Barriers to Gambling Treatment Among American Military Personnel: A Qualitative Study
PMCID: PMC12360973
PMID: 40274714
Abstract
Gambling disorder (GD) poses a significant public health problem, with treatment access frequently hindered by barriers. This study sought to identify the unique internal and external barriers encountered by military personnel with GD using a qualitative descriptive method. Twenty-eight United States military veterans and service members (SMs) were recruited through purposeful sampling strategies and interviewed using a semi-structured interview format. Content analysis revealed two main themes: “ Emotional Suppression in Military Culture ” reflecting military cultural norms that emphasize strength, discipline, and emotional control, which were internalized by the participants and created significant internal barriers; “ Structural Ignorance of Gambling Problems ” uncovers external barriers such as the normalization of gambling, insufficient recognition of gambling’s addictive nature within military and Veterans Affairs (VA) settings, and inadequate treatment options within the VA healthcare system. The study underscores the complex interplay between cultural norms and institutional practices and proposes policy recommendations to improve help-seeking behaviors for veterans and SMs.
Full Text
Gambling disorder (GD) is a growing public health concern worldwide, creating significant negative consequences for individuals, families, and the society at large (Abbott, 2020). It refers to a pattern of repeated betting and wagering that continues despite creating multiple problems in an individual’s life (American Psychiatric Association, 2022). The estimated lifetime prevalence of GD in the USA ranges from 0.42 to 4.0% (Black & Shaw, 2019). Notably, GD can be effectively treated with pharmacological and psychosocial interventions (Etuk et al., 2020; Pickering et al., 2020); however, accessing treatment is often hindered by internal barriers, such as denial, low motivation, fear of stigma, and shame (Barnett et al., 2021; Cernasev et al., 2021), as well as external barriers, like inadequate insurance, financial constraints, and limited access to trained professionals (Ocloo et al., 2021; Sheikh et al., 2021; Troup et al., 2021).
Recent literature focuses on the internal and external barriers that hinder access to treatment for GD (Quigley, 2022; Ribeiro et al., 2021; Stenbro et al., 2023), emphasizing the need to address these challenges in different socio-cultural contexts (Håkansson et al., 2024). Studies underscore the vulnerability of veterans and SMs to developing GD compared to the general population (Etuk et al., 2020; Levy & Tracy, 2018), in part due to veterans’ and SMs’ unique characteristics, such as suffering from higher rates of posttraumatic stress disorder (PTSD), depression, and substance use disorders (SUDs) related to their military service (Grubbs et al., 2023; Shepherd-Banigan et al., 2023; Silvestrini & Chen, 2023). Nonetheless, only a handful of studies have explored the barriers to GD treatment among veterans, with GD often being overlooked in clinical screenings (Kraus et al., 2020). Thus, our study sought to identify the unique internal and external barriers encountered by U.S. military personnel living with GD.
Existing literature suggests substantial internal and external barriers to accessing healthcare for various health conditions, including GD (Daugelat et al., 2023; Håkansson et al., 2024). Internal barriers refer to personal attitudes and psychological obstacles individuals face when considering seeking treatment for their health problems (Sarkar et al., 2021), including denial of an existing problem, insufficient motivation for treatment (Barnett et al., 2021), feelings of shame, and fear of social stigma (Cernasev et al., 2021). These feelings might be triggered by various external factors, such as cultural and social contexts (Schuler et al., 2015).
A growing body of literature is beginning to connect internal and external barriers to accessing treatment specifically for GD. A notable internal barrier is that individuals with GD often prefer to manage their gambling issues on their own and struggle with feelings such as denial, shame, secrecy, and fear of stigma (Quigley, 2022; Stenbro et al., 2023). The psychological impact of GD, combined with stress from debts and strained relationships, can lead to a state of denial or a belief that one can “gamble their way out” of the situation, entrenching the gambling behavior and creating a reluctance to seek help (Ribeiro et al., 2021). Feelings of hopelessness predict an escalation in gambling problems (Otis et al., 2021), and in combination with other emotions, such as shame, can further delay seeking treatment (Estévez et al., 2023, 2024). External barriers to seeking treatment for GD involve difficulties with the organization and availability of treatment, as well as societal and regulatory factors that hinder access to care. For example, access to treatment can be limited by geographical factors. Specialized services for GD may not be available in all regions, making it difficult for individuals in remote or underserved areas to access care (Håkansson et al., 2024).
