclusion, ability to set limits on time and money spent on slots

ReCOVERY Support recovery. How do we help military personnel sustain their recovery on a base filled with slots, stress and without services? How do we help veterans sustain their recovery in a society filled with slots, stress and sparse services?

CASE STUDY: NORA, R.  Chief of Psychiatry, Lyons VAMC, 1975–1994.  Southern Nevada (VA) Healthcare System, 1995–2004.  “In our day-to-day work with problem gamblers, we emphasize behavior that has gotten them into trouble, how their use of poor judgment and their character flaws generated chaos in their lives. But in the last few minutes of a session, I look for something positive they can use when they leave. The big word is HOPE.”

CONCLUSI ON Military/veterans at higher risk for gambling addiction Highly co-occurring, hidden addiction But progress is being made… For active duty NDAA For veterans—adding PG to MH manual.

Hope & help is available!

NATI ONAL COUNCI L ON PROBLEM GAMBLING 730 11th Street, NW, Suite 601 Washington, DC 20001 Tel: 202.547.9204 Fax: 202.547.9206 Email: [email protected] Web: