Mindfulness-Based Relapse Prevention for the Treatment of Gambling Disorder among U.S. Military Veterans: Case Series and Feasibility

Abstract

Gambling disorder (GD) occurs at higher rates in U.S. veterans than civilians. The present case series describes the application of a manualized mindfulness treatment used with U.S. veterans seeking outpatient treatment for GD at a Department of Veterans Affairs hospital. Mindfulness-Based Relapse Prevention (MBRP) was developed to treat substance use disorders, but its core principles can be readily applied to the treatment of behavioral addictions. However, there has been little empirical evidence demonstrating its successful application for GD, and none demonstrating its successful implementation with U.S. veterans. Three veterans receiving treatment for GD participated in a 9-session adapted MBRP protocol. Following completion of treatment, the veterans reported less frequent engagement in their gambling behavior, fewer cravings, and less intense craving. The veterans also experienced increased self-efficacy in managing urges, less impulsivity and emotion dysregulation, and improved functioning. Preliminary results provide support for a larger treatment trial for veterans seeking treatment for GD.

Keywords

veterans problem gambling gambling disorder mindfulness-based relapse prevention

1. Theoretical and Research Basis for Treatment

Although the diagnostic classification of behavioral addictions is relatively new, they have been discussed for decades in research, clinical literature, and in popular press. Behavioral addictions involve a compulsion to engage in rewarding non-drug-related behavior without regard to incurring negative physical, mental, social, and financial consequences. Binge eating, frequent shopping, and overuse of videogaming are examples of behaviors that may lead to the development of a behavioral addiction (Grant et al., 2010). In the present article, we will discuss a common, yet understudied, behavioral addiction among U.S. veterans–gambling disorder (GD). Originally developed for the treatment of substance use disorders (SUD) (Bowen et al., 2009), this case series describes the successful adaptation and implementation of the Mindfulness-based Relapse Prevention (MBRP) intervention for the treatment of problematic gambling in U.S. military veterans who were being treated at an outpatient specialty mental health clinic in a Department of Veterans Affairs medical center in the northeast United States.

Gambling Disorder: Description and Prevalence

GD, formerly pathological gambling, was originally defined as an impulse control disorder but was reclassified as a Substance-Related and Addictive Disorder in DSM-5 (APA, 2013). GD is a psychiatric disorder characterized by recurrent and maladaptive patterns of gambling behavior that cause clinically significant impairment and distress in one’s life (Hodgins et al., 2011). Common forms of gambling behavior include the use of electronic gaming devices, casino-type table and card games, lotteries, dice games, wagering, and sports betting. The severity of gambling disorder is defined as mild (meets 4-5 criteria out of the total nine criteria), moderate (meets six to seven criteria out of total nine criteria), and severe (meeting eight to nine criteria out of total nine criteria; APA, 2013). Over the past 20 years, researchers have often described individuals as having problem gambling if they endorse two to three diagnostic criteria but do not meet the full criteria for gambling disorder (Loo et al., 2019).

GD is associated with adolescence and young adulthood, male gender, ethnic minority status, lower socioeconomic status, lower education level, familial history of gambling, unmarried status, intimate partner violence, and risky sexual behaviors (Potenza et al., 2019). Both GD and problem gambling are highly comorbid with other psychiatric and substance use disorders (Loo et al., 2019). Among U.S. military veterans with GD or problem gambling, common co-occurring conditions include posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD; see Etuk et al., 2020 for details).

The estimated lifetime rates of GD among U.S. adults range from 0.4% to 1.6% and between 1.0% and 4.0% for problem gambling (Potenza et al., 2019). For U.S. military veterans, estimates suggest that lifetime rates of GD are approximately 2.0%, while the lifetime rates of problem gambling are as high as 9.0%. These increased rates suggest a vulnerability toward developing problem gambling and GD among U.S. veterans (Etuk et al., 2020). Despite these data, there is a dearth of research describing the prevalence of GD and effective treatments for U.S. veterans (Etuk et al., 2020).

