Problem Gambling A New Zealand Perspective On Treatment

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This article is written from the viewpoint and experiences of two counselors who are community development workers and researchers working in the field of Asian social services for people with gambling problems. It discusses the factors that shape Chinese migrants’ gambling behaviors in New Zealand in relation to the difficulties that they may encounter during their migration process, such as insecurity in the new country and disconnection from their family and friends. Also, some individuals have little experience of legalized casino gambling prior to coming to New Zealand and they tend to use gambling as a form of escape from their problems. The article concludes by proposing directions for future research and development of services to help Chinese people affected by gambling problems.

Asians make up the fastest-growing ethnic community in New Zealand today. Between 1991 and 2001, the number of people who self-identify as “Asian” grew by 140% to 238,180 people, or 6.7% of the New Zealand population (Statistics New Zealand, 2002a). Asians are now the third largest ethnic group in New Zealand, just after European and Maori. Chinese are the largest ethnic group within the Asian population (105,057), followed by Indian (62,190) and Korean (19,023) (Statistics New Zealand, 2002b). The percentage increase in the Asian population has been mainly due to large migration gains; 52% of the Chinese group, 42% of the Indian group and 87% of the Korean group were born overseas and have been residents in New Zealand for less than 10 years (New Zealand Immigration Services, 2001). Ninety-eight per cent of Asians live in metropolitan areas.

1. Problem gambling services are funded through a levy on gambling operators. The levy is collected from the profits of New Zealand’s four main forms of gambling: gaming machines in pubs and clubs; casinos; the New Zealand Racing Board and the New Zealand Lotteries Commission.
2. There are three main sources of information on gambling in New Zealand. First, there are administrative collections in which data are collected in processes ancillary to taxing, licensing or treatment. Second, there are data produced through prevalence surveys or surveys of attitudes towards, or participation in, gambling.

There were 3 main forms of legal gambling available in New Zealand during the period covered by this assessment (in descending order of expenditures in New Zealand in 1994): lotteries and scratchcards, on- and off-track betting on horse and dog races, and gambling machines in taverns, sports clubs, and social clubs. 23 The first casino was not.

Anecdotal accounts and media reports have made frequent reference to the disproportionate level of participation in gambling by people of Asian appearance or from Asian countries (Horton, 1996; “When the stakes,” 2000; Tan, 1998; Tse & Tan, 2002). Bell and Lyall (2002) recalled:

At Sky City Casino last night, Pakeha [i.e. “Europeans” in the Maori language] made up perhaps five percent of those present. Numerous young Maori and Pacific Islanders, smart in their gold metallic waistcoats, were croupiers and cashiers. A few older Polynesian women smoked and drank beer at the poker machines, perhaps running two or three machines at one time. Everyone else was Asian. (p. 233).

To date there are only very few studies on gambling problems among members of the Asian communities. In the 1991 New Zealand National Survey (Abbott & Volberg, 1991), Asians had similar prevalence rates (1.2%) of probable pathological gambling (past six months) to Europeans. However, in the 1999 National Survey, no Asians were identified who had current gambling problems (Abbott, 2001a). The researchers noted that these findings should be treated with extreme caution because of the small sample size of Asians and other methodological factors that could reduce the quality of the information obtained (Abbott, 2001b).

Blaszcynski, Huynh, Dumlao and Farrell (1998) distributed Chinese and/or English versions of questionnaires to parents (n=508) through children attending a local Chinese-speaking school in Sydney, Australia, and found that 2.9% of the sample could be classified as pathological gamblers during the previous 6 months (using a South Oaks Gambling Screen (SOGS) cut off of 10 items) and 7.8% of the sample could be classified as problem gamblers (cut off of 5 items). The Victorian Casino and Gaming Authority (Australia) commissioned a telephone survey using cultural groups’ first language in interviewing their research participants via telephone. It was found that 10.7% of Chinese (n=159) and 10.5% of Vietnamese (n=173) scored 5 or more on the SOGS, compared to 1.5% of the general community (Cultural Partners Australia Consortium, 2000). Moreover, for those who participated in gambling activities, Chinese (mean = A$55.74; median = A$20) and Vietnamese (mean = A$23.26; median dollar = A$6) tended to spend considerably more money than the general community per week (mean = A$10.83; median dollar = A$1). However, it is unclear what proportion of the respondents in these studies were recent immigrants to the countries where the studies took place. Also Abbott (2001b) added “while some Asian sub-groups may have low rates of problem gambling it is expected that, overall, this rapidly growing sector of the population will have rates at least as high as those of the general population if not higher. Further research is required to clarify the nature and extent of problem gambling among Asians and recent migrants to New Zealand” (p. 31).

