Transcript for The Curious Science of Cravings

In high school, I had a very strict diet, because I was trying to dial in everything that I had control over to try to improve my athletic performance. And I needed all the help I could get. So I was no sugar, no refined foods, sweets, no candy, no fast food, no junk food, and certainly no ice cream. And when I was off season, I would see people eating ice cream, and I would just be struck with this craving. I was like, Oh, that looks so good. And I remember eating close to half a tub, like half a gallon of ice cream, you know, in single settings. Generally, I would do this by myself. But I was like, oh, I just, you know, just had to get it in.

The way they work is I think they're designed as somebody put it to taste like more. They're not necessarily going to taste good, but they're going to be in your mouth, making you want that next one before you even finish chewing the one that you're eating. And that few turned into many turned into the whole bag virtually every time. And it was generally late at night, plenty of food that I just eaten, so I wasn't hungry. And suddenly I'd hear them calling. It would be that sirens song of the gummy worms, where they'd be in the cabinet calling to me saying, you know, eat me, come come here. And I guess I wasn't quite Odysseus where I was lashing myself to the mass to keep myself from eating them or having somebody do that for me. It was basically they would call and I would call.

Well, Jackie back as a kid had this idea that, you know, she needed to look more like Gwyneth Paltrow, but she had the build of, you know, the rock star pink who is pretty muscular, I have to say, that's how I would describe her physique. And so she would try everything that she could to meet this societal norm, you know, of what skinny look like. And really, you know, struggled for a long time. To the point where she would restrict eating, at some point she discovered cigarettes and found that that could be a way to curb her appetite. She also fell into this pattern with a friend of eating to suit her emotions. She would learn to eat because she was sad. And then eventually just got into this cycle of severe restriction and then binging when she couldn't stick with that restrictive diet.

Yes, and she's not the first person to describe this. I think it's a very common thing where she would set all these food rules and then she would put herself in jail for violating the rules and then beat herself up for not being able to resist the urges. She felt like there was something wrong with her and ironically, she would put herself in jail for something that she couldn't control.

Jackie described what she called the craving monster, where there was this big, looming, lurking, powerful, scary monster that would just basically said eat. and it could often start as a whisper. Like, oh, you know, you like this, you want this. And then if she ignored her, it didn't listen to it, it would, you know, get louder. Like, well, you're gonna do this anyway. So you might as well do it now. And then eventually just like taunting her and then egging her on and then even yelling at her.

You know, feeling like there was no way to win, she'd relent. And so she dialed her Tonya's restaurant in order as she put it, disgustingly vast amounts of carbs. So fried potatoes and rice and rice noodles with curry dishes. And then, you know, interestingly, she said that there's this huge relief that it's not there anymore, even though you feel all battered and bloated. But she described it, at least you're not fighting that monster anymore.

Oh, I love this movie. It's about this small, quaint French town that's very clean and orderly and pious. And this woman blows in on the north wind or something and she's wearing this red cape, you know, kind of signifying the devil. And this is really, you know, this is about temptations. And she sets up this chocolate shop and then starts making these amazing chocolates that nobody in the town can resist. And so the mayor of the town who is, you know, considers himself to be the most pious in the model, citizen, you know, during length, of course. And so I think he's giving up sweets for Lenton. So he drinks like lemon water. as his pious acts, you know, throughout the course of length. But over time, this temptation builds up more and more and more throughout the movie.

he goes and I don't want to ruin the movie for anybody that hasn't seen it but I'm going to go ahead and you know it's a spoiler alert end of the movie he goes and to destroy the chocolate shop so he literally bus into the chocolate shop and starts destroying the place. So she has all these beautiful chocolate set up in the front window and he goes in there and he just starts, you know, treading them, starts tearing them apart, breaking them, you know, destroying them. And at one point, a little drip of like chocolate, new get or syrup lands in his mouth. And it's like is cryptidite. And suddenly he's like, oh, I can't do this anymore. And he just starts gorging himself on chocolate. And he passes out from his chocolate frenzy, just covered in chocolate. And he's like, oh, no.

