Latest / Art of the Question / Why We Become Addicted to Gambling - Dr. Timothy Fong - #7

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Why We Become Addicted to Gambling - Dr. Timothy Fong - #7 · Art of the Question

• Julius Moorman: When did you first get interested in studying gambling addiction and when did you realize the severity of the problem? So first of all, thanks for having me on your podcast. It's great to be talking to someone across the pond, we say, and also fascinated and learn about what's happening there in the streets of Amsterdam. So I grew up in suburbs of Chicago, Illinois, and I majored in college in English and biology. And I was always fascinated with what You know the human brain and the mind and what motivates folks But I also grew up in a time and consider myself a generation X physician I grew up in a time in the mid 90s where addiction as a brain disease came about for the first time imagine 1995 it's announced that hey people with substance use disorder alcohol tobacco cocaine opioid use disorder There are things in their brains that are creating this condition Then when I came to be a physician in Los Angeles, finishing my psychiatry residency right at the turn of the century, 2002, we started to see gambling really emerge as a cultural activity. Online gambling, brick and mortar casinos, poker boom. And everyone would say, oh, this isn't an addictive behavior. And I always wonder, well, wait a minute, how could it be a disorder of addiction? How could it be an addiction as a brain disease? If there's no substance being ingested to change the brain structure and functioning, right? So right around 2002, that's when I really got fascinated by gambling and intersection on the body, the brain, the mind, the spirit, the wallet, all those sorts of things. And that led me to start asking questions and ultimately I found a mentor here in Los Angeles, a psychiatrist by the name of Dr. Richard Rosenthal, who was responsible for putting the criteria for diagnosing gambling addiction back then known as pathological gambling into the APA handbook. And really it's been 25 years of me asking questions about gambling and learning about gambling and trying to under cover its impact again on body, brain, mind, spirits and wallets. Super interesting. And yeah, I mean, in those 25 years, the landscape of gambling has changed significantly and is still evolving today, which we'll touch on later as well. But before we do all that, how do we define a gambling addiction? Because you briefly mentioned something about defining it. So I'm curious, what is the definition of having a gambling addiction and why is it so important to have a proper definition? I'll start with why it's important. need language. We need a uniform understanding how to characterize behavior and tell a difference between when is it just expected behavior, when it's versus pathological or a sign of the brain's functioning gone awry. So we start with defining basic words and that's gambling. So I define gambling simply as putting something of value at risk, usually money, but it could also be time. on an event of uncertain outcome in the hopes of winning a larger reward, but also recognizing a possibility of losing. So when you think about that, gambling is something we do every day in our lives. Do I take this job or do I not? Do I take this certain road to work or do I take a different road? Do I break up with my boyfriend or do I stay with him? So these are just different forms of risk taking and gambling. behaviors we have in our own lives. But what's changed in the modern day world is many, many, many forms of gambling are essentially now around games of chance. Slot machines, craps, roulette, betting on sports and things like that. So I think we too often just recognize gambling under that behavior related to trying to win money on games of chance. Then you pour into other words we use all the time. betting, wagering, and these are different ways of describing different forms of gambling. However, people will say, no, a bet is like between you and me. It's a contract. It's not based on ⁓ luck. It's based on I have a position, you have a position, and we just happen to put money against our positions. So all of that, we don't call it wagering addiction. We don't call it betting addiction. We call it gambling addiction. And for years, we called it addiction, addiction, addiction. But the word addiction doesn't have a scientific definition like substance use disorder. So now in 2026, what I say properly is gambling disorder, which is in line with all the other substance use disorders, alcohol use disorder, tobacco use disorder. That's all outlined in our APA handbook, a diagnostic manual for psychiatric conditions, which was put forth in 2013, 12 years ago. But you know, when we say again, the term problem gambling, gambling addiction, gambling disorder, we all mean the same thing, which is again, a pattern of continued gambling despite harmful consequences. And that's it. I think people at times, people say, well, what's the difference between gambling addiction, gambling disorder, or just frankly losing money gambling? Well, gambling by definition is risky. So, It's expected you will lose money if you just engage in it. So just because you lose money, it doesn't mean you quote, are a person with gambling disorder. Gambling disorder is very, very different. It's a set of behavioral actions around gambling, whereas characterized again, you continue to gamble despite harmful consequences. The gambling is the solution to all your problems. You experience. urges and cravings and thinking about gambling to the point where you struggle doing other things. You ask for bailing out for loans. You can't stop gambling. You have tolerance to gambling where you gamble more and more to get the same thrown effects. Again, very similar to what we experienced with addiction. I think if I had a hundred men and women with gambling disorder come into your show today, you'd have a hundred different stories of how their gambling disorder shows up. So unlike asthma, or lung cancer, or even a heart attack where the symptoms are somewhat similar, maybe a little bit different, but mostly similar. The symptoms of gambling disorder vary widely from person to person. Some people come in and they talk about, I have all this debt, I've been chasing my losses, I can't stop gambling, I had to ask my mom to bail me out and I'm struggling. Others say, well, you know. I gambled to escape my depression or I just can't stop thinking about gambling in of itself. Or I say, I'm going to, that's it, I'm going to slow down and then I just can't stop. Anyway, so words do matter. And I think it's certain, super important for people to say, well, do I, or do I not have a gambling addiction? How would I know? We had to remember the vast majority of people who that gamble on a regular basis. a of times a month, a couple of times a year, do not develop gambling disorder. We know about one to 2 % of the general population have gambling