A study by the Chinese Family Life Services of Metro Toronto (1995) in Canada found that Chinese there gamble for many reasons, including making money, escape from problems, excitement, entertainment, social activity, fantasy, charity, and low self-esteem. Despite the likelihood of higher levels of gambling problems, research has indicated that Asian people may be less likely to seek help for their problems. In New Zealand in 2001, Asian clients using the telephone helpline and personal counseling were greatly underrepresented, at 2.6% and 3.0% respectively of the total client population seeking specialized services for gambling problems (Paton-Simpson, Gruys & Hannifin, 2002). Asian clients attending counseling services indicated that casino table games were their primary gambling mode whilst a small proportion mentioned non-casino gaming machines and track betting. Immediately prior to seeking professional help, Asian clients tended to have lost large sums of money (Abbott, 2001b).

Against this background it becomes necessary to investigate the incentives and restraints that operate for Chinese gamblers, especially those new to New Zealand. Based on treatment and research experiences, the aims of this opinion article are to (1) explore the reasons why Chinese migrants gamble; and (2) formulate key research questions for future studies.

Between 2000 and July 2002 the number of clients (migrants to New Zealand) using the face-to-face Asian counseling services increased steadily from 17% to 37%. A similar trend was also noticed for the Asian telephone hotline services, with the number of clients increasing from 11% to 17% between 2001 and July 2002. The clients’ countries of origin include China, Hong Kong, Taiwan, Malaysia and Singapore. In what follows, we will examine carefully the non-specific factors that predispose a recent migrant to vulnerability to developing gambling problems.

Gambling has been part of the social fabric of the Chinese society for thousands of years. First recorded around 700 BCE (A Brief History, 1991), some forms of gambling have become so intertwined with social life that they are considered acceptable, even as healthy hobbies. For example, Mah-jong has been around since 10 ACE (A Brief History, 1991). Some Chinese feel that playing Mah-jong can keep the mind active, especially when they are old, as a way of preventing deterioration in mental functioning. It is widely considered to be a normal way to socialize with friends and relatives. Horseracing is considered a harmless hobby as long as the money involved is “reasonable” and the player's peers are socially acceptable. There is a Chinese proverb saying: “A little gambling is soothing and relaxing; heavy gambling could affect your mental health.” Furthermore, a government's attitude to gambling can influence people's participation. For example, beginning in November 1995, prisoners in Hong Kong have been allowed to read horseracing news. Lotteries are popular in Hong Kong and Vietnam because of the small amount of money involved and most people see it as harmless (Chinese Family Life Services of Metro Toronto, 1995).

At social gatherings such as wedding banquets and during such festival celebrations as Chinese New Year, Chinese people play games of chance such as Mah-jong, card games, and attend cockfights and cricket fights with their family and friends. Children and teenagers are introduced to these games or gambling activities without being told the potential harm caused by gambling. The boundary between recreational and problematic gambling may be indistinct, and people may have difficulty recognizing when and how gambling might become a problem to individuals and family. However, we must acknowledge that all of these potentially harmful activities have provided recent Chinese migrants a great deal of opportunity for social gathering, meeting new friends and enjoyment. What remains a challenge to recent migrants is how to reduce the harm to themselves and their family caused by gambling and how individuals can be responsible for their own gambling behaviors.

Among the clients who seek specialized counseling services for gambling problems, most of them (e.g. from China, Hong Kong, Taiwan and Korea) reported they did not have easy access to gambling activities prior to coming to New Zealand. Over the last three years of operation of the specialized Asian gambling counseling services in New Zealand, it is estimated that up to 95% of the total client population indicated they did not have gambling problems in their home countries before immigration. Some of them might have played Mah-jong or cards with members of their extended family but they seldom played with strangers, and had never been to a casino with free entertainment — for example, a grand Chinese restaurant and karaoke bar. Without forewarning, let alone education, Chinese migrants are exposed to a whole array of legalized gambling activities, including electronic gaming machines in pubs and sport clubs, lotto tickets and sports betting. These can be exciting and thrilling for recent migrants from Asian countries, who tend to find life in New Zealand a bit boring and monotonous, for their usual entertainments are not available here.

