Make a quick list of the things you loved doing as a kid: drawing, building, roaming the neighborhood with your friends, asking “why” forty times a day (this one might be hardwired but you get the idea). Now ask how many of them you’d still do if nobody paid you, praised you, or gave you a grade for them.

Fast forward to adulthood. For me, when I check my calendar on Sunday night to plan for the upcoming week, there are the things I get to do and the things I have to do. The patients I’m curious to see, and the form that has to be filed. The paper I want to write, and the one that would be “good for my career.”

How are these childhood and adult “funs” (and chores) linked?

Back in the early 1970s, Edward Deci and later his longtime collaborator Richard Ryan built a whole framework, Self-Determination Theory, around the difference between intrinsic and extrinsic motivation. Here’s how they are defined. Intrinsic motivation is when the activity is its own reward: you do the thing because doing the thing feels good. Extrinsic motivation is when the reward sits somewhere outside the activity: you do the thing to get a paycheck, a grade, a gold star, a flat stomach. Carrots and sticks live in the extrinsic pile. Playing in the woods as a kid lives in the intrinsic one.

So far so good. Now let me complicate it, using my own dinner as an example.

For most of my life, eating healthy sat squarely in the have-to pile. I grew up in Indiana with a mom who made sure I ate my vegetables, so you’d think it would come naturally, but for years my reasons for eating well had very little to do with the food itself. Picture three versions of me at the dinner table.

There’s the version that eats the salad because he wants to look a certain way: lean, fit, the guy who has it together. The reward there is entirely outside the food. It lives in other people’s eyes, in the mirror, in comparison. Notice how that one feels. There’s a low hum of pressure to it, a sense of it could always be better because someone is judging you.

Then there’s the version that eats the salad to keep his energy up. This is the one I stumbled into when I started paying attention: what I ate at lunch ran a straight line to whether I crashed at three in the afternoon or made it through my last few patients on my clinic schedule intact. The reward is still outside the eating. It’s the energy, the not-crashing. But it’s my reward, tied to what I care about rather than borrowed from someone else’s approval.

A close cousin of this functional version of eat healthy = optimal energy is the eat well = self-care. When I think of the best ways to take care of myself, I show kindness to myself and my body by eating healthy food. Eating junk food falls more on the self-indulgence side of the spectrum than self-kindness. Fast food says convenience is more important than health.

At its extreme of these 2.5 versions is a relatively new term that was recently introduced to the mental health lexicon: orthorexia. Orthorexia is an unhealthy obsession with eating only foods that a person considers pure, clean, and perfectly healthy, to the point where it severely disrupts their daily life and emotional well-being. This could be driven both by the external rewards (e.g. social media likes when we post a picture of our meal), and the internal ones (e.g. higher energy levels).

And now, a third version: enjoying cooking and eating this food. The smell of garlic hitting the oil, the taste of a good meal made well. Here the reward isn’t downstream of anything. The food is the reward. That one took years to sneak up on me, and it’s the one that added to the eat healthy = sustained energy + better emotional balance made eating well feel like a no-brainer, because just doing the thing felt good.

So which of those is intrinsic and which are extrinsic? If we want to get technical, the textbook answer is that only the third is truly intrinsic (the food is its own reward) and the other two are extrinsic. But what happens to “wanting to keep my energy up” when we zoom in a little more. We tend to think of wanting to be healthy as one of the good, inside reasons. By the strict definition, it’s extrinsic: you’re eating one thing to get a separate outcome. Yet it feels pretty different than the wanting to impress others version feels (scenario #1), doesn’t it?

That’s because the intrinsic-versus-extrinsic line, useful as it is, hides a second distinction that may be what is important. Deci and Ryan saw this too, and stretched the binary into a spectrum that runs from motivation that’s fully controlled (I do it because I’d be ashamed not to, or because someone’s watching) all the way to motivation that’s fully autonomous (I do it because it matters to me, up to and including doing it for its own sake). Keeping up appearances and keeping my energy up are both technically extrinsic. But one is controlled and one is autonomous, and that difference tells you whether the behavior will last, and how you’ll feel while doing it, far better than the intrinsic-or-extrinsic label ever could.

Sorry, I know our brains don’t like nuance, but there it is. And it is kind of important.

Which means that sorting your life into two piles is likely missing something that helps us tap into motivation in a sustainable way. The more useful question then, is where the reward comes from, and whether it runs out.

If you’ve read my other work, you know I think most of what we do runs on one ancient piece of machinery: reward-based learning. Trigger, behavior, reward, repeat. Your brain — in particular a region behind your eyes called the orbitofrontal cortex — is constantly comparing the reward value of your options and steering you toward whatever paid off best last time. Same system whether you’re a sea slug learning where the food is or a person reaching for their phone out of boredom. Run motivation through that equation and the whole intrinsic-or-extrinsic question turns into something that may actually be useful: where does this reward come from, and does it wear off?

Extrinsic rewards come from outside, and outside rewards eventually wear off. Termed habituation, our brain adjusts to whatever it’s getting and then needs a little more to get the same hit. There’s an old image for this in some Buddhist texts, the hungry ghost: a creature with an enormous belly and a throat as narrow as a needle, eating forever and never full. Constantly hungry for more. You needed one compliment, now you need another, and another. The raise felt great for a month. You swapped in cute puppy videos for your old habit and pretty soon you needed more of them, and cuter ones (+ kittens!).

Intrinsic rewards work differently: they come from inside, and they don’t keep our bellies rumbling and growling for more. Being honest, living a life of integrity (see my previous articles on this), being kind. All of these are intrinsically rewarding and have a different quality to them. They don’t share that urgy “more” hunger that feels driven and contracted. Instead, they feel more open and expansive.

Curiosity is the cleanest example of an intrinsically rewarding motivation I know. You can’t get to the bottom of being curious. There’s always more to be interested in, and being interested feels good on its own, no delivery truck of more required. It’s the kind of reward your brain will keep choosing, because it doesn’t leave you hungrier than it found you.

One of my favorite quotes about curiosity: “Curiosity is the cure for boredom. There is no cure for curiosity.” Boom.

Which is what makes a relatively famous study in this corner of psychology very interesting (and somewhat unsettling). In 1971, Deci sat college students down with a puzzle called the Soma cube, an absorbing little three-dimensional brain-teaser that people tended to enjoy for its own sake. He paid one group a dollar for every shape they solved and left another group unpaid. Then came the critical part of the study: a “free choice” period, where the experimenter stepped out, the puzzles sat there next to some magazines, and nobody was paying or watching. The students who had been paid spent less of that free time on the puzzles than the ones who never were. The money had quietly moved the motivation for doing it from the inside to the outside, and once the money stopped, so did most of the interest.

There’s your answer to the question in the title, at least some of the time. You stopped doing the thing you loved because at some point an external reward got bolted onto it, your brain updated the reason from “because I love this” to “because I get paid for this,” and then the pay became the point.

As with most science that isn’t a slam dunk, the finding has been fought over (more nuance!): in the 1990s, Eisenberger and Cameron argued the effect had been overstated, yet a large 1999 meta-analysis from Deci and colleagues mostly held the line while spelling out the fine print. Where it nets out is this: the effect is real, but conditional. Unexpected rewards don’t seem to undermine motivation. Plain encouragement, a “nice work,” tends to boost it. It’s the expected, tangible, do-this-and-you-get-that kind of reward, dropped on top of something you already loved, that does the damage. So this isn’t a case against ever being paid. Instead, it’s a warning about one specific way the wiring gets crossed (and how we might accidentally be training ourselves and others away from doing things that we love).

I crossed that wiring myself once, on purpose, at a fork in my career, though I didn’t have the words for it then. When I was finishing my psychiatry residency and deciding what my first lab at Yale would study–mind you, a very important decision that I didn’t want to screw up because it would possibly set the stage for the trajectory of my career–I had a respectable path teed up: my PhD was in molecular biology, mouse models of stress, and the sensible (conservative) move was to keep building on it.

But I’d also started meditating to deal with my own stress and anxiety, found it really helpful, and gotten curious about whether the same thing could be studied scientifically. There was no career path there. When I floated the idea to a colleague, that I’d pivot to studying mindfulness and have to learn translational neuroscience, clinical trials to fMRI, more or less from scratch, he told me flatly that I’d “kill my career,” alluding to the perception that I was about to go off the deep end to study the mystical world of rainbows and unicorns.

I remember telling myself that I’d rather kill my career doing something that I was really interested in, than follow the established path and build on the research that I had already done.

That sentence is the whole point, but it would be easy to tell this as “follow your passion and you’ll be vindicated.” The field did blow up over the next decade, but that was as much luck and timing as passion and hard work (both are important). Plenty of people follow their curiosity straight off a cliff and the field never shows up to catch them. The point here isn’t the payoff. In fact, the payoff is beside the point, a side effect or side “benefit” that followed my path of following my passion. That’s what intrinsic motivation looks like: you’d make the call even if it never paid off, because the doing is the reward in itself.

Yes cliche for a reason: journey beats destination.

Curiosity is also what keeps my clinical work from going stale. I try to walk into each new patient, and each new session with someone I’ve seen a hundred times, with what Korean Zen calls “don’t-know mind”: a deliberate letting go of any assumptions that I already know what’s going on or how this will end. It keeps me curious and present, and it keeps me from treating a person as a problem to be solved, a box to be checked, or an encounter to be billed.

Do I think about money? Of course I think about money! Who doesn’t? But when those thoughts pop into my head, I can bring my own awareness to those moments and compare what I get from going down the money thought train vs. staying present with my patient. The money thought train takes me away from actually performing well at my job because I lose the connection, miss key insights, and generally give off a vibe of not being in the room (even if it’s over Zoom). Being present feels SO MUCH better: I’m not lost in the itchy never-enough money brain thinking which drives restlessness, and more importantly, it’s easier to truly sit and be curious when I’m present. Being constantly curious also keeps me from getting burned out, because I’m approaching each day fresh, instead of looking at my calendar and wondering how I am going to make it to the weekend.

To be clear, the trouble isn’t extrinsic motivation humming along in the background, quietly keeping the lights on. The trouble is when it takes center stage and hijacks a moment that was supposed to be about something else.

I’ll stop short of one tempting overclaim, though. Staying curious does seem to keep me from burning out. That’s legit. But curiosity is not armor against a broken system. You can be the most intrinsically motivated clinician alive and still get ground down by an impossible caseload. Intrinsic motivation lets good work nourish you. It can’t fix bad conditions on its own.

So what’s the point of pointing out any of these differences between different types of motivation? Try taking an inventory. It’s the same habit-mapping I teach for anxiety loops, just pointed at a new target. For a day or two, walk through your hours and notice, for each thing you do, where the reward is coming from. Not to grade yourself; there are no points for being more intrinsic. Just to see the shape of your days and how they are being driven.

The trick is to skip the labels and go to the felt sense, because “intrinsic or extrinsic” turns out to be too imprecise, a noisy way to sort things. Paying for groceries is extrinsic, necessary and feels fine. Creative work can feel terrible while you’re in the thick of it (especially if it is driven by a deadline or other extrinsic motivations). So don’t ask which pile it goes in. Ask the hungry-ghost question: does this feed me, or does it just feed the loop? Does the motivation feel driven, contracted, restless, never-enough, that narrow throat that never fills? Or does it feel nourishing, the kind of reward that leaves you steadier instead of itchier? My lab has spent years confirming what you can check in your own body in about thirty seconds: contracted states like frustration, impatience, craving and anxiety reliably feel worse, more closed-down, than open states like curiosity, kindness and connection.

And watch it run both ways, because you can tip too far in either direction. We love to talk about the people who are too extrinsically driven, chasing money or status until the thing they once loved curdles into a job (there are way too many movies about this). But you can lean too hard the other way too. The person who only does what interests them, and lets the dull-but-necessary things rot (taxes, etc.). I’ve seen too many patients find out the hard way that “I only do what fascinates me” is more akin to addiction than a formula for sustainable happiness. A life that runs purely on what feels good this minute isn’t free. It just sounds appealing at the moment.

You don’t have to burn the extrinsic out of your life and live on pure curiosity like some sort of motivational monk. Plenty of what you do for outside reasons is fine, even good; the rent gets paid, the dishes get done. All I’m suggesting is that you look, closely and from the inside, at where each reward is coming from, and whether it sustains you or just leaves you reaching for the next one. Most of us never have. So look. Hmmm — what’s really driving this one?

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

References

Deci, E. L. (1971). Effects of externally mediated rewards on intrinsic motivation. Journal of Personality and Social Psychology, 18(1), 105–115. [from memory — verify volume/pages]

Deci, E. L., Koestner, R., & Ryan, R. M. (1999). A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin, 125(6), 627–668. [verified]

Eisenberger, R., & Cameron, J. (1996). Detrimental effects of reward: Reality or myth? American Psychologist, 51(11), 1153–1166. [from memory — verify]

Ryan, R. M., & Deci, E. L. (2000). Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist, 55(1), 68–78. [from memory — verify; the standard one-stop cite for the framework]

Lepper, M. R., Greene, D., & Nisbett, R. E. (1973). Undermining children’s intrinsic interest with extrinsic reward. Journal of Personality and Social Psychology, 28(1), 129–137. [not used in this draft; on hand if you want the preschool/markers example — from memory, verify]

What is going on in our brains, when stress is getting in the way of learning? And perhaps more interesting: does stress affect our ability to fluidly associate things, connect dots and even be creative?