disorder. So it's not so rare that it's invisible, but it's enough that the significant number of people, and that doesn't matter what country on earth you're at. A lot of epidemiologic studies have shown that range, either 0.5 % up to 3 % in certain countries. So it really shows you it's a human condition that depending on what's happening there in your local country might have a different rates, but it's still very much a, a human, human condition that we see. Yeah. And why I can imagine that a gambling addiction, mean, all addictions are pretty bad. Otherwise we wouldn't really call them an addiction. They're problematic. So to say, however, I would. I would think that a gambling addiction is especially insidious because it can be very invisible, right? I mean, I know people who have struggled with an alcohol addiction, for example, and they can be pretty smart about it. People are known to be quiet about their alcohol addiction and they can suffer in silence for years. But still, if you're really truly addicted to alcohol, people smell it. You start like performing worse at your job. You have like bloodshot eyes. It's more visible. Whereas a gambling addiction in a lot of cases, I assume can, can be a bit more covert. You, you don't necessarily see whether someone has developed a gambling addiction other than maybe looking at their bank accounts. right. And that's, that's, that's when I first learned it 20 years ago. said, well, how do you tell? Because they can look. really fit. They can look like a million dollars and they can look spectacular, but inside they may be experiencing tremendous amount of harm and shame and guilt and lying and covering it up. And it goes back to again, just how we as humans think about money, right? When you have money, you're viewed as successful. You're viewed as someone highly skilled. When you lose money or even particularly when you give money away to a casino or to an online operator or a bookie, you're kind of viewed as, only a fool and his money are parted, right? And there's still that kind of false belief that gambling is something that's a little bit shadowy or it's a vice. It's only the lane for the greedy. So that's why there's a lot of guilt and shame to admit that, I lost it. But you're absolutely right, is that there is no intoxicated state of gambling that you can smell. There's a kind of an intoxicated state of gambling. There's a state of withdrawal where people are feeling miserable or where they're feeling euphoric or high, but because they're not altered by a substance, is impossible to detect. We don't have a blood test. We don't have a urine test. We don't have a brain scan. And again, it's the guilt and shame of the harm of gambling that drives people to hide it. I've had so many patients say to me, you know what, if I had a drug problem, You know, I just tell everyone and say, you know what, I got an alcohol problem on cocaine problem. People would be like, oh, that's terrible. But Hey, we're behind you a hundred percent to go to the rehab. Right. Or even more so they would say it's because of the drugs. When I was high on cocaine or meth, that's why I did those terrible things. When you're stone cold sober and you take out a loan or you spend your childhood, uh, know, child's budget, or you blow through your credit cards. When you're stone cold sober, you can imagine how powerfully guilty and shameful that is. And that's why I think people hide it even more. Cause it's just, no one wants to admit that they did these things to their loved ones or to themselves. Cause again, we equate when you lose money, you're not just a loser financially, but somehow you were a loser morally. You were someone who wasn't smart enough to stop. You didn't have the ⁓ self-control and shame on you for not knowing when to stop that sort of thing. Yeah, it's terrible. And why do we as humans get addicted to gambling? What happens in the brain when we gamble and why are some people more likely to develop an addiction and an unhealthy relationship to gambling? So it's an awesome question. The way I think about it is all addictions, all addictive disorders, why they show up is a combination of biological, psychological and social risk factors. So when we think about the brain, ⁓ naturally our brains react to all sorts of things that we're exposed to, lights, sounds, smells, experiences, you name it, right? So the same thing is true with gambling. When people gamble for the very, very first time, the ones who have gambling sort of tell me, you know, there's a genetic risk factor, there's family history of it. They describe, ⁓ my gosh, I feel alive. I feel incredible. I feel... normal, feel like I'm in a safe space for the first time in their lives. These are all biological responses to the gambling experience. So what's happening in the brain is as the body and brain are shown the gambling activity, the brain responds. And we do know that neurochemicals like dopamine and serotonin and epinephrine are highly involved. We do know that the neural networks that are responsible for attention, for reward, for self-control. for motivation are all somewhat built a little bit differently. And I think that's the easiest way I can explain it because I've had patients say from the very first time I sat down at a blackjack table, I knew that this was going to be part of my life for a long, long time. It's very similar to when the very first time people say, the very, very first time I took heroin, I said, ⁓ my God, this is amazing. I really like the way it makes me feel. That's a naturally. gifted, given biological response. You can't control that. That's just what's going on in the body and the brain. So again, it goes back to this understanding addiction as a brain disease, a combination of people born a little bit differently so that they respond and react in very, very different ways than the general population. And then as you do that behavior over time, the brain starts to have adaptations. It starts to change in and of itself so that it of adapts. There's a wonderful professor in Europe, Anna Gudrian, who did a tremendous amount of work on the neuroscience of gambling. And I think she came from the Netherlands or out there and she really has a lot of great work on that. But when I described to patients, that's how I describe it. I said, what's happening in your brain is so rapid, right? It's really under unconscious control. So when you're faced with all the experiences of gambling, the lights, the sound, the smell, the anticipation, the the game you're playing that you naturally like, your body responds and responds by pouring out neurochemicals that draw intention and how it responds and things like that. So there's been neuroimaging studies, there's been genetic studies, there's been a lot of blood sampling studies showing that again, the bodies and brains of people with gambling disorder react differently. As example, one study that was a landmark study really showed that, know, folks with gambling disorder versus folks without. If folks with