Just say no. They basically said, you know, there's this formula. calories and calories out. And they stated it like it was a fact of Newtonian physics. You know, it was like this is the law and this is true and it works every time. What they didn't tell me was that's not actually how it works in clinical practice. The formula is true. I think students probably still learn it, but that's not how it actually works in real life. For smoking cessation, for example, which is one of the hardest conditions to quit, there are these evidence-based five A's. So you ask, you advise, you assess, you assist, and you arrange. But the idea is, like, just check to see if somebody's ready to quit at this time, give them a very strong statement that like smoking's really bad for them, which they all already know. And then, you know, say, okay, let's help you quit. And the counseling piece was mostly focused on willpower, just great, your teeth and quit.

You know, everything from cocaine to alcohol to opioids to social media and then porn and all sorts of things. So you name it, they were addicted to it. And you know, they've had this warrior mentality. And so it was baffling to so many of them that they could do all of these extremely hard things that so many other people could never even think of doing. Yet they couldn't quit smoking.

Yes, so there's this saying, the people places and things. So for example, somebody struggling with alcohol, if they avoid bars, if they avoid the liquor store, if they avoid their drinking buddies, they're much less likely to be triggered to drink. And that actually makes sense from a, you know, from a mechanistic standpoint, these triggers kind of set off the process. If you think of smoking, though, if somebody smokes a pack of cigarettes a day, there are 20 different times or places that they are triggered to smoke. So it could be their car, it could be outside of work, it could be on their front porch or in their house. And so they basically have to be dropped onto a desert island. If they wanted to use the avoidance approach. So we can see it can be somewhere helpful in some situations and in other situations like smoking, extremely difficult to use that method.

Well, again, it makes a lot of sense. It's very logical, you know, just distract yourself. If you have a craving for a cigarette, you know, go for a walk or watch a YouTube video or do something that distracts you. The problem is that it's always lingering in the background. You know, kind of like we talked about with Jackie, it's going to be there behind the curtain in system matter of when they eventually, you know, eventually it gets out.

Two things would happen and one of them is so common that there's now a scientific term for this called the abstinence violation effect. And what that means is that when somebody, they've resisted smoking for a long time or resisted drinking, that first cigarette or that first drink just opened the floodgates and they would just go nuts. So somebody could quit smoking for six months and suddenly they're back up to a packet day in three days. And then on top of it, They would cast it to get themselves. They'd feel guilty for what they did. They'd feel ashamed as a person. And the guilt and shame kind of fed on each other as these vicious cycles, where guilt would feed shame, which would feed more behavior, which would then lead them to feel more guilty again.

Yes, pretty much every day. It was pretty humbling. And, you know, I felt like I missed something in medical school, you know, maybe I slept through some class that was really important or I hadn't gotten something. And my patients were really struggling, but I was really struggling to help them.

Yes, this is kind of a light bulb moment for me, so the VA hospitals is smoke-free campus, and so my patients couldn't smoke on campus, but they could find the parking lot where nobody would really police that. And so I was looking out my window one day and seeing, you know, my patients smoking in the parking lot, and I had this all-home moment, because my lab admin's studying habit change for years. And I was thinking, wait a minute, my patients don't learn to smoke in my office. They don't learn to overeat my office. They don't learn to get into any of their addictive behaviors in my office. Is there some way that I could actually develop a way to purge my office to them in their situations because the mechanism behind this is really about them learning things in a particular context. It's in their home environment, it's in their car, it's when they're stressed and hopefully they're not particularly stressed in my office. So that was a big aha for thinking, well, there's got to be a different way to do this.

Oh, yes, it's tremendously humbling. I ate a lot of humble pie.

Yes, in my observation clinic, we would have these group medical visits where people with similar conditions, I could kind of work with them all at the same time as a group. And so I'd collected a group of individuals that happen to be all women at the time who were really struggling with binge eating disorder. Very severe clinical disorder where they basically just can't stop eating in certain situations. And so I was really excited to get started trying to help these people. And for about a month, I was sitting there thinking, like, what am I missing? I felt like we were speaking a different language. So my language was, well, you know, I had this assumption that people would eat when they're hungry. I was really blind to what their experience was. And so I started asking them to put me in their shoes. And like starting from the first bite, you know, sketch out the details for me. What urge them to eat? What were their cravings like when did they eat? So they all started talking at once. Like, oh, finally. He wants to understand our world. It's another humbling experience for me. And so they were describing all the different times and triggers that led to a ban. You know, it could be time of day, it could be different emotions. It could be people. They were recounting how their cravings and urges really were the same relentless drive to eat. One of the people said, well, I just eat when I have a craving. And then I was thinking, oh, I'm telling me more about this. You know, like, what are the cravings like when you're hungry? Everybody was quiet. They're like, hunger. I have an urgenite, like, full on. That's it. And so, you know, it's like angry, lonely, tired, bored, sad, distracted, excited. All of these things had one thing in common. They caused a craving. And so it was that hedonic hunger, right? Not actual physiologic hunger. It was the emotional hunger for most of them that was driving them to eat most of the time.

