Cultural Factors In Problem Gambling Among The Chinese

The most current Diagnostic and Statistical Manual of Mental Disorders (APA, 2000) provides only a single gambling-related diagnosis: Pathological Gambling. This diagnosis requires that an individual meet at least five out of ten criteria which are representative of problem gambling among Western samples. However, even in the West, many individuals suffer significant financial and interpersonal consequences from gambling without meeting full criteria for this mental disorder. The literature typically refers simply to “problem gamblers,” a category which is inclusive of these subclinical cases as well as those which would meet diagnostic criteria (Raylu & Oei, 2004). In this paper we will follow the same convention, referring to problematic gambling behavior as that which is subjectively “out of control” for the gambler, whether or not it meets the Western diagnostic criteria. We will also see that conceptions of normative and problematic gambling vary across cultures, such that culturally-appropriate practices of diagnosis and treatment are called for.

In this article we will examine the differences in the ways that problem gambling is conceived of and presented within Chinese culture versus Western culture. We will review literature on the role that culture plays in the etiology and progression of problematic gambling behavior in general, as well as the specific cultural factors affecting its development among the Chinese people. We will see how the cognitive and emotional factors that lead to problem gambling in the Chinese are similar to and different from the factors that drive these behaviors in Western samples. Finally, we will examine whether our understanding of problem gambling among the Chinese may also inform our understandings of problem gambling in other Asian cultures.

We will conclude that, given the similarities between presentations of problem gambling across cultures, a cross-cultural model of gambling treatment which takes cultural differences into account may be possible. Because of the increasing size of immigrant communities in the West and the increasing intermingling between Eastern and Western cultures, such a model would be of inestimable value to clinicians now more than ever before. Regardless of whether a true cross-cultural model of gambling treatment can or will be developed, however, it is critical that clinicians consider both cultural and individual differences when designing and administering treatments.

The Role Of Culture In Problematic Gambling Behavior

Citing a significant gap in the literature on the role of culture in problem gambling, Raylu & Oei (2004) prepared a systematic review of the cultural variables involved in problem gambling and the cultural variations in problematic gambling behavior. They assert that gambling is a nearly universal human activity, with both problematic and non-problematic variations occurring in nearly every culture. Although there are not many studies investigating the prevalence rates of problem gambling across cultures, there is evidence that certain cultural groups are more vulnerable than others. The Western literature on gambling points to a number of significant genetic, social, and individual factors which contribute to problematic gambling. However, in order to develop better and more culturally appropriate treatments, the authors argue that these factors must be reexamined across cultures.

Cultural Prevalence of Gambling

Although there have been many anecdotal media reports that gambling problems are more prevalent among certain cultural groups, few systematic reviews currently support this notion. In the scientific literature, there is disagreement between studies as to which demographic characteristics predispose individuals to problematic gambling. Furthermore, most studies which have examined the prevalence of problematic gambling have done so within Western samples, while evidence suggests that cultural variations in the forms and functions of gambling may play a role in the initiation and maintenance of gambling behaviors. Even those studies which have attempted cross-cultural research on the topic have failed to explore the specific cultural factors which might influence gambling behavior. Raylu & Oei (2004) hold that this is a major limitation of the current literature on problematic gambling.

Many studies examining the prevalence rates of problem gambling have compared minority cultural groups such as indigenous peoples to the majority groups in the countries under study. Indigenous groups in the United States, Canada, New Zealand, and Australia have all been found to exhibit substantially higher rates of gambling behavior than the general populations of those respective countries. However, these studies have failed to investigate the relationship of problematic gambling with specific cultural factors such as norms, beliefs and values. It is therefore unknown whether culture is a significant determinant. Other factors such as socioeconomic status, unemployment, minority stress, or even genetic differences may very well be more important in generating this discrepancy (Raylu & Oei, 2004).

Cultural Perspectives On Gambling

In light of these limitations of the available literature, Raylu & Oei (2004) look to the cultural factors which have been implicated in other mental health concerns, and especially in substance abuse. They cite three primary, interrelated cultural factors which recur throughout the literature: cultural values and beliefs, acculturation effects, and attitudes toward seeking professional help. The authors hypothesize that these factors should also be important in the development and maintenance of problematic gambling.

Reylu & Oei (2004) argue that culture provides a framework by which individuals assess the desirability and risk of a given situation or behavior. These valuations are passed on by family members, respected community members, and through the social history of the community. According to the authors, each of these means of value transmission have been found to be relevant in the development of substance abuse disorders. They state that substance abuse is more common among individuals whose parents engage in and/or demonstrate positive attitudes toward substance use, as well as individuals living in communities where substance use is encouraged and considered normal.

