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Steal That Look: Ariana Grande
Because who wouldn't want to look that perfect?
Steal That Look: Ariana Grande
Because who wouldn't want to look that perfect?
Celebrate National Pie Day with these easy and delicious recipes!
5 Reasons Spiders Aren't That Scary
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Cute Overload: Carrie Underwood and Puppies
Are you ready to love country sweetheart Carrie Underwood more than you already do? If not, don't read any further. You've been warned!


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New Methods in the Classical Economics of Uncertainty: Comparing Risks
In addition to showing the connection between parallel contingent and noncontingent risk comparison problems, we articulate a method for solving both kinds of problems using the "basis" approach. The basis approach has often been used implicitly, but we argue that there is value to making its use explicit, particularly in indicating which new, previously unsolved problems can readily be solved by the basis approach and which cannot.Download Info
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Paper provided by Toulouse - GREMAQ in its series Papers with number 96.412.Length: 20 pages
Date of creation: 1996
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Handle: RePEc:fth:gremaq:96.412
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Keywords: ECONOMETRICS; UNCERTAINTY; RISK;Find related papers by JEL classification:
- C10 - Mathematical and Quantitative Methods - - Econometric and Statistical Methods and Methodology: General - - - General
- C19 - Mathematical and Quantitative Methods - - Econometric and Statistical Methods and Methodology: General - - - Other
- D80 - Microeconomics - - Information, Knowledge, and Uncertainty - - - General
- D81 - Microeconomics - - Information, Knowledge, and Uncertainty - - - Criteria for Decision-Making under Risk and Uncertainty
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Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.Cited by:
- Gollier, Christian, 2005.
"Optimal Illusions and Decisions under Risk,"
IDEI Working Papers
340, Institut d'Économie Industrielle (IDEI), Toulouse.
- Christian Gollier, 2005. "Optimal Illusions and Decisions under Risk," CESifo Working Paper Series 1382, CESifo Group Munich.
- Jouini, Elyès & Marin, Jean-Michel & Napp, Clotilde, 2010.
"Discounting and divergence of opinion,"
Journal of Economic Theory,
Elsevier, vol. 145(2), pages 830-859, March.
- Elyès Jouini & Jean-Michel Marin & Clotilde Napp, 2010. "Discounting and Divergence of Opinion," Post-Print halshs-00176636, HAL.
- Jordi Caballé & Joan Esteban, 2002.
"Stochastic dominance and absolute risk aversion,"
Economics Working Papers
643, Department of Economics and Business, Universitat Pompeu Fabra.
- Jordi Caballe & Joan Esteban, 2007. "Stochastic Dominance and Absolute Risk Aversion," Social Choice and Welfare, Springer, vol. 28(1), pages 89-110, January.
- Jordi Caballé & Joan Esteban, 2003. "Stochastic Dominance and Absolute Risk Aversion," UFAE and IAE Working Papers 602.03, Unitat de Fonaments de l'Anàlisi Econòmica (UAB) and Institut d'Anàlisi Econòmica (CSIC).
- Jordi Caballé & Joan Esteban, 2003. "Stochastic Dominance and Absolute Risk Aversion," Working Papers 9, Barcelona Graduate School of Economics.
- Jordi Caballe & Joan Ma. Esteban, 2002. "Stochastic Dominance and Absolute Risk Aversion," UFAE and IAE Working Papers 506.02, Unitat de Fonaments de l'Anàlisi Econòmica (UAB) and Institut d'Anàlisi Econòmica (CSIC).
- Gollier, Christian, 1996. "Deductible insurance and production: A comment," Insurance: Mathematics and Economics, Elsevier, vol. 19(1), pages 55-59, December.
- Gollier, Christian & Schlesinger, Harris, 2002.
"Changes in risk and asset prices,"
Journal of Monetary Economics,
Elsevier, vol. 49(4), pages 747-760, May.
- Harris Schlesinger & Christian Gollier, 2001. "Changes in Risk and Asset Prices," CESifo Working Paper Series 443, CESifo Group Munich.
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Cheap is spelled with an A, not cheep. How can we expect our kids to get it right if the press can't.
@kes — only when you're not talking about either the the noise a bird makes or about how extravagant the government will be with this pie-in-the-sky initiative.
If we all get HDTV (or, better yet, 3D TV) and fiber optic internet at 25 Terabytes per second — we'll all go to heaven. There won't be any more ignorance or poverty or crime or disease or depression (either kind) or stray kittens — everything will be just (Daffy) Ducky. ; )
Please just go away……I don't want you in charge of my health care or my internet, I don't want you in charge of anything in my life or anyone's life that I care for. If you say its fee I'd say your lying, anything that's given to you can be taken from you and I doubt you would like the websites I go to.
How do they work?
I hope the writer meant that as a pun….
What does two kids in the EU writing a handheld game have to do with the US government funding of anything? Is it like a spin off of NASA technology like tang and velcrow?
"I hope the writer meant that as a pun…."
Seriously? You have to hope? Isn't it obvious? You people are dense!
Wow, it only took Obama three years to learn what anyone in the tech sector was saying all along – that spending billions on expanding wired internet – which wouldn't be completed for 10 years – will be wasting money on something that will be obsolete before it's ready.
Of course, I'm sure the government can find a way to bungle a wireless initiative, too.
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OCR for page 185
Access to Care for Substance
Use Disorders
review of access to care for substance use disorders (SUDs)
was a central component of two tasks in the committee's
• a comparison of the adequacy of the availability of and access to
care for SUDs for members of the active duty and reserve compo-
nents of the armed forces; and
• an assessment of the adequacy of the availability of and access
to care for SUDs for dependents of members of the armed forces,
whether such dependents suffer from their own SUD or because of
the SUD of a member of the armed forces.
To address these tasks, this chapter begins by defining access to care for
SUDs and providing a framework for the ensuing analysis. Subsequent
sections examine the availability of care, policies and other factors that
affect access to care, and data on utilization of care. The chapter concludes
with findings based on this analysis. The committee's analysis considers
the direct care system (military treatment facilities), the Veterans Health
Administration (VHA), and the system for purchase of care (TRICARE). It
reviews access to SUD care for active duty personnel; military dependents;
and, to the extent data were available, members of the National Guard
and Reserves. The assessment examines each branch of the military where
sufficient detail was available.
OCR for page 185
The armed forces focus on maintaining warrior fitness and promoting
resilience among service members and military families. Active duty person-
nel experience frequent mobilizations, difficult transitions, combat situa-
tions, and an operational tempo with long and multiple periods away from
their families and supports. The physical and emotional stressors experi-
enced by many military women and men may contribute to an increase in
their use of alcohol and other drugs. Access to substance use services—from
prevention to a wide spectrum of interventions for substance misuse and
abuse—can help military personnel and their families maintain psycho-
logical resilience and fitness. Access to routine screening, confidential brief
education, brief counseling, brief interventions for those with emerging
substance use problems, and more intensive treatment for those with SUDs
promotes good health and may reduce the current high rates of alcohol and
prescription drug misuse. If these services are delivered without sanctions or
stigma, they promote an effective response to emerging alcohol and other
drug use problems, and foster a system in which individuals seek help rather
than hide problems.
The committee's framework for assessing access to SUD care is based
on its view that alcohol and other drug use behaviors exist on a contin-
uum, and that certain patterns of alcohol and other drug use place some
individuals at high risk of developing medical and social problems and
possibly abuse or dependence. The discussion here focuses on the use of
legal substances (i.e., alcohol, controlled substances prescribed by a clini-
cian) since the use of illicit substances (when detected) prompts separation
Addressing access to brief intervention and treatment for alcohol and
other drug use is a complex undertaking. Access includes both the availabil-
ity of services and the use of appropriate modalities and types of services at
the appropriate times. As described in Chapter 5, contemporary substance
use treatment systems include frequent screening, brief counseling, brief
interventions in primary care settings, a focus on client-centered motiva-
tional interviewing, multiple entry points to treatment, pharmacothera-
pies that reduce cravings and maintain functioning, outpatient counseling,
intensive outpatient programs, residential treatment when needed, and
continuous contact with counseling professionals after an intense period of
treatment. Modalities of care utilize evidence-based environmental, psycho-
social, and medication interventions. The standard of practice in modern
SUD treatment no longer relies on inpatient hospital services, except for
the most medically complex patients. Continuity and duration of ambula-
tory services are more important than the provision of care in residential
settings (IOM, 2006).
