Problem Gambling in Veteran Populations Office of Problem Gambling Summit March 4, 2014

1. Problem Gambling in Veteran Populations Office of Problem Gambling SummitMarch 4, 2014 Jacquelene Moghaddam, Ph.D. Postdoctoral Fellow UCLA Gambling Studies Program

2. Presentation Overview • Prevalence of gambling in the U.S., California • History of gambling in the military • Current gambling in the military • Gambling treatment for Veterans • Current research • Future directions

3. A Case Vignette • “In Baghdad he found it increasingly difficult to transition from battlefield action, during which there was no time to think, no downtime at his housing unit in Camp Liberty, when bouts of boredom led to creeping doubts about the war's purpose. There was, however, an antidote to the monotony: poker. The veteran, who says he'd never gambled before, recalls anteing up for his first hand of Texas hold 'em. What began as a once-a-week diversion escalated to a nightly routine, fueled by the buzz of energy drinks combined with wagering limits that ballooned to $200 a round. Every now and then, a fellow player's wife would ship over a care package with whiskey disguised as Mott's apple juice. ‘It was almost like a high," he says. It got to the point where sometimes we'd start at six and we wouldn't be done until three in the morning….poker provided a much-needed respite from the psychological toll of the war. Gambling with their money at night seemed a fair tradeoff for gambling with their lives by day.’”

4. Gambling in the U.S. • $600 billion wagered annually • Revenue Comparisons (2005) • Gambling (Legal) $83 Billion per year • NIH Annual Budget: $30 Billion per year • DVDs: $22 Billion per year • Cigarettes: $19 Billion per year (American Gaming Association, CDC, Hollywood Reporter)

5. Availability of Gambling;1975

6. 2008 Casino only (incl. tribal) (5) Lottery only (12) Lottery & casino (15) Lottery & tribal casino (14) Racetrack only (1) Availability of Gambling; 2008 Timothy Fong, UCLA

7. Gambling in CA; An Economic Portrait • 60% Californians gambled in 2011 • Total Revenue • $3 billion in 1997 • $11 billion in 2008 • Tribal casinos:$ 7 billion • Lottery: $ 3 billion • Card rooms: $ 889 million • Horse race wagering: $37 million

8. The Range of Gambling Behavior Social Gambler (85-90% of the population) Problem Gambler (5-6%) Pathological Gambler (1-2%) Total Prevalence: 6-8%

9. CA Prevalence Study (2006) • N=7,121 • 18 years+ • Telephone survey about gambling behaviors • Largest statewide survey ever done • Goal to understand current epidemiological information • Sponsored by OPG; Conducted by NORC

10. CA Prevalence Study; Highlights • Prevalence: • Problem gambling: 2.2% • Pathological gambling : 1.5% • ~1,000,000 problem/pathological cases

11. CA Prevalence Study; Highlights • Highest Risk for gambling problems: • African-Americans • Disabled • Unemployed

12. Gambling and the Military

13. A History of Gambling in the Military • Slots have been on some military bases since the 1930s. • They were banned from domestic military bases in 1951 but rose in popularity in the 1960’s. • Slots were removed from Army and Air Force bases in 1972, after a cash skimming scandal. • 1500 machines remained on Navy and Marine Corps bases overseas, and in 1980 the Army and Air Force began restoring machines at overseas bases.

14. A History of Gambling in the Military II • U.S. service members may legally engage in slot machine gambling at the age of 18. • Slots and video gambling at overseas bases brought in about $185 million for Morale, Welfare and Recreation programs in 2007. • The four military branches currently operate more than 5,400 gambling machines on military premises.

15. Estimates of Gambling Among Veterans • It is estimated that at least 36,000-48,000 active duty U.S. service members may have a gambling problem. • For the general adult population, rates of PG are between 0.3 and 2.0%. One survey cited the rate of PG amongst veterans as 0.2 (Edens&Rosenheck, 2011). Among ethnic minority veterans, rates are 4.3-10% (Westermeyer, et al., 2005). • A 2008 study of 31,000 active-duty airmen showed that 1.9% had no control over their gambling; 10.4% gambled weekly.

16. Why do Veterans Gamble? • Relieve stress/negative feelings • Supplement income, competition • Belief in luck, superstition • Fills a void, use gambling to elevate mood • Relieve boredom/social isolation • Cope with trauma • Readily available during downtime

17. A Case Vignette • “In Baghdad he found it increasingly difficult to transition from battlefield action, during which there was no time to think, no downtime at his housing unit in Camp Liberty, when bouts of boredom led to creeping doubts about the war's purpose. There was, however, an antidote to the monotony: poker. The veteran, who says he'd never gambled before, recalls anteing up for his first hand of Texas hold 'em. What began as a once-a-week diversion escalated to a nightly routine, fueled by the buzz of energy drinks combined with wagering limits that ballooned to $200 a round. Every now and then, a fellow player's wife would ship over a care package with whiskey disguised as Mott's apple juice. ‘It was almost like a high," he says. It got to the point where sometimes we'd start at six and we wouldn't be done until three in the morning….poker provided a much-needed respite from the psychological toll of the war. Gambling with their money at night seemed a fair tradeoff for gambling with their lives by day.’”

