Judson’s TED Talk, which has reached more than 10 million viewers. Video and photo credit ted.com
When Judson Brewer started medical school, he also began meditating. He found that it was a really helpful practice when he was stressed out or sitting through a boring lecture. Meditation opened up a whole new world for him and with his newfound interest, he started attending Buddhist meditation retreats, often for months at a time.
During his studies in Buddhism, Brewer learned about the Buddhist Law of Dependent Origination, represented by a wheel that depicts the cycle of life, death and rebirth. The wheel contains twelve links, each of them dependent on each other. In particular, Brewer became interested in the eighth link, Trishna, which refers to desire or craving.
Trisha espouses the theory that if we’re not mindful, we’re perpetually led around by our desires. And when we’re in that condition, it’s impossible to stop the cycle of rebirth.
From his training in medical school, Brewer recognised that this ancient Buddhist idea aligned almost perfectly with what he had been taught about reward-based learning from his western studies. The alignment peaked his interest and he decided to go into psychiatry where he researched habit formation and how the mind works on a behavioural level, as well as a neurobiological level.
Thankfully he did, because he’s made a number of valuable contributions to that field ever since. Today Brewer is the Director of Research in Innovation at Brown University’s Mindfulness Center. He holds an MD and a PhD, and specialises in addiction psychiatry and neuroscience.
The Mindfulness vs Cognitive Therapy Smoking Study
Back in 2008, before his time at Brown, Brewer worked at Yale where he stumbled across perhaps his most remarkable finding. It started when he launched the Yale Therapeutic Neuroscience Clinic — a smoking cessation study that hoped to answer whether mindfulness was as effective as the gold-standard of cognitive therapy treatment. In this case that “gold-standard” of therapy was the American Lung Associations’ program named Freedom from Smoking.
The study spanned two years and involved around 20 programs. Each program lasted for one month at a time and involved a group of participants who were looking to quit smoking.
Down the hall, a psychologist trained by the American Lung Association ran separate participants through the Freedom from Smoking program, which was set to last for the same length of time and involve roughly the same number of participants. To ensure there was no bias, each month Brewers group and the Freedom from Smoking group switched rooms.
On the first day of the study, participants each drew a piece of paper from a hat. If they drew a one they would receive mindfulness training. If they drew a two they would go through the American Lung Associations’ Freedom from Smoking program.
Twice a week for four weeks participants came to a session. At the end of the month they would blow into a contraption that looked like a breathalyser to see if they had quit smoking.
In the first class he taught participants the concept of reward-based learning.
What is Reward-Based Learning?
Brewer explains, “The reward-based learning process basically goes like this. We see some food that looks good, our brain says ‘Calories!… Survival!’ We eat the food, we taste it — it tastes good. And especially with sugar, our bodies send a signal to our brain that says ‘Remember what you’re eating and where you found it’.
“We lay down this context-dependent memory and learn to repeat the process next time. See food, eat food, feel good, repeat. Trigger, behaviour, reward.
“Simple, right? Well, after a while, our creative brains say ‘You know what? You can use this for more than just remembering where food is. You know, next time you feel bad, why don’t you try eating something good so you feel better?’ We thank our brains for the great idea, try this and quickly learn that if we eat chocolate or ice cream when we’re mad or sad, we feel better”.
Dr. Judson Brewer explaining reward-based learning to Aljazeera in 2016. Source Aljazeera
Participants Are Taught Brewer’s Mindfulness Technique
Once participants had a good understanding of reward-based learning, Brewer sent them home with one instruction — pay attention to your triggers and what it feels like when you smoke. As Brewer described, “this is mindfulness — the process of paying attention to whatever is happening without allowing yourself to be pushed or pulled by it. Instead, you experience it as more of a neutral observer.
In the next session, Brewer taught participants how to start to actually map out their smoking habit. This involved seeing what the trigger is, what the behaviour is, and what the result is. He demonstrated this through a technique called ‘RAIN’ — a mindfulness acronym that a senior meditation teacher had taught him.
- Recognise/relax into what is arising. For example, a craving.
- Accept/allow the craving to be there.
- Investigate bodily sensations that arise physically and mentally. For example, ask what is happening in my body right now?
- Non-identify. Non-identification reminds us not to take things personally.
Once participants started to be okay with having cravings, and even turned toward them, Brewer dropped the bit about forcing them not to smoke and instead encouraged them to focus on being curious. Brewer shared:
In fact, we even told them to smoke. What? Yeah, we said ‘Go ahead and smoke, just be really curious about what it’s like when you do’.