Little experience of gambling, coupled with the fact that some Chinese migrants might have a significant amount of cash and time on-hand, make them particularly vulnerable to developing gambling-related problems. Indeed, they are susceptible to experiencing a large loss of money to the extent that it could threaten their ability to start a business, seek employment, pay tuition fees or simply establish a new life in the new land they now call home.

Within a new country, the migrants that can speak English still find that they have difficulties in communicating with local people, as both groups have different accents and topics of interest for conversations. Those who cannot speak English have tremendous difficulties in making new friends and conversing with new neighbors. Consequent to this are experiences of social isolation, withdrawal and disconnectedness from a place that is already foreign to them. The irony is that gambling seems to take away the language barrier and social isolation problems. For instance, in a casino one does not need to speak or have command of a spoken language. Gambling activities can be satisfactorily conducted purely by using hand gestures. One does not have to speak a single word to enjoy the presence of other patrons in a gambling venue, by feeding money continuously into the machine or just making sure money is put in the right place. In addition, recent migrants are more likely to meet Chinese or old friends in a casino than anywhere else in the community.

Adjustment to living in a new country is not an easy process and may not work out for everyone. Chinese migrants may come across multiple difficulties. Culture shock and persistent anxiety can result from the loss of familiar signs and symbols of social intercourse. These signs, or cues, include many different ways in which we orient ourselves to situations in daily life such as when to shake hands and what to say when we meet people, when to take statements seriously and when not. The usual extended family network no longer exists and new support systems have not been established. Whenever new migrants are confronted with difficult situations, whether related to employment, relationships or finances, they have difficulty finding people to provide support. Extended family structures and community-centered ideologies are one of the major characteristics of Chinese culture (Arthur, 2000). Fundamental to Confucian thinking is how the maintenance of one's well-being begins with the individual and proceeds through the regulation of family (Tseng, 1973). Emphasis is placed upon harmonious relationships between parents and the children, and caretaking by elders for younger family. The family is expected to and would provide the needed practical and emotional support to their members during times of stress.

It is sad that people seeking counseling services for their gambling problems often say they use gambling as a form of escape from problems, at least temporarily. When this happens, a vicious cycle is activated. When migrants cannot cope with the enduring adjustment difficulties related to recent migration, some resort to gambling as a form of release from stress. But the more they lose at gambling, the higher their level of frustration and anxiety. They become trapped into chasing money they have already lost. The problems are exacerbated by the sheer fact that new Chinese migrants have limited social supports, little knowledge about the types of local services available (e.g. budget or legal advice, mental health, social and family services) and are not accustomed to seeking help from others, including from social services and health professionals.

Problem Gambling A New Zealand Perspective On Treatment Plan

Obtaining employment is acknowledged as one of the major obstacles during the settlement phase in a new country. In New Zealand, 95% of recruitment consultants and human resource managers believe that some groups in New Zealand experience discrimination in employment (Ministerial Advisory Group, 2001). Research by the University of Auckland and Auckland City Council revealed that most Asian migrants believe that New Zealand employers undervalue their qualifications and skills. They feel that businesses put unduly high emphasis on local experience and language proficiency at the expense of their outstanding qualifications, substantial skill and experience (Equal Employment Opportunities Trust, 2001). Some of the recent migrants who are unable to obtain employment come to consider gambling as a legitimate alternative to earn a living. Additionally, feelings of impotence, loss of status, unworthiness and low self-esteem are associated with unemployment or underemployment. Some new migrants might feel that they can regain status through successful gambling. Some individuals may even find a sense of pride when they lose a vast amount of money; they are seen by their peers or friends from their home countries as big spenders and splendid gamblers — of course, assuming they can afford to lose the money.

Uprooting from one's country of origin and moving to another country is not always a straightforward process. Some people cope well and settle happily in their new country, but some experience various degrees of difficulty. Gambling is sometimes used by migrants as a form of coping for the problems encountered. Gambling is interwoven in Chinese culture and social traditions. Moreover, little prior experience in participating in legalized, freely available gambling and adjustment difficulties render Chinese migrants more vulnerable to developing gambling problems.