Mindfulness and Mindfulness-Based Relapse Prevention for Gambling Disorder

There are varying conceptual definitions of mindfulness that often differ when describing trait or state mindfulness. Additionally, there are varying methods and approaches of mindfulness inductions and interventions that positively impact the person's functioning and well-being, both immediately and with long-term practice. Mindfulness-based interventions (MBI) have demonstrated promise in the treatment of varying physical, psychiatric, and substance use disorders (Baer, 2003; Heppner & Shirk, 2018).

There is growing evidence that MBI may be effective in the treatment of problem gambling (Chen et al., 2014; de Lisle et al., 2012; Maynard et al., 2018). There is less research exploring effectiveness of MBI among U.S. military veterans despite evidence indicating that this population are at increased risk for developing GD in their lifetime (Etuk et al., 2020), which often co-occurs with high rates of psychopathology (e.g., SUDs, PTSD, depression; Shirk et al., 2018). Addiction treatment tailored for U.S. military veterans must therefore address the multi-morbidity often found in U.S. veterans with addiction issues (Bhalla & Rosenheck, 2018). The present case series investigates whether a single addiction-focused MBI, MBRP, might serve as one approach to treat GD among U.S. military veterans–a population who have reported an interest in mindfulness-based interventions as a treatment option (Goldberg et al., 2020).

MBRP has demonstrated effectiveness in supporting SUD recovery (Bowen et al., 2009; Bowen, Witkiewitz, et al., 2014; Grant et al., 2017; Li et al., 2017). MBRP is a treatment approach combining aspects of relapse prevention, Mindfulness-Based Stress Reduction, and Mindfulness-Based Cognitive Therapy for depression (Bowen et al., 2009). In the context of MBRP, the act of being mindful is commonly described as paying attention to the present moment with purpose and without judgment (Kabat-Zinn, 2003). In the treatment of addiction, mindfulness practice intends to bring awareness to the experience of cravings nonjudgmentally and without reacting to them (Witkiewitz & Bowen, 2010). In contrast, cognitive-behavioral approaches utilize cognitive interventions of restructuring and reframing thoughts related to cravings and urges, but cravings can be complex, stemming from more than cognitive processes (Skinner & Aubin, 2010). In response, MBRP was created to integrate cognitive-behavioral skills training and mindfulness meditation for treating addiction (Bowen, Chawla, et al., 2014).

There is a growing body of research exhibiting empirical support for MBRP for substance use recovery (Sancho et al., 2018). For instance, the results from the first randomized-control trial evaluating the efficacy of MBRP as a treatment for SUDs revealed a reduction in days using substances and the magnitude of cravings, as well as an increase in acceptance and awareness compared to treatment as usual (Bowen et al., 2009). Further, Bowen, Witkiewitz, et al. (2014) assessed the long-term effectiveness of MBRP in a 12-month follow-up period and found that individuals in MBRP had significantly fewer days of substance use and drinking compared to relapse prevention and treatment as usual. Meta-analyses examining mindfulness treatment for substance use noted that mindfulness treatments were effective in decreasing substance use days, the intensity of cravings, and stress (Grant et al., 2017; Li et al., 2017).

Neurobiologically proposed areas targeted by MBRP include, but are not limited to the amygdala, the anterior cingulate cortex, the ventral striatum, and the prefrontal cortex (Witkiewitz, Lustyk, et al., 2013). These brain regions play a substantial role in developing and maintaining SUD (Koob & Volkow, 2010, 2016). SUD and GD share clinical features and presentation (Leeman & Potenza, 2012), and there is evidence that the same brain areas play a role in both addictive behaviors (Potenza, 2008). Therefore, given the two disorders’ clinical and neurobiological overlap, MBRP’s exercises should show similar benefits for those struggling with GD. Due to the similarities between GD and SUD (Leeman & Potenza, 2012), we posit that MBRP could be an effective treatment for GD among U.S. military veterans given previous findings on MBI more broadly (see Goldberg et al., 2020 for details).