I don't even remember what prompted me to go on the gummy worm binge that night, but there I was. And I'd been kind of learning how to pay attention to my own senses more. So I kind of started just paying attention as I was eating gummy worms. And so instead of just chowing on them in like craving the next one while one was, you know, while I was chewing on one, I ate one at a time and really paid attention to what they felt like and what they tasted like. And I can still remember to this day, and this was years ago, because it was so vivid, because it was such a shock to me. My first reaction was, oh, this tastes like slimey petroleum product. Not exactly food. The mouth feel was slightly off. The taste was too sickly sweet. They were getting stuck in my teeth. So that was kind of annoying. It was like, you can't really bite all the way through it, but you can. And so it was everything was kind of off in terms of probably what my brain and body had evolved to expect in terms of food. But I had never paid attention to that before. I was just busy shoveling them in my mouth.

You know, I've learned so much for my patients. Often, they're not motivated to change until they've often lost everything literally. And so for me as a clinician, I'm thinking, you know, I am failing as a clinician. So it was a rock bottom moment for me as a clinician. And so I started, I did this crazy thing, which was, or seemed crazy at the time. which was, I thought, well, okay, if the standard approach is the willpower approach is not working for me and my patients, let's try something completely different. And so my patients would come in, they wanted good smoking, they'd all tried willpower before I hadn't worked. And so I said, okay, go ahead and smoke. And they would look at me like I was crazy. And they're like, did I hear you right? My doctor just told me to smoke. And they all know that smoking is one of the worst things for them. So I don't need to reiterate that, you know, some lecture on a, you know, from a podium. But I can say, hey, you know, when you smoke, because you're going to do it anyway, right? You can't stop. So just pay attention as you smoke, and I would give them a homework assignment. I would say, report back to me exactly what it's like when you smoke. So, what does it taste like? What does the smoke feel like going into your lungs? What does it smell like coming out of your mouth or your nose? What do your clothes feel smell like? You know, what is your breath smell and taste like? All of that. So, you know, I had them do a science experiment, you know, and they were the experiment and they were the experimenter and they would come back blown away.

Yes, I was really curious. You know, often the joke and research is research is research and often people go down these rabbit holes where they're like, oh, something worked for me. And so it must work for everyone. And often these are very smart. You know, very disciplined scientists or psychologists. And so then they go and develop a treatment. They're like, well, it worked for me. It should work for everyone else. And it may not work for everyone else. It's if it's not really based on a mechanism. And so for me, you know, I was like, well, let's look at this to see how this works and do some randomized controlled trials to see if it actually works. But first, you know, I had a lot of patients who were generous enough to kind of try this out themselves. So I could just do some pilot work to see if there was even a signal there. And every time I do this, I still love it because I can't wait to hear your back from my patients. So, you know, typically, I remember a guy had been smoking for 40 years. And so the first thing we did was calculate the number of times he had reinforced this habit. You ready for this? It was roughly 293,000 times that he had kind of reinforced this habit. So, and so I said, start paying attention. He comes back and he goes, how did I not notice this? You know, for 40 years he'd been smoking. He's like, these things taste like crap. How did I not know this? He was blown away. You know, I've never had a patient come back and thank me for helping them realize how delicious cigarettes taste. Never.

Yes, well, I think of kindness and curiosity being best friends. So often to truly be curious, which means we're not going in with a preconceived notion or a judgment, we're just going in like, oh, let's see what this actually is. So in Zen, they often talk about beginners mind or don't know mind, right? It's like, oh, I don't really know. Let's explore this. Well, often we have these these voices in our heads that are like, you know, judging everything and that judgmental voice kind of gets in the way of us seeing clearly. And one thing that our brains so often do is getting this habit loop of judging ourselves and you know, shaming and blaming and all of these things that just suck all of this energy away from us being able to be curious in this situation and also get a stuck fighting ourselves. instead of actually addressing the issue. So if somebody can be kind to themselves, they can help step back from the self-judgmental stories and truly explore what's happening in their experience without that judgmental lens.