Individuals with GD may experience a variety of internal and external barriers to accessing treatment. However, there has been little attention surrounding the unique experiences of veterans and SMs with accessing treatment for GD. Given that military personnel have a unique socio-cultural context relative to civilians and endorse higher rates of GD at the population-level, it is pertinent to consider the unique internal and external barriers this population may encounter when seeking services for GD (Stefanovics et al., 2023).
Studies examining military culture observe that veterans and SMs often hold values that impede help-seeking, which presents notable internal barriers to addressing mental health concerns (Randles & Finnegan, 2022; Silvestrini & Chen, 2023), including addictions (Edwards et al., 2021; Kiernan et al., 2018). For example, military culture promotes stoicism and self-reliance, prioritizing mission accomplishment over personal discomfort and labeling sickness as a sign of weakness, which ultimately discourages veterans and SMs from seeking help (Randles & Finnegan, 2022). Veterans also face unique health-related challenges, such as higher rates of morbidity, physical impairment, PTSD, depression (Shepherd-Banigan et al., 2023; Silvestrini & Chen, 2023), and SUDs (Grubbs et al., 2024). The transition to civilian life for veterans often involves several external barriers that can hinder their ability to seek help. One major challenge is often the struggle with the loss of their former structured environment and camaraderie they experienced in the military, leading to feelings of isolation and identity confusion. Navigating civilian life requires them to translate their military skills to civilian job markets, leading to underemployment and economic difficulties (Adams et al., 2021). They may also encounter logistical barriers, such as long appointment waiting times, difficulty accessing Veterans Affairs (VA) services, or being unaware of available services altogether (Silvestrini & Chen, 2023).
Despite evidence that SMs and veterans are at increased risk of experiencing GD (Etuk et al., 2020; Metcalf et al., 2022) and co-morbid psychiatric disorders (Fogle et al., 2020), few studies have addressed the barriers these populations may experience in accessing GD treatment (e.g., Kraus et al., 2020; Shirk et al., 2022). To our knowledge, no studies have qualitatively explored barriers to GD treatment in U.S. veterans and SMs, though prior work has examined challenges faced by veterans reporting issues with addictions (Champion et al., 2022). The present study poses one main research question: What are the unique internal and external barriers to GD treatment that veterans and SMs in the U.S. experience? Through this work, we seek to gain insights needed to promote practical recommendations for clinicians and policymakers and enhance the help-seeking behaviors of veterans and SMs.
A descriptive qualitative method was utilized (Sandelowski, 2010). This method, widely applied in healthcare settings, is also employed regularly in mental health research because it offers rich and direct accounts of individuals’ perceptions and experiences of a given phenomenon or event. Specifically, it is characterized by minimal interpretation, and therefore, it remains closely aligned with the data throughout the analytical process (Colorafi & Evans, 2016). Due to the straightforward nature of this method, it is particularly suitable for capturing precise accounts of perceptions and experiences of phenomena, resulting in findings that are comprehensible to vulnerable populations and clinical practitioners (Sullivan-Bolyai et al., 2005). Hence, we believe the descriptive qualitative method was most suitable for the current study.
Semi-structured interviews were conducted with 28 U.S. military veterans and SMs. A combination of two purposeful sampling strategies (Patton, 2015) were employed: criterion-based case selection and maximum variation sampling. The eligibility criteria required participants to be either currently serving in the U.S. Armed Forces or have previously served but had been formally discharged (veterans) from the military, be at least 18 years of age, and endorse at least four criteria of the DSM-5 GD diagnosis (American Psychiatric Association, 2013).
Upon obtaining informed consent, the interviews occurred over confidential Zoom meetings, which were recorded and transcribed verbatim. Using a semi-structured interview schedule to elicit rich data (Bearman, 2019), participants were asked broad questions to explore their experiences relating to barriers to treatment for GD (e.g., “Please describe the barriers you encounter while seeking treatment for your gambling problem”). Participants were compensated for their time with $75 gift cards. The interviews were conducted from August 2023 to August 2024. The study was approved by the Institutional Review Board of XX. Overall, as can be seen in Table 1, a diverse sample of 28 participants was obtained, including 24 veterans and 4 SMs, with an average age of 46.5 years (ranging from 27 to 73). All names used in the paper are pseudonyms.