Overall, the research mentioned above indicates that there are current gaps in understanding treatment approaches for GD. There is evidence suggesting that MBRP can reduce cravings and drug use in SUD, which suggests that MBRP could have positive treatment effects for other addictive behaviors (Kraus et al., 2016; Leeman & Potenza, 2012). Therefore, we expect similar benefit for GD. Specifically, we expect to see less engagement in GD behavior engagement, decreased cravings, and less impulsivity. In addition, this case series explores whether MBRP might improve a patient’s functioning more globally. No studies have assessed MRBP as a treatment for GD. Therefore, we offer this case series to illustrate the utility of MBRP as a treatment for GD among a sample of three U.S. military veterans.

2. Case Introduction

The participants for this study were U.S. military veterans engaged in outpatient mental health care in the Behavioral Addictions Clinic at a Department of Veterans Affairs hospital in the northeast United States. The Behavioral Addictions Clinic is an integrated outpatient recovery-oriented clinic that began in 2016. The clinic provides a range of services for veterans and active duty military personnel, including evaluation, individual and group psychotherapy, medication management sessions, in addition to training and consultation services for other health care providers. The clinic staff consists of a licensed clinical psychologist, research psychologist, social worker, nurse practitioner, and board-certified addiction psychiatrist. The clinic also serves as a training clinic for trainees in family medicine, psychology, and social work disciplines. All trainees received weekly clinical supervision by a licensed psychologist (SWK) who supervised the MBRP group. All patients completed a standardized clinical intake where they were assessed, diagnosed, and referred for appropriate treatment offered within the clinic. Data reported in the current case series also includes diagnosis taken from the initial intake appointment.

Among veterans and active duty service members treated in the clinic, almost 95% of the patients are men, ranging in age from mid-20s to mid-70s, with the average person seen being in their 50s. The behavioral addiction issues referred for treatment to the Behavioral Addictions Clinic are GD or problem gambling, compulsive sexual behavior disorder, binge eating, and problems with shopping, videogaming, and overuse of the internet. GD is one of the behaviors most frequently addressed within the clinic. At the time of referral, veterans are typically in significant distress from these behavioral addictions and have suffered significant negative consequences in their lives, including impaired interpersonal relationships, homelessness, and unemployment.

3. Presenting Complaints

Three veterans in this case series identified problems in their lives that resulted from GD and expressed that the experience of stigma and shame made it difficult to initially seek treatment in the Behavioral Addictions Clinic. When engaged in the MBRP group treatment in the clinic, veterans were provided a set of assessment measures at the initial and final group meetings. Within the assessment measures, veterans were asked questions regarding their engagement in the problematic behavior, intensity of urges, capability to handle urges, intensity of craving, frequency of craving, length of craving, and frequency of craving.

4. History

The three veterans participated in the MBRP group to address their gambling problems. First, Mr. A was a 57-year-old Black/African-American heterosexual, cisgender male who served in the Army during the post-Vietnam era. He was single, never married, obtained a high school education, and was employed full time but homeless. He reported first experiencing problems stemming from gambling at 22 years-old and has gambled “on and off” since. In addition to GD, Mr. A had an active diagnosis of PTSD and a history of polysubstance use, including cocaine, alcohol, and cannabis. During his engagement with the MBRP group, Mr. A maintained abstinence from substances and indicated that his gambling behavior increased while his substance use recovery improved.

The second participant, Mr. B, was a 52-year-old Latinx/Hispanic heterosexual, cisgender male who served in the Army during the Persian Gulf War. He was divorced, obtained a high school education, was unemployed, had stable housing, and lived alone. He reported first gambling during his adolescent years and indicated challenges with gambling throughout his life. In addition to GD, Mr. B had an active diagnosis of bipolar disorder, generalized anxiety disorder, reported passive suicidal ideation within the last year, and a history of polysubstance use, including alcohol, cocaine, and cannabis. At the time of the MBRP group, Mr. B indicated that he had not used any substances or alcohol for a significant period.

Lastly, Mr. C was a 46-year-old White heterosexual, cisgender male who served in the Air Force during the Persian Gulf War. He was single, never married, obtained a high school education, was unemployed, had stable housing but was at risk of becoming homeless, and lived alone. He reported having challenges from gambling starting between 20 and 21 years of age. In addition to GD, Mr. C had active diagnoses of schizoaffective disorder, depression, and tobacco use disorder. Mr. C had a history of polysubstance use, including alcohol and cannabis, but indicated that he remained abstinent from all substances during his engagement with the MBRP group, excluding tobacco use.