OCR for page 185
Aday and Andersen (1974) developed a health services framework with
which to examine access to medical treatment. Subsequent investigators
modified this framework to assess access to services for alcohol and other
drug use disorders (Hser et al., 1997; Weisner and Matzger, 2002; Weisner
and Schmidt, 2001). The Aday and Andersen (1974) model addresses bar-
riers and facilitators to access using three domains: (1) predisposing, (2)
enabling, and (3) need. The predisposing domain consists of individual and
social facilitators and barriers. Individual factors are intrinsic characteristics
that describe the propensity of individuals to use health services. Social fac-
tors include marital status, family, and social networks; these are the social
contextual characteristics that influence treatment seeking. In the substance
abuse field, social networks are distinguished by whether they include indi-
viduals who are influences for not using versus using substances, as well
as treatment seeking versus nonseeking. The enabling domain consists of
structural/financial and environmental factors. Structural/financial facilita-
tors are similar to those for general health care and include the supply and
availability of treatment and the types of treatment and medications avail-
able. The need domain includes the severity of alcohol and other drug use
and comorbid mental health or medical problems.
Barriers to Access in the Military
Barriers to accessing care for SUDs can be environmental, structural,
social, and/or cultural. Environmental factors, such as pressure or mandates
to enter treatment, sanctions, perceptions about the effectiveness of treat-
ment, and stigma, are unique to the behavioral health field, particularly the
addiction field, and more apparent in the military than the civilian sector.
Civilian individuals frequently enter SUD treatment as a result of legal, wel-
fare, employment, or family pressures or even mandates (Weisner, 1990).
The same is true in the military; most service members are assessed for the
need for treatment only after receiving sanctions for a substance-related
incident (e.g., driving under the influence [DUI], assault) or other drug-
related infraction (e.g., possession of an illegal substance) or upon having
their substance use discovered through random drug testing. Thus, the
most important structural factors in the military are (1) policies that treat
alcohol misuse and other drug use as a discipline problem, (2) heavy reli-
ance on deterrence (i.e., random drug testing) as the prevention approach,
and (3) the lack of a standard medical protocol for early identification and
brief intervention before a disciplinary infraction occurs.
While many predisposing and need-related facilitators of and barriers
to treatment in the military are similar to those in the civilian sector, some
structural and environmental barriers are unique to the military— otably,
policies and practices that result in random drug testing as a primary
OCR for page 185
pathway to obtaining substance use services. First, random drug testing
technology is not applicable to alcohol or to designer drugs not yet classi-
fied as illicit (e.g., Spice, bath salts). Second, civilian best practice addresses
unhealthy substance use as a preventable and treatable health problem with
known risk factors and offers screening and interventions as part of primary
care services early and confidentially. Military practices, however, focus on
abuse and dependence and view alcohol and other drug misuse as violations
of the code of conduct and/or as criminal activities (e.g., DUI, drug pos-
session). The emergence of unhealthy use before a negative incident occurs
generally goes unnoticed or is ignored by medical programs, and while
policy describes the need for prevention programs (see Chapter 6), the vast
majority of resources are used for random drug testing.
The lack of distinction between unbecoming conduct and a medical
problem creates an environment in which engaging in substance use treat-
ment has counterproductive implications. Receiving treatment, even when
treatment causes the desired change in behavior, is perceived as resulting
in a negative career trajectory. Consequently, active duty service members
(ADSMs) are not highly motivated to enter treatment. This can have the
unanticipated effect on public safety of having service members continue to
perform critical tasks without having had their problems treated. Indeed,
during its information gathering meetings and site visits, the committee
heard from military treatment professionals that many service members per-
ceive alcohol treatment as a threat to their military career and consequently
avoid it.1 The vignette in Box 7-1 describes an extreme, but not isolated,
case in which early intervention with a soldier could have occurred. A ran-
dom drug test in 2007 identified cocaine use, but 15 subsequent tests were
negative. In 2011, the soldier self-enrolled in an Army Substance Abuse
Program (ASAP), fully 8 years after a problem was first indicated.
In keeping with the military's occupational health model, policy DODI
1010.6 requires that a service member's commander be notified of and
involved in treatment for an SUD (DoD, 1985, 220.127.116.11.3) (see also Chapter
6). This policy applies whether the soldier self-refers, is referred by a medi-
cal provider, or is referred by the commander, and regardless of whether
an alcohol-related incident or positive drug test is involved. Branch policies
impose similar requirements. For example, the Army policy for self-referral
The ASAP counselor will contact the unit commander and coordinate the
Soldier's formal referral using DA Form 8003, which will be signed by the
1 Personal communication, Vladimir Nacev, Ph.D., Resilience and Prevention Directorate
Defense Centers of Excellence, and Col. John J. Stasinos, M.D., Department of the Army,
Office of the Surgeon General, May 4, 2011.
OCR for page 185
A Soldier's Untreated Substance Abuse
A soldier tested positive for cocaine use in March 2007. He was not
required to enroll in an Army Substance Abuse Program (ASAP), and a
Department of the Army (DA) Form 4833 was never completed. Despite
15 negative urinalyses from October 2008 to January 2011, the soldier
self-enrolled in ASAP during the latter month for cocaine abuse and
marijuana and alcohol dependence. He was apprehended in July 2011
for assault consummated by a battery (domestic violence). A review of
law enforcement databases revealed that these offenses were not the
beginning of the soldier's high-risk behavior; he had been arrested for
criminal trespass, marijuana possession, and evading arrest in 2003—3
years prior to his delayed-entry report date of August 2006. While driv-
ing on an interstate highway in November 2011, the soldier collided with
another vehicle, killing himself and two others instantly and injuring two
others. He had been driving the wrong way on the highway for 2 miles at
the time of the accident. While drug and toxicology results are unknown
at this time, packets of Spice were found in the soldier's vehicle.
SOURCE: U.S. Army, 2012a, p. 30.
unit commander and be annotated as a self referral. The commander will
be a part of the rehabilitation program and, as a member of the Rehabilita-
tion Team, will be directly involved in the decision of whether rehabilita-
tion is required. (U.S. Army, 2009, p. 49)
These policies are necessary to ensure that service members are medically
ready for deployment. Yet in current practice, the lack of confidential treat-
ment even for problems that do not meet symptom criteria for substance
abuse or dependence has the perverse effect of leaving many treatable
problems undetected and unaddressed. As a consequence, several Army
reviews have identified a high proportion of suicides, other deaths, and
other negative consequences associated with untreated SUDs (U.S. Army,
2010, 2012a).
Historically, military policy has not addressed unhealthy alcohol use or
reliance on prescribed medications that places service members at high risk
for SUDs and later disciplinary problems. The military now has programs
that provide screening and early intervention for depression and posttrau-
matic stress disorder (PTSD) within primary care settings to reduce the
stigma associated with seeking treatment for these conditions, but it has not
OCR for page 185
adopted similar early-intervention, best-practice models for discussion of
emerging alcohol and other drug use problems. In civilian model programs,
early intervention for problem alcohol and other drug use is available in
medical care settings such as primary care and emergency rooms. A new
DoD policy, DODI 64990.08, may permit further development of brief
interventions in military health care settings for service members at risk of
alcohol use problems.
Military culture also creates unique environmental barriers to access-
ing care for SUDs. First, there are few to no public health interventions
targeting the medical consequences of heavy drinking. Military person-
nel are warned of the severe sanctions for alcohol or other substance use
that results in a formal consequence (e.g., DUI); the message conveyed,
however, is that heavy drinking is acceptable, while getting into trouble
because of the behavior is not (Burnett-Zeigler et al., 2011; Gibbs et al.,
2011; Skidmore and Roy, 2011). Second, alcohol and other drugs often
are misused as coping mechanisms for combat and other stress and hence
recognized on a continuum of medical problems (Stokes et al., 2003), yet
many service members are treated for long periods of time with opioid pain
medications and with controlled drugs to treat anxiety and sleep disorders.