Content analysis is recommended for data analysis when using the descriptive qualitative method (Sandelowski, 2010). In the current study, we used directed (deductive) content analysis—using a pre-existing coding system based on the literature representing various internal and external barriers to treatment (e.g., shame, accessibility), and conventional (inductive) content analysis based on codes and categories that emerge from the data (Hsieh & Shannon, 2005; Patton, 2014). Directed content analysis is applied when there is an established theory that could be further elaborated in a different context, while conventional or inductive content analysis is utilized when there is limited existing research (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). For the current study, we found both approaches suitable. Given the existing knowledge surrounding barriers to treatment for addictions, directed content analysis was appropriate for coding the initial interviews. However, less is known about the unique barriers encountered by U.S. military veterans and SMs seeking treatment for GD, which necessitated the use of conventional content analysis as new codes and categories emerged from the data. According to Sandelowski (2010), who initiated the descriptive qualitative approach, when researchers decide to start the analysis by implementing pre-existing coding systems, such coding systems are often modified or even completely replaced during the analysis process because new codes have emerged from the data.
Specifically, after reading the interviews, we chose five interviews of participants from diverse backgrounds and military experiences and analyzed them using the coding system. At the same time, while reading the interviews, we also labeled new codes reflecting unique aspects of veterans’ and SMs’ experiences that were not included in our initial coding system. After five interviews, we amended the initial coding system, and the additional 23 interviews were analyzed accordingly. Again, segments that did not appear in the amended coding system were then labeled. As can be seen, the analysis began by using directed content analysis and later transitioned to conventional content analysis (Armat et al., 2018). At the end of this process, 57 codes were generated. All data within each code were reviewed, discussed, and refined by the research team. Codes were merged and conceptualized into nine categories according to differences and similarities in the content and then consolidated into five categories (Hsieh & Shannon, 2005). In the last stage, these categories were formulated and grouped into two final main themes to encapsulate the comprehensive meaning derived from the codes. Detailed information on themes, categories, and codes is provided in Table 2.
By adhering to Elo et al. (2014) criteria for trustworthiness, the following steps were conducted: Credibility was achieved through thorough familiarization with the data, involving repeated readings of the interview transcripts, with field notes added to the transcriptions after the interviews. Team collaboration played a significant role in enhancing the dependability and confirmability of the findings. Regular team meetings facilitated reflection on the codes, categories, and themes, ensuring consistency and reliability. MAXQDA software was used to manage and organize the data efficiently, facilitating the systematic handling of codes, memos, categories, and themes, thereby supporting the transferability and transparency of the results. Finally, to ensure that the findings consistently capture participants’ viewpoints, the authors present an abundance of participant quotations.
This study uncovered significant internal and external challenges to seeking help for GD within both the U.S. military and VA contexts, illustrating how environmental factors and individual experiences are intertwined and shape access to GD treatment (Hutchison, 2018). In the current study, internal barriers to accessing GD treatment were rooted in the military culture, largely stemming from the internalization of the socio-cultural context by veterans and SMs through their socialization to the military culture. Our first theme, Emotional Suppression in Military Culture, pertains to internalization process of military culture and largely corresponds with the influential work on emotional regulation written by Arlie Hochschild (1983), who argued that “Feeling Rules” are deeply embedded social and cultural guidelines. This internalization functions as a form of “deep etiquette,” guiding emotional responses and making them appear natural despite being socially constructed. For instance, while interviewees in the present study were able to describe their perceptions of GD as a weakness, they often struggled to recognize that this view is socially embedded within them. This finding aligns with other research demonstrating that mental health problems among military personnel are consistently described as a weakness preventing help seeking (Sharp et al., 2015; Silvestrini & Chen, 2023).