5. Assessment

Pre- and Post-Intervention Assessments

Gambling behavior: Frequency, craving, and self-efficacy

Gambling frequency within the past month was measured using a 7-point Likert scale item ranging from 0 (None) to 21 or more times. Craving was measured in terms of both frequency and intensity. Frequency of cravings within the last 24 hr was measured by asking, “Write in the number of times you think you had craving to do this behavior during the past 24 hr.” Intensity of cravings was measured using a 5-point Likert scale ranging from 0 (None at All) to 4 (Extreme). Self-efficacy is defined as the ability to manage the craving to gamble which was measured using a 7-point Likert scale ranging from 1 (Not at All Capable) to 7 (Completely Capable).

Cognitive and affective mindfulness scale—revised (CAMS-R)

The CAM-R is a 12-item self-report inventory that assesses four aspects of mindfulness which are attention, present-focus, awareness, and acceptance/non-judgement. The CAMS-R uses a 4-point Likert scale from 1 (Rarely or Not at All) to 4 (Always Almost Always) to examine broad conceptualization in mindfulness (Feldman et al., 2007).

Short-UPPS-P impulsive behavior scale (SUPPS-P)

The SUPPS-P is a 20-item self-report inventory that measures impulsivity in five facets, including negative urgency, lack of perseverance, lack of premeditation, sensation seeking, and positive urgency. All items on the self-report measure are rated on a 4-point Likert scale from 1 (Strongly Agree) to 4 (Strongly Disagree) (Cyders et al., 2014).

Difficulties in emotion regulation scale—short form (DERS-SF)

The DERS-SF is an 18-item measure that examines emotion regulation in six facets: nonacceptance of emotional responses, difficulty engaging in goal-directed behavior, impulse control difficulties, lack of emotional awareness, limited access to emotion regulation strategies, and lack of emotional clarity (Kaufman et al., 2016).

Cognitive and physical functioning questionnaire (CPFQ)

The CPFQ is a 7-item self-report measure to assess cognitive fatigue and executive problems. Items on this measure are rated on a six-point Likert scale from 1 (Greater than Normal) to 6 (Totally Absent) (Baer et al., 2014; Fava et al., 2009).

Sheehan disability scale (SDS)

The SDS is a self-report measure that examines if there has been a disruption due to symptoms in three areas of functioning: work/school, social life, and family/home life responsibilities. The SDS rating value is between 0 (Not at All) to 10 (Extremely). Additionally, this scale asks respondents to articulate a numerical value for the number of days lost in engagement of work/school and unproductive days because one’s symptoms (Sheehan, 1983).

6. Case Conceptualization

MBRP (Bowen et al., 2009; Witkiewitz et al., 2005) was designed to target experiences of craving (Witkiewitz et al., 2013) and negative affect (Witkiewitz & Bowen, 2010) to prevent substance use relapse. Mindfulness exercises target an increase in awareness of external triggers and internal cognitive and affective processes to increase the clients’ ability to tolerate challenging cognitive, affective, and physical experiences (Bowen et al., 2009; Witkiewitz & Bowen, 2010) as well as enhance the clients’ metacognitive abilities (Teasdale et al., 2002). Mindfulness-based approaches emphasize changing the relationship with one’s thoughts and behaviors, rather than changing specific thought content. For instance, cognitive-behavioral approaches might challenge the validity of a statement that someone is “bad;” however, mindfulness approaches encourage individuals to observe thoughts nonjudgmentally to help reduce personal identification with negative automatic thoughts. This section will highlight the understanding and nature of each veteran’s gambling behavior.

Mr. A. When presenting to the Behavioral Addictions Clinic, Mr. A reported that he views his gambling behavior as compulsive and retains little to no control over his behavior. He identified “payday” as a significant trigger to engage in gambling behavior because it is difficult to control his spending on other items than gambling. Mr. A described his gambling behavior as “I like the rush, it helps me feel better about myself,” but also recognized the long-term consequences of feeling guilt and shame related to this behavior. Mr. A also shared negative consequences from gambling, including financial issues, eviction notices as he was unable to pay rent, and increased anxiety and depression. Mr. A identified treatment goals for abstinence from gambling, further highlighting his motivation to manage, control, and improve insight into his gambling behaviors.