This latter aspect is especially pertinent in the case of the Chinese, whose social norms and cultural history have portrayed gambling as “a way of life” for many generations, particularly among males (Reylu & Oei, 2004, p. 1096). Reylu & Oei offer that when one contrasts this Chinese cultural depiction of gambling with the historical condemnation of gambling among Muslim cultures, or the reserved approval that gambling has historically received in Western cultures, it becomes easy to see how the increased level of exposure and identification with gambling as a lifestyle and tradition could lead to increased gambling behavior among the Chinese. They argue that the collectivist orientation of Eastern cultures may further promote the retention of socially-endorsed gambling behaviors.

Because culture provides a framework not only for the assessment of value but also the assessment of risk, Reylu & Oei (2004) posit that cultural factors should play a role in individuals’ determination of what types of gambling behaviors are problematic. They cite research indicating lower overall rates of help-seeking behavior among minority groups, as well as the specific reluctance of some particular groups to seek help for mental health problems. It appears to be those cultures where the shame associated with problematic gambling is greatest whose members are the least likely to present for treatment, even when facing greater material consequences. This includes Arabic cultures for whom gambling entails an inherent shamefulness, as well Asian cultures for whom the loss of internal balance that problematic gambling represents is seen as disgraceful.

Cultural Factors in the Treatment of Problematic Gambling

In turn, the problem of poor service utilization among these groups may be caused or exacerbated by a lack of cultural sensitivity in the available treatment models. Treatments for problem gambling tend to be based on Western treatment models and do not take cultural variables into account, according to Reylu & Oei (2004). Thus, the treatment approaches used for problem gambling may be incompatible with the nature and etiology of problem gambling as seen from within other cultures.

For example, Reylu & Oei (2004) cite one study of Hong Kong residents which found that the solutions to psychological disturbances tend to be attributed to internal actions on the part of the patient. This is quite different from the predominantly external attribution that psychological treatments are afforded in Western cultures. Perhaps as a result of this cultural difference, the Chinese have repeatedly been found to rely on self-help and support from primary social networks when attempting to overcome mental health problems, rather than seeking professional help.

Gambling And Problem Gambling Among Chinese People

In order to correct a lack of systematic reviews of gambling and problem gambling among Chinese people, Loo, Raylu, & Oei (2008) performed an analysis of 25 studies on gambling among the Chinese. The Chinese culture is uniquely steeped in gambling, with its history including the oldest recorded accounts of gambling worldwide more than 3000 years ago. In modern China, social gambling is a common and accepted form of entertainment and celebration. This is also the case for many Chinese immigrant communities. A recent New York Times article described what has become a Thanksgiving tradition for many American Chinese: spending the day and night at a casino (Buckley, 2009). Problem gambling is also commonly reported among the Chinese, yet there is an unmet need for prevention programs and interventions that are tailored to the unique needs of the Chinese culture.

For the Chinese, gambling is predominantly considered a social activity. Several studies have found social and entertaining forms of gambling to be much more popular among Chinese respondents than other forms, such as games of skill or betting on horse races. The rates of engagement in gambling activities are consistently higher among Chinese people “who consider gambling to be a form of entertainment rather than as ‘gambling’” (Loo et al., 2008, p.1154).

The reported prevalence of gambling among Chinese communities has varied widely between studies. This may be due to culturally-determined variations in self-report. Studies on Chinese-speaking populations in both China and Australia have shown that individuals in these groups tend to underreport their own gambling problems, compared to the third-party reports of their friends and relatives. Loo et al. (2008) conclude that this is an example of the characteristic reluctance of Chinese people to admit self-regulatory failures.

Loo et al.’s (2008) analysis suggests that acculturative, social learning, and gender differences may also play a significant role in the development of problematic gambling behaviors in the Chinese. For example, higher levels of gambling were associated with both greater age and less education. Additionally, the country of residence influenced the amount of gambling that took place within Chinese groups. Chinese individuals living in Taiwan, a country whose dominant culture and attitudes toward gambling are relatively similar to those of China, gamble significantly more than those living in Australia. Australian Chinese were also more likely to report feeling guilty about their gambling behavior and to conceal it from others. Finally, Chinese males tended to have a longer duration of problem gambling than their female counterparts, and were much less reluctant to acknowledge that gambling had become a problem.

These findings have clear clinical implications for Western clinicians working with Chinese individuals. The practitioner should remain mindful of the potential for under-reporting of gambling behavior, particularly with male clients and in communities where gambling is not as accepted as it might be in a predominantly Chinese community. Furthermore, the practitioner would do well to frame the issue in a way that is sensitive to the Chinese client’s need to maintain a sense of internal control.