As for external barriers, the normalization of gambling, lack of structural awareness of gambling as addictive, inadequate screening methods to identify individuals with GD, and the lack of tailored treatment options for GD in the VA healthcare system were all identified as notable barriers to accessing GD treatment. Weber (1978) foundational analysis of organizations explains why military institutions necessitate higher degrees of discipline, order, and rational thought to fulfill their role in national defense and the organization of violence on behalf of the state. This observation distinguishes them from other institutions, such as law enforcement, which primarily regulates civilian affairs at the local level (Nuciari, 2018); this also extends to healthcare systems, which emphasize patient care and public health, requiring adaptability and responsiveness to diverse medical needs (Soeters, 2018). Ample studies have documented how strongly military culture stigmatizes mental health struggles, as they challenge the fundamental bureaucratic principles of rationality, objective decision-making, control, and efficiency (e.g., Mansoor & Murray, 2019; Reed, 2015). Moreover, Weber’s organizational analysis has formed a foundation for understanding how institutional culture constructs norms, and acts as a mechanism of external control shaping individual actions (Kunda, 1995).
Furthermore, Weick and Sutcliffe’s (2011) work employs the concepts of “mindlessness” and “normalization” to explain how both individual and structural levels of awareness can be compromised in organizations. They argued that when individuals or groups in institutional settings rely on established routines and past experiences, these routines and normalized activities become “mindless,” leading them to overlook or fail to question underlying assumptions. On a structural level, “normalization” involves the organizational tendency to categorize events and activities into familiar patterns, often overlooking unique or unusual elements, thus obscuring the recognition of emerging threats that do not fit established expectations, leading to inadequate structural responses. Hence, it is unsurprising that many SMs mindlessly gambled without recognizing its associated risks. At the structural level, the military’s bureaucratic tendency to operate according to known patterns probably inhibited it from recognizing risks associated with gambling and adapting to them. Such gaps in organizational knowledge may create profound implications for individuals and organizations, for example, the widespread gambling practices without the awareness of their harmful consequences among SMs and the organizational failure to provide adequate support and treatment for those affected by GD.
Notably, a recent meta-review concluded that given the reported low prevalence of GD and subclinical gambling problems among the SM population, routine screening may be unfeasible (Segura et al., 2024). The authors argued that screening efforts should instead be focused on higher-prevalence subpopulations (SMs already identified with substance use or mental health problems), concluding that routine screening of all SMs for GD is unwarranted. Conversely, other authors have suggested that the DoD should proactively screen all SMs for GD to protect the operational readiness, financial stability, mental health, and overall security of its personnel (Smith et al., 2024). We expect the debate around screening SMs for GD will continue, however, the current study uniquely speaks to the specific internal and external barriers that exist for SMs and veterans with GD, shedding some insights on where potential policy changes could be made within the U.S. Armed Forces.
This study has several limitations. First, the sample included only four SMs (age range-27–37) who were considerably younger than the veteran sample (age range = 29–72). We found that the lived experiences of SMs and veterans varied widely, and the large age difference between them also reflected different eras of military service. Moreover, the difference in age between SMs and veterans should also note that many of the SMs grew up with access to various forms of digital technology, reflecting a possible difference in their increased familiarity with using internet-based technologies to facilitate help seeking. Although the U.S. Armed Forces has made progress with routine screening for mental health disorders among SMs, current barriers (e.g., stigma, career concerns) still remain (Hom et al., 2017). The degree of comfort SMs or veterans would experience if utilizing an internet-based treatment specific to GD remains unexplored, though we posit that such a resource could potentially reduce barriers around seeking helping.