18. Comorbidity and Gambling • In a 2003 study of Brecksville pts, 40% had attempted suicide at least once and over 65 % had a lifetime history of substance abuse or dependence (Kausch, 2003). • Alcohol use and personality disorders increased odds of PG by more than 3.5x, respectively (Edens and Rosenheck, 2011). • In veteran samples, homelessness during the past year, 40-64 age, and income of 25k or greater were associated with increased incidence of PG (Edens and Rosenheck, 2011).

19. PTSD and Gambling • In a study of veterans entering treatment for PTSD 17% met DSM-IV PG criteria(Biddle et al., 2005). • 64% of a veteran sample entering gambling tx reported a history of emotional trauma, 40% physical trauma, 24% sexual trauma; Most trauma had occurred in childhood (Kausch, et al., 2006). • History of trauma was associated with more suicide attempts, drug and alcohol dependence, and more severe scores in measures of psychiatric distress(Kausch et al., 2006).

20. The Government &Military Gambling • The DoD added gambling items to its Survey of Health Related Behaviors Among Military Personnel (SHRBAMP) in the early 1990’s. • Results from the 1992, 1998 and 2002 surveys suggested elevated rates of probable pathological gambling among active-duty servicemen and women. • Thereafter, gambling items were not included in the SHRBAMP.

21. The Government & Military Gambling II • In 2001, the Pentagon released a report on the effects of slot machines on members of the armed forces. • The Pentagon stated slot machines “had no negative effect on the morale or the financial stability of military personnel or their families. Comparisons of the [SHRBAMP] survey data to the general public cannot readily be made.”

22. Official Government Position • Undersecretary of Defense Leslye Arsht has stated 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.”

23. Military Gambling and Advocacy • In 2005, the NYT published the story of a decorated helicopter pilot, Aaron Walsh, who developed a gambling problem while stationed in South Korea. Walsh left the military, eventually became homeless and died by suicide in 2006. • Not long afterward, U.S. Rep. Lincoln Davis of Tennessee presented the “Warrant Officer Aaron Walsh Stop DoD-Sponsored Gambling Act.” • The bill proposed a ban on military slot machines; the bill was introduced to Congress, but died in committee.

24. How Do We Treat Veteran Gamblers? • 1) Screening • 2) Intake • 3) Treatment Plan • 4) Treatment • Residential • Outpatient • 6) Follow up

25. Treatment Programs for Veterans • Brecksville Gambling Treatment Program • VA West Los Angeles Gambling Treatment Program • Outpatient services; Various VA’s

26. Brecksville Gambling Treatment Program; Louis Stokes Cleveland VA Medical Ctr. • First clinical treatment center for gambling in world; 1971 • ~115 patients per year; Treated more than 3,500 PG’s • Ages 19-80 • Inpatient program; four weeks • Extensive Assessment Process • Gambler’s Self-Report Inventory (GSRI) • Addiction Severity Index • Barratt Impulsiveness Scale (BIS-10) • NEO Personality Inventory, Revised (NEO-PI-R)

27. Brecksville Gambling Treatment Program Structure & Effectiveness • 1) Individual/ group psychotherapy • 2) Educational groups • 3) 12-step • 4) Marital and family counseling • 5) Mindfulness training* (Rosenthal, 2008). • Outcome studies demonstrate gambling sobriety following program completion, gains in quality of life measures, and decreases in psychological distress (Russo, et al., 1984; Taber, et al., 1987).

28. VA West Los Angeles Addictive Behaviors Clinic Gambling Treatment Program • < 40 patients since founding • Outpatient • Group therapy • Individual treatment, as needed • Emphasis on “Freedom from Gambling” workbook • 12-step • Assessment; currently transitioning into research

29. VA West Los Angeles Addictive Behaviors Clinic Gambling Treatment Program • Program Evaluation • Demographics • Male • Vietnam era • Mean age 58 • N = 36 • 14% combat experience • Slots/ Cards

30. Future Directions • Impact of PTSD and other traumas on gambling treatment • How can we address treatment for Veterans with co-morbid diagnoses? • What is the role of GA for this population? • In what areas is the program doing well? • How can treatment be improved?

31. Acknowledgements • Timothy Fong, M.D. • Richard Rosenthal, M.D. • Michael Campos, Ph.D. • Grace Rosales, Ph.D. • VA West Los Angeles Addictive Behaviors Clinic Gambling Treatment Program • California Problem Gambling Treatment Service Program • California Office of Problem Gambling • For questions, please contact: Jacquelene Moghaddam, Ph.D. UCLA Gambling Studies Program Email: Jmoghaddam@mednet.ucla.edu

32. In 2011 Westermeyer, who has studied addiction for 40 years and served for a time as the Minneapolis VA's director of mental-health services, completed a VA-funded study that delivered a jolt to his profession. He looked at the gambling behaviors of 2,185 vets who sought treatment at least once in the prior two years, either at the Minneapolis VA or at the New Mexico VA Health Care System. He found that 2 percent had a pathological gambling addiction and another 8 percent had a gambling problem — statistics that are double the rates commonly found in surveys of civilian populations.

33. In the fiscal year ending September 30, 2011, the military netted $142.3 million through its slot machines. The funds are earmarked for the upkeep of golf courses, bowling alleys, skate parks and other recreational facilities the military operates for personnel and their families.