These high prescribing rates introduce opportunities for abuse and addic-
tion. The epidemiological data reviewed in Chapter 2 suggest that abuse of
prescribed medications used to treat pain and/or sleep disorders is growing.
While tracking of medications dispensed to individuals in theater is
problematic (Defense Health Board, 2011), recent changes have been made
to prescribing practices for certain controlled medications. For instance,
ALARACT (All Army Activities) 062/2011 (U.S. Army Surgeon General,
2011) requires an expiration date on prescribed opioid medications. How-
ever, the U.S. Central Command (CENTCOM) Formulary still permits the
dispensing of 180 days of certain controlled substances for personnel who
are deployed to war zones (DoD, 2012). These prescribing practices are
intended to address the potential lack of access to medications currently
being taken by the service member in a deployed environment. Yet these
practices may contribute to physical dependence on such medications in sev-
eral ways—being given for a longer duration than is clinically prudent, given
without close medical supervision, and given to service members who have
alcohol or other substance use problems. The Army has made recent policy
changes aimed at reducing the prescribing of medications with the potential
for abuse and addiction (U.S. Army, 2012b; U.S. Army Surgeon General,
2011). As discussed in Chapter 6, DoD instated stricter limits on the length
of prescription for controlled drugs in May 2012 (see Finding 6-1).
In both civilian and military populations, a frequently cited barrier
to seeking treatment for SUDs is denial of the need for treatment among
OCR for page 185
those who need it (SAMHSA, 2011). Respondents to the National Survey
on Drug Use and Health described their problem as not severe enough
to require treatment and said that drug use helped them cope with diffi-
cult emotional stimuli. Among military personnel returning from Iraq and
Afghanistan stigma was the most frequently cited reason for not seeking
treatment for combat-related mental health conditions, including substance
use (Dickstein et al., 2010; Hoge et al., 2004; Stecker et al., 2007). Self-
stigma was particularly poignant; it is difficult for military personnel to
identify themselves as being in need. In the civilian sector, one role for brief
advice from a clinician to patients is to address their perception of their
need for treatment and the value of the available treatment, but this func-
tion currently does not exist in the military.
Role of Primary Care and Medical Treatment
The military's medical care model for first-line treatment of behavioral
health problems that are commonly comorbid with SUDs (e.g., PTSD,
depression, suicidal ideation and attempts) now relies heavily on detection
and treatment in primary care. Screening for behavioral health conditions,
including hazardous alcohol use, occurs routinely in primary care. As
discussed in Chapter 5, evidence-based approaches of brief advice, early
intervention, and referral to treatment when needed through models com-
monly known as screening, brief intervention, and referral to treatment
(SBIRT) should be a focus of the full continuum of care. Medical protocols
for SBIRT, however, have not been implemented in military primary care
programs. The Department of Veterans Affairs (VA) health care system,
in contrast, routinely screens for alcohol use problems and offers brief
intervention and referral to further treatment if needed. As discussed in
Chapter 6, the screening and brief intervention elements of the VA/DoD
Clinical Practice Guideline for Management of Substance Use Disorders
(VA and DoD, 2009) have not been implemented in the Military Health
System. Primary care also is the setting in which pharmaceutical therapy
for SUDs often takes place in the commercial sector. The lack of primary
care protocols in the military (and policy restrictions on the use of some of
these effective medication therapies) is an additional barrier to accessing
SUD care and is inconsistent with the VA/DoD Clinical Practice Guide-
line (VA and DoD, 2009). Consequently, primary care is the single largest
missed opportunity in the military for early and confidential identification
of alcohol and other drug misuse. DoD and branch policies and practices
currently do not provide for early and confidential interventions for alcohol
and other drug misuse. The committee perceives this to be a tremendous
barrier to service members' accessing SUD care.
OCR for page 185
DoD policy requires the armed services to provide alcohol and drug
abuse prevention and treatment services for active duty personnel as part of
medical readiness and risk reduction programs (DoD, 1997). The commit-
tee's analysis of access to and utilization of SUD care is organized by branch
and includes a review of the size of the population addressed, the number
of SUD programs available, and the data on utilization of services. The
content of these programs is described in Chapter 6 and Appendix D, and
the SUD workforce is described in Chapter 8. This section concludes with a
brief review of DoD-wide programs that may enhance access to SUD care.
There is no uniform DoD reporting system for monitoring the number
of detected alcohol incidents or drug-positive events, the number of refer-
rals for assessment or treatment, or the number enrolled in direct care treat-
ment programs. In response to queries from the committee, each branch
provided data using its own definitions, formats, and level of detail. In its
site visits, the committee learned that program directors at installations
can query their own systems, but do not have access to system-wide data
for judging overall trends or monitoring the transfer of patients from one
military installation to another. The committee does not know how any
methodological differences in data reporting among branches or compo-
nents affected the information provided for this study.
One major challenge confronting all branches with respect to access to
SUD care is that troops are dispersed across the United States, abroad in
permanent stations on U.S. territories (e.g., Guam), and in foreign nations
(e.g., Japan, Germany). Family members also reside with troops where
there are permanent stations. Thus, access to SUD care for these troops
and family members may require travel to obtain the appropriate level of
clinical care. The capacity for integrated behavioral health services in areas
outside the continental United States may be particularly important when
SUD programs are not available.
Air Force
The Air Force provides SUD services through 75 Alcohol and Drug
Abuse Prevention and Treatment (ADAPT) programs, one at each military
treatment facility, with nearly 400 counselors. None of these programs
offer inpatient, medically supervised treatment or residential, medically
monitored treatment. The Air Force has one ADAPT program that provides
intensive outpatient care at Andrews Air Force Base. The Air Force Medical
Operations Agency reported to the committee that during fiscal year (FY)
2010, 736 service members self-referred to ADAPT, and 4,644 members
OCR for page 185
TABLE 7-1 Utilization of Alcohol and Drug Abuse Prevention and
Treatment (ADAPT) Services by Active Duty Air Force Personnel*
1,559 1,429 1,532 1,565 1,454
*Includes 11-26 persons treated annually who were activated National Guard/Reserve
SOURCE: Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations
Agency, October 25, 2011.
were referred by Command.2 Beyond self-referrals and Command refer-
rals, individuals can be referred to ADAPT by medical providers, but these
represent the smallest proportion of referrals. Table 7-1 displays the number
of active duty patients enrolled in treatment at ADAPT clinics from FY
2006 to FY 2010. Comparing the number of self- and Command referrals
in FY 2010 (5,380) with the number of patients enrolled in treatment in
the same period (1,454) suggests that most referrals do not lead to enroll-
ment in treatment. As described in Chapter 6, most individuals receiving
services through ADAPT do not meet diagnostic criteria for enrollment in
formal treatment and instead are enrolled in alcohol brief counseling as an
indicated prevention measure. The number treated has not increased over
time and was lower in FY 2010 than in 3 of the 4 prior years.
ASAPs are located within the Army Installation Management Com-
mand (IMCOM) as part of the human resources program (see also Chapter
6). The Army has 38 ASAPs, which typically offer American Society of
Addiction Medicine (ASAM) Level I (outpatient service) care to military
personnel and have insufficient capacity to serve family members with
SUDs.3 Army regulations require all ASAP counselors to have a master's or
doctoral degree in psychology or social work. The ASAP counselors may
be uniquely positioned to provide integrated care for service members with
SUDs and comorbid mental health problems, but are credentialed only to
treat SUDs and are not authorized to treat mental health problems. Mili-
tary personnel who require partial hospitalization or inpatient care or have
a dual diagnosis often are referred by Command to the civilian provider
network. The extent to which ASAP programs are available to Army per-
2 Personal communication, Lt. Col. Mark Oordt, Air Force Medical Operations Agency,
October 25, 2011.
3 Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Pro-
grams, March 30, 2011.