Yes, I love this metaphor. We even use it in our digital therapeutic programs. This highlight several things. One is if the parent gets wrapped up in the story, it becomes about them and not about their child. So if they ignore their child, it's about them. If it's fighting, it's resisting their child's tantrum, it's about them. Instead, we can get curious and ask a very different question that's going to actually solve the problem and also take care of the child. So it's really about being able to step back and instead of going, oh, no, they're screaming again. You know, I need to get them to be quiet as quickly as possible. They can go, oh, what do they need? And that brings in kindness, it brings in curiosity. And turns it toward the question that is critical that needs to be answered then is like, what is my child actually need?

Yes, and this is a paradox. So I think of it this way. You know, we're so trained to do something. Oh, no, they're screaming. Oh, no, there's a craving. Oh, no, there's this. I need to do something about it to make it go away. Well, the doing something about it is just like what Jackie was doing at the craving monster. We either run away or it runs after us or we fight with it and it gets stronger. So here the paradox is that if we can learn to be with our experience, that curiosity helps us lean in and just explore, oh, what is this experience? And that being with our experience becomes the new doing. We learned that these are thoughts, these are sensations, these are emotions that come and go. and by opening ourselves to them, allowing them to manifest in all their colors and energies and timeframes that they will go away on their own without us doing anything. And the last we feed them, the last they come back.

Well, I'll give you maybe we can start with the story that kind of highlights this. And I remember this patient coming into my office and the first thing he says is, hey Doc, my head's going to explode if I don't smoke. And I'm thinking, oh crap, I didn't learn this one in medical school, you know, chief complaint head exploding from not smoke, you know, from craving. And so I had to improvise. And of course, my habit is to go to a white board as a researcher and as a teacher. I'm trying to buy time so I fumble out a dry race marker and I say, okay, describe what head exploding feels like and how intense it is. And so he was describing, you know, heat and burning and tightness and tension. And then he was describing that the intensity was going up and up and up and up. And so I was drawing this arrow and trying to capture some of the words along the way. And then at some point, the intensity peaked and started to go back down. And he stopped at that moment. And I said, what's going on? And he said, you know, I've always smoked before the craving got this intense. But here, it went down and I didn't smoke a cigarette. And it was this big aha moment for him where he realized that these cravings were made up of thoughts, sensations, emotions, and that just by naming them, and even naming them out loud, it helped them see them for what they were. And in psychology, they describe this as the observer effect. by observing our thoughts. We cannot simultaneously be identified with them. And so this patient was observing his thoughts and body sensations instead of being consumed by them and identified with them. By doing that, he realized that he was not his thoughts, he was not his body sensations, and that he had control by simply observing them. He could be with his body sensations rather than having to do something like resist a craving or smoke a cigarette.

But it's interesting, Rob first came to me for anxiety. He had panic disorder. He had generalized anxiety disorder for probably 30 years when he came to see me. And he could, oh, and I should also mention he was 400 pounds. He had clinically relevant obesity in the sense that he had obstructive sleep apnea, affecting his a lot of his body systems. He had hypertension, high blood pressure. He had basically a fatty liver. All of these related to his unhealthy weight. And so what he described to me was that as a kid, he started eating, so he had anxiety, you know, probably starting, I don't know, fifth grade or something like that, where he tried everything he could to help his panic and his anxiety. And the only thing at the time that seemed to help was him going home and eating a bunch of food. And for him, especially by the time he came to see me, it wasn't even a temptation. It was a drug. And he described fast food as his addiction. He would secretly eat fast food and in his car and throw out all the garbage to hide his behavior from everyone else. And then he would tell himself, just like I've had so many other people with addictions say, you know, I'll be better tomorrow. I'm going to start tomorrow.

When he started paying attention as he ate, he realized that the fast food was actually giving him more health anxiety. Because he knew that he needed to lose weight because of all these clinical conditions. And so he started to realize eating was actually making things worse. The fast food wasn't helping. And no kidding, between the first visit and his first follow-up visit two weeks later, The first thing he says to me is, hey doc, I lost 14 pounds. And I was stunned because we hadn't even really focused on his clinical obesity issue at that time. We were mainly just focused in this first visit focusing on anxiety. But he had started to realize he was starting to understand who his mind worked. And he was starting to leverage his brain to help him change his eating habits without any willpower.