We all probably know the answer from our own experience. Yes. But how?

A new neuroimaging study might have some answers. First some background.

You see a friend’s new scooter, a particular shade of light blue, parked outside the university library, and without any effort at all you land on the thought that she is probably inside studying. Nobody handed you that fact. You stitched it together from two separate experiences (your friend with the scooter, and the scooter at the library) that happened to share an overlapping piece, and your brain wove them into a conclusion about a place you cannot even see. We do this constantly, so fluidly that it feels like nothing at all, and it is the difference between a mind that merely records and a mind that builds a working model of the world. The region doing most of that weaving is the hippocampus, and the process has a name: memory integration.

Neat trick!

This matters well beyond friends and scooters. Building cohesive structures out of related experiences is how a student turns scattered facts into understanding, how a witness assembles a coherent account from glimpses, and how any of us lean on the past to make sense of the present. When the weaving breaks down it tends to show up in places we care about a great deal, including psychosis and the anxiety disorders, where trouble linking related experiences is part of the clinical picture.

That leaves an obvious question, given how much of modern life is spent at least mildly stressed. We already know from decades of research that acute stress is a powerful editor of memory, reliably strengthening the laying-down of new memories while making it harder to retrieve old ones. And we know the hippocampus is studded with receptors for the very stress hormones that flood the system when we are under pressure (glucocorticoids such as cortisol). What we have understood far less well is what stress does to this more flexible, integrative work, the weaving itself. Does being stressed change our ability to braid separate experiences together and infer the things nobody ever told us directly?

That is the question a group led by Kai Schüren and Lars Schwabe in Hamburg set out to answer, and they just published their results in Science Advances. The design is clean enough to describe over coffee or tea. On day one, people learned a set of pairs (call them A and B, a face and an animal). The next day, half of them went through the Trier Social Stress Test, which is the gold-standard way researchers manufacture acute stress in a lab and is exactly as unpleasant as it sounds: an impromptu job-interview speech and some backward arithmetic, performed in front of a stone-faced panel in white coats while a camera films you. And don’t forget the bright lights shining in your face! Right afterward, everyone learned a second set of pairs that overlapped with the first (B and C, the same animal now linked to an object). Then, an hour later, came the twist nobody had warned them about: could they infer a link they had never been taught, the one between A and C?

So what happened?

Both groups learned the A-B pairs equally well, both learned the B-C pairs equally well, and both could recall those pairs on the final test with no group difference at all, so the raw material was plainly intact. What stress degraded was the inference, the capacity to put the pieces together into something larger than either piece alone (A linked to C). When the researchers used fMRI to look at participants related brain activity, they saw why: during that second learning session, the stressed brains were reactivating the old, related memory far less than the unstressed brains were, and the less a given person’s hippocampus lit up with that old memory, the worse they did at the inference later. Nothing had been erased; what stress had done was stop the brain from holding the new experience and the old one in mind together long enough to associate them. In other words, stress impaired the spontaneous retrieval of prior, related memories during new encoding. During stress, those old memory pairs couldn’t be brought up to help connect the dots between A and C.

Now for the boring parts that remind us that science isn’t a slam dunk (as much as the popular press wants a clean story to report). These were a hundred and twenty-one healthy young adults, screened to exclude anyone with an anxiety or mood disorder, exposed to a single sharp jolt of laboratory stress, with these associations being studied in a brain scanner, which is a long way from a person who has been marinating in worry for years, and then asked to defend their decision during a presentation in front of a large group of coworkers. Where does that leave us (and why would I bother to write about this study)? What we have is a real, mechanistic, carefully done study (a really careful and thoughtful design), but one that doesn’t directly connect the dots to the real world, especially that of mental health like anxiety, where people are constantly jacking their cortisol levels by worrying.

With those caveats in hand, the work still hands anyone who treats anxiety a real problem, and I want to flag it as a problem rather than dress it up as an answer. Anxiety is usually described in terms of overgeneralization. The classic finding is that anxious brains spread fear too widely, treating a safe thing as dangerous because it faintly resembles something that once wasn’t. That looks like the mirror image of what this study found, where stress made the brain keep things too separate. How do those two live in the same head? My best guess (and it is a guess, the kind I would want to test before I would want to assert it) is that they are running on different systems pulling in opposite directions at once: the fear circuitry smears threat across everything that rhymes with danger, while the hippocampal machinery that would let you integrate the reassuring counter-evidence (”I have felt precisely this and been fine”) goes quiet at the very same moment. The frightening associations generalize while the comforting ones fail to connect. If that is even partly right, it is a fairly cruel evolutionary hiccup, and it lines up uncomfortably well with what I watch happen in my clinic.

All of which circles back to the people I work with in my clinic. The thing we most want an anxious person to be able to do in the moment, to reach back across a hundred prior waves of anxiety and worry to feel, not just recite, that this one will pass too (or whatever they’ve been told to do to relax), is itself an act of memory integration, and it likely leans on the hippocampal weaving that stress appears to dampen right when the stress is running highest. Telling someone to remember they have done this before is asking the overwhelmed part of the brain to do the one thing that it has been blocked from doing. The span between what they already know and the moment they are standing in is a bridge too far.

In my own lab’s work, the practices that seem to actually help in those moments tend not to route through that kind of retrieval at all: dropping into the raw sensation in the body, getting curious about what the anxiety honestly feels like rather than what it threatens for the next twenty-four hours, all of it works in the present tense and does not need to build some cognitive bridge. I have wondered for years why “just remember last time” lands so flatly with people who remember last time just fine. This study leaves me suspecting that part of the answer is that, in the moment we most need it, the wiring that turns memory into useful inference is the wiring that builds that bridges is momentarily washed out with stress.

This is why I have my clinic patients and the members in my Going Beyond Anxiety program start with a grounding practice so that they can get their inference brain bits back online, BEFORE trying to take that next step. (See my previous articles on Five Finger Breathing, and The Simple Eye Trick for more). And this new study suggests why that might be so important: stress and anxiety keep us locked into very concrete thinking (and learning) patterns so that we (figuratively and literally) can’t open our minds to make connections or solve problems, let alone tap into our more creative sides.

The work that helps with stress and anxiety is less about handing people new information and more about keeping the lights on in the part of the brain that already holds everything they need to know.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Armstrong, K., Avery, S., Blackford, J. U., Woodward, N., & Heckers, S. (2018). Impaired associative inference in the early stage of psychosis. Schizophrenia Research, 202, 86–90.

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 198–203. https://doi.org/10.1016/j.copsyc.2019.01.014

Cahill, L., Gorski, L., & Le, K. (2003). Enhanced human memory consolidation with post-learning stress: Interaction with the degree of arousal at encoding. Learning & Memory, 10, 270–274.

de Quervain, D. J.-F., Roozendaal, B., & McGaugh, J. L. (1998). Stress and glucocorticoids impair retrieval of long-term spatial memory. Nature, 394, 787–790.

de Quervain, D. J.-F., Roozendaal, B., Nitsch, R. M., McGaugh, J. L., & Hock, C. (2000). Acute cortisone administration impairs retrieval of long-term declarative memory in humans. Nature Neuroscience, 3, 313–314.

Kirschbaum, C., Pirke, K.-M., & Hellhammer, D. H. (1993). The “Trier Social Stress Test”: A tool for investigating psychobiological stress responses in a laboratory setting. Neuropsychobiology, 28, 76–81.

Laufer, O., Israeli, D., & Paz, R. (2016). Behavioral and neural mechanisms of overgeneralization in anxiety. Current Biology, 26, 713–722.

Lissek, S., Kaczkurkin, A. N., Rabin, S., Geraci, M., Pine, D. S., & Grillon, C. (2014). Generalized anxiety disorder is associated with overgeneralization of classically conditioned fear. Biological Psychiatry, 75, 909–915.

Madan, C. R., Scott, S. M. E., & Kensinger, E. A. (2019). Positive emotion enhances association-memory. Emotion, 19, 733–740.

Roozendaal, B., Okuda, S., de Quervain, D. J.-F., & McGaugh, J. L. (2006). Glucocorticoids interact with emotion-induced noradrenergic activation in influencing different memory functions. Neuroscience, 138, 901–910.

Schüren, K. A., Varga, N. L., Heinbockel, H., Preston, A. R., Roozendaal, B., & Schwabe, L. (2026). Stress disrupts hippocampal integration of overlapping events and memory inference in humans. Science Advances, 12(21), eaea5496. https://doi.org/10.1126/sciadv.aea5496

Schwabe, L., Hermans, E. J., Joëls, M., & Roozendaal, B. (2022). Mechanisms of memory under stress. Neuron, 110, 1450–1467.

In Part 1 (last week), I left you with a paradox that one of my patients, Maya, named more clearly than I usually manage to: actively trying to let go of an experience is itself a form of resistance to it. The more you try to accept, the more you’re confirming there’s something here that needs to be gotten rid of. Acceptance isn’t and can’t be a form of effort. But then what is it and how can we make it happen?

But first, the pushback that I get from my patients, in case your brain is going or getting stuck there.

If acceptance means not resisting our experience, does that mean accepting an abusive partner? Accepting a cancer diagnosis as if it is not a big deal? Accepting injustice or harm? Of course not. Acceptance is about the internal experience of what is already happening, not the external situation that needs to change.

You can accept the fear in your chest about a diagnosis and also get aggressive treatment. You can accept the grief of losing someone and also keep functioning. You can accept the rage you feel about an injustice and also organize against the injustice (see my previous article on anger for more). The two are not in conflict, and in fact, tend to support each other, because trying to act from a place of unacknowledged feeling is exhausting in a way that acting from a place of acknowledged feeling isn’t. What often gets confused is the assumption that accepting how you feel about a situation means endorsing the situation. It doesn’t. Accepting that you are afraid is not the same as accepting whatever caused the fear. Accepting that something hurts is not the same as agreeing to be hurt.

Maya was not being asked to accept that she might have cancer (which she didn’t have). She had already done the right external things: seen her doctor, scheduled the tests, etc. What she was working with was something narrower and, in a way, more humbling: the experience of being afraid right now, in her body, on a Tuesday afternoon when she could not yet know the test results. That is what acceptance was being asked of, and it was the thing she could not get to with effort or aspirations.

So what is it, then?

Here is where I start with my patients: acceptance starts with an acknowledgment of what is happening. The thought, feeling or situation is here. Without that acknowledgment, every move we make is most likely to be a reaction against a reality we have not yet admitted is real, which is exhausting in the same way that arguing with a closed door is exhausting (the door is not going to argue back, and you are wasting your energy).

Notice that this first step has nothing to do with approval. Acknowledging that fear is in my chest is not the same as approving of the fear, or wanting it to stay, or being a good sport about it. It’s just looking at what is already true. The fear was there before I noticed it. It will be there whether I notice it or not. Noticing it doesn’t add anything. Refusing to notice it doesn’t take it away. Acknowledging what is, is. It’s a sober reckoning with reality.

Forcing acceptance is a contradiction, because the forcing is itself a refusal of what is. Maya’s affirmation was a beautifully constructed refusal: by repeating “I allow and accept these anxious feelings” with effort and intention, she was, underneath the words, telling herself that the anxious feelings were a problem she needed a tool to handle. Yet, her body knew what her head didn’t (her affirmation was a form of resistance). That’s why she described it as a head experience. Her shoulders weren’t dropping because the words she was saying didn’t match what she was actually doing.

Just like telling ourselves to relax tenses us up more. The act of relaxing tells our head everything that it needs to know (“Hey up their, you three-pound organ devoid of sensory neurons, all is good.”)

So how does the door open?

The thing I have found, over years of working with patients and watching them try to push that door open, is that acceptance doesn’t happen through trying. It happens through curiosity. Not the deprivation kind of curiosity (the closed, restless, need-to-know kind) but the interest kind, the open-ended one, the huh, what is this? feeling. And that’s exactly what I explored with Maya on that (non-cancerous) Tuesday afternoon. When Maya turned toward her anxiety with curiosity instead of with effort to push it away or accept it, something shifted that her affirmation could not manufacture.

I asked her to get curious, turn toward and feel into her feeling of anxiety. She paused for a moment, and then she said: “I felt my shoulders drop. I became more aware of my breath, deeper breathing. The constant whirlwind in here stops for a moment.”

That moment, the shoulders dropping, the breath deepening, was the body doing what the affirmation could not. It was not produced by trying harder. It was produced by paying attention to what the trying had been covering up or avoiding. Curiosity, in this context, isn’t a technique. It’s the absence of the thing that was blocking her: the absence of the wish that this experience were different.

This is the critical piece of acceptance. Once we acknowledge what is happening, we can then turn toward our experience with curiosity. Acceptance isn’t a thing you do. It’s what’s there when you stop doing the other thing. Stop pushing, stop forcing, stop running, and what remains is acceptance. Critically, this is not because you constructed it but because there was never anything else there. The mind was already looking at its experience. Curiosity helped it shift from looking through a layer of struggle to simply looking. That’s acceptance: being with what it without resisting or avoiding.