However, four key questions remain unanswered. Firstly, on one hand, some new migrants utilize gambling as a short-term escape from their problems; on the other hand, the majority of recent migrants do not use this avoidance-coping strategy. In other words, there is an urgent need to identify the key variables that determine how people cope with adjustment difficulties arising from the migration process. Why do some people turn to gambling as a solution while some do not and never would? What are the more specific factors that shape and reinforce one's gambling behaviors, in addition to the non-specific factors proposed in this paper (Zane & Huh-Kim, 1998)?

Secondly, it is of paramount importance to investigate the factors that either trigger or hinder help-seeking behaviors amongst those members of the Chinese community who develop gambling problems. Our service sees many people seeking professional counseling when they find themselves in desperate situations after incurring large debts or after being directed by the courts or the police. Also, we have little understanding of how this usually short-term, episodic, externally driven help-seeking behavior could be turned to internalized, self-owned determination to deal with the gambling problems. Our observation is consistent with data from the United States where Asians tend not to use mental health or related social services, or, when they do utilize these services, they exhibit more severe mental stress than their American counterparts (Sue, Fujino, Hu, Takeuchi & Zane, 1991).

Thirdly, we assert that gambling problems amongst Chinese in New Zealand have to be viewed in the context of adjustment difficulties associated with migration. Therefore, it would be useful to study if more comprehensive social, family and employment services, including an intensive case management approach (as opposed to traditional counseling interventions in an interview room) would be more effective.

It is important to realize that among the Chinese migrants, whether in New Zealand or around the world, there is great diversity in the level of participation in gambling activities and the extent of gambling problems. Features surrounding the immigration process, reasons for immigration, age at immigration, number of years in the new country and proficiency in English might determine how individuals cope with their new life and if they develop gambling problems. Therefore, the fourth research and development issue is to identify which are the high-risk groups of people within the community of Chinese migrants. Once these are identified we need to investigate what is the most effective way to deliver mass media campaigns to promote early detection of gambling problems and provide therapeutic interventions to those affected by gambling problems.

Problem Gambling A New Zealand Perspective On Treatment Center

We extend our appreciation to Dr. Peter Adams and Dr. Maria Bellringer for their comments on an earlier draft of this manuscript.

The perspective of pathological gambling as an addiction is a relatively accepted paradigm, despite it being categorised in DSM as an impulse disorder. Non-chemical dependence appears to be an uncomfortable concept, and so pathological gambling has, since its inclusion in DSM-III (1980), remained described as an impulse that has not been restrained.

In New Zealand, however, problem gambling (inclusive of pathological gambling, its most extreme expression on the gambling-problem gambling continuum) has been largely accepted as an addiction, and presentations have been regularly delivered at Cutting Edge conferences over the past decade or so. In the last year addressing the issues of problem gambling passed another important milestone with the enactment of the Gambling Act in September 2003. From that date the Ministry of Health assumed responsibility for the minimisation of harm that may rise from problem gambling, for the first time bringing problem gambling under the direction of mainstream health provision.

An important question now to be answered is, how should problem gambling treatment be delivered most effectively? The placing of problem gambling treatment under the umbrella of other mental health services not only legitimises the field formerly funded directly by the gambling industry, but also raises the potential of treatment delivery through other allied addiction therapy providers. There is evidence of varying levels of persuasion that problem gambling, as it becomes more intense, will co-exist with a number of additional negative conditions, some of which will be addictions. Substance abuse, particularly alcohol, is common with findings of between 25% and 63% of pathological gamblers meeting the criteria of substance use disorder in their lives (Shaffer & Korn 2002). In New Zealand, research with alcohol treatment providers has identified 11% of clients to meet the criteria of pathological gambling (Mackinnon & Paton-Simpson 1999).

Problem gambling appears to constantly co-exist with a range of other conditions, such as (in varying degrees), depression (up to 78%), anxiety disorders including Post-traumatic Stress, GAD and Panic Disorder, is commonly associated with alcohol abuse, personality disorders including Borderline PD and the previously inconsistent Antisocial PD, and so the list goes on (Unwin et al 2000; Shaffer & Korn 2002). Some researchers have queried whether problem gambling is not better defined with these symptoms rather than describe them as separate co-existing conditions (Shaffer et al 1997).