Cognitive & Emotional Differences in Chinese Versus Caucasian Gamblers

Oei, Lin, & Raylu (2008) noted that a substantial literature has developed over the last decade implicating two primary variables in problematic gambling among Western populations: gambling cognitions and psychological states. Some common types of gambling-related cognitions override the rational controls that would otherwise help to maintain control over the behavior. The psychological states of anxiety and depression are also related to problem gambling, and may further depress the gambler’s capacity to evaluate and react to the gambling situation pragmatically. Several studies have shown that the reduction of these two factors through cognitive and behavioral interventions was “the most effective treatment for pathological gambling” (p. 148).

Gambling-related cognitive errors can be divided into three major categories: illusions of control, illusions of predictability, and inconsistent framing of gambling outcomes. The “illusion of control” refers to a gambler’s sense that he or she can exert an unrealistic level of control over the outcome. This often includes superstitious behavior such as carrying a rabbit’s foot or not associating with losing gamblers. By “illusions of predictability” we refer to an unrealistic sense that the outcomes of gambling events can be predicted based on factors such as the weather, hunches, or the sequence of past wins and losses. Finally, “inconsistent framing” refers to a gambler’s tendency to attribute wins to internal factors and losses to external ones (Oei et al., 2008).

However, Oei et al. (2008) note that knowledge of these gambling cognitions has resulted from the study of Western samples. Despite the frequent generalization of these findings to other ethnic groups, it is largely unknown whether these same cognitive and emotional factors apply to Chinese problem gamblers. Research has shown that individuals with a Chinese cultural background are exposed to different environmental and socialization pressures, maintain different values and beliefs, and exhibit psychobiological differences from Caucasian populations that are evidenced in early patterns of development. They may therefore also exhibit differences in cognitions and psychological states related to gambling.

One example suggested by Oei et al. (2008) is the greater prevalence of superstitious thinking within the Chinese culture. Superstitious evaluation of the potential outcomes of gambling events has frequently been implicated as a cognitive factor in the development and maintenance of problem gambling in Western studies. In Chinese gamblers, culture-specific beliefs about luck, fate, and spiritual influence on events may present an “insidious and profound” (p. 150) precursor to problematic gambling.

To fill this gap in the literature on cultural factors in problem gambling, Oei et al. (2008) conducted a study of 501 residents of Brisbane, Australia. Of those, 306 participants were identified as Caucasian and 195 were identified as Chinese. All participants were administered a problem gambling screening questionnaire, a measure of gambling-related cognitions, and a measure of depression, anxiety, and stress.

This study supported the hypothesis that the same cognitive and affective factors known to be related to problematic gambling behavior among Caucasians are also significantly related to problem gambling among Chinese Australians. Some differences of degree were found between the two study groups, however. Specifically, the Chinese participants had a significantly higher illusion of control over gambling events than their Caucasian counterparts, as well as a significantly lower perceived ability to stop gambling (Oei et al., 2008).

Clearly additional research is needed to confirm and expand upon these results. However, these findings suggest that similar clinical approaches may be effective with both Caucasian and Chinese problem gamblers. We are also given clues about how to design more culturally appropriate treatments for gambling problems. Interventions for problem gambling should target those cognitive and affective elements that are most culturally and individually relevant.

Applicability to Other Asian Cultures

As we have previously noted, many cultural similarities can be found between Asian peoples. This raises the question of whether our understandings of problematic gambling behavior among the Chinese might also apply to other Asian cultures. The literature on this topic is extremely sparse.

Emotional and Acculturative Factors in Vietnamese Women

One qualitative study of Vietnamese women living in Australia suggests that acculturative factors may play a substantial role in the development of problem gambling for female Asian immigrants, particularly those whose ethnic communities are very small (Chui, 2008). Loneliness and boredom are cited as primary reasons for taking up regular gambling activities. Some Asian immigrants feel that gambling is the only entertainment available to them in areas where they do not speak the local language. Study participants also discussed their reluctance to seek outside assistance for their problematic gambling. They described the same sense of shame and personal failure that we have seen to be associated with mental illness and help-seeking among the Chinese.

This study was too small for us to infer much about the larger Asian immigrant population. Additionally, the study participants were all women, while most studies of problem gambling have focused on men. Males in all cultures yet studied tend to be impacted more by cognitive errors than by emotional factors (Oei et al., 2008). However, the interviews described by Chui (2008) do underscore the necessity for clinicians to evaluate acculturative stress and culture-related resistance to treatment on an individual basis.