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sonnel and family members permanently stationed abroad or in states and
territories outside the continental United States is unclear.
The TRICARE Management Activity (TMA) Section 596 report indi-
cated that the Army operates only one inpatient (around-the-clock), medi-
cally monitored treatment program, which has 20 inpatient beds (DoD,
2011b, p. 30). During a site visit to Fort Belvoir Community Hospital
(see Appendix A for the committee's site visit agenda), the committee
learned of a newly opened residential treatment center (ASAM Level III
rehabilitation program for SUDs under the Army's Medical Command).
This medical service will provide care for ADSMs from all branches of the
military and eligible retirees. When referred by Command, personnel may
be treated in any SUD facility under a budget agreement with the military
treatment facility commander; that is, commanders are not restricted to the
use of TRICARE network Substance Use Disorder Rehabilitation Facilities
(SUDRFs) (SUDRFs are discussed later in the purchased care section).4
With regard to in-theater care, a report of the Army Inspector General
concludes that there is a lack of compliance with Army alcohol and other
drug use policy when units are in a combat operation environment (U.S.
Army, 2008). CENTCOM General Order #1 states that alcohol consump-
tion and possession and drug use are illegal in the combat environment
(United States Central Command, 2006). AR 600-85 requires that deployed
commanders maintain a drug deterrence program. However, the Inspec-
tor General's report finds little compliance with these directives and notes
that DoD provides no guidance on how to implement the policies and no
professional staff to implement them and monitor compliance, and that
the rotation of personnel in and out of the combat environment inhibits
enforcement. In efforts to deter drug use during deployment, the Army
updated AR 600-85 in 2009 to include new language meant to increase
random drug testing in theater. To increase access to screening and treat-
ment in theater, the Army is in the first phase of rolling out an Expedition-
ary Substance Abuse Program to provide SUD services during deployment,
primarily through telephone contact with in-theater providers.5
Table 7-2 shows data on initial referrals of Army ADSMs to ASAP for
FY 2006-2010. The Army Center for Substance Abuse Programs (ACSAP)
reported to the committee that for FY 2010, 3,401 distinct active duty
individuals enrolled in treatment as self-referrals, and 10,968 enrolled
because of Command referral.6 ACSAP provided detailed information on
4 Personal communication, John Sparks, TRICARE Regional Office-West, March 18, 2012.
5 Personal communication, Col. John J. Stasinos, M.D., Department of the Army, Office of
the Surgeon General, March 15, 2012.
6 Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse Pro-
grams, January 13, 2012.
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TABLE 7-2 Army Active Duty Initial Referrals to the Army Substance
Abuse Program (ASAP)
Initial Referrals 16,826 18,164 20,316 23,044 23,093
SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Substance Abuse
Programs, January 13, 2012.
gender, rank, and substance of initial referral (not treatment enrollment)
for 23,093 individuals in FY 2010. According to a recent Army analysis
(U.S. Army, 2012a), 52 percent of soldiers referred to treatment for either
alcohol or other drug problems enrolled in outpatient treatment. Many
who are referred to ASAP for assessment fail to meet diagnostic criteria for
SUDs and are enrolled in the Army's indicated prevention course Prime for
Life (described in Appendix D). When soldiers are enrolled in treatment at
ASAP, they do not always complete the program for various reasons (e.g.,
deployments). The rates of successful completion of rehabilitation from FY
2001 to FY 2010 averaged 66 percent for alcohol and 47 percent for other
drugs (U.S. Army, 2012a).
The committee also received data on treatment enrollment in ASAP.
Figure 7-1 shows the data received on the distribution of enrollment ranked
2% 1%
Alcohol (9,895)
Cannabis (1,451)
Opiates (663)
Cocaine (366)
Other Substances (216)
Amphetamines (148)
FIGURE 7-1 Number of Army Substance Abuse Program (ASAP) treatment enroll-
ments by substance of abuse for fiscal year 2010. Enrollments for the following
substances were small in number and not included in the above chart: inhalants
(52), sedatives (41), hallucinogens (41), and PCP (3).
SOURCE: Personal communication, Les McFarling, Ph.D., Army Center for Sub-
stance Abuse Programs, March 30, 2011.
Figure 7-1
vector editable
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While the definition of these settings is unclear, the table supports the find-
ing that few individuals received SUD care in the purchased care system.
This finding is not surprising for ADSMs given that in most circumstances,
they have access to outpatient services at their military treatment facility
and potentially to other levels of care if transferred to inpatient programs
offered by the larger installations. As noted in Table 7-6, however, typically
fewer than 1 per 1,000 ADFMs received SUD care at military treatment
facilities. Combined with the low utilization rates in Table 7-15, these data
are evidence that ADFMs face strong barriers to gaining access to SUD care
in the military treatment facility and purchased care systems combined.
Data in Table 7-15 on the treatment of SUDs in purchased care facilities
further demonstrate that network facilities do not provide all the SUD care
received by ADFMs. In part, this reflects the finding that non-SUDRF hospi-
tals are used for emergency detoxification and withdrawal from substances.
Nevertheless, these data also show that the majority of inpatient SUD care
was delivered outside of SUDRFs. The majority of outpatient services were
received from settings other than professional SUDRFs. However, some of
these outpatient services may represent not counseling services but claims
for ancillary services associated with other types of care.
The data in Table 7-15 indicate a substantial underutilization of care
but do not directly identify the full range of barriers that contribute to this
pattern. It is apparent that there is a lack of capacity in network SUDRFs;
in some states there are no SUDRFS, and in most regions the SUDRFs serve
only some geographic areas and are too distant to accommodate many mili-
tary families. Further, all SUDRF care is facility rather than office based as
prescribed by regulation, and a substantial or majority portion is in inpatient
hospital facilities. This implies a reliance on the highest-cost setting for SUD
care, an approach not supported by the evidence (see Chapter 5) and no
longer practiced in the commercial insurance sector. According to practice
guidelines, most individuals can be treated with outpatient SUD protocols.
Taken together, these data imply an extreme shortage of outpatient
settings for SUD care for ADFM adults and children. There may also
be a shortage of outpatient services for ADSMs who lack access to SUD
programs at their military treatment facility. Outpatient settings are the
appropriate setting of care for most individuals with SUD needs, and they
are also the setting in which aftercare services should be provided for those
individuals who have undergone an inpatient episode of care.
The committee's review of access to SUD care suggests that while
services are available for ADSMs through military treatment facilities, the
number of patients treated is below epidemiological expectations. Many
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barriers to care apparently inhibit ADSMs' use of these services. These bar-
riers include the structure and location of the services, a reliance on residen-
tial care, and stigma that substantially inhibits help-seeking behavior in a
system in which regulation requires the "employer" (i.e., commander) to be
informed about any use of services for SUDs. Further, many policies (e.g.,
drug testing and Command involvement) may actually inhibit rather than
enhance access (as intended) to early SUD treatment and discourage screen-
ing and brief intervention in medical settings for alcohol use disorders.
Additionally, access to care for ADFMs is extremely limited in TRICARE's
purchased care system. The barriers to care in the purchased care system
appear to be associated with the limitations of benefit coverage (far dif-
ferent from the standard of coverage in the commercial sector) and the
requirements for SUDRF certification (again different from the standards
used in the commercial sector). The restriction of services to SUDRFs leads
to an expensive reliance on geographically distant hospital-based treatment
services, a lack of access to existing community-based outpatient and inten-
sive outpatient services, and poor transition from SUDRF care to primary
care and from inpatient to outpatient services. Thus, access to prevention
and treatment services that incorporate the latest scientific evidence and
predominate in the commercial sector (pharmaceutical therapy, individual
therapy, intensive outpatient programs), as well as care in individual prac-
titioners' offices and outpatient clinics, is limited in the military largely by
an outdated benefit structure, outdated benefit limits, and other unique
policy restrictions that appear to be inconsistent with the military's goal of
providing the best possible SUD care to those who need it.
Finding 7-1: There is a significant unmet need for SUD care among
service members in the U.S. armed forces.