Mr. B. During his engagement with the Behavioral Addictions Clinic, Mr. B identified that the main reason for gambling was to provide financial support for his children. Additionally, he noted experiencing guilt related to his gambling when he could not support his family and perceived that his family was ashamed of him. He indicated that his gambling difficulties relate to impulsivity and a desire for an “adrenaline rush.” Mr. B endorsed experiencing excitement when gambling and signified that feeling “bored” and receiving his paycheck were significant triggers. While Mr. B noted that he could “always pay [his] rent,” he also added he “never has money in [his] pockets.” Mr. B recognized that the benefits of changing his gambling behavior include less financial stress, more “freedom,” and improved interpersonal relationships. These perceived benefits further amplify Mr. B’s strengths related to his motivation and involvement in treatment.

Mr. C. Throughout treatment, Mr. C expressed that his gambling behavior worsened when experiencing guilt and shame, leading him to isolate socially. Mr. C also identified triggers where his gambling behavior increased when receiving income through his service connection disability and social security. Additionally, he recognized that feeling “bored” was another trigger to gamble as he experienced “fun” and “excitement” when gambling. Mr. C also noted the negative consequences of this behavior, such as increased depression and financial stress. Mr. C reported motivation to engage in treatment to stop gambling behaviors, emphasizing his hope to gain skills to manage his GD.

In this case series, all three veterans have similarities in experiencing shame and guilt related to their gambling behavior, which is evident in repetitive and intrusive negative thoughts. Consequently, a cycle establishes where guilt and shame-related thoughts and feelings then elicit gambling behaviors as an automatic action in response to these experiences. MBRP treatment promotes a curious attitude when focusing on an immediate experience to challenge the automatic process of engaging in behaviors, activities, including urges to gamble.

7. Course of Treatment and Assessment of Progress

There was no direct contact made with the participants of this study. All data variables were collected in the process of regular clinical care as part of pre- and post-measures provided by the group facilitators. The facilitators were under the supervision of a licensed clinical psychologist who met with them weekly for supervision. All participants were informed that their de-identified data would be used for program evaluation and research purposes. In addition, ethical guidelines were followed as required by the Department of Veteran Affairs. Because this a case series study, it is not considered research and is exempt from Institutional Review Board.

MBRP Intervention

MBRP was specifically created for individuals in recovery from addictive behaviors. The intervention integrates mindfulness with cognitive behavioral approaches to increase awareness, acceptance, and self-compassion for cravings and urges (Bowen, Chawla, et al., 2014; Bowen, Witkiewitz, et al., 2014). This manualized treatment program includes eight sessions incorporating mindfulness practice to bring awareness to physical, affective, and cognitive components of cravings associated with addiction. Participants identify high-risk situations for relapse, engage in exercises to elicit cravings, practice imaginal exposure and nonreactivity towards cravings, and learn skills to approach cravings with curiosity (Bowen et al., 2009; Bowen, Witkiewitz, et al., 2014).

The MBRP group was adapted in two ways for use in the Behavioral Addictions Clinic. Since behavioral addictions are not specifically addressed in the protocol Bowen et al. (2009), an introductory group session was added, providing psychoeducation about different types of behavioral addictions and what is known about the common mechanisms underpinning addiction. The goal of this session was for group members to understand why the MBRP group was selected as a transdiagnostic intervention to address addictive behaviors, and to establish a common language (e.g., behavioral addictions) to employ throughout treatment. Due to this additional session, the Behavioral Addiction Clinic’s MBRP groups have nine sessions each time the group is offered. In addition, the clinic’s therapists were cognizant that many veterans coming to treatment for their behavioral addictions carried shame, guilt, and other negative feelings about themselves, thus raising significant concerns about judgment from others if they disclosed their behavioral addiction diagnosis. Therefore, the MBRP group therapists informed group members that they would not be asked to disclose specific details about their behavioral addiction while in the group. Group members were instead encouraged to remain focused on the process of applying mindfulness exercises privately to their specific problem behavior and encouraged to talk more generally about their experiences. This approach was taken to provide a comfortable and secure environment for the group members to encourage their participation in the sessions. It had the added benefit of modeling the present moment focus that is a central component of the MBRP intervention, contrasting with other group dynamics that encourage the sharing of personal histories. See Table 1 for a summary of treatment sessions.