Cognitive Factors in Thai Lottery Gamblers

With regard to cognitive errors, we find a related quantitative study of lottery gamblers in Thailand (Ariyabuddhiphongs & Phengphol, 2008). This study examined the effects of superstitious thinking  by comparing two groups of regular Thai lottery gamblers. The first used superstitious methods to select their lottery numbers, such as searching for numbers at temples or divining numbers by dripping candle wax into bowls of water. The comparison group did not engage in any superstitious procedures to select their numbers.

The study found that lottery gamblers who used superstitious methods to select their numbers were also more susceptible to two particular cognitive errors: the “gambler’s fallacy” and entrapment. The gambler’s fallacy refers to the irrational belief that a particular gambling outcome is less likely immediately after it has taken place, and more likely when it has not taken place for some time. In the case of a lottery, the gambler’s fallacy leads players to believe that a number which has recently been drawn is unlikely to be drawn again. “Entrapment” refers to the escalation of commitment that occurs when a gambler has lost a substantial sum and feels that he or she is “close to winning” or has “gone too far to give up” (Ariyabuddhiphongs & Phengphol, 2008, p.296).

These cognitive patterns fit into the categories of gambling-related cognitive errors outlined by Oei et al. (2008). The gambler’s fallacy is based on an illusion of predictability, while entrapment seems based on a combination of attribution error and an illusion of control. Because it has been successfully applied to both Western and Chinese populations, and is a good fit with these findings from Thailand, Oei et al.’s basic model of gambling-related cognitive error appears to have cross-cultural applicability. This provides clinicians with a good starting point for evaluating individual cognitive factors which may encourage problematic gambling.

Conclusions

There is a relatively small amount of research on the cultural factors that affect problem gambling. However, based on the research we have reviewed, we believe there is sufficient evidence to conclude that cultural factors are significant. In order to provide culturally sensitive treatment to individuals with gambling problems, it is therefore important to take inventory of their cultural values and beliefs, acculturative experiences, and attitudes toward help-seeking.

Cultural factors are particularly salient when working with individuals from Chinese cultural backgrounds. Gambling is a heavily entrenched and widely accepted social activity in this culture. Superstitious beliefs about gambling outcomes, which have been associated with the development of gambling problems, are also more congruent with normative thought patterns in China than they are in the West. Oei et al. (2008) have suggested that psychoeducation targeting culture-specific superstitions about gambling outcomes may be of great benefit to the Chinese.

Individuals from Chinese cultural backgrounds also experience problematic gambling differently than those from Western backgrounds. They are more likely to attribute the problem to personal failures, are more likely to feel shameful as a result, and are more hesitant to seek help from outside their immediate social networks. This is an extremely important consideration for those working within Chinese communities, and indicates that preventive programs and community psychoeducational efforts may be very useful in these communities.

There are significant gender differences among Chinese problem gamblers that clinicians should also be aware of. Chinese females tend to be more heavily impacted by psychological factors such as anxiety and depression than their male counterparts. Conversely, Chinese males tend to be more susceptible to gambling-related cognitive errors.

Finally, although much more research is needed, it seems that cultural understandings of problem gambling among the Chinese may be largely generalizable to other Asian cultures. The current literature shows a broad overlap between the components of problematic gambling in Western cultures and those in China. The primary differences appear to lie in the degree to which particular cognitive and affective factors are expressed, rather differences in the types of factors that are present. This bodes well for the development of cross-cultural treatment models.

Discussion

How Changes in Chinese Culture May Affect Problem Gambling & Its Treatment

The articles which we have reviewed have not discussed the potential effects that changes in culture may have on the presentation and conceptualization of problematic gambling. However, neither mental illnesses nor their associated diagnoses are stagnant. They change based on new scientific understandings as well as cultural shifts which alter the range of what individuals consider to be possible within their cultural frameworks. The range of possibilities also varies widely from one individual to another even within an apparently unitary cultural framework.

It will therefore behoove the culturally-sensitive clinician to pay attention to the phenomenological differences in clinical problems both within and between cultures. Depending on an individual’s level of exposure to Eastern or Western thoughts, ideals, and role models, he or she may exhibit attitudes toward gambling which are more or less congruent with the “Eastern” or “Western” attitudes which we have described. In a complicated and changing world, we must always be mindful of individual differences, no matter how scientifically grounded our preconceptions of a given culture may be.

Personal & Professional Importance of this Topic

The Chinese people comprise the largest ethnic group in the world, representing 22% of the planet’s population (Loo, Raylu, & Oei, 2008). Many millions of those live outside of mainland China, making it likely that the average clinician in just about any geographical location will encounter patients from Chinese cultural backgrounds. Unless clinicians are apprised of the unique cultural factors affecting these individuals, they will have difficulty providing them with high-quality services.