You can test this in your body the way I suggested to in Part 1. Bring something difficult to mind. Notice the contraction. Now, instead of trying to make the contraction go away or trying to accept the contraction, get curious about the contraction itself. What does this actually feel like? Where exactly is it? What’s its shape? Does it have an edge? Notice what happens when you do this. For most people, the contraction softens. Not because they fixed it. Because curiosity is not compatible with bracing. The body cannot, at the same time, close around something and open to and look at it with interest.

This is also what my lab has found in the imaging studies. The brain regions associated with the contracted, restless, self-referential states (the posterior cingulate cortex and other parts of the default mode network) quiet down when people drop into curious, present-moment awareness. The two states are, mechanistically opposed. You can’t be in both at once. Which is part of why curiosity works as a way out of resistance loops: it isn’t fighting the loop. It’s just incompatible with it.

And when we release that resistance, acceptance is there.

There’s a passage from a poem by Stephen Mitchell, that speaks to this beautifully. He’s writing about the myth of Sisyphus, the king condemned by the gods to push a boulder up a hill, only to have it roll down again, forever:

We tend to think of Sisyphus as a tragic hero, condemned by the gods to shoulder his rock sweatily up the mountain, and again up the mountain, forever. The truth is that Sisyphus is in love with the rock. He cherishes every roughness and every ounce of it. He talks to it, sings to it. It has become the mysterious Other... Life is unimaginable without it, looming always above him like a huge gray moon. He doesn’t realize that at any moment, he is permitted to step aside, let the rock hurtle to the bottom, and go home.

Mitchell is not saying we love our anxiety (or whatever we’re resisting) in any conscious way. He’s suggesting that we have built our lives so completely around the rock that we no longer notice we are pushing it. The pushing has become the shape of the day. We do not see the rock as a separate thing we are choosing to push. We see it as part of who we are.

That, I think, is the deepest version of resistance. Not the obvious bracing, not the forced affirmation, not the reach for distraction, but the slow accumulation of habit that makes the rock feel like part of us. By the time someone like Maya arrives in my office, she has been pushing some version of this rock for years. The act of pushing is so familiar that the question “what would it feel like not to push?” can sound almost meaningless. Push against what? There is no rock, there is just life.

Curiosity is what allows us to realize that we have fallen in love with our “burdens” and even resistance itself (ie. it has become a habit). Once we notice, we wake up to our infatuation, which helps us sober up and see much more clearly what we are holding (and how much of a burden it is).

At the end of Maya’s session, we had been talking about how she could practice all of this, and she was worried (surprise!) that she wouldn’t be able to capture the feeling of openness when she needed it. She wasn’t sure how to remember what it felt like.

I told her that it was simpler than she thought. The contraction-versus-expansion check, the shoulders-up-versus-shoulders-down check, was almost everything she needed. If she could remember to notice whether she was closed or open, the rest would tend to take care of itself, because closed and open are not states you have to think your way into. They are states you can feel, immediately, without consultation with the part of your mind that loves to argue..

That, in the end, is what I think acceptance is. Not a posture, an affirmation or a brave decision to stop fighting. Just looking at what is here, with enough curiosity that we stop adding anything to it. And then noticing, in our body, that something has loosened that we didn’t have to loosen.

Here are some questions I have my patients sit with:

What rock have you been pushing for so long that you’ve forgotten it’s a rock?

What would it feel like, just for a moment, to look at it with curiosity instead of effort?

And if you noticed something soften, in your shoulders or your chest or your breath, would you be willing to trust that as evidence?

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

“It’s mostly a head experience.” A patient said this to me recently, describing an affirmation she’d been using to try to accept her anxiety. She’d been repeating it to herself for weeks and could tell that there was something that wasn’t quite right; by the way it was landing in her body, it wasn’t reaching the part of her that needed it.

Acceptance is a word that gets used so often in clinics and meditation apps and self-help books that by the time it reaches a person who is actually struggling, it can land more like an instruction than an invitation (maybe even a command!). Just accept it. Anyone who has been told to just accept chronic pain, or grief, or a difficult diagnosis knows how that sentence feels.

I’ll get into what acceptance actually is in Part 2 of this series. But before I can do that, it’s important to spend some time with its opposite: resistance. Why? Because resistance turns out to be much more interesting/challenging/important than it seems on the surface. Most of us think we know what resisting our experience means. What I’ve found, working with patients over the years, is that a whole lot of everything that we do when we think we’re not resisting is, in fact, another version of resistance dressed up as something different so it can hide itself. My patient’s affirmation was one of those versions. She just hadn’t seen it yet.

Let me back up and show you what I mean.

A patient I’ll call Maya is the one I quoted above, and she had come into our session in a particular kind of spiral. She had returned from a trip with a body symptom that scared her, had gone to her doctor (who reassured her the symptom almost certainly wasn’t serious: “no it’s almost certainly not cancer”), had scheduled the appropriate follow-up test, and was now, by her own description, “completely bowled over.” Her thoughts had gone straight to the worst possible diagnosis (cancer). Should she start planning her funeral? Would her husband survive losing her? Would there be chemo? She knew, intellectually, that her doctor had already told her this was unlikely (really, it’s almost certainly not cancer), which her anxiety was getting in the way of her hearing and comprehending. She was getting the test anyway. The catastrophizing was happening on top of all that, in a layer of mind that the reassurance hadn’t reached.

When I asked her what was driving it, she answered: “When I feel okay,” she said, “my mind starts scanning for things to be anxious about.” She’d globbed onto the symptom because the symptom was available. If it hadn’t been there, she explained, her brain would have found something else.

This is what worry actually is, when you look at it without the content. It is not a response to a specific problem. It is a habit of the mind looking for problems to attach itself to (the way a cow chews on whatever happens to be in its mouth, which is in fact where the word rumination comes from). When I asked Maya what she got from running off into the future this way, planning her own funeral, she didn’t hesitate. “More distress. Extreme fatigue. Nausea. Depression. Just this crappy feeling.” She knew. She had known for a while.

And she couldn’t stop.

This is the part of the picture that most explanations of anxiety skip over. We tend to assume that if a person sees clearly that a behavior isn’t helping, they will stop. (This is, incidentally, the basic logic of most cognitive approaches to anxiety: you challenge the thought, you see it isn’t accurate, the thought stops having power.) But anyone who has actually tried to think their way out of a worry spiral knows this is not how the mind works. Maya could see the loop. She could even name what it was costing her. The seeing did not make it stop.

It did not make it stop because she was, the entire time, doing something other than what she thought she was doing.

Resistance shows up in at least three ways, and they all look and feel different. The first is the obvious one, the one we recognize: pushing away. Oh no, not this again. You feel the anxiety (or whatever unpleasant experience it is) rising and you brace against it, the way you might brace against a wave. There’s a tightness, a closing-down, a sense of “I do not want this in my body right now.” Most people, asked to point to resistance, point to this.

The second is sneakier, and it’s the one Maya was caught in. Forcing yourself to let go. Trying to actively accept. Repeating an affirmation about not resisting your feelings, with such effort that the effort itself becomes the resistance. Yes, note the irony here. We will return to this one because it’s the heart of what makes acceptance so paradoxical to teach (and to learn). For now, just notice that “trying to be okay with this” and “actually being okay with this” are not the same thing, and that the first one usually feels worse.

The third face of resistance is the one we rarely call resistance at all, because it doesn’t feel like fighting. It feels like coping. It’s a sort of running away to the land of avoidance. Maya described doing it most nights: she would watch a video, listen to a soothing meditation, hear a pep talk that told her she was going to be fine, and feel calmer. Then she would wake up the next morning and the anxiety would be there again, unencumbered, and she would feel guilty for having relying on the video in the first place. Was she doing something wrong by reaching for things outside herself to feel better?

She was not doing something wrong, exactly. The video probably did help her sleep. But she began to notice something important about her own pattern, which is that anything we use to make a feeling go away in the moment is, by definition, not engaging with the feeling. Avoidance is a workaround, temporary at best. The next morning the feeling is still there because nothing about the underlying loop has changed. We have just gotten better at distracting ourselves from it, which is not the same as moving through it. Distraction is the most socially acceptable form of resistance we have. We don’t think of it as fighting our experience, but if you watch what it actually does (it ushers us away from what we are feeling so we don’t have to feel it), it’s the same machinery wearing a friendlier outfit.

Push away, force away, run away. Those are the three. They are all powered by the same engine, which is the wish that this experience were not happening right now.

Here is something you can test in your own body, and I’d actually invite you to try it before you read on, because the point of this is not to take my word for it.

Think of something you’ve been resisting recently. It doesn’t have to be dramatic. A conversation you’ve been putting off. A feeling you keep pushing down. A piece of news you don’t want to deal with. Just bring it to mind for a moment and notice what happens in your body. Where do you feel it? What does it feel like? Most people, if they look honestly, find some version of the same thing: tightness somewhere, often in the shoulders or chest or stomach, a sense of closing or bracing or pulling in.

Now think of a recent moment when something opened up for you. A laugh you didn’t expect. Someone letting you go in front of them at the grocery store or in traffic. A small piece of good news. Where do you feel that? What does it feel like? For most people, this one is harder to locate at first, because we don’t usually pay attention to it, but when you do find it there’s a clear quality of opening. A deep breath, dropped shoulders, something settling inside.

Closed and open. Contraction and expansion. This is, as far as I can tell from years of doing this work with patients and from research my lab has done on the felt quality of different mental states, the most useful pair of markers we have for telling resistance from its opposite in real time. They are not subtle. They are not metaphorical. They show up in your body and have nothing to do with thinking your way into or out of them.

When Maya and I were talking, she mentioned that she had been working with an affirmation she’d written for herself: “I allow and accept these anxious feelings.” She would repeat it to herself when the worry rose up, sometimes several times in a row. I asked her how it landed in her body when she said it. She paused for a long moment, and then she said, with a kind of dry honesty I appreciated, “I think there’s a momentary shift. A light, brief shift. But it’s mostly a head experience.”

She was right, and she could feel that she was right, which was the important part.

A little later in the same conversation she pushed back gently. “Isn’t there something to be said,” she asked, “for reinforcing the ideas of non-resistance? I’ve heard it a thousand times, but sometimes I’ll hear it like I’ve heard it for the first time.”

There is something to be said for it, of course. Concepts matter. Concepts are what point us in the direction of wisdom. Reading about acceptance, hearing teachers describe it, watching another person work with their own anxiety, all of this can prime the soil. But Maya had already named the problem with relying on it: she had heard the idea a thousand times. The thousand times had not been enough. Something about hearing it as an idea, even hearing it well, did not translate into the thing itself.

Why not?

Why would a person who can perfectly articulate the concept of acceptance, who has an affirmation she repeats with sincere intent, who has done all the right external things and read all the right books, still wake up each morning at the bottom of the same hole?

Experience is how we walk our way into wisdom.

The answer is the thing we’ll work with in Part 2. It has to do with a paradox that Maya put more clearly than I usually manage to: that actively trying to let go of an experience is, itself, a kind of resistance to it. The more you try to accept, the more you’re confirming there’s something here that needs to be gotten rid of. Acceptance, if it means anything, can’t be a form of effort. But then how does it happen? What are you actually doing when you stop pushing, stop forcing, and stop running, given that “stopping” can’t itself be one more thing you’re doing?

That’s where we’ll pick up next week in part 2.

For now, if you find yourself in one of these three habit loops of resistance (push away, force away, run away), start by simply noticing which one you’re in. Not to fix or change. Just to see, over the next few days, how often you can catch yourself in one of the three faces. You don’t have to do anything with what you find. Noticing is, as it turns out, already doing most of the work for you.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

It’s the kind of quote that can sound folksy until you really let it sink in. To put it bluntly, Lincoln wasn’t a man with the luxury of easy moral choices. He suspended habeas corpus during the civil war, signing off on the imprisonment of citizens without trial, while working toward what most of us now consider one of the most just causes in American history.

So when Lincoln says his entire ethical framework comes down to noticing how good and bad actions actually feel, was he being naive? Falling back on what could sound like an overly simplistic version of morality because the more sophisticated versions were too complicated? Or was he doing something more sophisticated than the philosophers, something they had been circling for centuries without quite landing on?

Could less be more here? Perhaps we now have the science to explain why.

Aristotle was working on this same question almost twenty-three hundred years earlier, in the Nicomachean Ethics. He nailed a great deal (IMHO), more than most modern ethical frameworks give him credit for. But there’s a piece he may not have had the tools to explore and/or articulate. And the piece he missed is what Lincoln was pointing at, and exactly what shows up in my lab when we measure how different mental and emotional states feel in the body.

This convergence highlights the question of how we become good people. And that answer has very little to do with thinking or reasoning your way to the right principles, and a lot to do with how your nervous system actually responds when you’re paying attention to what you’re doing.

To get there, we have to start with what Aristotle called hexis.

Hexis is one of those Greek words that loses something in translation. Most English versions of Aristotle render it as “habit,” which isn’t wrong (and how I first learned it), but flattens it into something we’d recognize as a behavior loop. Looking more deeply, the translation may be something closer to a settled disposition. A way of being that has become so integrated into who you are that it shows up automatically, without internal negotiation. Distinction without a difference?