gambling disorder were shown just images of money in the brain scanner, there were different parts of their brains that were activated compared to folks without gambling disorder. So again, it's a combination you're born differently and then as you gamble excessively, it changes kind of the brain functioning. Yeah. What I, what I liked that you said in the beginning is that we gamble. ⁓ During our daily lives, should I take the job? Shouldn't I take the job? Should I break up with this person? Shouldn't I break up with this person? I think in a sense, we have been doing that for a very, very long time. we back when we were still hunting for food, we were gambling essentially. And a big part of that was the unpredictability. We are going out to hunt. It's cold, it's snowing, but we need food. We are going to risk it anyway to go out there. And then as soon as you, you hunted deer or whatever animal you're chasing, you get a good feeling. get this, this, this hit, the dopamine is driving you to go out there and seek for success. And I think that that unpredictability is something which sometimes a win and then no wins for a long time. And then almost, almost a win is something that casinos and online gambling websites have gotten so good at to, to supercharge our, our primal desires for this unpredictability and success. of the greatest ways to reinforce human behavior is to give intermediate reinforcement, right? So that's exactly what gambling is. It's like, you know, you may or may not win. You just don't know whether you're to win the next time. And then you combine that with the idea that you could put a small amount of risk to win a massive jackpot, right? That's incredibly hopeful. So it combines both, you know, we naturally will reinforce ourselves when we don't know when the next reward is coming. Cause that's interesting, right? We're just. fascinated by uncertainty, but we know a reward's coming. We just don't know when. So imagine you're at a craps table and you're waiting for a long roll and you know it's coming and mathematically it may or may not, but you hope it's coming. And then that's why you stay there waiting and waiting and waiting. But also, you know that there could be a huge jackpot for a small amount of money, which is why lotteries are so popular, right? You just put a small amount in hopes of winning a massive reward. Well, that's incredibly seductive. But the other thing that, you know, gambling operators have, you know, they have a lot of things they can try out. So they can try out different kinds of bets, different kinds of wagers, different kinds of games. And if people love them, well, they can just pour more resources into them. If people don't like them, they shut them down and they go on to the next game. So they have an advantage, a built in advantage compared to us folks who are trying to help people stop, which is they can just try out different things and eventually, you know, the ones that work great work out really great. Which is why the online gambling stuff is, think is particularly concerning because it changes so quickly. ⁓ it's so available and it literally does not take much resources to try out different kinds of bets and wagers online. You know, it's not like you have to go put it in a lab somewhere. can just program it differently and see the public like it. Yeah. And in, in. In preparation of our conversation today, I've looked at some numbers and some research and one really interesting finding that I hope maybe you can tell me a little bit more about that is that they, when looking at brain activity of people who have a gambling addiction or they, it almost doesn't matter whether they are winning or losing. they, the same amount of dopamine gets released when people almost win or when they do win, like chemically in our brains, it's the same. Yeah. That's what's suppressing to me. Is what we call the near miss phenomena that you almost had it and that's what's going to keep you coming back for more. And it makes sense from a survival skill standpoint, because if you didn't have that, it's hard to maintain optimism, right? It's hard to maintain motivation. I think we forget a lot of what gambling is. It's about maintaining hope. It's about maintaining persistence and keep going toward the goal. If the goal is to try to win money and you lost and said, ⁓ that hurts so badly. I never want to try it again. People would never really take risks. And so on the flip side, again, why we have this gambling baked into our human condition is so that we can take risks. that we can try out different things that we can persist even in the face of losses or adversity. And it's hard to put the two together, but it makes a lot of sense. you know, even more so, not just the near miss, uh, that's rewarding. It's the anticipation of getting into the game that actually very, very rewarding. So for instance, a lot of my patients describe, well, it's, you know, as I'm driving to the casino, I feel as high or as excited as when I'm actually gambling, right? Or as, ⁓ the anticipation of a good thing happening is also another separate rewarding experience combined in the actual plane in of itself. So interesting. And what does, is it like some people are more likely to, to become hooked to gambling? Is that also the people that are, well, perhaps they, we've talked about like the, near miss experience and people that are persistent in a way, which persistence is, is in a way a good trait to have, right? If you don't, if you never, if you never give up and you've came, you've come so close and you've almost got it and you just keep trying, you keep trying until you get it. If we take out the gambling, that would be a great trait to have. I think many people that are successful are the ones that aren't willing to give up. to me, that's kind of interesting that that same trait possibly makes you more likely to become addicted to gambling. Well, again, think about, the psychological risk factor, we talked briefly about the biological risk factors, family history, genetic history, things like that. psychological risk factors that lead people to gambling disorder or things like that. Things like having a high level of impulsivity, acting without thinking about the consequences, being primed to really want to take risks, being primed to really want big, what we call sensation, know, somebody who just loves stimuli, light, sound, smell, action, and who wants to be, know, but there are other psychological traits. One is called loss aversion where Typically we are all pre-programmed when we lose something meaningful to us, it hurts, it's painful and we retreat and think about, we process what just happened. So imagine people with gambling disorder, they take a big financial loss and it hurts that day. The next day they may wake up and instead of that hurt still holding them back from doing it again, that loss aversion is gone. And they're like, you know what? I'm going to get it back today. So in other words, It's kind of ⁓ almost being too optimistic or too