Table 1.

Outline of Mindfulness Based Relapse Prevention (MBRP) Adapted Protocol for U.S. Veterans with Gambling Disorder.

Session	Session description
1	Group members are welcomed, and brief introductions are made. Confidentiality and group expectations are reviewed. Group members are asked not to disclose their diagnosis. A brief introduction of mindfulness is provided. Group members practice mindfulness through an eating exercise, using their senses by holding, seeing, touching, smelling, tasting, and swallowing the food.
2	Group members are introduced more fully to mindfulness as bringing attention to one’s surroundings, bodily sensations, thoughts, and accepting the impermanence of the present moment. Psychoeducation is provided to understand how behaviors and thoughts occur automatically in the context of relapse. For homework, group members are asked to practice mindfulness with one activity in their daily life and record their experiences.
3	Group members are introduced to triggers and cravings. Group members are encouraged to think of triggers and the urge to engage in behaviors as a chain of sensations. Psychoeducation is provided around urges such as the duration of urges as temporary and fighting urges can increase the intensity to want to engage in behaviors to relieve the urge. Group members are taught urge-surfing as a coping skill to notice sensations as a wave to “ride out” the urge without surrendering to the associated behavior.
4	Group members are introduced to mindfulness through breath and the focus of how each breath can bring attention to the present moment. Psychoeducation is provided on how breathing increases awareness of sensations and decreases levels of reactivity. Group members engage in a breathing exercise called SOBER breathing. SOBER is an acronym that offers five steps to respond to triggers or stressors: stop, observe, breathe, expand, and respond.
5	Group members examine past situations where individuals engaged in behaviors where they succumbed to urges and cravings for specific behaviors. Specifically, group members are encouraged to examine how to look at urges differently and not engage in behaviors related to urges. Group members continue to utilize SOBER breathing in challenging situations and meditation to bring awareness to sound, breath, and bodily sensations.
6	Group members learn about acceptance and skillful action. Psychoeducation is provided in how acceptance can be utilized in situations that can be stressful and triggering. Additionally, acceptance can help to implement change in thoughts and behaviors regarding behavioral addictions.
7	Group members further examine how thoughts are related to relapse. Group members are taught to understand how they do not have to act on thoughts and can view them nonjudgmentally.
8	Group members examine healthy lifestyles in which they can engage.
9	Group members explore how vital social supports are and encouraged to continue practicing skills learned in the MBRP group. The elements in MBRP focus on increasing the ability to tolerate discomfort without engaging in behaviors to relieve distress temporarily.

8. Complicating Factors

U.S. veterans are known to have more complicated medical and psychiatric histories compared to their civilian counterparts (Seal et al., 2011). The psychiatric histories of the three veterans included in this case series exemplify this difference. Veterans reported PTSD, bipolar disorder, suicidal ideation, schizophrenia, and tobacco use disorder. In addition, one veteran was currently homeless and the other two were unemployed. Veterans also tend to minimize mental health concerns, possibly because of the stoic culture instilled in them through their military service training. Factors such as guilt and shame have been found to negatively impact help seeking among U.S. veterans (Gaudet et al., 2016), and as such, should be accounted for when adapting treatment protocols only tested on non-military populations.

9. Access and Barriers to Care

Despite evidence suggesting the increased likelihood of developing problem gambling and GD among the veteran population (Etuk et al., 2020), there are relatively few specialized programs for preventing and treating problem gambling. To our knowledge, there are two inpatient programs and one outpatient program within Department of Veterans Affairs hospitals across the country. This lack of access to specialized care undoubtedly plays a substantive role in the high rates of GD among U.S. veterans and poorer treatment outcomes.