Aristotle is famous for suggesting that we become just by doing just acts, brave by doing brave acts. The action comes first; the character follows. He seemed pretty clear that you don’t reason your way into being a good person. You practice your way there.

What he was describing maps closely onto what we now call reward-based learning. He didn’t have the luxury of modern-day neuroscience that maps out how habits are formed. But he had the phenomenon. Reinforce a behavior enough times and it stops requiring deliberation. The trained person doesn’t have to white-knuckle their way through the right action. They see the situation and respond ethically.

Aristotle saw clearly that you cannot think your way out of a poorly trained disposition. He understood, more or less, what we now call weakness of will, and he understood that the cognitive solution to it is mostly, let’s call it, a fantasy. If your training points one direction and your reasoning points another, your training wins.

Aristotle also went somewhere that most pop treatments of his work skip over. He held that pleasure and pain are the real guides to virtue, not abstract principles. The truly virtuous person, he says, takes pleasure in virtuous action. The person who has to grit their teeth and force themselves to do the right thing isn’t yet virtuous in his sense. They’re what he called enkratic, which usually gets translated as “continent” or “self-controlled.” A continent person does the right thing while still wanting to do the wrong thing. Then they can’t hold it in any longer, and poop their pants. A virtuous person doesn’t have the wrong-thing wanting in the first place, because their training has reshaped what feels rewarding.

This is a remarkably embodied account of ethics. Aristotle is already partway to where my lab studies were going. He understood that the felt sense of an action matters more than the rule about it. He understood that the body has to be on board, and that knowing the right thing in your head while your gut wants something else is a state of moral childhood (not yet potty trained so to speak), not moral maturity.

What Aristotle didn’t focus on, was a way of studying that felt sense directly. He built on the training as a given. The polis, the family, the teachers shaped you, and reason supervised the result. Whether the training was pointing in a good direction was a question he could answer only by appealing back to reason, or to the consensus of virtuous men, which is a much shakier foundation than it sounds. We’ll come to why that matters in a moment.

Here’s where Aristotle’s account starts to wobble.

His framework rests on the assumption that the training you receive is pointed in roughly the right direction. The polis shapes you, the family reinforces it, your teachers refine it, and reason supervises the whole process. If everything goes well, you end up with a settled disposition that takes pleasure in genuinely virtuous action. The pleasure becomes the confirmation that the training worked.

But what happens when the training is wrong?

Aristotle has a hard time answering this. His own moral perception, which he treated as a reliable guide, missed on some of the central questions of his era. He defended slavery as natural in the Politics, arguing that some humans were suited by nature to be ruled rather than to rule themselves. His views on women look, from a modern perspective, like pretty obvious moral failures rather than the careful conclusions of a careful thinker. The Spartans, whom Aristotle and his contemporaries looked to as a working model of civic virtue, trained boys in cruelty in the name of courage.

This points to a central problem with his account. If virtue is a trained disposition and the training comes from the surrounding culture, then your virtues are only as good as your culture’s. Reason was supposed to be the safeguard. Aristotle’s own reasoning didn’t save him from inheriting and defending the moral blind spots of his era. We are no different now; it rarely saves any of us from ours.

The deeper issue is one I’ve spent a bit of time on in my own clinic and research programs. The cognitive control regions of the brain, the parts we’d hope to recruit when reason needs to override a culturally trained disposition, are exactly the parts that go offline first when we’re under stress or duress. Reason turns out to be much better at justifying our existing dispositions than at correcting them. The slave-owner who reasons his way to a defense of slavery is not failing at reason. He’s using reason exactly the way reason usually gets used, to give shape and articulation to what the trained disposition already feels like the right answer.

So if Aristotle is right that virtue is hexis, and right that pleasure and pain are the guides, but a bit off the mark that the polis and reason can be trusted to point the training in a good direction, what’s left? Where would a more reliable signal come from?

His framework may benefit from something he didn’t have. The tools to study it weren’t available for another two and a half millennia.

A few years ago my lab ran a study that started as a side question and turned into something much bigger. We wanted to know how rewarding different mental and emotional states actually feel. Not what people say about them, not what they think they should feel, but what shows up when you ask them to compare states directly against each other.

The setup was simple. In the study, we took fourteen mental states, things like kindness, curiosity, connection, anger, anxiety, fear, and frustration, and asked hundreds of individuals to rank them by preference. Preference is a simple and useful proxy for reward value because the brain’s job, when choosing between behaviors, is to figure out which one feels better. Our orbitofrontal cortex is doing this kind of ranking constantly, mostly below the level of awareness. It’s how I know, without thinking about it, that I prefer seventy percent dark chocolate to milk chocolate.

The rankings were pretty clear. People consistently and significantly preferred kindness, curiosity, and connection over anger, fear, and meanness. Across hundreds of subjects, the pattern held.

On top of the rankings, the states people preferred had a particular quality to them. They felt open and expansive. Not in a metaphorical sense, but in the way subjects actually described what was happening in their bodies. The states they liked less felt closed or contracted. My lab has done imaging work showing that this contracted quality lines up with activation in default-mode network regions, including the posterior cingulate cortex, the same region that lights up when people are caught in craving and self-referential rumination. The expanded states show decreased activation in those same regions.

What these studies suggest is that our bodies have all of the data that they need. Real data about how different actions and states actually feel. When you act out of frustration or anger, something contracts. When you act with kindness, something opens. These signals are available to anyone paying close enough attention to notice them. Awareness is key here.

Aristotle didn’t talk about this. He understood that pleasure and pain were guides. He understood that the trained person takes pleasure in virtuous action. What he didn’t say, is that the felt sense itself can be studied, refined and used as an ethical guide or compass. You don’t have to inherit your training from the polis and hope it pointed in a good direction. You can pay attention to what your nervous system is reporting, in real time, and let that information be your guide.

Now you could take this in a direction I am not intending, so I’ll point this out now. The argument is not trust your gut. Your gut has been trained too. Saying “just notice how it feels” without qualification is the kind of advice that gets people walked on or worse.

My suggestion is a bit more specific. With sustained, curious awareness, the kind that takes practice to develop and that most of us have not been trained to bring to our own experience, the data start to converge. The closed quality of cruelty becomes recognizable as cruelty’s signature, separate from any momentary reward the cruel act provides. The open quality of kindness becomes recognizable too, separate from the social performance of being nice. The signal underneath the trained reaction begins to come through.

This is not a quick fix. As suggested by his pretty consistent wrestling with what is right throughout his life, Lincoln likely spent quite a bit of time paying that kind of attention.

The most common pushback I get when I talk about this work goes something like: I tried being kind and it felt terrible. People took advantage. I ended up resentful and depleted. So much for kindness feeling open.

In cases like this, what people are usually describing when they say this is not kindness in the sense I mean. They are describing a habit loop that looks like kindness from the outside. The trigger is something like discomfort with conflict, or fear of disapproval, or a long-trained sense that their job is to manage other people’s feelings. The behavior is accommodation, smoothing, soothing, agreeing, or giving in. The reward, in the short term, is relief from the discomfort. The longer-term result is exactly what they describe: resentment, depletion, the sense of being walked on. That’s a habit, not kindness.

If you actually pay attention to what’s happening in the body during one of these episodes, the felt sense is not open at all. There’s tension. There’s a tightness in the chest or the gut. There’s often a script running about what the other person needs and what will happen if you don’t provide it. Nothing about it feels expansive. Habits feel closed. In essence, they are a closed loop.

Most of what passes for kindness in everyday life is one of those loops, and it doesn’t feel open because it isn’t. Genuine kindness, the kind that shows up as actually rewarding in the lab data, has a different signature. It shows up when you’re present enough to notice what’s happening, including what you actually want and what the other person actually needs, and you act from that. Sometimes it means telling someone a hard truth they don’t want to hear. The defining quality is the state underneath the behavior, not the behavior itself.

The other objection worth taking seriously is harder. What about people whose felt sense really does report pleasure in cruelty? It seems to be the case that there are nervous systems that may not generate the contraction signal in response to harm, or that generate something like satisfaction instead (e.g. sociopathy).

The argument here is not that every human nervous system is exactly the same or reports the data accurately. It is that for most people, the pattern shows up reliably enough to be useful. And it might be even more accurate with a bit of awareness training. Aristotle likely would have recognized this. He acknowledged that some people are so badly trained, or so naturally disposed toward vice, that the framework of virtue ethics simply doesn’t reach them. My suggestion is similar, with the difference that I think the path is available without depending on the polis as the starting point and/or the guide.

Which brings us back to Lincoln.

The line about doing good and feeling good is easy to read as folk wisdom or even sentimentality. Sit with it longer, feel into it more deeply, and something more interesting starts to come through. Lincoln was making a simple statement about an internal signal he had learned to trust. Doing good felt one way in his body. Doing bad felt another way.

He could not have read or reasoned his way to that anchor. There was no philosophical text that would have given it to him, and reading the philosophical texts of his era would have given him plenty of material to argue himself out of it. What he had was decades of acting in morally weighted situations, paying attention to what those actions actually felt like afterward, and letting the data accumulate. The result was something like an evidence base, built one decision at a time.

This is why the quote holds up under pressure in a way that more elaborate ethical frameworks often don’t. Frameworks are vulnerable to clever reasoning. A sufficiently motivated person can argue their way to almost any conclusion if the only check is internal consistency. What’s much harder to argue your way out of is a felt sense that has been built up over years of careful observation. The body’s report is harder to gaslight than the mind’s.

I think this could have been what Aristotle was articulating when he said the truly virtuous person takes pleasure in virtuous action. He saw that the felt sense had to be on board, that white-knuckling your way through good behavior was a lower stage of moral development. What he didn’t have was a way of describing how someone could refine that felt sense directly, without depending on the surrounding culture to install it correctly. Lincoln, who was often pretty isolated in a country tearing itself apart, found his way to it anyway. Most of us are not Lincoln, but we all have that capacity.

What Lincoln called religion, I would call evidence-based faith. It is the same posture I have asked patients and program participants to adopt about their own habit change practice. You do not need to take my word that mindfulness will help. You do not need to take Aristotle’s word that virtue is hexis. You need to pay attention to your own experience, with enough sustained care that the patterns become visible, and then trust what you find.

This is how I explain it to my patients: I’m not asking you to adopt a position. I’m suggesting that you run an experiment.

Pick a moment in the next few days when you are about to do something you would call kind, or something you would call unkind, or something that falls in the murky territory between. Before the action, notice what is happening in your body. After the action, notice again. Not the story you tell about it. Not the justification or the regret. The actual felt sense.

Do this enough times and patterns will start to show up. The patterns are not subtle. The contracted feeling that comes with being mean or selfish is recognizable once you have seen it a few times. The open feeling that comes with genuine care is recognizable too. The datapoints accumulate pretty quickly. The only question is whether you are paying enough attention for them to register.

Aristotle thought we needed the polis to start this process for us. Lincoln found his way in a war-torn country. My patients find their way through a different route, working with their own habit loops one moment at a time. The mechanism underneath all three is the same. A nervous system, paying attention, learning what its actions actually feel like, and letting that information shape what it does next.

Whether the result counts as ethics in the philosopher’s sense, I will leave to the philosophers. What I can say is that it works the way Aristotle said virtue works, builds the way reward-based learning builds, and produces in people I have watched go through it the kind of ethical leaning that he was pointing at; acting from a place that does not require white-knuckling, reasoning or argument. A felt sense that the right action is also the one that feels open, and the wrong one is also the one that closes you down.

Lincoln called that his religion. I am content to call it paying attention.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

References

Aristotle. (350 BCE/2009). Nicomachean Ethics (D. Ross, Trans.; L. Brown, Ed.). Oxford University Press.

Aristotle. (350 BCE/1998). Politics (C. D. C. Reeve, Trans.). Hackett Publishing.

Arnsten, A. F. T. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10(6), 410–422. https://doi.org/10.1038/nrn2648

Arnsten, A. F. T. (2015). Stress weakens prefrontal networks: Molecular insults to higher cognition. Nature Neuroscience, 18(10), 1376–1385. https://doi.org/10.1038/nn.4087

Brewer, J. A. (2017). The craving mind: From cigarettes to smartphones to love—Why we get hooked and how we can break bad habits. Yale University Press.

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 198–203. https://doi.org/10.1016/j.copsyc.2019.01.014

Brewer, J. A. (2021). Unwinding anxiety: New science shows how to break the cycles of worry and fear to heal your mind. Avery.

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Garrison, K. A., Scheinost, D., Worhunsky, P. D., Elwafi, H. M., Thornhill, T. A., Thompson, E., Saron, C., Desbordes, G., Kober, H., Hampson, M., Gray, J. R., Constable, R. T., Papademetris, X., & Brewer, J. A. (2013). Real-time fMRI links subjective experience with brain activity during focused attention. NeuroImage, 81, 110–118. https://doi.org/10.1016/j.neuroimage.2013.05.030

Hare, R. D. (2003). The Hare Psychopathy Checklist–Revised (2nd ed.). Multi-Health Systems.

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She is also so anxious that she hasn’t been able to drive without raising her blood pressure and hasn’t gotten a good night’s sleep for several years.