hopeful. ⁓ So that's another psychological trait. And think about all the great inventions of humankind, know, the light bulb, the internet, know, computers, what not. There's no way these things succeeded on their first try. And how many times have we heard those stories of people who persisted in the face of adversity or rejection, or when things didn't work out and then ultimately... It did, or maybe they decided to pivot instead of being coming in a carpenter, they became a musician and now we have, you know, a great song that they produced. So psychological traits though, that do lead to addiction are the same ones that can lead to spectacular success in other ways. So again, I've had so many patients say, yeah, I've been standing at a craft table for 10 hours or I've been playing the slot machine for 30 hours straight. And it's like, wow, well, on one hand we know that's obviously very addictive and harmful. On the other hand, if you can channel that strength and energy and persistence into something positive and useful, then suddenly that's called a good work ethic, as they say. So psychological risk factors are really unique. And I think that's when we try to do a lot of work with, with folks with gambling disorder to reduce the guilt and shame that they have. Right. And we do that by highlighting, you know what, you have some personality traits that may have led you to develop gambling disorder. But those same personality traits could lead you to be really, really great in other areas of life. And I think when people hear that, it's refreshing because they don't think of themselves as damaged or degenerate or a loser or somebody who should be blamed for doing terrible things. I think that's super, super important. Yeah. If anything, they're optimistic and persistent, which I would think of as very good traits to have. If you take out the gambling, if we look at the whole landscape of gambling, how has it evolved since you started to become interested in researching gambling addiction? Yeah. Where did we start 25 years ago? And what were some of the watershed moments during that time that really amplified? the gambling epidemic as we know it today. So a couple of things to keep in mind. So least in America, we've always had a very interesting and complex relationship around legalized gambling. know, our country was founded around gambling. It's funded the 13 colonies. had California Gold Rush and the desire to go make for a better life. Just coming to America is a massive gamble for a lot of folks, you know. So gambling's always been in American culture. But we've had waves of it where we promoted it, we prohibited it, we've allowed it, we've forbidden it. But really since, you know, early 2000s where we've now, I'd say the last 20 years have normalized and allowed legalized gambling to enter American culture everywhere. So fast forward even more so in the last five or six years where we've now allowed sports betting and other forms of gambling on our phones. Where to the point where we now have right now, every single phone in America, essentially in the world is able to gamble on some form of gambling activity, whether it's legal or illegal, it's there. And so you back all that up to we've changed what the world looks like. We now made gambling on games of chance. an expected part of our daily lives, not just allowable, not just normalized, but it's expected. So that's a huge part. So it's kind of like breakfast, lunch, and dinner. People expect it to be on their phones. The big watershed moments in gambling studies over the last 30 years, I think was really moving gambling, problem gambling, from the idea that this was kind of an impulse control disorder, we're not sure what this is, into the category that we know that for some folks it is an addictive disorder. It is no different than drug and alcohol addiction. So that really changed how we viewed it. Then I think number two is this idea that gambling is a public health issue. Meaning we regulate gambling like we regulate food and air quality and water safety, right? And why do we regulate it? Because it's risky, because there's money involved and we want gains a chance to be run fairly. We don't want consumers to be cheated out of their money and things like that. We also want to make sure that people don't use this as a way of moving money illegally. There are all sorts of reasons why we regulate it. So you fast forward to where we're at right now is I would argue the biggest step is that gambling is part of the public health lifestyle. It affects our economy. It affects our mental health. It affects relationships. It affects how people spend their time. It affects, and in partnerships, all sorts of different businesses that are now partnered together. Sports leagues, advertisers, internet, tech companies, software companies, credit cards, banks, payment processors. You know, a lot of the fabric of society is a run around just gambling behavior. So that's why it really is a public health issue. food quality and air safety. So now I think that those are some of the big watershed moments, but I think we're in this world where again, gambling and using money to wager on things, whether it's sports, politics, video games, ⁓ TV shows are just baked in to the world order. You know, there's very few countries left that literally do not have brick and mortar casinos. There's very few countries that don't have access to the internet where you can gamble online on a variety of things. And think that's so fascinating to me is that, you know, where you're at in Amsterdam versus where I'm in in Los Angeles, we can access literally hundreds, not thousands of gambling websites across the world and pour our real money into these things ⁓ today. Yeah. I mean, I think anyone who has ever looked into starting or developing ⁓ a habit, whether usually positive, maybe for the people that have read ⁓ Atomic Habits by James Clear, they will know that in order to form a habit, you want to remove friction or you can also do the inverse. If you want to stop a bad habit, you want to increase the friction. I would assume that having gambling websites on our mobile phone. ⁓ I don't assume I know that removed a lot of the friction back in the day. You had to drive all the way to the casino and yeah, it takes time. You have to physically be there. And now that we can gamble on our mobile phones, I think that's probably. Yeah. Kickstarted a lot of these numbers. that also visible in, the numbers of the amount of people that have a problem with gambling? Can we, can we see those moments in time? Like this is when we were able to start doing it on our phones and this is the amount of people that have a problem with, with gambling go up. What do those numbers look like? we're starting, we're starting to see that impact. It really starts with our smartphones, like 2010, 2012, something like that. Here in America, sports betting legalized are allowed for states to be legalized starting in 2018 or seven years later. Every few months we see more more