DoD policy mandates a postdeployment assessment and screening
interview to identify emerging health problems, and each branch has its
own procedures for ensuring the medical fitness or readiness of its person-
nel for future deployments. These surveillance programs generate data on
the impact of deployment and combat on mental health, including concerns
about drinking, depression, and stress-related symptoms. Unfortunately, the
identification of problems does not lead to referral for treatment. A recent
study showed that of 6,669 Army soldiers self-reporting levels of drinking
categorized as alcohol misuse, only 0.2 percent received a referral for alco-
hol services, and only 29 of these were seen within 90 days (Milliken et al.,
2007). Figure 2-3 and Table 2-3 in Chapter 2 provide anonymous survey
data illustrating high rates of heavy drinking. Given the epidemiological
data showing high rates of weekly binge drinking among military person-
nel (Bray et al., 2009), it is apparent that only a fraction of those needing
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brief intervention and advice to change their alcohol-related behavior are
being reached.
This low level of access is potentially attributable to the lack of a clear
public health message and vision within DoD with respect to its charac-
terization of SUDs. A full range of SUD service modalities is not available
to ADSMs and their dependents in the direct and purchased care sectors.
Particularly lacking are any medical services for prevention and early inter-
vention for emerging problems that could be identified through confidential
medical discussions about behaviors that increase the risk of developing
alcohol use disorders. While the civilian world has protocols for routine
standardized medical screening, brief advice, brief counseling, and brief
treatment, the armed forces lack these protocols and practices. Although
medical protocols for brief intervention for those individuals who have
unhealthy alcohol use are recommended in the VA/DoD Clinical Practice
Guideline for Substance Use Disorders (VA and DoD, 2009), the committee
found little evidence of their actual use. While the estimated unmet need for
SUD care is significant, it is of note that DoD is not consistently tracking
measures of need for care across service branches. The committee found
that DoD has no uniform reporting system for monitoring the number of
detected alcohol incidents or drug-positive events, the number of referrals
for assessment or treatment, and the number enrolled in direct care treat-
ment programs. While individual service branches have their own databases
for collecting this information, it is challenging to understand the extent of
the unmet need for care without more consistent data that are incorporated
into the medical record.
Finding 7-2: Access to care is restricted by the TRICARE SUD benefit's
lack of coverage of intensive outpatient services, office-based outpatient
services, and certain evidence-based pharmacotherapies.
The committee concurs with the assessment in DoD's Comprehensive
Plan on Prevention, Diagnosis, and Treatment of Substance Use Disorders
and Disposition of Substance Abuse Offenders in the Armed Forces (Com-
prehensive Plan) that additional inpatient and residential capacity for SUD
care is not needed. However, the committee disagrees with that report's con-
clusion that the full range of SUD services is sufficient. As discussed above,
current policies that limit outpatient services to SUDRFs inhibit access to
care and require the use of expensive and increasingly antiquated inpatient
facilities. In reviewing data provided by TMA, the committee found that
much of the SUD care that is claimed under the TRICARE benefit is pro-
vided in inpatient settings. A comparison of TRICARE utilization data with
commercial practices suggests that TRICARE overemphasizes inpatient
settings and underutilizes outpatient care. According to contemporary stan-
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dards, however, systems of care for SUDs should rely on outpatient services
and ongoing management of a potentially chronic disorder, particularly
after episodes of inpatient and residential treatment. Both the direct care
and TRICARE systems lack the necessary capacity for providing intensive
outpatient and outpatient services.
The implication of the current SUDRF regulations is that many SUD
services delivered through community-based addiction treatment centers or
through licensed independent practitioners are not available to TRICARE
beneficiaries. This particularly affects access to SUD care for dependents
of service members, who generally are unable to receive care at military
treatment facilities since programs give priority to providing care to service
members. Continued reliance on a small number of hospital-based and free-
standing SUDRFs and limits on the settings and levels of care contribute to
overall low utilization rates and to a lack of continuity in care. According to
a draft update to the Comprehensive Plan, DoD is aware of this issue and is
currently drafting policy language for internal review and coordination that
would expand the authorized providers of SUD treatment services beyond
SUDRFs.18 While it was outside the charge for this study to investigate total
expenditures on SUD services, the committee notes that the current con-
figuration of capacity and the current TRICARE benefit structure promote
use of the most expensive settings of care and limit access to lower-cost
modalities that are evidence based (outpatient counseling, intensive out-
patient, and partial hospitalization modalities). The restriction of care to
SUDRFs appears to be unwarranted in the current health care environment,
in which the quality of services and the need for different levels of care
can be determined using managed care technologies. In reviewing claims
data from TMA, the committee also found limited use of pharmacological
therapies for alcohol and other drug use disorders, presumably due in part
to the TRICARE benefit's limit on the use of maintenance pharmacotherapy
for the treatment of SUDs. The committee finds that underutilization of
effective treatment modalities such as outpatient therapy and maintenance
medications inhibits service members and their dependents from accessing
effective and quality care for the treatment of SUDs.
Finding 7-3: Low rates of ADSM self-referral to treatment corroborate
reports provided to the committee regarding the perceived stigma of
receiving treatment.
When the numbers of self-referrals to treatment are compared with
the numbers of Command referrals, it is clear that, across the different
18 Personal communication, Alfred J. Ozanian, Ph.D., TRICARE Management Activity,
June 6, 2012.
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branches, the numbers of self-referrals remain very low. The Army had
a higher proportion of self-referrals than the other branches in FY 2010,
a differential that presumably is due to the Army Confidential Alcohol
Treatment and Education Pilot (CATEP) program (described in Chapter
6), which offers confidential treatment. The committee finds that policies
requiring Command notification for the treatment of SUDs encourage
ADSMs and their families to avoid rather than seek care and therefore
contribute to low numbers of self-referrals. These policies also inhibit medi-
cal professionals from conducting routine screening for alcohol misuse and
identifying those at risk and in need of intervention.
Finding 7-4: Access to SUD care is inhibited by various structural,
social, and cultural barriers that are specific to military procedures,
programs, and policies.
A primary barrier to access to the full continuum of SUD care for
military populations is the body of DoD and branch policies that rely first
and foremost on the detection and adjudication of alcohol and other drug
misuse as a disciplinary problem. These policies have the effect of attach-
ing negative consequences and stigma to seeking help for alcohol and other
drug use disorders (Gibbs et al., 2011). Studies have shown that negative
attitudes and beliefs about treatment can inhibit help seeking among service
members as well (Kim et al., 2011; Stecker et al., 2007). The mistaken belief
that seeking help and receiving treatment are a sign of weakness, coupled
with policies that tie negative career consequences to alcohol and other
drug misuse, creates a climate that hampers military leaders who wish to
help service members, inhibits accurate screening and diagnosis by medical
professionals who care for service members, and leads to very low self-
referral rates for SUD treatment.
In addition to this inhibition of care seeking, there are key structural
barriers to SUD care in the armed forces. Specifically, military treatment
facilities lack the full continuum of SUD services. In the smaller instal-
lations of some branches, there are no specialty treatment programs. In
no branch did the committee learn of early, primary care-based indicated
prevention for substance use problems that do not meet clear diagnostic
criteria. Furthermore, there are severe practice restrictions on prescribing
some pharmaceutical therapies known to support patients who wish to cut
down on or abstain from alcohol and other drug use, and utilization data
indicate a much lower than anticipated use of pharmaceutical therapies that
are approved and known to be efficacious. One explanation for the low
use of approved medications is the lack of SUD service delivery through
primary care settings. Overall, the committee found a lack of adherence in
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practice to the VA/DoD Clinical Practice Guideline for SUD care (VA and
DoD, 2009) that has been acknowledged as the military's standard of care.