Margaret has done everything right by the lifestyle medicine playbook, and she still spends a fair amount of her day rehearsing catastrophes. She echoes what a lot of patients have said over the years: “I don’t get it. I’m doing all the things you’re supposed to do.”

Yes, and... The playbook may be incomplete.

As a psychiatrist who has spent the past two decades studying how people get hooked on things, lately I’ve been thinking about some related subtleties and derivatives of that question. Not “why does anxiety persist,” which gets a lot of attention, but “why do the things we tell anxious people to do so often fail to stick?” Sleep more. Drink less. Move your body. Practice stress management. The advice is fine (and evidence-based). So why is Margaret, who follows it all, still white-knuckling her way through life?

I think part of the answer may be that lifestyle medicine may have a mechanism problem. We’ve built a generation of evidence around six pillars (nutrition, physical activity, restorative sleep, stress management, social connection, and avoiding risky substances) as a way to prevent and reverse chronic disease. I’m not here to argue with the pillars. And I’m a big fan of lifestyle medicine. I would go as far as saying that these pillars likely keep people healthier (in theory) than any combination of medications. Instead, I want to argue with the model we use to deliver them, which boils down to prescription + education + willpower. That’s roughly the same model that has failed addiction medicine for fifty years, and it fails for the same reason. It doesn’t account for how the brain actually learns.

Reward-based learning is older than humans. Eric Kandel won the Nobel Prize in 2000 for showing that this learning process operates in the sea slug, an organism with twenty thousand neurons in its entire nervous system. The basic structure is trigger, behavior, reward, and then repeat. Your brain encodes the reward value of each behavior in a region called the orbitofrontal cortex, where it gets compared against the reward value of other available behaviors and used to drive your future choices. This is how you learned to prefer dark chocolate to milk chocolate. It’s also how a forty-year patient of mine reinforced his smoking habit roughly 293,000 times before he walked into my clinic asking for help to quit.

Anxiety lives inside this same machinery. A trigger shows up. Maybe it’s an email, maybe it’s a tightness in your chest, maybe it’s a thought about tomorrow. Your brain reaches for whatever behavior has, in the past, made the discomfort go away even temporarily. Worry. A drink. An innocent scroll through your phone. A second helping of dessert. The behavior gets reinforced.

By the time someone like Margaret arrives at a clinic, her worry-and-avoid loop has been grooved thousands of times (or more), and her brain has stored that worrying has, paradoxically, some level of reward. Not because worry feels good. Because at some point it seemed to help her prepare for something bad, and her prefrontal cortex hasn’t been able to update that reward value since then.

There’s one more thing about this: the prefrontal cortex, which is where willpower-based interventions live, is the first brain region to go offline under stress. Amy Arnsten’s research at Yale has shown this in elegant detail. The very brain system we ask patients to use to implement our recommendations is the system that goes dark precisely when implementation is hardest. We hand people a flashlight and turn the lights out at the same time.

Substance use

The pillar I know best, and the one where the mechanism story is hardest to miss, is the avoidance of risky substances. Most clinicians treat substance use and anxiety as two conditions that travel together. The patient has anxiety and drinks, and we treat each in parallel. But for a big slice of patients, the substance isn’t the comorbidity. It’s the anxiety, in disguise.

I see this in my clinic pretty regularly. One patient stands out, a woman in her fifties whose anxiety was so severe in her twenties that she couldn’t make it to the grocery store without “pre-partying” first. A few decades of that, and by the time she walked into my office she had a textbook alcohol use disorder. The loop she described was almost too clean: drink to take the edge off the anxiety, drink past the edge because by then the off-switch was already underwater, wake up the next morning with anxiety worse than the one she had been trying to medicate. The substance wasn’t sitting next to her anxiety. It was the only tool she had ever found for it, and it was making the anxiety worse on a delay long enough that her brain never quite connected the two.

Alcohol is anxiety-relieving for an hour or two and anxiety-producing on the back end. The colloquial word “hangxiety” turns out to point at something real, with the day-after anxiety often hitting hardest in people who were already anxious to begin with. Nicotine is a stimulant that somehow reduces self-reported anxiety, because the withdrawal between cigarettes is itself anxiogenic, so each cigarette relieves a discomfort that the previous cigarette created. And when my patients and I examine this carefully, nicotine (a stimulant) isn’t the anxiety reliever; it’s the smoke BREAK that they take (which can be substituted by simply taking a break to stretch or go for a short walk, or to do a short mindfulness exercise).

Cannabis is more complicated, but for a lot of habitual users it follows the same arc. Benzodiazepines are the cleanest example, in a sad way: prescribed to treat anxiety, they generate, over time, a worse anxiety than the one they were prescribed for. And getting off of them is a bitch.

Telling these patients to “avoid risky substances” isn’t wrong. It’s just not a treatment. The substance is doing a job inside an anxiety habit loop, and unless we address the loop itself, the slot doesn’t stay empty. It gets filled by overeating, or doomscrolling, or, often enough, a new prescription.

Stress management

If risky substances is the pillar where the link to anxiety is most concrete, stress management is the pillar where I think the field has the thinnest mechanistic account. From my admittedly not complete read of the literature, most stress management content in lifestyle medicine boils down to a list. Diaphragmatic breathing. Progressive muscle relaxation. Yoga. Journaling. Time in nature. Good things, all of them, and not enough research on why they work or for whom.

Perhaps more importantly, anxiety and stress aren’t the same animal. Techniques that work for acute stress, like downregulating the sympathetic nervous system in the moment, often do nothing for the rumination loops that define generalized anxiety. I’ve talked to patients who diligently practiced box breathing for months and reported that it didn’t touch their 3 a.m. worry spirals.

The mechanism that does seem to address rumination is awareness applied to the loop itself. Noticing the trigger. Watching the behavior of worrying as it unfolds. Feeling clearly what the actual reward, or lack of reward, of worry is in the body. In trials from my lab and others, this kind of awareness training has produced clinically meaningful reductions in anxiety symptoms, and the proposed mechanism is exactly the one I’ve been describing: updating the reward value of worry in the orbitofrontal cortex so that your brain stops reaching for it. That’s a different approach that may get at the underlying driver of anxiety itself, and is quite different than being told to take a few deep breaths when you’re stressed.

Sleep

Sleep is the pillar where the two-way relationship with anxiety is best established. Anxious people sleep worse, and people who sleep worse become more anxious. A single night of sleep deprivation makes us (and our brains) more reactive (e.g. work that Yoo and colleagues laid out back in 2007 and that Goldstein and Walker have since built into a broader picture).

The lifestyle medicine teaching for patients is sleep hygiene. Consistent bedtime. Cool dark room. No screens before bed. Watch the caffeine. All sensible, and with quite a bit of evidence behind them. Unfortunately, none of what to do addresses the patient who already knows this stuff and still lies awake from 2:47 to 4:30 a.m. running through a list of things she can’t fix.

Insomnia, in a lot of these cases, is itself a habit loop. The bed becomes a conditioned anxiety cue. “Trying to sleep” becomes the failed control behavior, and lying awake feeling frustrated about lying awake gets reinforced as the actual behavior the brain practices, night after night. Cognitive Behavioral Therapy for Insomnia works partly by breaking this conditioned association, through techniques like stimulus control and sleep restriction.

In my own lab’s randomized trial of app-based mindfulness training for people whose worry was interfering with their sleep, we saw something pretty remarkable (yes I’m biased, but the data speak for themselves). In a randomized controlled trial, after two months, participants reported a 27% reduction in worry-related sleep disturbances, compared with 6% in the control group, and the mediation analysis pointed at a specific mechanism: their ability to not get hooked by their own anxious thoughts increased, which reduced their worrying, which reduced their perceived sleep problems. The part that complicates the story in an interesting and perhaps useful way is what didn’t change: their actual sleep duration, measured objectively, was about the same.

What changed was the loop. Their bedtime brains stopped being the same hyperaroused, ruminating brains they had brought into the bedroom for years, and the subjective experience of sleep improved even when the Fitbit data didn’t move. The thing that got better was the patient’s relationship with her own mind at 2 a.m. which is likely much better than your wearable telling you that you did/did not get a good night of sleep.

Exercise

I’m leaving exercise out of the main argument, but it deserves a paragraph, because it’s the pillar with arguably the strongest evidence for anxiety reduction (e.g. Stubbs and colleagues’ meta-analyses are reasonably solid), and it’s also the pillar that most clearly illustrates the limits of the prescription model. We can demonstrate in a trial that exercise reduces anxiety symptoms (and many have). We can also fail completely at getting an anxious patient to exercise, because the anxiety itself is what makes initiating and sustaining exercise hard. Even the pillar with the best evidence doesn’t implement itself. The implementation problem is the learning problem.

I’m not arguing that lifestyle medicine has the wrong pillars. The pillars are well-chosen and the evidence supporting them as targets is real. I’m suggesting that the model of how a patient gets from where they are to where the pillars say they should be is borrowed largely from a willpower-and-education tradition that hasn’t aged well in the addiction literature, and that anxiety is the cleanest place to see this, because anxiety renders willpower-based intervention nearly inert.

What might it look like to take learning seriously? Probably something like this. Clinical encounters that start not with “here’s what to do” but with “here’s the loop you’re already running.” Treatment plans that treat the OFC’s reward value as a thing to be updated, not a thing to be overridden. Time spent with patients in the actual texture of their behavior. What does that cigarette taste like? What does the worry feel like? What is the real reward of the second or third glass of wine? Sit with it long enough that your nervous system gets a chance to learn what it hasn’t yet had the chance to learn. That’s how reinforcement learning works (with a notable absence of the need for willpower).

I don’t think any of this is a departure from lifestyle medicine. Instead, I think it’s what lifestyle medicine gets up to date on the latest neuroscience about why so many of its prescriptions fail to stick.

A question worth sitting with, whether you’re a clinician or someone who has been on the receiving end of all this advice: when the change doesn’t happen, is the first instinct to ask for more education, more motivation, more discipline (or read another self-help book)? Or is it to ask what the loop is, and how to make it visible?

Those lead down completely different roads, and toward very different results.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Arnsten, A. F. T. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. *Nature Reviews Neuroscience, 10*(6), 410–422.

Arnsten, A. F. T. (2015). Stress weakens prefrontal networks: Molecular insults to higher cognition. *Nature Neuroscience, 18*(10), 1376–1385.

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? *Current Opinion in Psychology, 28*, 198–203.

Goldstein, A. N., & Walker, M. P. (2014). The role of sleep in emotional brain function. *Annual Review of Clinical Psychology, 10*, 679–708.

Kandel, E. R. (2001). The molecular biology of memory storage: A dialogue between genes and synapses. *Science, 294*(5544), 1030–1038.

Ong, J. C., Manber, R., Segal, Z., Xia, Y., Shapiro, S., & Wyatt, J. K. (2014). A randomized controlled trial of mindfulness meditation for chronic insomnia. *Sleep, 37*(9), 1553–1563.

Stubbs, B., Vancampfort, D., Rosenbaum, S., Firth, J., Cosco, T., Veronese, N., Salum, G. A., & Schuch, F. B. (2017). An examination of the anxiolytic effects of exercise for people with anxiety and stress-related disorders: A meta-analysis. *Psychiatry Research, 249*, 102–108.

Yoo, S. S., Gujar, N., Hu, P., Jolesz, F. A., & Walker, M. P. (2007). The human emotional brain without sleep: A prefrontal amygdala disconnect. *Current Biology, 17*(20), R877–R878.

Yet, he wasn’t talking about gambling. He was talking about what perfectionism actually does to his workday. Yes, not the inspirational poster version of perfectionism, but the other kind, the real kind, where an impossible standard sends us off to procrastination land: our social media feed, the news, the refrigerator, anywhere that creates the sensation of movement while the actual work sits there, gathering dread.

My patient knew he was doing it. He could watch himself do it in something close to real time, which made it worse, because now there were two things going wrong: the original task he wasn’t doing, and the watching-himself-not-do-it that he also wasn’t able to stop.

Perfectionism is its own kind of hell, and procrastination is one of its main manifestations. Another is getting stuck in the never-enough, never-good-enough cycle, which is a hell realm in itself.

After hearing versions of this story across the years, the self-tripping-over-the-self itself has stopped raising my eyebrows. Our brains are exquisitely good at it, and we’ll get to why in a moment. The even more interesting problem is the measuring issue underneath it.

When I ask patients what “good enough” would actually look like for the thing they’re avoiding, the answers tend to drift. The bar moves while they’re describing it. Meet it, and it was probably too easy, so it gets raised. Miss it, and that confirms you’re a failure, so it gets raised there too. After enough years of this, the ability to accurately perceive where the bar sits starts to degrade. That last part is the part worth sitting with.

The standard becomes what Hector Berlioz called an idée fixe in his Symphonie Fantastique — a fixed musical theme that recurs throughout the work, returning each time more distorted than the last. The term had already found a home in French psychiatry, where it described a fixed, dominating preoccupation that persists despite all evidence against it. The perfectionist’s standard works the same way. It returns, dominates, and distorts rather than resolves.