gambling operators opening up their business because technology is easier and faster with AI. Again, the frictionless isn't just gambling websites, right? It's the ability to move money in and out of gambling websites. So if you had no ability to move money, then it doesn't matter how many gambling websites you have. Right. So, ⁓ imagine you had a gambling website, but they're like, ⁓ in order to deposit money, you got to send a check and wait four to six weeks for your account to open. Well, that's not what we have here today. So we really forget that the gambling websites are easy and it's also easy to move money in and move money out. That's where the frictionless parts go goes away. The part that's even more under the Nixon level of reducing friction is the teaser, you know, getting people to not only just log on, but just. here's a notification, do you want in on this action? Do you want this bet? All you gotta do is hit yes. So if you reduce that ability, you don't have to log on anymore. You just literally have a notification, click yes or no. That's even less frictionless. I imagine a day where it'll be not even on the phone, where it'll be either embedded in your glasses, like your meta glasses, or in your embedded chip in your arm or in your thought. That's science fiction, but you know, we might get there. So you put all together, what do we know? We know that gambling addiction prevalence rates have changed and they're changing faster than we can keep up. In America, we don't have a lot of great early detection warning signs. We don't have a lot of money poured into monitoring epidemiologic studies of incidents and prevalence of gambling disorder. But we have some and the few things that we know are the following. In every state in the United States of America, There's been increases in the number of people asking for gambling treatment help by when folks call the gambling helpline or when they Google gambling addiction help. We've seen those numbers rise up. We've seen more and more folks come into treatment. We also have seen a few states that have done surveys before they introduced mobile gambling and then after. Shockingly or not shockingly, you see those incidents and prevalence rates go up by a couple percentage points. where I grew up in the state of Illinois, that number was like 4%, you know, and that was much higher than previous epidemiologic studies survey. So, but we don't need, you know, fancy PhDs to know that is that when you have more access to an addictive behavior, you're going to have more addiction because you're going to expose the people who are biologically, psychologically, and socially vulnerable to this, to that product. It's no different than if you had heroin delivered into the front door. of every house three times a day. And eventually some, they're going to rise the number of people having problems with heroin that can happen. So again, but we focus on the good stuff is that again, the vast majority of folks are not going to develop full on blown gambling disorder, but that doesn't mean they're not going to be harmed. I think we forget that is that you can still incur a degree of harm by just spending money on these products. And although you may not meet criteria for gambling disorder, you may still end up spending a couple hundred bucks more than you intended. So there was a recent survey I saw that showed that the average United States sports better online was spending about $3,500 a year on sports betting. The average. The average. mean, again, we have no idea what their incomes were. We have no idea how those $3,500 spent impacts their financial health or their mental health. but that's still a pretty significant amount of money. And we know that the law of the few probably predominates where the big vast majority of revenue driven by gambling is probably still in the backs of the folks who are gambling disorder or really into this stuff. So you put it all together, it makes for some really interesting questions. And I think instead of saying, ⁓ my gosh, you know, what are we going to do? Because it's everywhere. is actually empower ourselves and empower the people around us to say, hey, it is everywhere and here what you need to know. ⁓ Don't fear it. Don't run away from it. Don't get too deep into it, but stay curious about what this product is. And it's kind of like the same thing where 30 years ago, the internet wasn't spread throughout, right? Now the internet is, and we've all kind of learned how to deal with the internet and we're still learning. But we see a lot of, you know, positive and negatives attached to it. So I think the same thing goes, holds true for gambling and increased access to gambling. We really need to just educate and empower ourselves to really understand what our, what we want our relationship around gambling to look like. Yeah, we legalized gambling in the Netherlands or online gambling, I should say in It was illegal. And then we decided to legalize it. Because so fought the government, people are going to gamble anyway. currently they're doing that from illegal websites. So if we just legalize it, then at least we have some sort of control over it and we know what's happening, which on paper makes sense. mean, our government did the same for cannabis, for example, and that turned out to work pretty well. mean, We don't really have a lot of people who have a problematic relationship with cannabis in the Netherlands. there are some people, but it's not a crazy problem and it's been been legal here for a long time. So I understand the reasoning, but it's not what happened with gambling at all. ⁓ As soon as it was legal, hundreds of thousands of new users entered the market, predominantly very young people from 18 to 25 years old. were, ⁓ yeah, the majority of the, of the new users and it created real problems. There were so many people who got into depth. then this was also part of my research when I still worked for the Dutch news. ⁓ pretty soon the government understood that they messed up. And that at least they had to ban advertisements on, on, on betting on gambling or at least very strictly regulated. So we saw, that's what we found out by, I don't know, you have something similar in the, ⁓ in the U S I believe it's called the freedom of information act or something that anyone can just ask for, for certain documents. So me and a colleague did that. And we saw that there were all these big gambling companies, they were lobbying. So they were directly ⁓ included in the legislation process to help shape the anti gambling advertisement laws, which was insane to me. And they were far more, they had far more influence than anyone. on the prevention side. any prevention addiction prevention experts, ⁓ the gambling website had far more more influence. And I will say now it's pretty strictly regulated and I think things are fine now. But to me, it's just so incredible that we it was illegal, decided to legalize it. And we just introduced gambling to so many. So many young people, it's astonishing. sports