In addition to minimal access to the necessary care, there are also psychological barriers to seeking treatment, perhaps the most significant being stigma. Those with problem gambling perceive that their behavior draws public stigma and is publicly viewed as a reflection of a character flaw or personal failing (Hing, Nuske, et al., 2016), which can significantly impact people from receiving care (Hing, Nuske, et al., 2016; Hing, Russell, et al., 2016). All three veterans within this case series reported feelings of shame and expressed concern about perceived stigma from others and expressed that it was a reason for not seeking treatment.

10. Follow-Up

Frequency of Gambling and Craving

Overall, the veterans in this case series reported decreases in engaging in gambling behavior within the past month by the end of the MBRP group treatment. Mr. A reported gambling 6 to 10 times during the past month at the beginning of treatment to once post-treatment. Mr. B reported gambling 21 or more times within the last month at the beginning of treatment to 3 to 5 times at the end of treatment, and Mr. C reported gambling 3 to 5 times at the beginning and no change after treatment. As depicted in Figure 1, veterans reported a decrease in the frequency of cravings to gamble, but the intensity of cravings differed across veterans. Mr. A reported a decrease (2-Moderate to 1-Slight); Mr. B reported no change (2-Moderate to 2-Moderate), and Mr. C reported an increase (2-Moderate to 3-Considerable). All veterans, however, reported increased self-efficacy in being able to handle their cravings (M = 2.3 vs M = 4.3).

Mindfulness, Impulsivity, and Emotion Dysregulation

Overall, there was an increase in reported mindfulness as measured by the CAMS-R (M = 24.3 vs. M = 28.3). The veterans also reported a decrease in impulsivity as measured by the UPPS-P Short-Form (M = 50.7 vs. M = 44.3). Lastly, the veterans reported less emotion dysregulation after treatment as measured by the DERS-SF (M = 56.3 vs. M = 49.0).

Cognitive, Physical, and Social Functioning

All three veterans reported increases in cognitive and physical functioning as measured by the CPFQ where lower scores indicate better functioning (M = 20.7 vs. M = 15.3). Mr. A and Mr. B reported no change in social life and familial and home responsibilities as measured by questions from the SDS. Mr. C, however, reported improvement in these areas.

11. Treatment Implications

The results of this case series suggest MBRP could serve as a viable, transdiagnostic treatment option for addressing GD. Three veterans were enrolled and completed the entire protocol, marking MBRP’s feasibility and acceptability as an intervention for veterans with GD. It is particularly noteworthy that the veterans completed the MBRP treatment protocol despite their reported shame, guilt, and concern about others’ judgment prior to beginning the treatment. We believe that knowing that they would not be required to explicitly discuss their gambling behaviors and the ramifications of those behaviors to the group allowed them to feel comfortable enough to participate and commit to attending all the sessions. While other clinical settings may incorporate the use of shared experience and self-disclosure as clinical tools, the Behavioral Addictions Clinic’s group guideline about self-disclosure demonstrated benefits by both levels of engagement and completion rates. This approach highlights the importance of developing stigma reduction strategies to decrease shame and guilt among individuals seeking mental health care services as a necessary step in achieving positive treatment outcomes and addressing potential treatment barriers. Despite these proximal measures of feasibility and acceptability, additional attention needs to be given in future studies to the subjective experience of the MBRP group members regarding the specific aspects of the program that they found most supportive and beneficial in their recovery from GD.

Throughout the course of MBRP treatment, two of the three veterans reported less gambling. All three veterans reported reduced frequency in cravings to gamble and greater self-efficacy in managing their cravings over time. It is important to note that although the frequency of engaging in gambling was measured, the intensity or duration of the gambling was not assessed—a limitation of the current case study, which may be of consequence. For example, it may be possible that Mr. C did not reduce his gambling frequency (e.g., the number of times he gambled), but he may have reduced the intensity or duration of his gambling (e.g., reducing from 5 to 3 hours of gambling). Unfortunately, such data was not collected, but it is recommended that future studies should include both gambling frequency and intensity.