I’ve started thinking of this as a kind of “standards dysmorphia”. Body dysmorphic disorder is a serious diagnosis and I’d never want to flatten it into a metaphor. What I’m building on is the underlying idea: that the perceptual instrument itself can be miscalibrated. With perfectionism, what’s being misread is a threshold of acceptable performance. And because the instrument is broken (because we can’t see ourselves as ever being good enough), no amount of actual output corrects the reading.

Framing it this way may be helpful in changing how we view what kind of problem perfectionism is. Many people treat it as a motivation problem, or a standards problem, or, in the particularly brutal self-diagnosis I hear most often, a character flaw dressed up as some type of virtue. What neuroscience suggests is something more specific: a calibration failure in the brain’s reward system that traps people in habit loops which feel nothing like habits, precisely because the walls of the trap are built from something that looks, from the inside, a lot like caring deeply about your work.

The brain region most relevant here is the orbitofrontal cortex (OFC), which functions roughly as the brain’s comparison shopper. Every time you perform a behavior and experience an outcome, the OFC registers the reward value and stores it for future reference. The OFC keeps score so that future decisions can be made efficiently. I’ve written about this mechanism in the context of smoking and anxiety, but perfectionism puts a specific and underappreciated pressure on the system.

In most habit loops, the OFC is comparing real things, like the taste of a cigarette. The reward value is grounded in actual experience, which means the OFC can update its records accurately over time. Perfectionism runs the same circuitry with one complicating difference. The reward being sought is a mental image of a completed, flawless thing. The brain is running its standard cost-benefit analysis, measuring current performance against an ideal that exists only as a projection, and finding current performance perpetually wanting. The comparison target was never fixed to begin with, which is why the OFC can never get accurate information to work with.

Here’s where the popular story about perfectionism gets murkier than the version most of us have absorbed. The assumption has long been that perfectionism causes procrastination. That fear of not doing something perfectly leads people to avoid starting. The research picture is messier. Piers Steel’s 2007 meta-analysis found the direct link between perfectionism and procrastination to be surprisingly weak. Fear of failure predicts procrastination far more reliably, along with the negative affect that anticipates it. Fuschia Sirois and Timothy Pychyl have argued convincingly that procrastination is primarily a problem of emotion regulation.

The person who can’t start the report is more likely to be avoiding the feelings associated with attempting it: the anxiety of falling short, the anticipatory shame of producing something that doesn’t match the image in their head. The distraction behavior gets negatively reinforced because it provides temporary relief from that aversive state. Which means the habit loop running here isn’t really about the standard at all. The trigger is the bad feeling that arrives when current reality gets compared to the imagined ideal, and the behavior is whatever takes the edge off. Perfectionism is the engine generating the bad feeling, but the loop itself runs on emotion.

There’s also more of this loop running than there used to be. Thomas Curran and Andrew Hill published a large analysis in 2019 in Psychological Bulletin, pooling data from tens of thousands of college students over 25 years, and found that perfectionism has increased substantially across all three of its main varieties: self-oriented (holding yourself to impossible standards), other-oriented (holding everyone else to them), and socially prescribed (the sense that others are watching and evaluating, and the evaluation is never quite favorable). That last one showed the sharpest rise. It’s not hard to see why. Twenty years of being perceived through a quantifying looking glass, where the feedback comes back to you as numbers (likes, follows, view counts) and where the comparison to other people happens involuntarily every time you scroll, has done something to the experience of being a person trying to make something. The instrument was never well-calibrated and the surrounding conditions have been actively shaking it.

So what do we do with all of this?

The first step, which may sound obvious but isn’t, is recognizing that you’re working with a broken instrument. Most people carrying this kind of suffering have spent years treating their distorted standard as accurate (and helpful), which means treating the gap between their performance and their standard as meaningful information about their character. That gap is more accurately an artifact of a miscalibrated system, and recognizing this changes what the problem actually requires.

The same patient I mentioned earlier told me that the times when he felt most at ease with his performance was when he had a fitness coach. This wasn’t because the coach pushed him harder, but because having an external assessor meant that he didn’t have to trust his own instrument (himself). He admitted that his relief at handing that function over to someone else was a little embarrassing to acknowledge to himself. When his scale was “broken,” as in, miscalibrated from futzing with it and not trusting himself so much, he felt much better when handing that measurement off to someone else.

In my program, we focus less on destination-based goals and more on process metrics: how much time are you spending in a contracted, closed-down state versus an expanded, open one? My lab has studied this, and what we find, consistently, is that people prefer the open state, because it feels better. The reward value is higher, and the OFC can register that if you give it accurate information.

For readers who’ve been working with the three gears, this maps on in a specific way. First gear is mapping the loop, getting clear that for most people with this pattern, the actual trigger is the aversive feeling that arrives when current reality gets measured against the imagined standard. The distraction behavior is the analgesic. Seeing this clearly is more than it sounds like, because most people are so focused on the behavior (why do I keep checking my phone) that they never get curious about what it’s actually for.

Second gear gets tricky with perfectionism. The reason it works for smoking is that the reward, on close inspection, turns out to be underwhelming. People in our smoking cessation studies report things like “smells like stinky cheese, tastes like chemicals.” The OFC updates its records, and the behavior loses its grip. With perfectionism, the reward being chased is a mental image of a flawless completed thing, and you can’t taste a mental image and find it lacking. So second gear here means turning the same curious attention onto the distraction behavior itself: what relief it provides, how long that relief lasts, whether the trade is worth it. My patient noticed that thirty seconds of sitting with discomfort was almost always better than another hour of avoidance. He was running the experiment on himself.

Third gear is curiosity. I’ve written about this elsewhere at more length, so I’ll keep it brief here: the move is shifting from treating your inner experience as a problem to be solved to treating it as something interesting to investigate. The contraction you feel when you sit down to start the avoided task. That feeling has a location, a texture, something that changes when you actually pay attention to it. That quality of curiosity applied as an exploration of the moment feels better than dreading it, and the OFC can register that.

The hardest part of working with perfectionism is likely that the whole apparatus is powered by something real. Yes, caring about doing good work is genuine. The problem is that it has gotten hooked into a learning system running on distorted data, holding real performance up against a hypothetical that shifts every time you approach it.

My patient eventually said he wanted, above everything, to be at ease with his life. He said it somewhat sheepishly, as if ease were a small ambition. He had moments of it, he said. Now, it was about stringing those moments together, more and more.

He could already feel the difference between those moments and the rest. The work, as he saw it, was learning to string them together.

Essentially, the goal is not to dismantle high standards but to rebuild a measuring instrument that gives accurate readings, so that moments of genuine accomplishment can register as such. The OFC is doing its job. It just needs better information. This naturally comes from “working the gears” to recalibrate what we expect from ourselves, and how we relate to words like “perfect.”

So, if you are like my patient and find yourself in the perfectionism loop again (which you will, because that’s how loops work), see if you can get curious about it rather than immediately trying to escape it. Notice what the contraction feels like. Notice whether the standard you’re holding yourself to is the same one it was an hour ago, or whether it’s moved again while you weren’t watching.

It’s worth returning to Berlioz, because the full arc of the Symphonie Fantastique is more instructive than the idée fixe alone. The symphony tells the story of an artist consumed by an obsessive love. He poisons himself with opium and tumbles into a fever dream. He dreams he has murdered the woman he loves, is arrested, and marched to the scaffold; Berlioz writes the guillotine blade into the score, the head falling audible in the brass at the end of the fourth movement. In the fifth movement, his soul watches helplessly as his own funeral descends into a witches’ sabbath. The idée fixe returns one last time there, but she’s become a witch, the theme now grotesque and mocking, dancing over his grave. The obsession hasn’t resolved, but instead consumed him. In the Symphonie, he never wakes up.

Perfectionism, left unexamined, runs a similar program. The standard returns, dominates, distorts, and if you never stop to listen carefully to what it has actually become, you can end up marching toward a mental scaffold of your own making, guillotined by an instrument inside your own head. The work, such as it is, is hearing the theme accurately while there’s still room to do something with what you hear.

P.S. I still remember playing Symphonie Fantastique with my college orchestra. The music was, well, fantastic, but the story behind it is even more memorable. Our conductor explained that Berlioz had fallen madly in love with an Irish actress named Harriet Smithson after seeing her playing Ophelia in Paris in 1827. He fell madly in love, sent letters she never answered, rented rooms near her apartment, and when none of that worked, wrote the symphony as what one music historian generously called “the ultimate romantic gesture.” She didn’t attend the premiere or even hear it until two years later, at which point she apparently realized she was the idée fixe, agreed to meet him, and eventually married him, despite neither speaking the other’s language.

They separated eventually, as you might expect of a marriage that began this way, but are buried together in Montmartre Cemetery, which is either romantic or fitting depending on your disposition. I’m not sure this particular courtship strategy translates well to modern dating, but we all continue to benefit from an inspired piece of music.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 198–203. https://doi.org/10.1016/j.copsyc.2019.01.014

Brewer, J. A. (2021). Unwinding anxiety: New science shows how to break the cycles of worry and fear to heal your mind. Avery/Penguin Random House.

Curran, T., & Hill, A. P. (2019). Perfectionism is increasing over time: A meta-analysis of birth cohort differences from 1989 to 2016. Psychological Bulletin, 145(4), 410–429.

Kringelbach, M. L. (2005). The human orbitofrontal cortex: Linking reward to hedonic experience. Nature Reviews Neuroscience, 6, 691–702.

Sirois, F. M., & Pychyl, T. A. (2013). Procrastination and the priority of short-term mood regulation: Consequences for future self. Social and Personality Psychology Compass, 7(2), 115–127.

Steel, P. (2007). The nature of procrastination: A meta-analytic and theoretical review of quintessential self-regulatory failure. Psychological Bulletin, 133(1), 65–94.

There is a second dimension of burnout that gets much less airtime, for reasons that become obvious the moment you try to describe it out loud. The research literature calls it cynicism, which is a clinical-sounding word for something that feels considerably worse from the inside: you have started to not care about the people you are supposed to care for. The patient telling you about his back pain has become a problem to move through rather than a person to sit with, the colleague asking for a consult has become an imposition, and somewhere along the way the warmth went out of the room, except the room turns out to be the one inside your own chest.

This is the part of burnout that clinicians keep to themselves, and only talk about when they are exhausted and can’t hold it in anymore, because admitting it can feel like a moral failure. Exhaustion happens to you; cynicism feels like something you did. A character flaw or worry or that not-good-enough feeling dressed up as a work problem.

There may be a different way of looking at it, one that I think is both more accurate and more useful, and this is what I spend a good portion of my clinical and burnout research life on: cynicism is a habit loop. Once you can see the shape of the loop, you have more room to move than you thought you did.

This includes the relief that there isn’t something wrong with people who get burnt out, clinicians or otherwise. If it’s a habit, that means it was learned, and can be unlearned.

The setup is fairly straightforward, though the implications take some sitting with. You walk into a room with a patient who is suffering, and your nervous system (being a nervous system that senses) picks up on that suffering, because that is what empathy is at the neuronal level. Their distress becomes, briefly, your distress.

So maybe you do what brains do in that situation, which is to find something that helps with the (your) pain. Maybe you detach a little, stepping back from the feeling and going into checklist mode so that you can handle the encounter with technical competence but not much presence. Maybe you notice a flicker of irritation at the patient for being “difficult,” which is often code for “making me feel something I don’t have bandwidth for right now.” Maybe you make a dark joke with a colleague afterward. Whatever the specific move is, it works for a moment: the emotional temperature drops for the moment (or you’ve been distracted from it), and you can keep going.

That relief, right there, is the reward. Not pleasure, which is a different reward signal, but relief, which happens to be one of the most powerful reinforcers your brain has available. (This is why negative reinforcement is so sticky, and why people will do some remarkable things to avoid feelings they would rather not feel.) Now do this a few thousand times over the course of a career, and you have a very well-grooved loop. The trigger is someone else’s suffering arriving on top of your own overload, the behavior is emotional distancing in whatever flavor is yours, and the reward is a small hit of relief from empathic distress. The loop runs more and more efficiently over the years as it gets grooved into a habit, until eventually it runs without bothering to consult you, and one morning you notice that you do not feel much of anything about your patients anymore, and you find yourself wondering when that happened.

It did not happen in any single moment you could point to. It got trained, one encounter at a time, by a brain doing exactly what brains evolved to do. That’s how habits form.

Notice that your brain has learned (through thousands of repetitions) that detachment is what works when a patient’s suffering lands in your body. You cannot willpower your way out of a learned response, or at least you cannot do it for very long before the response wins. What you can do is give the brain better information about what is actually rewarding and what isn’t, which is a different kind of intervention altogether.

My lab recently published a study testing whether a short, pragmatic mindfulness training, designed with input from clinicians who told us what they actually had time for in their lives, and delivered as a podcast, could move the needle on physician burnout. Seven modules, each about fifteen minutes, with the aim that it was listenable on a commute, because most clinicians commute for at least 15 minutes and listen to podcasts. That was the entire intervention.

Ready for this? 7 x 15 minute modules led to the following results: Cynicism dropped by 33%, and the reduction was still there a month after the training ended. Anxiety dropped by 43%. Intolerance of uncertainty (which can be an indication of the not-knowing that drives a lot of the over-testing and defensive medicine we all complain about) dropped by 26%. We replicated the cynicism finding in a second study that delivered the same content via a smartphone app, with results in the same ballpark.