One of my own clinical interests is the treatment of impulse-control disorders. These disorders include substance abuse, problematic gambling, eating disorders, and compulsive behaviors. Behaviors which are subjectively involuntary and yet apparently volitional represent a fascinating interaction between conscious and unconscious processes. These include not only neurological, cognitive, and emotional factors, but cultural influences as well. As Castillo (2001) has argued, culture is a determinant of possibility, and so shapes the way in which both pathology and its resolutions are able to manifest.

Problem gambling is a fascinating topic for cultural study, because it is a rather pure form of impulse dysregulation. Unlike substance abuse or eating disorders, the problematic behavior is not tied to any physiological dependency. However, the manifestations of problem gambling often resemble substance abuse in both their inward and outward aspects. I was very interested to find such good research on this problem within the Chinese culture, and to find out the ways that cultural differences play into its etiology.

A Treatment Scenario

Clinical Vignette

We will now adapt a clinical vignette presented in Chui (2008, p. 277), in order to see how our understandings of culturally-appropriate treatment for Chinese problem gamblers might play out in clinical practice:

Ms. Choi, aged 39, is a divorced mother of four who is receiving a government pension as a single mother. She came from China to Australia in 1995 when her ex-husband sponsored her and the children. She was introduced to gambling by her friends who would drive her to the casino. Her ex-husband also encouraged her to gamble as a social activity because she stayed home most of the time. With limited English skills, she lacked vocational skills and felt dependent on her ex-husband. At the casino she would play card games, in particular blackjack. She would also watch other people play and bet her money on them (or “back” them). She believed that these other people had the “skill.” She would spend AUS$500-$600 a week on gambling and often borrowed money from her friends. She also felt obligated to financially support her family back in China.

Treatment Planning

This case exemplifies some of the cultural differences we have examined. The Chinese, as we have seen, tend to consider gambling a much more social activity than do individuals from Western backgrounds. In this vignette we see a lot of social encouragement for Ms. Choi to engage in gambling as a way to augment her social life and seek entertainment. An effective treatment plan for Ms. Choi will therefore need to help her to improve her social connections and find recreational activities outside of gambling.

The gender differences that we have seen described in Chinese gambling patterns also come into play in the case of Ms. Choi. Compared to Chinese men, cognitive errors related to gambling processes and outcomes play a relatively small role in the etiology of problem gambling. This appears to be the case for Ms. Choi, who engages in gambling primarily to fulfill emotional needs. It will therefore behoove the clinician to assess Ms. Choi for symptoms of anxiety and depression and to address these symptoms as needed. Based on the literature we have reviewed and on Ms. Choi’s clinical presentation, we will be surprised if these emotional factors do not underlie her loss of control over gambling behaviors.

Finally, we see in Ms. Choi’s presentation a combination of dependency and obligation that are almost certainly damaging to her self-concept under the present circumstances. Each of these feelings is related to gender roles that would be and most likely were adaptive for Ms. Choi during her life on mainland China, but which now are failing to serve her emotional needs. It will therefore be a major task of the therapy to assist Ms. Choi in becoming acculturated to her new environment. The therapist will need to help her critically evaluate the differences in cultural and personal expectations that face her in her new life in Australia.

References

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
• Buckley, C. (2009, November 26) A tradition that cherishes poker, not pumpkin pie. The New York Times, p. A28.
• Ariyabuddhiphongs, V. & Phengphol, V. (2008). Near miss, gambler’s fallacy and entrapment: Their influence on lottery gamblers in Thailand. Journal of Gambling Studies, 24, 295-305.
• Castillo, R.J. (2001). Lessons from folk healing practices. In Seng, W.S. & Streltzer, J. (Eds.), Culture and psychotherapy: A guide to clinical practice (pp. 81-101). Arlington, VA: American Psychiatric Publishing.
• Chui, W.H. (2008). True stories: Migrant Vietnamese women with problem gambling in Brisbane, Queensland. Journal of Social Work Practice in Addictions, 8(2), 276-280.
• Loo, J.M.Y., Raylu, N., & Oei, T.P.S. (2008). Gambling among the Chinese: A comprehensive review. Clinical Psychology Review, 28, 1152-1166.
• Oei, T.P., Lin, J., & Raylu, N. (2008). The relationship between gambling cognitions, psychological states, and gambling: A cross-cultural study of Chinese and Caucasians in Australia. Journal of Cross-Cultural Psychology, 39(2), 147-161.
• Raylu, N. & Oei, T.P. (2004). Role of culture in gambling and problem gambling. Clinical Psychology Review, 23, 1087-1114.