Sections
"[{\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR1\", \"CR4\", \"CR8\", \"CR21\", \"CR42\", \"CR6\", \"CR10\", \"CR39\", \"CR52\", \"CR61\"], \"section\": \"Introduction\", \"text\": \"Gambling disorder (GD) is a growing public health concern worldwide, creating significant negative consequences for individuals, families, and the society at large (Abbott, 2020). It refers to a pattern of repeated betting and wagering that continues despite creating multiple problems in an individual\\u2019s life (American Psychiatric Association, 2022). The estimated lifetime prevalence of GD in the USA ranges from 0.42 to 4.0% (Black & Shaw, 2019). Notably, GD can be effectively treated with pharmacological and psychosocial interventions (Etuk et al., 2020; Pickering et al., 2020); however, accessing treatment is often hindered by internal barriers, such as denial, low motivation, fear of stigma, and shame (Barnett et al., 2021; Cernasev et al., 2021), as well as external barriers, like inadequate insurance, financial constraints, and limited access to trained professionals (Ocloo et al., 2021; Sheikh et al., 2021; Troup et al., 2021).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR43\", \"CR46\", \"CR59\", \"CR26\", \"CR21\", \"CR35\", \"CR24\", \"CR53\", \"CR55\", \"CR33\"], \"section\": \"Introduction\", \"text\": \"Recent literature focuses on the internal and external barriers that hinder access to treatment for GD (Quigley, 2022; Ribeiro et al., 2021; Stenbro et al., 2023), emphasizing the need to address these challenges in different socio-cultural contexts (H\\u00e5kansson et al., 2024). Studies underscore the vulnerability of veterans and SMs to developing GD compared to the general population (Etuk et al., 2020; Levy & Tracy, 2018), in part due to veterans\\u2019 and SMs\\u2019 unique characteristics, such as suffering from higher rates of posttraumatic stress disorder (PTSD), depression, and substance use disorders (SUDs) related to their military service (Grubbs et al., 2023; Shepherd-Banigan et al., 2023; Silvestrini & Chen, 2023). Nonetheless, only a handful of studies have explored the barriers to GD treatment among veterans, with GD often being overlooked in clinical screenings (Kraus et al., 2020). Thus, our study sought to identify the unique internal and external barriers encountered by U.S. military personnel living with GD.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR14\", \"CR26\", \"CR48\", \"CR6\", \"CR10\", \"CR49\"], \"section\": \"Internal and External Barriers to Help-Seeking for Gambling Disorder\", \"text\": \"Existing literature suggests substantial internal and external barriers to accessing healthcare for various health conditions, including GD (Daugelat et al., 2023; H\\u00e5kansson et al., 2024). Internal barriers refer to personal attitudes and psychological obstacles individuals face when considering seeking treatment for their health problems (Sarkar et al., 2021), including denial of an existing problem, insufficient motivation for treatment (Barnett et al., 2021), feelings of shame, and fear of social stigma (Cernasev et al., 2021). These feelings might be triggered by various external factors, such as cultural and social contexts (Schuler et al., 2015).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR43\", \"CR59\", \"CR46\", \"CR40\", \"CR19\", \"CR20\", \"CR26\"], \"section\": \"Internal and External Barriers to Help-Seeking for Gambling Disorder\", \"text\": \"A growing body of literature is beginning to connect internal and external barriers to accessing treatment specifically for GD. A notable internal barrier is that individuals with GD often prefer to manage their gambling issues on their own and struggle with feelings such as denial, shame, secrecy, and fear of stigma (Quigley, 2022; Stenbro et al., 2023). The psychological impact of GD, combined with stress from debts and strained relationships, can lead to a state of denial or a belief that one can \\u201cgamble their way out\\u201d of the situation, entrenching the gambling behavior and creating a reluctance to seek help (Ribeiro et al., 2021). Feelings of hopelessness predict an escalation in gambling problems (Otis et al., 2021), and in combination with other emotions, such as shame, can further delay seeking treatment (Est\\u00e9vez et al., 2023, 2024). External barriers to seeking treatment for GD involve difficulties with the organization and availability of treatment, as well as societal and regulatory factors that hinder access to care. For example, access to treatment can be limited by geographical factors. Specialized services for GD may not be available in all regions, making it difficult for individuals in remote or underserved areas to access care (H\\u00e5kansson et al., 2024).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR58\"], \"section\": \"Internal and External Barriers to Help-Seeking for Gambling Disorder\", \"text\": \"Individuals with GD may experience a variety of internal and external barriers to accessing treatment. However, there has been little attention surrounding the unique experiences of veterans and SMs with accessing treatment for GD. Given that military personnel have a unique socio-cultural context relative to civilians and endorse higher rates of GD at the population-level, it is pertinent to consider the unique internal and external barriers this population may encounter when seeking services for GD (Stefanovics et al., 2023).