This perception has a considerable impact upon the future development of the field of problem gambling. Questions that arise may rightly be:

• How do these co-existing conditions impact upon the effectiveness of problem gambling focussed therapy (whether the co-existing condition existed before the gambling problem or not)
• In any event, if these ‘additional’ conditions common co-exist, shouldn’t they be addressed in any treatment plan of ‘problem gambling’?
• Does the current problem gambling workforce have the skills to identify and address these ‘additional’ symptoms?

All of these questions require consideration if the signalled importance placed upon addressing problem gambling sent by the mainstreaming effect of the Gambling Act is to be realised in the treatment sector. The WHO in a recent seminal paper in the chemical addiction field noted:

‘There is significant comorbidity of substance dependence with various other mental illnesses; assessment, treatment and research would be most effective if an integrated approach were adopted…..Attention to comorbidity of substance use disorders and other mental disorders is thus required as an element of good practice in treating or intervening in either mental illness or substance dependence’
p248, WHO (2004)

This view appears to be even more appropriate to problem gambling addiction. The high degree of comorbidity, and the poor history of problem gamblers to complete referrals raises the need for a ‘one stop shop’. Pathological gambling is defined as a ‘persistent and recurrent’ behaviour in DSM-IV and it may well be that a major influence on relapsing is failure to address these comorbidities as an integral part of the gambling behaviour.

Some amongst us may note that few therapists in addictions have skills in treating anxiety, depression and particularly personality disorders. The catchcry ‘a little knowledge is a dangerous thing’ is likely to be voiced strongly, and that referral to experts in these fields is the best practice. In addition, raising the skills of the existing problem gambling workforce to an expert standard in a number of additional fields may seem unlikely.

Others, however, may counter-argue that a level of expert is not required and would be ‘gilding the lily’. Training to recognise the various categories of anxiety disorders, depression and drug misuse, could be supported by brief, effective screens. Brief interventions may reduce the negative effects of these symptoms that may impact upon recovery from problem gambling. Almost certainly not addressing these symptoms will contribute to relapse, while recognising when, as a therapist, you are getting out of your depth would be part of the necessary training to ensure safety. In addition, both training and limits to interventions are determined not only by clinical considerations, but also by funding requirements. The often heard ‘we are not funded to do that’ can conflict with clinical sensibility.

Perhaps the welcoming of problem gambling into the mainstream health field can be a catalyst for skills enhancement for all addiction therapists. Problem gambling therapists may also be interventionists for substance misuse and anxiety/depression, while AOD therapists become problem gambling interventionists and anxiety/depression.

The future of problem gambling therapy delivery now appears to be wide open with the possibility of several new ‘starters in the field’. The skills appropriate to best practice in this field may require further training, and rather than viewed from the perspective of a barrier, perhaps the better view would be that outcomes may improve while improving the quality and skills of the field as a whole. A parallel approach would be upskilling other addiction therapists to address problem gambling amongst their own clients. The integration of problem gambling treatment into mainstream health provision may be an opportunity to start with a clean slate and model a new approach for all addiction treatment delivery. It could really be a winner!

References

American Psychiatric Association (1980) Diagnostic and statistical manual of mental disorders, third edition. Washington DC: Author

American Psychiatric Association (1987) Diagnostic and statistical manual of mental disorders, revision of third edition. Washington DC: Author

American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, fourth edition. Washington DC: Author

Mackinnon S & Paton-Simpson G (1999) Rates of problem gamblers presenting to alcohol and drug services. Paper presented at the Problem Gambling and Mental Health in NZ: National Conference on Gambling in Auckland.

Shaffer H, Hall M & Vander Bilt J (1997) Estimating the prevalence of disordered gambling behavior in the United States and Canada: A Meta-analysis. Boston MA: Harvard Medical School Division of Addictions.

Shaffer H & Korn D (2002) Gambling and related mental disorders: a public health analysis. Annu. Rev. Public Health 23:171-212.

Unwin B, Davis M & De Leeuw J (2000) Pathologic gambling. American Family Physician. Feb 1.

WHO (2004) Neuroscience of psychoactive substance use and dependence. Geneva: Author