betting or that online casino games or what type of gambling? It's both. It's both. So, we, there, it was both sports betting and online casino games, ⁓ just both at the same time. Do you, do you think what one of, of the two is, is there, is one of those more problematic than the other? Well, it's a great question. mean, Possibly. The way we think about it is, for instance, ⁓ in America, sports betting encompasses a wide number of different kinds of bets and wagers, right? ⁓ The one that's the most popular is what we call the same game parlay, where you put a small wager down, you bet on four or five, six, seven different things to happen in one game, and you might get a much larger payout. That's much more random and the odds on winning that are much, much lower than say traditional sports betting where you bet your team versus another team to win or lose. So depending on the type of wagering and bets, I think the odds obviously are much more favorable depending or unfavorable. The concern with traditional online casino gambling like Blackjack and poker and you know, ⁓ dice and roulette and slots is that, you know, the longer you play, there's a much greater, the odds are very clearly in the favor of the casino and the house, right? So that's why there is a potential where those games over a long run are going to be profitable versus if you only bet on sports, betting only on winners or losers, you could actually, you know, the odds for the house are actually much lower. So it's a mixed message, but I think it goes back to, again, the type of bets that are being offered. What you're highlighting there is just that simple story. know, again, here's a product and here's an activity that by nature, by definition is risky. It's supposed to be risky. It's supposed to create a question. You know, you're not supposed to win. And I think that's part of the problem. The advertisement is false. When it says, ⁓ everyone's a winner and you can win big. And you know, there people with special skill on it. That creates a narrative that's not true. This is entertainment. We never question how much it costs to spend on a ticket to see a soccer game or a football game or have a nice meal, right? But we don't question how much should I spend on gambling? We say, how much can I win or how much am I willing to lose instead of using the word spend? But very simply again, why that matters is this, is that here are these folks that come in and are expecting gambling to be a moneymaker for them. See gambling as a job. See gambling as a way of bettering their lives financially. See gambling as an investment. None of these are true. That's where the advertising comes in. If the advertising is blatantly false or misleading, it shows only parties and fun and wonderful times, that's kind of like, you know, false advertisement that drives false expectations. So instead though, I think regulating it is super critical. because there's a huge difference between regulated gambling markets and unregulated. So the problem though, I think is that the average consumer can't tell a difference between what's a regulated casino gambling operator versus what's unregulated. And why I'm so concerned about unregulated is because of course, no protection for players, no tax revenue back to the government, no education, no guarantees to the player that they're going to get paid out. So a lot of my patients, when I say to them, why do you still insist on using unregulated gambling websites? And they'll say, well, you know, I could be anonymous. I don't want people to know they offer better games and the regulated ones. It's just easy. Something that frankly said to me, ⁓ I had no idea it was unregulated because they look really, really good. So in Amsterdam, didn't, did they reverse position and say, we no longer are offering regulated cause online. gambling or are they just tightened up the ads and things around it? It's still legal. Like certain platforms are illegal, such as we recently decided that Polymarket, example, which is a prediction market platform, but ⁓ we ruled that it is a gambling platform for sure. So we banned Polymarket, for example, you can still access it through VPN and stuff, but It's, ⁓ it's almost impossible to get your money out to that. We've briefly discussed friction, but you have to use crypto and then the Dutch crypto websites will not allow you to deposit crypto from polymarkets. So there's a lot of friction there. ⁓ but I argue like most of the just traditional gambling websites, they're all still perfectly legal. can wait, you, can log on right now. and wager on, I don't know, volleyball, women's Korean volleyball, don't know, whatever random sport comes to mind, but it's very easy and they did nothing to... Well, they did a few things, right? So first of all, they banned advertising, but also they made it more... ⁓ They gave some... responsibilities to the platform that if they notice that people were logging on a couple times a week, that they would get have to send out these warning messages and they would like have to get in touch with them. Are you sure that you still want to continue to play? And there's also people can ⁓ also enroll to exclude themselves from these websites. So if you recognize that you have a problem and you can't control yourself, You can basically ban yourself from all websites. there's definitely, we, definitely made some progress, but we made progress after we legalized something that shouldn't have been legalized in my opinion. mean, shouldn't it have, I don't know. I think I'm, I don't know if I'm, if I'm for a full band ban against gambling because I think for example, I have gambled. I have gambled maybe I gamble maybe once or twice a year and usually it goes something like this when I'm watching a football game or some other sports event together with friends. It will be a social event and in order to to raise the stakes in order to make the game more exciting to watch, we'll put on some put down some money and it'll be more. more fun, more exciting, you know, get a little more dopamine, you get a little bit more action and you're willing to spend a certain amount for an enhanced form of entertainment. Yeah. Some skin in the game. Yeah. Yeah. So, but, but to me, like that, I, I think that's fine, but I do also think that a lot of people are. Yeah, it's enough for everyone. So I think it's a very difficult issue. That's why I'm not sure if I, if I would be, ⁓ for a ban on, all casinos or whether we should just ban advertising. What is your take on this? So again, you know, it's getting rid of all online gambling is impossible. ⁓ it's going to happen. The technology is, is just too fast. So I think again, If I were running a government, I'd no, we have to offer some parameters for safety for the public. And we have to take it seriously to shut down the ones that are affecting the public health of our folks who are going into unregulated space. I think absolutely from everything around it though, needs to be looked at. Advertising in a way that's