The committee's findings are in line with earlier findings of the DoD
Task Force on Mental Health (DoD, 2007). That task force observed that
the stigma of mental health disorders inhibits military members and their
families from seeking care. The task force recommended that DoD (1)
develop public education campaigns to dispel this stigma; (2) embed mental
health professionals in primary care to improve access and reduce stigma;
(3) train officers, families, and medical professionals to value and promote
psychological health and services; and (4) recognize that DoD regulations
often inhibit seeking care (DoD, 2007). Recommendation 18.104.22.168 specifi-
cally addresses the effects of policy on care for alcohol use disorders and
suggests policy changes to promote access to care:
The Department of Defense should promote earlier recognition of alcohol
problems to enhance early and appropriate self-referral. If, in the clini-
cian's judgment, alcohol use does not warrant a diagnosis, mechanisms
should exist to ensure that service members receive appropriate and non-
prejudicial education and preventive services, without a requirement for
command notification. Evaluations resulting in a diagnosis of substance
abuse or dependence or entry into a formal outpatient or inpatient treat-
ment program should continue to require command notification, as should
reporting of alcohol-related incidents. (DoD, 2007, p. 21)
Lack of confidentiality is a persistent barrier to SUD care and appears
as well to influence the lack of preventive and early intervention services
that may prevent the development of an SUD. To reduce the stigma associ-
ated with seeking help for mental health and substance abuse problems,
a recent DoD policy (DODI 6490.08) gives health care providers more
latitude in responding to requirements for notifying Command of mental
health and substance abuse disorders. The policy clarifies that if a service
member voluntarily seeks drug and alcohol abuse education and does not
meet diagnostic criteria, brief intervention services can be provided with-
out Command notification (DoD, 2011a). The instruction also creates an
opportunity for health care providers in primary care or other medical
settings to screen for alcohol and other drug misuse and provide patient
education. The committee suggests that policies such as DODI 64990.08
are a step toward creating confidential systems of intervention and may
encourage help-seeking behavior. If DoD and branch policies do not pro-
vide for early and confidential treatment of alcohol and other drug misuse,
the committee believes that stigma will remain a significant barrier to SUD
services. While these subclinical behaviors are not detected or treated, they
may still have a tremendous impact on force health and readiness.
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The committee finds that the structure of SUD services in the armed
forces also inhibits access to care. For example, DoD's Comprehensive Plan
acknowledges that "gender-specific programs to treat SUDs in women are
not available at MTFs [military treatment facilities]" (DoD, 2011b, p. 26).
With increased enrollment of women in the military and their greater expo-
sure to combat deployments, the need for gender-specific services is appar-
ent. Additionally, the availability of SUD treatment at the time it is sought
is an important principle in the commercial sector. On-base substance abuse
programs typically offer care during duty hours, so participation in treat-
ment programs often necessitates notifying Command to arrange adjust-
ments to one's work schedule. If SUD services were available at times that
did not conflict with work duties (perhaps through increased use of tele-
mental health technologies, which could provide care outside of duty hours
delivered remotely by a provider in another time zone), ADSMs would have
greater opportunities to enter care before the severity of an SUD required
leave from their duty assignment. While this conflict with work duties is
one rationale for commander involvement on the treatment team, it also is
a perceived barrier to seeking care, particularly for career-minded service
members who see daytime therapy appointments as often conflicting with
job demands (Kim et al., 2011).
Similarly, while waiting to enter treatment or in the middle of treat-
ment, a service member may leave on deployment. Upon return, he or she
may receive a different permanent station, which again disrupts continuity
of care. The DoD Task Force on Mental Health reached similar findings
and recommended that DoD support a full continuum of services for service
members and their families, and develop policies that would ensure conti-
nuity of care during deployment transitions and transitions between civilian
and military providers (DoD, 2007). The task force encouraged DoD to
develop strategies for recruiting and retaining mental health professionals,
including social workers. The task force's findings raised concern about
access to mental health services within TRICARE and led to recommenda-
tions for policy revisions to require access to care within 7 days, competitive
reimbursement rates, the use of intensive outpatient services and other new
approaches to care, and the use of qualified professionals not affiliated with
hospitals to provide outpatient services (DoD, 2007).
Finding 7-5: Members of the National Guard and Reserves have no or
limited access to SUD care within the Military Health System.
The large numbers of National Guard and Reserve personnel who
have been activated and deployed to Iraq and Afghanistan raise concern
about specific barriers to SUD care that they confront. Reserve component
personnel often are dispersed within the civilian community and often live
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in rural areas a great distance from a VA medical center. Outreach efforts
are challenged by this geographic dispersion, and must rely on innovative
delivery methods such as Web-based outreach, telephone counseling, and
telemedicine consultation. Additionally, members of the National Guard
and Reserves and their families may not qualify for the same services
as active duty personnel, who receive comprehensive care through the
military's direct care system. Discharge status also can present barriers to
accessing care. Reserve component and discharged military personnel must
have an honorable or general discharge to be eligible for the special combat
veteran medical care at VA health centers. Combat veterans with SUDs are
more likely to receive a less than honorable discharge because of disciplin-
ary infractions. Consequently, those in need of care may be ineligible. Fur-
thermore, while family members may be involved in a veteran's care, VA
clinics do not provide individual therapy for family members.
An additional system-level barrier is the lack of a "warm hand-off"
from the Military Health System to the VA health system (GAO, 2011a).
Service members who have substance use or mental health problems must
navigate the complex transition from one system to the other on their own.
In contrast with physical injuries (which may result in medical treatment
within the military, visible impairment, and a disability rating from the VA),
the fact that many military personnel do not receive needed substance abuse
care while in the military also means they do not receive a formal refer-
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National Guard and Reserves may be concerned about a perceived lack of
confidentiality of their VA medical record with regard to their current mili-
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literature review and corroborates those findings through interviews. The
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VA (Department of Veterans Affairs). 2008. Uniform mental health services in VA medical
centers and clinics: VHA handbook 1160.01. Washington, DC: VA.
VA and DoD. 2009. VA/DoD clinical practice guideline for management of substance use
disorders. Washington, DC: VA and DoD.
VA and DoD. 2010. VA/DoD clinical practice guideline for management of post-traumatic
stress disorder and acute stress reaction. Washington, DC: VA and DoD.
Weinick, R. M., E. B. Beckjord, C. M. Farmer, L. T. Martin, E. M. Gillen, J. D. Acosta,
M. P. Fisher, J. Garnett, G. C. Gonzalez, T. C. Helmus, L. H. Jaycox, K. A. Reynolds,
N. Salcedo, and D. M. Scharf. 2011. Programs addressing psychological health and
traumatic brain injury among U.S. military service members and their families. Santa
Monica, CA: RAND Corporation.
Weisner, C. 1990. Coercion in alcohol treatment. In Broadening the base of treatment for
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Weisner, C., and H. Matzger. 2002. A prospective study of the factors influencing entry
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velopments in alcoholism. Vol. 15, edited by M. Galanter. New York: Kluwer Academic/
Plenham. Pp. 107-136.
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Come for lunch, music, great crafts for Christmas, and yummy baked goods. Get your car washed while you eat & shop and support our youth group's summer work camp fund. Select Christmas gifts for family and friends or consider honoring those who "have everything" with a gift that gives to others as we support Heifer Project International, African Good Samaritan Mission, and the local scholarship fund for Cedarkirk summer camp. Don't miss this opportunity to take care of your Christmas shopping!!
Copyright ©2014 Planck LLC d/b/a Patch Media. All rights reserved.


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Developer: Ed Key, David Kanaga
Publisher: Ed Key, David Kanaga
Platforms: PC
Have you ever wondered just why young would be poets are so drawn to the dark and emo-riffic themes of death, loneliness, alienation and unrequited love? It's simple. Negative emotions are easier to write about without seeming to be insincere.
Make fun of that spotty kid with too much eyeliner writing ponderously about the second law of thermodynamics all you like, but at least she's not breathlessly bouncing around the stage at an Up With People marathon concert. If I only had one round in my shotgun, I know who I'd pull for.
But you know what? That doesn't mean that good love poems or just flat out happiness and whimsy is intrinsically sappy. It's just that it's hard to do well. Call dealing with positive emotions the soufflé making to the spaghetti cooking of the "edgy" games that seem so popular these days. Speaking of spaghetti, admit it. You loved Mario Kart. Right. Where was I? Oh yeah, positive emotions making for a good game that no one will snicker about.
Hello, Proteus.