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR44\", \"CR55\", \"CR16\", \"CR32\", \"CR44\", \"CR53\", \"CR55\", \"CR25\", \"CR2\", \"CR55\"], \"section\": \"The Socio-Cultural Context of US Military Veterans and Service Members\", \"text\": \"Studies examining military culture observe that veterans and SMs often hold values that impede help-seeking, which presents notable internal barriers to addressing mental health concerns (Randles & Finnegan, 2022; Silvestrini & Chen, 2023), including addictions (Edwards et al., 2021; Kiernan et al., 2018). For example, military culture promotes stoicism and self-reliance, prioritizing mission accomplishment over personal discomfort and labeling sickness as a sign of weakness, which ultimately discourages veterans and SMs from seeking help (Randles & Finnegan, 2022). Veterans also face unique health-related challenges, such as higher rates of morbidity, physical impairment, PTSD, depression (Shepherd-Banigan et al., 2023; Silvestrini & Chen, 2023), and SUDs (Grubbs et al., 2024). The transition to civilian life for veterans often involves several external barriers that can hinder their ability to seek help. One major challenge is often the struggle with the loss of their former structured environment and camaraderie they experienced in the military, leading to feelings of isolation and identity confusion. Navigating civilian life requires them to translate their military skills to civilian job markets, leading to underemployment and economic difficulties (Adams et al., 2021). They may also encounter logistical barriers, such as long appointment waiting times, difficulty accessing Veterans Affairs (VA) services, or being unaware of available services altogether (Silvestrini & Chen, 2023).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR21\", \"CR37\", \"CR23\", \"CR33\", \"CR54\", \"CR11\"], \"section\": \"The Socio-Cultural Context of US Military Veterans and Service Members\", \"text\": \"Despite evidence that SMs and veterans are at increased risk of experiencing GD (Etuk et al., 2020; Metcalf et al., 2022) and co-morbid psychiatric disorders (Fogle et al., 2020), few studies have addressed the barriers these populations may experience in accessing GD treatment (e.g., Kraus et al., 2020; Shirk et al., 2022). To our knowledge, no studies have qualitatively explored barriers to GD treatment in U.S. veterans and SMs, though prior work has examined challenges faced by veterans reporting issues with addictions (Champion et al., 2022). The present study poses one main research question: What are the unique internal and external barriers to GD treatment that veterans and SMs in the U.S. experience? Through this work, we seek to gain insights needed to promote practical recommendations for clinicians and policymakers and enhance the help-seeking behaviors of veterans and SMs.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR47\", \"CR13\", \"CR60\"], \"section\": \"The Methodological Approach\", \"text\": \"A descriptive qualitative method was utilized (Sandelowski, 2010). This method, widely applied in healthcare settings, is also employed regularly in mental health research because it offers rich and direct accounts of individuals\\u2019 perceptions and experiences of a given phenomenon or event. Specifically, it is characterized by minimal interpretation, and therefore, it remains closely aligned with the data throughout the analytical process (Colorafi & Evans, 2016). Due to the straightforward nature of this method, it is particularly suitable for capturing precise accounts of perceptions and experiences of phenomena, resulting in findings that are comprehensible to vulnerable populations and clinical practitioners (Sullivan-Bolyai et al., 2005). Hence, we believe the descriptive qualitative method was most suitable for the current study.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR41\", \"CR3\"], \"section\": \"Procedure and Participants\", \"text\": \"Semi-structured interviews were conducted with 28 U.S. military veterans and SMs. A combination of two purposeful sampling strategies (Patton, 2015) were employed: criterion-based case selection and maximum variation sampling. The eligibility criteria required participants to be either currently serving in the U.S. Armed Forces or have previously served but had been formally discharged (veterans) from the military, be at least 18 years of age, and endorse at least four criteria of the DSM-5 GD diagnosis (American Psychiatric Association, 2013).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR7\", \"Tab1\"], \"section\": \"Procedure and Participants\", \"text\": \"Upon obtaining informed consent, the interviews occurred over confidential Zoom meetings, which were recorded and transcribed verbatim. Using a semi-structured interview schedule to elicit rich data (Bearman, 2019), participants were asked broad questions to explore their experiences relating to barriers to treatment for GD (e.g., \\u201cPlease describe the barriers you encounter while seeking treatment for your gambling problem\\u201d). Participants were compensated for their time with $75 gift cards. The interviews were conducted from August 2023 to August 2024. The study was approved by the Institutional Review Board of XX. Overall, as can be seen in Table\\u00a01, a diverse sample of 28 participants was obtained, including 24 veterans and 4 SMs, with an average age of 46.5 years (ranging from 27 to 73). All names used in the paper are pseudonyms.