thoughtful, truthful, and not false is super important. Enforcing it. And the rules that you create are super important. So that means from the operators to do it safely to the users, you know, to the people that pay money, you know, all that needs to be done safely and quickly, you know, and have it there. And then lastly, again, you know, shutting down the unregulated operators, you know, to say, we take this so seriously to protect our citizens. If you try and do this in our country, we're going to say no, you're not going to allow to do it because we believe this product is so important that we don't want to see this happen again. If I were running and making illegal, you know, alcohol and selling it in the Netherlands and shipping it out, they eventually would shut me down. If I were selling cannabis that I made here in the US and brought it in the Netherlands and sold it without properly, I would get arrested. It's the same thing. It's just a different product. It's a digital product, which is very, I think sometimes people have hard time wrapping themselves around. So you remove the morality, you remove the, what you believe and just say, you know, this is what people do. And then we embrace what people do, but we do a better job of educating people at the very beginning of how to do it. The problem that I see is for at least my patients, by the time they come see a gambling addiction treatment person like myself, things are really severe. It's been years that have been going on with these behaviors of lying and chasing losses and running up debt and spending way more than the intended. And so by the time they come in, we're talking about $80, $100, $200,000 of money gone. You know, really horrible things like cancer spread to all the parts of the body. Instead, what we would like to do is educate people from across the lifespan, whether you're young or you're an adult or your middle age or an older adult about what these gambling opportunities can and can't do. What you just described there, you kind of naturally just found on your own and you said, you know what, this is going to be part of my life a little bit, but it's not so captivating to me. It's not so stimulating to me and not so activating to me that I want this every day in my life or I want it more and more. I'm not turning it to it as a way to deal with my own stress. That's what I'm hearing from you, Julius. And thank you for sharing that. And I think that's where some people naturally can manage that. Others though, who are biologically, psychologically vulnerable, as they get introduced to gambling, that's not what happened. They get into it, they get excited, they start chasing losses, start developing a firm relationship with it. And nowhere along the way does someone intervene. And that's really where we hope someone would. Maybe it's the gambling operator. Maybe it's the payment person saying, Hey, you know, we notice you're really spending a lot of time and money and we really want you to think twice before you do more. Maybe it's a healthcare provider. Maybe it's a family member. Maybe again, it's it's a father teaching a young son or daughter about what these things are. One of the biggest things we have here in California or America, that many of the young people that are gambling, are doing so because their parents are allowing them to gamble. The parents are the ones giving them their password and login. So in other words, the parents themselves don't realize how potentially harmful or addictive this could be. They just think, ⁓ it's normal. So those are the sorts of things that, you know, when you go back to like, what can we do? We really can do a lot better job of educating everybody what these things are and aren't, and just basically following the rules that we set for. So, ⁓ You know, again, when we've seen some countries have buyers remorse, you know, don't know what Australia did when it came to spread of video poker machines and they put them out there, they created some social harm, they yanked them back. But when it comes to online gambling, I think it's so difficult because again, even if you clawed it back and said, we no longer want this illegal, it's going to still spread. It's just too easy on the unregulated side because there's literally You know, it doesn't take much energy, just, you know, you and I could put together, if we had a little bit of computer knowledge and ability. And now particularly with AI that can generate all of the software and all of these numbers and stats that can put bets out. Right. think that's the thing about a lot of these sports betting apps. You don't have 24 seven gambling if you can't generate betting lines. Right. So in the old days, it was a human, you know, writing on a board, you know, teams and how much they're to win by. Now it's all computer generated to generate betting options and availability. That I think the story a lot of times people don't recognize is that it's not like some human cranking out these odds. It's all automated software. Yeah, no, for sure. And one thing before I really want to touch on some of the treatments, but before we do ⁓ one thing I was curious about. Are men more likely to have a problem with gambling or is it pretty even distributed? Yeah, we see the trends are still predominantly more biological men and biological females developing gambling disorder. There's lots of speculation as to why, but it's not the way I think about it. It's not that female or not. They're still gambling, but they're gambling on different types of games and Oftentimes I think they're having signs and symptoms that are oftentimes even more hidden and harder to come out. but biologically, yeah, there's something different about the male brain that ⁓ where the appeal of gains and ⁓ reward instantly, instant gratification, getting stuff, power, competition, know, that sort of thing that's kind of celery, but it's reinforced by. you know, cultural stereotypes and again, by the advertising and things like that. Sure, sure. Yeah, no, but I do know a lot of, I have a lot of friends who really enjoy gambling. Some of them, I mean, not so much anymore, at least not physically, but I used to have some friends that I was like honestly worried about their gambling behavior. ⁓ But none of my female friends ever really had, yeah. showed, maybe they were very secretive about it. So, ⁓ that's why I was curious. Anyway, I, ⁓ we've discussed a lot about, ⁓ yeah, gambling addiction and, and why some people are more likely to develop it, why it's so prevalent in, today's society. But what are we doing for treatment? What is a successful treatment look like? Because it's different from. alcohol or cocaine addiction in the sense that you're not addicted physically to a substance. Like usually with substance abuse, it's both a mental addiction and a physical addiction that you if, if for example, if you're used to drinking every single day and you just stop cold turkey, you don't have a drink. might actually be dangerous physically to your body. However, gambling