A game "about" life. Literally so. You are birthed into the ocean, bodiless observer, you. And then you swoop your way over to a pixelated island where you mostly observe what is going on. You might scare a frog or two, and the bees are none too pleased with your poking your ethereal snout into their business, but mostly you just float about, exploring. Seasons come and go while the world changes as you watch.
A game "about" life. Literally so.
While its cheerfully low-res graphics are pretty enough to look at, I wasn't really expecting much out of Proteus after the first few minutes of gameplay. I was prepared to file it away as a cute demonstration about how one doesn't need super realism in games for them to be aesthetically pleasing. For all that I've gushed about Dear Esther, I think this is rather indisputably true. Despite what 2K's Christopher Hartmann recently said about graphics limiting emotional range I don't think this is really a controversial point. And besides, a game built around proving a point isn't so much a game as a blog post. Fair enough, I think, you've convinced me of the inherent correctness of your position. Now would you please amuse me?
Then one notices the subtler things going on. The music is retro-ambient electronica (fine, I just made that category up), reminiscent of old school videogames just like the graphics are. But rather than just having a looping track with a few sound effects, the music alters based on where and what you're exploring. A ruined tower has one sound, an animal another, the wind swept hills yet another. The sounds layer upon each other with increasing complexity, but slowly. Each encountered season has its own palette of sounds to choose from, and they feel programmatically appropriate (using program in the musical sense here). It's all very minimalistic yet effective, as if Philip Glass had written the soundtrack for Minecraft while channeling Vivaldi.
Like a plus sized model, Proteus is pretty, in a chunky sort of way.
But like the namesake seagod Proteus was named for, our little island keeps changing. There's a trigger event you'll need to do to move from season to season, but I'll just let you discover it on your own. It's not really a puzzle so much as yet another little discovery Proteus has. And it seems timed pretty darned well, its availability appearing just as you've discovered most (but not all) of the secrets the last season held for you.
It would be a stretch to call Proteus interactive. It's an exploratory game at its heart. Think of it as a game comprised almost entirely of Easter eggs. But in a sense, by exploring, you are interacting with the environment. The world you see is dictated by your choice of where to look.
The music you hear will be comprised of the themes of what you examine.
The music you hear will be comprised of the themes of what you examine. In a sense, you become a co-composer of the soundtrack through your wandering. I'm reminded of the game Sound Shapes, a platformer that has the player rolling about and collecting sounds. Creating and influencing the music becomes something of an auxiliary goal on top of the primary one of getting through the level. Unlike Sound Shapes and similar games, Proteus doesn't have a goal per se. But that doesn't mean that the players will be disinterested in controlling their experience.
And it's always fun to chase frogs.
Proteus Review Score 9/10
Why so high? A unique exploration game. Terrific (and interactive) soundtrack. Cheerful and beautiful. Surprising replay value, much like a favorite song you'll listen to repeatedly.
Why so low? Hard to just pop in and out– without a save function, you need to be ready to sit down for the entire piece. Some might not like the retro art style (I did, but hey, I've got to say something in the "con" section, right?)
David Parish-Whittaker
Latest posts by David Parish-Whittaker (see all)
- Neverwinter Review - June 20
- Tropes vs. Women in Videogames: a Review - April 26
- Marvin's Mittens Review - January 10
- Mass Effect 3 Leviathan DLC Review - September 16


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Top 40 Under 40 2013: Nate Macek
"I'm a member of the Planning Commission in Alexandria, Va., where I live. I'm an urban planner by training and it's a good way for me to give back to the community and keep my land use planning skills honed. I've enjoyed my involvement in developing a new waterfront plan and developing strategies to link land use and transportation decisions in Alexandria."
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The Ohio State University
Creating the Extraordinary Student Experience
Time: Friday, February 15, 2013 2:00 PM - 3:30 PM
Location: Ohio Union Round Meeting Room
The Society of Professional Journalists is excited to host David Carr of the New York Times on Feb. 15 as part of the School of Communication's William D. Stewart Lecture Series. There will be a student discussion session from 2-3:30 p.m., in the Round Meeting Room at the Ohio Union. Please RSVP and direct questions to Nicole Kraft, email@example.com
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This is from another web site but is so awesome tasting that you will want to try it for sure!!! And its sooooo simple!! If the glaze is prepared ahead of time it will thicken, just reheat it in the micro until it melts and then use it. UPDATE:::Made this again the other day and DID marinate it. I made the sauce, added the pork and popped in the fridge for 2 hours, took out the pork and put on the grill and microwaved the sauce, if you dont heat the sauce it will be WAY too sticky for the grill and believe me you will have a mess! I have also done this with some very thick (1 1/2 inch) cook out style pork chops and they were super too!
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Just off the shores of Virginia Beach spectacular wildlife emerges each winter. From humpback and fin whale sightings to beautiful waterfowl like the northern gannet, the life along the coast is active and majestic. More
Drive-ins are a popular family pastime and old-school memory maker. Treat your kids to a most unique movie-viewing experience. More
Yellow Sulphur Springs has been an oasis of Montgomery County, Virginia, since before Blacksburg was incorporated in 1798.
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Montgomery Museum More Info
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The Town of Christiansburg LOVEwork represents Christiansburg's reputation in the area. We are known for aquatics, recreation, shopping and ... More Info
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Harkrader Sports Complex opened in 2006 and is located behind the Christiansburg Middle School. The complex has three lighted, multipurpose ... More Info
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Sam and Diane contemplate their future together. Sam returns to the bar for one of the most famous closing scenes in television history. watch
Sam and Diane are plagued with doubts about getting back together. watch
Why he says Shelley Long fought to have his character removed from the show.
S&M pair discuss Shelly Long.
An ordinary guy is transformed into a macho man by his sister to impress a young woman.
Two nighttime morgue attendants become "love brokers" for a group of hookers who have lost their pimp. Keaton is very funny in his first film!
More Clips & Interviews
Wealthy, successful gynecologist Sullivan Travis (Richard Gere) loves his seemingly perfect life. Unfortunately, his wife has a sudden mental breakdown, his lesbian daughter prepares to tie the knot with a man, daughter No. 2 obsesses over conspiracies, and his sister-in-law imbibes a gallon or two of champagne daily. Luckily, Travis discovers a woman (Helen Hunt) who may hold the answers to his problems.
Wealthy, successful gynecologist Sullivan Travis (Richard Gere) loves his seemingly perfect life. Unfortunately, his wife has a sudden mental breakdown, his lesbian daughter prepares to tie the knot with a man, daughter No. 2 obsesses over conspiracies, and his sister-in-law consumes a gallon or two of champagne daily.
Wealthy, successful gynecologist Sullivan Travis, in the throes of a mid-life crisis, is having as much trouble with his family's lives as with his own. Luckily, he discovers a woman who may hold the answers to his problems.
More Shelley Long Movies Videos
Phil and Claire get the dreaded late night call that Haley has been arrested for under-aged drinking, so they bring Mitchell, the family lawyer, in tow to the police station. Cameron stays back to watch over Alex and Luke, but they get into some crazy mishaps under his care. Meanwhile, Jay gets out of baby shopping with Gloria, but ends up having to deal with a surprise visit from Dede, and tries to scoot her out before Gloria gets home to prevent Dede from seeing that she's pregnant and to avoid the potential blowback. Also Available On Amazon Instant Video and VUDU
Bay gets stuck in the middle of Emmett's custody battle, while Daphne participates in a basketball game that has Carlton and Buckner facing off. Also Available On Netflix and Amazon Instant Video
The guest list for Lily's princess-themed birthday party gets a little out of hand when Mitchell decides to invite mom, much to Claire's dismay, and disinvite Fizbo, much to Cameron's dismay. Things get even more strange when Dede (guest star Shelley Long) shows up with Claire's old high school boyfriend (guest star Matt Dillon) in tow, and Jay and Gloria each turn to their own unique methods of dealing with this gathering of misfits. Also Available On Amazon Instant Video and VUDU
A New York executive, decides to drop everything while visiting his parents (George Segal and Jessica Walter) in Florida, and move into their retirement community. The move prompts his parents to make an unexpected life decision as well.