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR47\", \"CR29\", \"CR41\", \"CR18\", \"CR29\", \"CR47\"], \"section\": \"Data Analysis\", \"text\": \"Content analysis is recommended for data analysis when using the descriptive qualitative method (Sandelowski, 2010). In the current study, we used directed (deductive) content analysis\\u2014using a pre-existing coding system based on the literature representing various internal and external barriers to treatment (e.g., shame, accessibility), and conventional (inductive) content analysis based on codes and categories that emerge from the data (Hsieh & Shannon, 2005; Patton, 2014). Directed content analysis is applied when there is an established theory that could be further elaborated in a different context, while conventional or inductive content analysis is utilized when there is limited existing research (Elo & Kyng\\u00e4s, 2008; Hsieh & Shannon, 2005). For the current study, we found both approaches suitable. Given the existing knowledge surrounding barriers to treatment for addictions, directed content analysis was appropriate for coding the initial interviews. However, less is known about the unique barriers encountered by U.S. military veterans and SMs seeking treatment for GD, which necessitated the use of conventional content analysis as new codes and categories emerged from the data. According to Sandelowski (2010), who initiated the descriptive qualitative approach, when researchers decide to start the analysis by implementing pre-existing coding systems, such coding systems are often modified or even completely replaced during the analysis process because new codes have emerged from the data.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR5\", \"CR29\", \"Tab2\"], \"section\": \"Data Analysis\", \"text\": \"Specifically, after reading the interviews, we chose five interviews of participants from diverse backgrounds and military experiences and analyzed them using the coding system. At the same time, while reading the interviews, we also labeled new codes reflecting unique aspects of veterans\\u2019 and SMs\\u2019 experiences that were not included in our initial coding system. After five interviews, we amended\\u00a0the initial coding system, and the additional 23 interviews were analyzed accordingly. Again, segments that did not appear in the amended coding system were then labeled. As can be seen, the analysis began by using directed content analysis and later transitioned to conventional content analysis (Armat et al., 2018). At the end of this process, 57 codes were generated. All data within each code were reviewed, discussed, and refined by the research team. Codes were merged and conceptualized into nine categories according to differences and similarities in the content and then consolidated into five categories (Hsieh & Shannon, 2005). In the last stage, these categories were formulated and grouped into two final main themes to encapsulate the comprehensive meaning derived from the codes. Detailed information on themes, categories, and codes is provided in Table\\u00a02.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR17\"], \"section\": \"Trustworthiness of the Analysis\", \"text\": \"By adhering to Elo et al. (2014) criteria for trustworthiness, the following steps were conducted: Credibility was achieved through thorough familiarization with the data, involving repeated readings of the interview transcripts, with field notes added to the transcriptions after the interviews. Team collaboration played a significant role in enhancing the dependability and confirmability of the findings. Regular team meetings facilitated reflection on the codes, categories, and themes, ensuring consistency and reliability. MAXQDA software was used to manage and organize the data efficiently, facilitating the systematic handling of codes, memos, categories, and themes, thereby supporting the transferability and transparency of the results. Finally, to ensure that the findings consistently capture participants\\u2019 viewpoints, the authors present an abundance of participant quotations.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR30\", \"CR27\", \"CR51\", \"CR55\"], \"section\": \"Discussion\", \"text\": \"This study uncovered significant internal and external challenges to seeking help for GD within both the U.S. military and VA contexts, illustrating how environmental factors and individual experiences are intertwined and shape access to GD treatment (Hutchison, 2018). In the current study, internal barriers to accessing GD treatment were rooted in the military culture, largely stemming from the internalization of the socio-cultural context by veterans and SMs through their socialization to the military culture. Our first theme, Emotional Suppression in Military Culture, pertains to internalization process of military culture and largely corresponds with the influential work on emotional regulation written by Arlie Hochschild (1983), who argued that \\u201cFeeling Rules\\u201d are deeply embedded social and cultural guidelines. This internalization functions as a form of \\u201cdeep etiquette,\\u201d guiding emotional responses and making them appear natural despite being socially constructed. For instance, while interviewees in the present study were able to describe their perceptions of GD as a weakness, they often struggled to recognize that this view is socially embedded within them. This finding aligns with other research demonstrating that mental health problems among military personnel are consistently described as a weakness preventing help seeking (Sharp et al., 2015; Silvestrini & Chen, 2023).