Dr. Judson Brewer leading program participant Deb Riley to a room to measure her brain waves while practicing mindfulness. Deb was a smoker for 35 years who successfully managed to quit after completing Brewer’s mindfulness course. Source Aljazeera
Early Results of Brewer’s Study
Three days later participants returned to class and shared how many times they smoked because they were bored. One participant cutdown from 30 cigarettes to 10 in those two days because he realised majority of his smoking was either habitual or a ‘solution’ to fix other problems.
Another participant described, ‘Mindful smoking: smells like stinky cheese and tastes like chemicals, Yuck!’ Brewer describes, “She already knew cognitively that smoking was bad for her. That’s why she joined our program. What she discovered just by being curiously aware however was that smoking tastes like shit.
“She moved from knowledge to wisdom. She moved from knowing in her head that smoking was bad for her to knowing it in her bones, and the spell of smoking was broken. She started to become disenchanted with her behaviour”.
System 1 and System 2
What Brewer was doing was the same thing Nobel prize winning psychologist, Daniel Kahneman, famously laid out in his best-selling book, Thinking Fast, And Slow. In the book, Kahneman talks about the brain being comprised of two systems — System 1 and System 2.
System 1 is the brain stem — the more ancient part of our brain. Encasing the amygdala, hippocampus and thalamus, this part of our brain is often more focused on our direct survival.
System 2 is the prefrontal cortex, which developed later in our evolutionary history. Many call it our rational brain but often it takes a lot longer to kick in than System 1.
As Brewer describes, System 1 is that impulsive ‘see a donut, eat a donut’ part of the brain. System 2 says ‘You shouldn’t eat that donut, it’s bad for you’. While System 2 may try to instill some self-control, it’s actually the part of the brain that goes offline when we get stressed out. This means System 1 universally wins… especially when we are hungry or when we are stressed out or we are tired.
Mindfulness in Brewer’s eyes was a way to let go of the screaming siren of System 1 so that System 2 had an opportunity to weigh in on the discussion.
Long-Term Results of Brewer’s Study
Over the course of the one month program Brewer added formal meditation sessions to be completed by participants in the morning or evening of each day. This was a foundation for maintaining mindfulness throughout the day. Brewer also kept logs of what people did and didn’t practice throughout the week.
At the end of the two year period Brewer had screened over 750 people and randomised just fewer than 100 of them for the trial. When the last participants finished their final four month visits they took all the data and looked to see how well mindfulness training stacked up. Brewer hoped his novel treatment would work as well as the gold-standard of treatment.
When the data came back it showed participants of the mindfulness group quit at twice the rate of the Freedom from Smoking group. Better yet, nearly all mindfulness participants stayed quit, while many of those in the other group lost ground — yielding a 5 fold distance between the two methods
In light of this interesting research, it’s natural for general practitioners to wonder how they can take advantage of this information to better help their patients.
What Doctors Can Do to Help Patients Overcome Bad Habits
One great resource is Dr. Judson Brewer’s book, The Craving Mind. In the book, he dives deeper into the scientific findings that explain how addictions are formed and how these addictions can be overcome through the practice of mindfulness.
He also outlines the above smoking study in more detail.
Dr. Judson Brewer’s book, The Craving Mind: From Cigarettes to Smartphones to Love – Why We Get Hooked and How We Can Break Bad Habits, published in 2017
Brewer and his team have also developed three apps to help people quit smoking, handle food cravings, and reduce anxiety based on the same underlying principles.
His Eat Right Now app helps people overcome binge eating and has been scientifically shown to reduce cravings by 40%. Brewer’s Unwinding Anxiety app uses video lessons, weekly calls, journaling, and exercises to stop panic attacks and reduce anxiety. And his Craving to Quit app offers a 21-day mindfulness program that teaches exercises to reduce cravings, provide community support, and offers video chats with addiction experts.
When first talking to patients about their addictions he suggests using the method of motivational interviewing to encourage a patient to think more about their addiction without feeling threatened.
He gives an example of this technique by saying, “Let’s say you smoke cigarettes and I’m your doctor. I’ll ask you questions like ‘How many cigarettes do you smoke?’ and let’s say you say 20 and I say, ‘Why don’t you smoke more?’
“This puts it back in your lap and you might say, ‘Well, they’re expensive’, or ‘They’re bad for my health’, so it starts to bring up all the reasons that you actually want to quit smoking. So those types of things can help”.
Brewer also recommends teaching patients the habit loop of trigger-behaviour-reward. By just understanding this process and helping patients map out their own habits, they can start to experience disenchantment, ultimately finding their habit unappealing or expensive or unsatisfying.