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Paul Scheer is among the many famous faces heading to Modern Family this season.
The League star will guest-star in an upcoming episode as a Costco manager, TVGuide.cmo has confirmed. As first reported by The Hollywood Reporter, he'll interact with... read more
As if Jay Pritchett weren't dealing with enough on the upcoming season of Modern Family, now his ex-wife is coming back to town!
Shelley Long will reprise her role as Dede Pritchett, the mother of Claire (Julie Bowen) and Mitchell (Jesse Tyler Ferguson), TVGuide.com has learned exclusively.
Get the scoop on your favorite returning fall TV shows
Details on Long's return are being kept under wraps, but... read more
When Kirstie Alley stepped into the lead female spot on the hit sitcom Cheers, her fearless, bawdy, neurotic energy thwarted all predictions that she'd never fill Shelley Long's shoes. She even earned an Emmy. Since then, Alley has continued to catch the world off guard by segueing into feature films, both arty and mainstream (Deconstructing Harry, the Look Who's Talking movies), headlining popular post-Cheers series Veronica's Closet and making a name for herself as one of the most unapologetic of Scientology's brethren. Then, when her weight ballooned at age 53, she used her indomitable spirit to turn her bathroom-scale struggles into a new branch of her career: She's been a Jenny Craig spokesperson; invented her own weight-loss program, Organic Liaison; starred in a semiautobiographical Showtime sitcom, Fat Actress; and to show what it's like to be an overweight celebrity single mom of two teenagers — William True and Lillie Price — she welcomed a reality-TV crew into her hectic home for A&E's Kirstie Alley's Big Life.
Cheers to Modern Family for inviting Matt Dillon to the party.Want more Cheers & Jeers? Subscribe to TV Guide Magazine now!Dillon's big-screen career careened wildly off course after he unwisely chose to follow up his Oscar-nominated turn in 2004's Crash by taking a backseat to Lindsay Lohan and an anthropomorphized VW in the all-too-prophetically ... read more
Matt Dillon is set to guest-star on Modern Family as Claire's ex-boyfriend, Entertainment Weekly reports.
The Oscar-nominated actor, 46, will appear on an upcoming episode in which Claire (Julie Bowen) learns her ex has become good friends with her... read more
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Played through the demo. Great game, look forward to the full version.
Played through the demo. Great game, look forward to the full version.
Not Hype. Polish. This game is extremely polished. Something missing from most android games. The graphics are beautiful and the gameplay is extremely smooth. The music and sound effects are genuinely fun and add a tremendous amount to the game. Despite all of the above, it does not cause my Droid 1 to run hot.
Another game that exhibits the same qualities is Tiki Tower.
I LOVE this game. I had it on my iPhone and still use my wife's iPhone to play this game. SO happy its on Android now. Will be an instant purchase for me when its released as a full version. Everyone should try this game. I'll bet you'll love it too.
cant wait for the full release
NOW I see why some ppl coming from the iPhone always mention missing this game.
I havent played it yet, it just looks like fun. Anyone play Pain for the PS3? If u like Pain, this looks like something similar.
The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at times of challenge and controversy.
MLK, Jr.
I really wish there were more polished games like this, granted it's a new system and people are still getting used to it, theres only a few games that really shine on it.
Android does where iPhone doesn't. Droid can where Backflip shouldn't
I just finished all the beta levels. Great game. I was working on getting 3 stars in on the levels on my ipod touch so I guess I will stop that and wait for the full release on android.
The game seems to be running really smooth on my Motorola Droid 1. Actually it runs better on my droid than it did on my ipod touch. Loading times are extremely quick and I can switch between screens without any lag at all.
fun game, i finished all the beta levels pretty quickly. Will def check out the full version. I too noticed it ran really smooth the whole time, not a single hiccup, and I was running it from the sd card. Android needs more well polished games like this


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Food Stamps
NC Warned To Fix Food Stamp Applications Problems
Federal regulators have warned North Carolina's health agency to resolve delays in processing food stamp applications, or face losing federal money to run the program.
North Carolina To Continue WIC Program After Securing Funds
North Carolina state government announced it will resume issuing benefits to poor women and their children through a federally funded program.
NC Families Go Hungry As Food Assistance Delayed
RALEIGH, N.C. (AP) — Rahab Kinity didn't expect to be hungry. The 38-year-old single mother supported herself and her teenage son working two jobs as a medical assistant, managing to save enough to buy a […]
Poverty In America: Facts About Welfare
(CBS Charlotte) — Too often, poor Americans are judged, criticized and labeled simply because they do not make a lot of money or because they are "welfare dependent." There are a plethora of stereotypes that […]
NC To Require Criminal Background Checks On Those Seeking Welfare
Some North Carolina legislators agreed Tuesday to require county social service workers to perform criminal background checks on people seeking welfare and food stamps, but the legislation provides no money to pay for the reviews.
Bill Requires NC Welfare, Food Stamp Crime Checks
RALEIGH, N.C. (AP) — Some North Carolina legislators want social service workers to perform criminal checks on welfare and food stamp requests to ensure law-abiding people get federal benefits first. The House Health and Human […]
S.C. Lawmaker Challenges Haley To Use Food Stamps
A South Carolina lawmaker is challenging Gov. Nikki Haley and the state's DSS director to try to eat healthy foods on a food stamp budget for one week.
South Carolina Wants To Discuss Food Stamp Changes With Feds
South Carolina officials hope restricting what people can buy with food stamps will cut down on obesity.
Opinion: Romney's 47% Don't Pay Taxes Remark Is 100% Controversy
Romney thought he was talking amongst his teammates in the locker room last May 17 only to find out that there was somebody on the other team hiding behind the lockers. Had he known a member of the other team was lurking back there, he would have chosen his words more carefully and had presented more carefully-chosen data than the data of which he swiftly generalized.
GOP Leadership Protects Their Budget While Cutting Ours
On Friday, June 8, House Speaker John Boehner, House Majority Leader Eric Cantor and the Republican caucus perfectly summed up exactly how little regard they have for the American public. They talk about budget cuts. […]


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As a valued client of BMCFerrell, we have always believed in them, and been honored to represent this great ministry. But….when you go and roll your sleeves up in one of their events, like I did last month, you will be amazed at what God is doing through Steve and Catherine, and their wonderful staff and volunteers.
I was involved in the Ashe County Day of Blessing. Several hundred parents and children lined up for an admission ticket that entitled them to free games, hot dogs, shoes, clothing, and many other fun activities. I have never seen such smiles come on the faces of some of the children who live daily in oppression, poverty, and want.
I met a man and his wife who had two sons of their own, and were caring for a two year old daughter of a neighbor. The little girl was handicapped, and therefore, rejected by her mother. This dear couple was caring for her as if she was their own. However, they had no money, no car, no job, and were told by the utilities company's their lights, water, and gas would be turned off within a week. These are the kind of people that Steven and Catherine minister to tirelessly. Their mission field is right here in the United States. The Appalachian Mountains are full of children and families like these.
After the beautiful day outside sharing the love of Jesus and the "goods" with people, we had a service in the community center.
There were songs, dramatic and dance presentations, and then Steven shared the Gospel of Hope with the standing room only audience. I would say at least one half of the people received Christ.
At the end of the service, Steven sat in a chair, and asked the children to line up to come up on the stage. One by one, I saw him look each child in the eyes, and tell them they were special, they were beautiful, and that God had a good plan for them. I wept as I saw Steven lay his hands on their heads, and bless each child. This took a long time.
As the people left, they formed a line with their cars and trucks, and drove through an "assembly line" of blessing.
Bags of groceries, toiletries, and various household items were loaded in each vehicle. Now, they didn't just have a fun day, they had provisions for quite a while.
We have just got to get the message and story of Shelter Rock out, far and wide. Although they have expanded dramatically, they can't keep up with the need, or with their vision to make a difference. Please go to Shelter Rock. Contact Steven and Catherine, get to know them, and be a part of something awesome that God is doing in the mountains of North Carolina, Kentucky, and Tennessee.