I want to be careful about what the study does and does not show, because the last thing I want to do is overclaim from pilot data. Both studies were single-arm with self-selected samples, which means we cannot yet make the kind of clean causal claims that a randomized controlled trial would allow us to make (stay tuned! We just finished data collection for that study). The effect sizes were large enough, though, and the replication was clean enough, that I think we are looking at a real signal rather than noise. The question I find more interesting is why something this short and this minimal would do anything measurable to cynicism, and the answer, I think, has to do with what mindfulness actually does to a habit loop when you apply it correctly.

Mindfulness does not make you care more, and it does not try to argue you out of the detachment you have been practicing. What it does is insert a small gap between the trigger and the behavior, perhaps just enough of a beat where you can notice what is actually happening in the moment. Oh. That patient’s story just landed in my chest. My shoulders are tight, my jaw is clenched, and I am about to go into efficiency mode to make this feeling go away.

The noticing, by itself, is an important move, because once the loop is visible to you while it is running, the reward value of detachment gets quietly updated. Detachment stops registering as relief and starts registering as what it actually is, which is a subtle kind of leaving. And the alternative (staying present with the patient and with your own reaction to the patient), turns out to be more rewarding than you would predict from the outside, not because it feels good in any conventional sense, but because it is the thing you actually came here to do in the first place.

I want to say something about the version of this objection that I know some readers are already forming, because I would be forming it too if I were reading this from the other side. And I’ve seen it come up over and over when I’m giving talks about my burnout research or working with clinicians who are struggling with burnout.

A significant portion of cynicism can feel and is, straightforwardly, earned. It is earned by systems that treat clinicians as interchangeable throughput units. (For those not in the profession, we are literally called “RVUs”: Relative Value Units based on how much we are billing for our services.) It is earned by electronic health records that appear to have been designed by people who have never actually used one in a clinical encounter. It is earned by insurance denials, by the moral injury of watching patients lose coverage they need for reasons that have nothing to do with medicine, by the slow accumulating recognition that the institution you work for has priorities that are not always aligned with yours. My colleagues and I didn’t go into medicine so we could spend time fighting with insurance companies and documenting our charts to de-risk lawsuits.

Nothing I am describing here is meant to suggest that the cynicism is a clinicians fault, or that we all should use mindfulness as a way out of a structurally broken system. That’s not how mindfulness or systems work. The objective read of the burnout literature is quite clear that individual-level interventions are not a substitute for organizational change. We need both, and anyone telling you otherwise is likely whitewashing something.

What I am pointing at is smaller and more personal than the structural question. Inside the broken system, there is still a version of you that has to walk into the next room, and then the room after that, and what I am asking is whether the habit of distancing (once it is running on autopilot, which it is) is costing you something you would rather not pay. For a lot of the clinicians I work with, the answer they arrive at, once they can actually see the loop running, is yes. They notice that they have become someone they don’t quite recognize anymore, and they want to know if there is a way back toward the person they were when they started.

There is, and the way back is not particularly dramatic. It begins with being able to see the loop while it is happening, which is a skill, and skills can be trained, which is ultimately what the data in our study are pointing toward.

The system is not going to fix itself this week, the patient load is not going to lighten, and the charting is not going to do itself no matter how long you wait. What can shift, in the next encounter, is whether we are able to notice the moment when our nervous system reaches for the usual move. That noticing does not require an app or a retreat or an extra hour carved out of a day that does not have an extra hour in it. What it requires is the recognition that the thing we had taken to be a fixed feature of who we have become is actually a loop that got trained, and that loops which got trained can also get retrained, slowly and patiently, one encounter at a time.

The burnout training that I mentioned in this article is freely available on The Dr. Jud Podcast, on any podcast player.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Antico, L., & Brewer, J. A. (2025). Digital mindfulness training for burnout reduction in physicians: Clinician-driven approach. *JMIR Formative Research*, *9*, e63197. https://doi.org/10.2196/63197

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? *Current Opinion in Psychology*, *28*, 198–203. https://doi.org/10.1016/j.copsyc.2019.01.014

Brewer, J. A., Mallik, S., Babuscio, T. A., Nich, C., Johnson, H. E., Deleone, C. M., Minnix-Cotton, C. A., Byrne, S. A., Kober, H., Weinstein, A. J., Carroll, K. M., & Rounsaville, B. J. (2011). Mindfulness training for smoking cessation: Results from a randomized controlled trial. *Drug and Alcohol Dependence*, *119*(1–2), 72–80. https://doi.org/10.1016/j.drugalcdep.2011.05.027

Roy, A., Druker, S., Hoge, E. A., & Brewer, J. A. (2020). Physician anxiety and burnout: Symptom correlates and a prospective pilot study of app-delivered mindfulness training. *JMIR mHealth and uHealth*, *8*(4), e15608. https://doi.org/10.2196/15608

Roy, A., Hoge, E. A., Abrante, P., Druker, S., Liu, T., & Brewer, J. A. (2021). Clinical efficacy and psychological mechanisms of an app-based digital therapeutic for generalized anxiety disorder: Randomized controlled trial. *Journal of Medical Internet Research*, *23*(12), e26987. https://doi.org/10.2196/26987

Maslach, C., & Leiter, M. P. (2017). New insights into burnout and health care: Strategies for improving civility and alleviating burnout. *Medical Teacher*, *39*(2), 160–163. https://doi.org/10.1080/0142159X.2016.1248918

Shanafelt, T. D., West, C. P., Dyrbye, L. N., Trockel, M., Tutty, M., Wang, H., Carlasare, L. E., & Sinsky, C. (2022). Changes in burnout and satisfaction with work-life integration in physicians during the first 2 years of the COVID-19 pandemic. *Mayo Clinic Proceedings*, *97*(12), 2248–2258. https://doi.org/10.1016/j.mayocp.2022.09.002

World Health Organization. (2019, May 28). *Burn-out an “occupational phenomenon”: International Classification of Diseases.* https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases

Cooke, G. P., Doust, J. A., & Steele, M. C. (2013). A survey of resilience, burnout, and tolerance of uncertainty in Australian general practice registrars. *BMC Medical Education*, *13*, 2. https://doi.org/10.1186/1472-6920-13-2

Strout, T. D., Hillen, M., Gutheil, C., Anderson, E., Hutchinson, R., Ward, H., Kay, H., Mills, G. J., & Han, P. K. J. (2018). Tolerance of uncertainty: A systematic review of health and healthcare-related outcomes. *Patient Education and Counseling*, *101*(9), 1518–1537. https://doi.org/10.1016/j.pec.2018.03.030

Gleichgerrcht, E., & Decety, J. (2013). Empathy in clinical practice: How individual dispositions, gender, and experience moderate empathic concern, burnout, and emotional distress in physicians. *PLOS ONE*, *8*(4), e61526. https://doi.org/10.1371/journal.pone.0061526

Klimecki, O., & Singer, T. (2012). Empathic distress fatigue rather than compassion fatigue? Integrating findings from empathy research in psychology and social neuroscience. In B. Oakley, A. Knafo, G. Madhavan, & D. S. Wilson (Eds.), *Pathological altruism* (pp. 368–384). Oxford University Press.

From a neuroscience standpoint, that initial dopamine hit reinforces the behavior and makes us more likely to return to it, and just like any other addiction, the reward diminishes while the harm compounds. Anger starts to own us, and we don’t notice because we’re too busy feeling righteous about it.

Several years ago, I went on a month-long silent retreat with the aim of developing a specific concentration meditation practice I’d been working toward for two years, under the guidance of my teacher Joseph Goldstein. All the physical conditions were perfect — quiet, beautiful setting, no distractions, nowhere to be. The mental conditions were a complete mess.

I had a colleague at work, let’s call her “Jane,” with whom I was having serious difficulty. Every time a thought of her arose during meditation, I’d spiral into elaborate mental simulations: what I should have said, what I’d say next time, how thoroughly justified I was in all of it. That’s exactly the problem. Remember that honeyed tip? Self-righteous anger is about as seductive as it gets. Here I was on a silent retreat, supposed to be developing deep concentration, and instead I was running the same mental courtroom drama on repeat, prosecuting Jane for the hundredth time. Which is what made Confucius’ observation land so hard when it finally hit me: “Before you embark on a journey of revenge, dig two graves.”

For most people, anger doesn’t just flare up randomly. It starts with expectations — we want something, or expect something not to happen, and when reality violates that expectation, the fuse gets lit. And the fuse has a spectrum to it. Something small happens and we get miffed, a little perturbed. It happens again, and now we’re frustrated. The next time we’re upset, then angry, then furious, then enraged. What looks like a sudden explosion is usually just the latest step in a progression that’s been building through dozens of small reinforcements, each one making the next a little easier to reach.

Here’s a concrete example, one that I suspect most of us have lived through. You order something online and it arrives broken. By the time you’ve hunted down the phone number (which the company has helpfully buried three pages deep on their website), you’re already a little annoyed. You get routed through a chatbot that asks the same four questions in different orders and resolves nothing. Now you’re frustrated. You finally reach a human being, the situation gets heated, and eventually — somehow, after all of that — you get what you wanted. Problem solved, call over, you move on. Or so you think.

Here’s what your brain quietly recorded during that interaction: anger worked.

But did it? This is the causation problem that sits at the heart of the whole thing. Two events can be true simultaneously without one causing the other. The situation would probably have resolved whether you got heated or not. The customer service rep may have given you what you wanted specifically to end the call, which means anger worked in the narrowest possible sense while actively harming another person who was just doing their job. And your brain, which is not particularly interested in philosophical nuance when there’s a reward on offer, filed this away under “anger = results.” The habit loop gets reinforced, and you walk away a little more primed to do it again next time. You repeat the process to yourself and to whoever happens to be on the receiving end.

So we learn three things from this loop: (1) We learn that anger is a reliable way to get what we want (or at least we think it does). (2) We learn to harm others in the process of getting it. AND (3) We slowly poison ourselves, because each time we complete that loop, we make the loop more likely to run again. The ancient texts weren’t being poetic when they called anger a poison.

But what if I was right, and I was wronged?

This is where most people push back, and reasonably so. What about genuine injustice to us, to our community, to the world? Doesn’t anger serve a purpose when someone has actually done something wrong?

It’s worth separating two things that often get conflated: the wrongdoing itself, and how we respond to it. When the prefrontal cortex goes offline in blind rage (and “blind rage” isn’t called that for nothing — this is a literal description of what happens in our brain when the cognitive control regions of the brain get overridden by the stress response), everyone gets hurt, including the person trying to address the injustice. The smoke from those fires makes it hard to see clearly, and clarity is exactly what you need when something genuinely important is at stake.

I also want to be clear that I’m not suggesting we wrap ourselves in some fireproof kindness blanket and let the world burn. Compassion isn’t passive. Compassion is actually the opposite of passive. Gandhi’s movement to win Indian independence from the British. The civil rights movement in the United States. The anti-Apartheid movement that led to Nelson Mandela’s election. These were not passive endeavors, and the people leading them understood something that rage-driven action tends to miss: you fight for change and justice more effectively when you can see.

Martin Luther King Jr., preaching in 1967 about the violence being done to Black Americans, famously said: “Bomb our homes and threaten our children, and, as difficult as it is, we will still love you.” That is the opposite of wrapping ourselves up, being passive or avoidant. That is a different quality of fuel, one that doesn’t consume the person holding it. See how much stronger love is than hate? The goal isn’t to extinguish the energy — it’s to repurpose it.

Back on my retreat.

By day three I had developed a phrase I’d say to myself when I felt the anger starting to spin up: “big, big, big.” For me, that meant opening my heart wide when I felt it beginning to close down. Predictably, mid-walking meditation, I got swept up in another elaborate Jane fantasy. The mindstate was extraordinarily seductive. And then I asked myself the question I ask my patients when we’re mapping out habit loops: “What am I getting from this?”

The answer came to me in a blaze. NOTHING. I was getting nothing. For the first time, I saw clearly that the self-righteous buzz of anger itself was the reward. It wasn’t resolution, not justice, not even relief. Just the sweet, seductive honeyed buzz, feeding itself, and keeping me far away from my actual goal of developing concentration. Like patients who after twenty or thirty years of smoking finally pay careful attention to what a cigarette actually tastes like and realize with some shock that it’s not good, I finally tasted the poison in the root. It was right there the whole time. Acrid. Bitter. Yuck.

Once I tasted anger that clearly, something lifted. Each time anger arose after that, letting go became less of a struggle, not because I was suppressing anything or forcing myself through it with willpower, but because the reward had lost its shine. The fire still flared up. It still flares up now. But I could catch it earlier, before it set the whole mind ablaze.

That’s disenchantment, and it’s worth understanding what it actually is and isn’t. It’s not a technique we apply. It’s not positive thinking or counting to ten. It’s the result of looking honestly at what we’re actually getting from a behavior — all of it, not just the honeyed tip — and letting that seeing do the work.

We have to taste the bitterness of poison to spit it out.