Self-reported mindfulness, impulsivity, and emotion dysregulation improved from pre- to post-treatment. Specifically, the veterans reported greater mindfulness, less impulsivity, and less emotion dysregulation. The veterans also reported overall improved functioning. All three veterans reported apparent substantive and consistent improvement in cognitive and physical functioning. For one veteran, there was reported greater social and familial functioning after treatment. The experienced improvement in overall functioning may serve to further support the veterans’ recovery by better managing and interacting with others in their daily lives.

The veterans within this case series study reported varying active psychiatric comorbidities, including PTSD, schizophrenia, and bipolar disorder. Substance use problems are also common among U.S. veterans with GD (Etuk et al., 2020) as shown in this case series with all three veterans having a history of polysubstance use, and one veteran in this case series reported active tobacco use. Also, we found that one of three veterans reported suicidal ideation within the past year. Suicidality is a concerning pattern among veterans with GD (Ronzitti et al., 2019) and remains an important clinical consideration in treating this population. This reinforces the importance of screening for suicidality among veterans reporting problems managing their gambling.

Veterans are at an increased risk of developing GD (Etuk et al., 2020). It continues to be a chronic yet understudied problem among veterans, despite GD’s comorbidity with other psychiatric and substance use disorders among those seeking treatment (Shirk et al., 2018), and its association with suicide (Kausch, 2003; Ronzitti et al., 2019) and homelessness (Tsai & Rosenheck, 2015). Likewise, there is little empirical evidence demonstrating treatment efficacy for GD among this population which is known to have more complex psychiatric histories compared to their civilian counterparts. Mindfulness-based treatments are well-regarded by veterans (Goldberg et al., 2020), and the clinical and neurobiological similarities between SUD and GD suggest that MBRP could serve as a viable approach for GD treatment. This case series serves as the first step in demonstrating MBRP as a promising treatment option for veterans struggling with GD.

12. Recommendations to Clinicians and Students

As research continues to better elucidate GD among this high-risk population, it is important to pair the research with the development and testing of psychosocial interventions to treat GD. This case series suggests that MBRP is an acceptable and potentially efficacious intervention for the treatment of GD among veterans. Future research is needed to test this intervention in a large, well-powered randomized control trial for veterans seeking treatment for GD.

Footnotes

Acknowledgements

The findings and interpretations of the data reported in the article are the sole responsibilities of the authors and do not necessarily represent the views of the Veterans Health Administration or University of Nevada, Las Vegas.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Steven Shirk

Author Biographies

Steven D. Shirk, PhD, is a research health scientist within the VISN 1 New England Mental Illness Research Education Clinical Center and associate director of Research in the Behavioral Addictions Clinic at the VA Bedford Healthcare System. He is also an assistant professor within the Departments of Psychiatry and Population and Quantitative Health Sciences at the University of Massachusetts Medical School. His current research broadly examines the role of neurocognitive functioning in addictive behaviors with interests in emotion regulation, impulsivity, and mindfulness.

Lamisha S. Muquit, PhD, is a psychosocial rehabilitation post-doctoral fellow at the VA Bedford Healthcare System. She has been involved in research projects related to addiction, serious mental illness, and suicide risk assessment and management.

Joseph Deckro, LICSW, is a social worker within the Domiciliary, a hundred day residential treatment program, and a provider within the Behavioral Addiction Clinic at the VA Bedford Healthcare System. He is also certified as a Massachusetts Problem Gambling Specialist (MA PGS).

Patricia J. Sweeney, PsyD, is a licensed clinical psychologist and is the former director of the VA Bedford Healthcare System Behavioral Addictions Clinic where the subject matter of this article took place. Currently, Dr. Sweeney is the National director of Peer Support Services in the Department of Veterans Affairs Veterans Healthcare Administration’s Office of Mental Health and Suicide Prevention.

Shane W. Kraus, PhD, is a licensed clinical psychologist and assistant professor of Psychology at University of Nevada, Las Vegas. He has published over a 100 scholarly works on the study of psychopathology, substance use disorders, gambling disorder, and compulsive sexual behavior disorder. Dr. Kraus is the Editor-in-Chief of Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention.

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