is different in that sense, in the sense that it's a mental addiction, at least how I understand it. So what does treatment look like? How is it different from other sorts of addictions and are there any developments in that regard? So it's a great question. So again, as a addicted disorder, we use principles of addiction treatment, biological treatment, psychological treatment, social treatments. Under the biological treatments, we do have certain medications that have been looked at, like naltrexone, opioid antagonist blocker, that can reduce and diminish some of the urges and cravings or the rewarding experiences of gambling. have clinical trials underway right now looking at things like psilocybin and transcranial magnetic stimulation. There's a lot of excitement around the GLP-1 receptor agonists that we use for weight loss and alcohol use disorder. ⁓ There's a lot of medication options again, when you treat other mental health conditions or substance use disorders that are running with the gambling at the same time, like say ADHD is a common one. When you treat ADHD well, gambling disorder also goes down as well. So psychological treatments, have a wide variety of psychotherapies and different strategies that work that really help people navigate the journey of recovery, help them deal with urges and cravings, help them deal with triggers to gambling. help them stay motivated to work on repairing the consequences and harm that gambling created. ⁓ A lot of times the patients will say, well, what can you say to me that's actually gonna get me to stop gambling? And that's where our relationship with therapy, it's a safe space where we talk about a lot of things that help reduce the guilt, the shame, increase motivation. A lot of times what I do in psychotherapy is motivating folks to do the things that they've stopped. doing because gambling took over their lives. So increase exercise, increase finding new hobbies I like to do, focusing on health, nutrition, focusing on sleep hygiene, ⁓ know, just doing basic self care, things they neglected because their addiction took those things away from them. And then social treatments for gambling. Of course we have Gamma Wars Anonymous as a support fellowship for folks in recovery. We also have some like new online social products. have mobile apps that can help people navigate their journey for gambling by having, you know, discussion boards and podcasts that you can listen to. We have gambling blocking software that prevent them from going on their phone and getting to gambling websites, increasing, as you say, the friction between the itch to gamble and then actually placing a bet. So put it all together. I think people say, well, Oftentimes they say, well, there's nothing a professional can tell me to do. I just had to do it myself. And that actually is not true. There's a lot of things we can do as healthcare professionals that we do, similarly to ⁓ the substance use disorder space. There are residential treatment programs for this. There are intensive outpatient programs. And I think, again, a lot of, think I had a patient say to me very well, you know, what really helped Dr. Fong in my recovery was that I had a safe place to talk to someone understood what I was going through. You didn't yell at me, you criticize me, you supported me, you identified other mental health conditions that were happening and that allowed me the time and space and energy to do the work to find a better space so that I don't continue to gamble in a harmful way. Yeah. And you briefly mentioned the psilocybin treatment for gambling as well. What does that look like? So there's a colleague of mine, Dr. Pedro Romero out of ⁓ Gibraltar out there in Europe, who's really interested in running a clinical trial of psilocybin for gambling disorder. We have some signals that psilocybin may be potentially effective in other addictive disorders like cocaine use disorder or alcohol or opioid use disorder. And it's a lot of a theory right now. We're not ready to declare it a effective treatment. but there's a possibility and it just highlights that there's some interesting neuroscience work being done to say, how do we harness and understand what psilocybin can and can't do to the brain? And I think I'll just kind of leave it there. Super interesting. And finally, if people have, if people think that they have a problem with gambling, what should they do? That's our, I'm not. So if people think, yeah. So if people think they have, let me back it If people are concerned or they're just curious about their own gambling behavior or they're concerned that they don't want it to advance that problematic gambling. The first thing I always tell people is just get educated. If you're not ready to go see a professional gambling addiction specialist, you can do a lot of things online. know, listen to podcasts, go. There's a number of gambling recovery podcasts like the broke girl society or all men or voices or the Craig Carton show that kind of just talk about what gambling addiction is and isn't and they give you stories. And so if you're curious and concerned, you can download these 24 seven from your home. But again, the general rule of thumb is that if you're really worried or in particular, if you're worried about a family member or a friend, you got to get professional help, at least for an evaluation. That doesn't mean you need to go to a rehab or sign up for something major, but just get an evaluation. Just like any other medical condition, right? If you're concerned about your weight or your risk factors for a heart attack, or you're worried about cancer, you'd want to see someone who knows about that. So, and the good news is anywhere in the world now that there are more more gambling addiction treatment specialists and At the very least, know, folks in behavioral health or mental health or folks, even in the primary care setting are learning more and more. If people are interested in, I know more about it. They can take a look at our website, clagamblingprogram.org. Program.org. And if they're in America, they can call it a gambling helpline 24 hours a day, 1-800-GAMBLER or 1-800-MY-RESET. we'll get to immediate care and support. Great. I'll put it in the show notes for sure. Is there anything you would like to emphasize or anything that we didn't discuss that you would still like to mention before we wrap it up? No, think it's really, look, gambling is not a global phenomenon. Look, you're talking to me from Amsterdam and I'm here in LA and it's as if we were sitting right next to each other and we're impacted by some of the same issues of the day here. And I think that just shows you how our world has become so close in the similarities, but there's still so many interesting, unique cultural differences from place to place. But thank you so much for your time. And, you know, I look forward to talking again at some point and hopefully your listeners and viewers will take something out of it useful today. Thank you so much, Shatem. I really, really appreciate it.