Absolutely. So I think of this first step of the three-step process is just mapping out your habit loops. And it can be as simple as just identifying the behavior. So like my patients in the binge eating group, I had them start just recognizing, why is it that I'm reaching for food? Am I hungry? Or am I XY or Z? You know, lonely board, angry frustrated, you know, sleepy, whatever. and so just recognizing that eating habit is the first step.

Yes. We did our first randomized controlled trial. We published this back in 2011. So we had people randomized people to get cognitive therapy and your gold standard. This is the American Monet Association's Freedom from Smoking versus this mindfulness training that we had developed. And the mindfulness training was pretty much, you know, like, hey, let's help you explore these cravings, just like you and I've been talking about, you know, what is it craving? But they can also learn to write out cravings just like I did with my patient. If he's had did not explode, when we explore what had exploded, could feel like. And what we found first off, we found that we got five times the quit rates of gold standard treatment, which totally knocked my socks off. We were just looking for a signal, well, that was a signal. That was pretty striking.

Absolutely. So when we start looking at the core mechanism and start asking, how can we leverage the strength of the brain? The way that works is that our brain is going to keep doing things that are rewarding, and it's going to stop doing things that are not rewarding. And the only variable that's needed for that is awareness. And this goes back to the 1970s, these two researchers, Roscora and Wagner came up with these reinforcement learning models. And they're still at play today. We use these in our studies. Where basically, if you pay attention, you're going to get an error term. Meaning, I learned, hey, these are not as good as expected. And I become disenchanted with that behavior. So it could be a type of food. It could be an amount of food. It could be cigarettes. It takes only 10 to 15 times of somebody really paying attention when they do a behavior if it's not rewarding for that reward value to drop below zero. So that's the second step in this process. We call this developing disenchantment. It doesn't change the taste of food, especially when we are eating in amounts that are not overindulging, but it can actually help us much more easily stop when we're full.

I'm smiling just thinking about them. I had some this morning. They are blueberries. So for me, blueberries are the biggest bestest offer in terms of like a sweet treat. They pop in your mouth. They've got this, you know, a nice texture when you bite into them. They also have this intermittent reinforcement property. So you never know how sweet a blueberry is going to be, right? One might be slightly sweeter than another. Another might be a little more tart. I like them both. but they kind of keep you constantly surprised when you're eating them. And the nice thing about blueberries is, for me, they have this perfect amount of sweetness where I'm not craving the next one or the next pint. We actually, and this is true, we have some gummy things in our house right now that my wife's family member gave to us, and I'm not even interested. She doesn't even ask me anymore. Yeah, do you want some? She knows the answer.

Yes. So Jackie had a complicated relationship with her mom and had learned some of these eating rules from her mom, in fact. And she had just come from visiting her mom as she described it yet another horrible trip. that too hadn't connected. And so she used to be in the habit of going to a certain grocery store and sitting in the parking lot listening to loud music and just binging and binging. So she sat in her car and she said, it didn't make the upset go away. I still felt really upset and hurt with relation to her interaction with her mom. She said, I just bald my eyes out in the car. Here's where it gets really interesting. She said she allowed the craving monster to get in the car with her instead of ignoring it or resisting it or fighting with it. So she simply noticed what the craving for Chinese food felt like. She could already taste that magic combination of sweet and salty. And she investigated how it felt, how that craving felt in her body, asking exactly what she was feeling and noting this sensations. And then she had this moment of revelation. She put it, I went into the grocery store and each time I picked something up, I asked myself, how am I going to feel if I eat this? And she gave herself permission to binge if she wanted to. And here's what she walked out of the store with, some avocados and spinach. And she said, she was laughing like a lunatic as she drove out of the parking lot because it was her first taste of freedom as an adult. And she said, I don't have to be scared of the craving. The craving monster is so real for so many people, but she said, I see you. Yeah, you can't hurt me. You can't hurt me. There was a lot of fear with her with regard to the craving monster. And she said, the fear wasn't there anymore.

My pleasure, thanks for having me.