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR62\", \"CR38\", \"CR57\", \"CR36\", \"CR45\", \"CR34\"], \"section\": \"Discussion\", \"text\": \"As for external barriers, the normalization of gambling, lack of structural awareness of gambling as addictive, inadequate screening methods to identify individuals with GD, and the lack of tailored treatment options for GD in the VA healthcare system were all identified as notable barriers to accessing GD treatment. Weber (1978) foundational analysis of organizations explains why military institutions necessitate higher degrees of discipline, order, and rational thought to fulfill their role in national defense and the organization of violence on behalf of the state. This observation distinguishes them from other institutions, such as law enforcement, which primarily regulates civilian affairs at the local level (Nuciari, 2018); this also extends to healthcare systems, which emphasize patient care and public health, requiring adaptability and responsiveness to diverse medical needs (Soeters, 2018). Ample studies have documented how strongly military culture stigmatizes mental health struggles, as they challenge the fundamental bureaucratic principles of rationality, objective decision-making, control, and efficiency (e.g., Mansoor & Murray, 2019; Reed, 2015). Moreover, Weber\\u2019s organizational analysis has formed a foundation for understanding how institutional culture constructs norms, and acts as a mechanism of external control shaping individual actions (Kunda, 1995).\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR63\"], \"section\": \"Discussion\", \"text\": \"Furthermore, Weick and Sutcliffe\\u2019s (2011) work employs the concepts of \\u201cmindlessness\\u201d and \\u201cnormalization\\u201d to explain how both individual and structural levels of awareness can be compromised in organizations. They argued that when individuals or groups in institutional settings rely on established routines and past experiences, these routines and normalized activities become \\u201cmindless,\\u201d leading them to overlook or fail to question underlying assumptions. On a structural level, \\u201cnormalization\\u201d involves the organizational tendency to categorize events and activities into familiar patterns, often overlooking unique or unusual elements, thus obscuring the recognition of emerging threats that do not fit established expectations, leading to inadequate structural responses. Hence, it is unsurprising that many SMs mindlessly gambled without recognizing its associated risks. At the structural level, the military\\u2019s bureaucratic tendency to operate according to known patterns probably inhibited it from recognizing risks associated with gambling and adapting to them. Such gaps in organizational knowledge may create profound implications for individuals and organizations, for example, the widespread gambling practices without the awareness of their harmful consequences among SMs and the organizational failure to provide adequate support and treatment for those affected by GD.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR50\", \"CR56\"], \"section\": \"Policy Recommendations\", \"text\": \"Notably, a recent meta-review concluded that given the reported low prevalence of GD and subclinical gambling problems among the SM population, routine screening may be unfeasible (Segura et al., 2024). The authors argued that screening efforts should instead be focused on higher-prevalence subpopulations (SMs already identified with substance use or mental health problems), concluding that routine screening of all SMs for GD is unwarranted. Conversely, other authors have suggested that the DoD should proactively screen all SMs for GD to protect the operational readiness, financial stability, mental health, and overall security of its personnel (Smith et al., 2024). We expect the debate around screening SMs for GD will continue, however, the current study uniquely speaks to the specific internal and external barriers that exist for SMs and veterans with GD, shedding some insights on where potential policy changes could be made within the U.S. Armed Forces.\"}, {\"pmc\": \"PMC12360973\", \"pmid\": \"40274714\", \"reference_ids\": [\"CR28\"], \"section\": \"Limitations and Future Research\", \"text\": \"This study has several limitations. First, the sample included only four SMs (age range-27\\u201337) who were considerably younger than the veteran sample (age range\\u2009=\\u200929\\u201372). We found that the lived experiences of SMs and veterans varied widely, and the large age difference between them also reflected different eras of military service. Moreover, the difference in age between SMs and veterans should also note that many of the SMs grew up with access to various forms of digital technology, reflecting a possible difference in their increased familiarity with using internet-based technologies to facilitate help seeking. Although the U.S. Armed Forces has made progress with routine screening for mental health disorders among SMs, current barriers (e.g., stigma, career concerns) still remain (Hom et al., 2017). The degree of comfort SMs or veterans would experience if utilizing an internet-based treatment specific to GD remains unexplored, though we posit that such a resource could potentially reduce barriers around seeking helping.\"}]"
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