This is something all of us can practice. When anger has burned down, survey the scene before moving on. Have you burned a bridge? Scarred a relationship? Done damage you now have to repair? That retrospective, looking back and looking honestly at the results when the heat has died down, is what builds disenchantment over time, and disenchantment is what makes us less likely to reach for the match next time. We don’t need someone to tell us to stop getting angry. Simply seeing it clearly is enough.

From there, it becomes possible to start working with the earlier, smaller flares: the irritation, the frustration, the miffed, before they build into something harder to work with. Each time we catch it early and reach for something more rewarding than the loop (kindness to the situation, to the other person, to ourselves), we’re building a different habit, one whose rewards don’t leave a bitter aftertaste.

Ready for something really radical?

Here’s the Pali Canon text I quoted at the top, in full:

“Having slain what, does one sleep soundly? Having slain what, does one not sorrow? What is the one thing, O Gotama, Whose killing do you approve?”

[The Buddha replies:]

“Having slain anger, one sleeps soundly; Having slain anger, one does not sorrow; The killing of anger, O devatā, With its poisoned root and honeyed tip: This is the killing the noble ones praise, For having slain that, one does not sorrow.”

That’s right. An eye for an eye is way too much. The suggestion here is that the juice is not worth the squeeze. When anger only tastes bitter and we see how poisonous it is, we are moved to move beyond it. Radical indeed.

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Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

​​Bhikkhu Bodhi (Trans.). (n.d.). Sutta 1.71: Anger (SN 1.71). SuttaCentral. https://suttacentral.net/sn1.71/en/bodhi

King, M. L., Jr. (1967, December 24). A Christmas sermon on peace [Sermon]. Ebenezer Baptist Church, Atlanta, GA.

I’ve been sitting with that line, because it describes something I spent years learning the hard way in my own clinical training. Something that was intangible yet seemed important.

Let’s back up a bit in time.

Early in my psychotherapy training, I was taught the phrase “the less you know, the more you say.” The target of this little aphorism was therapist anxiety, specifically the way a trainee’s insecurity tends to spill out as verbosity. When you don’t know what you’re doing, you talk. You fill silence with theory, with interpretations, with carefully reasoned arguments that (you tell yourself) are serving the patient but are really serving your own need to feel competent. I understood this intellectually within about a week of starting my training. And it showed up big time.

Actually learning to keep my mouth shut took considerably longer.

I watched myself ramble on enough times to get embarrassed about it. I’d be sitting with a patient, they’d share something genuinely painful and complicated, and rather than following their thread with curiosity, I’d find myself mentally sprinting toward some theoretical framework that might “explain” what they were describing. I’d say whatever was running, or more accurately racing, through my mind (something appropriately clinical, I hoped) and then I’d watch their face. Their face would tell me, with remarkable consistency, that I had just taken a wrong turn. The session would flatten. The energy would drain out of it, the way a conversation does when someone realizes you’ve been half-listening. I would backpedal or check the clock, hoping that we were nearing the end of the session.

Apologies to all of my patients whom I worked with during residency. I look back on that time and try not to cringe too much.

What shifted things for me (not all at once, but gradually through growing pains, the way these things actually change) was noticing what happened when I stopped trying to demonstrate intellectual competence or lean too heavily on a particular theoretical orientation and instead started getting genuinely curious. Importantly, this was not about performing curiosity (and there is a difference, one your patient can feel from across the room), but actually wanting to know more about their experience, their story, what it felt like from the inside.

When I could settle into genuine curiosity, something different started happening in sessions. Patients would follow their own threads longer. Insights would surface that I never would or could have led them to. And (this is the part that still blows me away) they would often answer their own questions, resolve their own confusions, without my having to say much of anything. I found myself asking more and saying less, and the sessions felt qualitatively better for both of us, partly because patients were discovering that they were considerably wiser than they’d given themselves credit for. Instead of sweating and praying for the session to end, and feeling exhausted afterwards, I would finish up energized and surprised with how little I needed to say.

And critically, I started to gain confidence in something that might sound wild and even heretical: I really didn’t need to know much of anything theoretical to do good therapy. I only needed to be genuinely curious. Perhaps this is where the “dodo bird effect” comes in: the somewhat deflating finding (deflating, at least, if you’ve staked your identity on a particular theoretical orientation) that virtually all bona fide psychotherapies produce roughly equivalent outcomes across hundreds of trials. The name comes from the Dodo in Alice in Wonderland, who declares after a thoroughly chaotic race that “everybody has won and all must have prizes.” If CBT and psychodynamic therapy and interpersonal therapy all work about equally well, the obvious question is what they share rather than what distinguishes them. And what they share, it turns out, may not be a technique.

This is what Mahler was pointing at, I think. A pianist can master the score completely (every note, every dynamic marking, every tempo indication) and still walk onto the stage and produce something technically precise and utterly lifeless. What transforms precision into something that moves people is presence, not a technique for presence or a checklist of presence-adjacent behaviors, but the real thing: genuine attention to what’s unfolding right now, rather than to one’s own preparation for it. Therapy as music.

Again, this is not performative. True performers aren’t trying to perform. The performance is a result of curiosity, play and flow, which can’t be planned or prescribed. The more I tried to perform therapy the more I played out of tune. The more I simply let the sessions flow, the more musical they were.

The field has generated an enormous amount of technical knowledge over the past century (diagnostic frameworks, treatment protocols, intervention hierarchies) and the evidence suggests, somewhat uncomfortably, that it mostly doesn’t matter which one you use. Here’s where the dodo bird effect comes in again: what predicts whether therapy helps is the quality of the therapeutic relationship, regardless of theoretical orientation. The score is almost beside the point, and the essential is everything.

What creates that quality of relationship? The argument my colleague Fabio Giommi and I make in a paper we recently published in Frontiers in Psychology is that genuine curiosity sits at the heart of it, not what psychologists call deprivation curiosity (the anxious, contracted need to fill information gaps, to figure out what’s wrong and what to do about it) but interest curiosity, the kind that’s open and exploratory and feels, from the inside, more like wonder than like problem-solving. When a therapist is actually operating from that place, it tends to be contagious. Patients start exploring their experience more openly, rather than defending their story or performing their distress. Something in the room changes, and both people feel it.

In the paper, Dr. Giommi and I caution about synchopathy which is a form of reflexive (and even habitual) affirmation. The therapist who consistently validates, agrees, reflects back warmly, and never quite challenges, never sits with the patient in genuine uncertainty about whether the story they’re telling themselves actually holds up. It can look like empathy and feel like support, and in the short term patients often experience it as such. What it quietly forecloses and even trains both the therapist and patient out of (because it makes them both comfortable, and even comfortably numb over time) is challenge and growth, which requires someone willing to be honestly curious rather than reliably agreeable.

Curiosity, if it’s real, will more than occasionally take you somewhere uncomfortable. It will generate questions that don’t confirm the existing narrative, notice contradictions the patient has been carefully smoothing over, and follow threads the patient might prefer to leave alone. A therapist who is afraid of that territory (whether from their own conflict avoidance, or from a sincere but misapplied commitment to unconditional positive regard) isn’t being curious. They’re being careful, and their patients, on some level, tend to know it (unless they’ve learned to love coming to sessions to numb out over time).

What the neuroscience adds is that this isn’t just a vague interpersonal impression. The brain constructs its experience of the world by generating models and filtering incoming information through them, only updating when there’s a meaningful mismatch between what it predicts and what it actually receives. In neuroscience, these are literally called generative models. A simpler, more down to earth term is a world view. A therapist who has formed a confident model/world view of who a patient is, what’s wrong with them, and what they need, will be more likely to automatically filter that patient’s words through that model (filling in gaps, smoothing over contradictions) and in doing so, reliably miss the actual person sitting across from them. At the same time, patients develop their own world view (of themselves) and also filter their experience and what they hear in therapy through their own lens, which contributes to keeping them stuck but in familiar territory (familiar feels comforting). Curiosity disrupts this by keeping the model provisional, allowing new information to actually land.

Everything is written in the protocol except the essential. The essential (as far as I can tell from several decades of practice and more than a few embarrassing sessions early in my training) can’t be written down because it isn’t a technique. It’s a quality of attention, one that has to be cultivated, felt rather than performed, and that when it shows up in a room where someone is struggling, tends to make that room a safer place. Safety opens up the space for honesty (with themselves and their therapist), learning and growth.

Therapy as music = magic.

If you’re a therapist (early career)

When you notice yourself talking more than usual in a session (filling silence, reaching for theory, building an argument nobody asked for) what’s actually driving that? Is it that you have something genuinely useful to offer in that moment, or is sitting with not-knowing uncomfortable enough that talking has become how you manage it? And if it’s the latter, what would happen if you just didn’t? What might your patient say into that silence that they haven’t had room to say yet? And what happens when you bring curiosity into that space? This open space, imbued with curiosity, may be more useful than the theory.

If you’re a therapist (experienced)

The question I find more honestly difficult than anything I’d aim at a trainee is: how would you know if you were doing it? The brain builds models and filters incoming information through them, updating only when something surprising gets through. The more clinical experience you accumulate, the more refined and confident those models become, and the more seamlessly they sort incoming information into familiar categories before you’ve consciously registered what you just heard. This is confirmation bias operating at the level of expertise, and it’s more insidious than trainee anxiety precisely because it feels like competence rather than a problem. So the question worth sitting with (maybe after your next session rather than in the abstract) is how curious you were in session, whether you were genuinely surprised by your patient today, whether something they said landed in a way you didn’t expect, whether your model of them got updated, or whether everything more or less confirmed what you already thought.

If you’re a patient

The most useful thing therapy can offer (more than the “right” interpretation or the correct diagnosis or even particularly good advice) is a quality of attention that gives you enough space to hear yourself think, and let yourself feel. If your therapist’s questions are mostly opening things up rather than steering you somewhere, if you find yourself surprising yourself with what comes out of your mouth, if you leave sessions feeling more like a capable person and less like a problem to be solved, that’s the essential at work.

If that’s not what’s happening, it’s worth paying attention to that too. Therapy is not a situation that calls for politeness at the expense of honesty. You are allowed to notice if the curiosity mostly flows in one direction, if your therapist seems more interested in confirming their framework than in being surprised by you, and you are allowed to say so. “I feel like we keep coming back to the same explanation and I’m not sure it fits” is not a difficult patient being resistant; it’s useful clinical information, and any therapist worth their training will receive it as such. If they don’t, if what comes back is defensiveness or an escalation of the very certainty you were questioning, that’s worth making a note of. Finding a therapist who is curious about you specifically, rather than about the diagnostic category you happen to fit, is not a luxury. Any musician will tell you that the notes are the easy part. What you’re looking for is the person who can move beyond them.

PS. If this piece resonated and you’re a clinician looking to cultivate genuine curiosity as a clinical skill rather than just a concept, we’re offering a short training in exactly that: Cultivating Curiosity for Habit Change: Mindful Inquiry Training for Transformation.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Brewer, J. A., & Giommi, F. (2025). Psychotherapy as investigation: cultivating curiosity and insight in the therapeutic process. Frontiers in Psychology, 16, 1603719. https://doi.org/10.3389/fpsyg.2025.1603719

Luborsky, L., Singer, B., & Luborsky, L. (1975). Comparative studies of psychotherapies: Is it true that “everyone has won and all must have prizes”? Archives of General Psychiatry, 32(8), 995–1008. https://doi.org/10.1001/archpsyc.1975.01760260059004

Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “all must have prizes.” Psychological Bulletin, 122(3), 203–215. https://doi.org/10.1037/0033-2909.122.3.203

“It’s food,” she said. “I’m either eating right or I’m not. If I’m not, what’s the point?”

I asked if anyone else in the meeting could relate to this and looked around the Zoom gallery. Hands were going up everywhere. She was speaking for the masses.

“I can’t eat perfectly every day,” she continued, “so I go to bed feeling like I failed again.”

I asked her how long she’d been doing this.

“Since I was seven. I’m turning fifty.”

Forty-three years. That’s a lot of nights going to bed feeling like a failure.

I wanted to understand what was happening in the moment when everything fell apart. “When a craving hits, what happens?” I asked.

“By the time it hits, I go do it.”

“Okay, but what about right before? That moment just before you eat?”

“It’s a war inside me. Will I, won’t I, should I, shouldn’t I? Then I do it.”

“Is that war in your body?”

“Yes. I’m tense just thinking about it.”

What she was describing, that tight warring feeling in the body before a craving lands, was contraction: that physical signature of resistance that shows up whether we’re fighting anxiety, cravings, or, as it turned out, something deeper.

We started exploring what happens in her body when this war begins. Just talking about it, she described how she could feel the tension (and I could see it in her face). I asked her to get curious about it, to simply ask herself: “What does this feel like?”

“Just thinking about it releases it a bit,” she said.

“What if that’s all you need?” I suggested.

She paused. “It can’t be that easy. There’s a voice saying I have to fight [the urges to eat].”

Of course there is, because for forty-three years, fighting had been the strategy. Diet plans, food rules, willpower, the whole battle. And where had it gotten her? Heartache and exhaustion, by her own account.

Then she said something that shifted the whole conversation: “I guess shame gets in the way too.”

Shame is that heavy, crushing feeling that shows up right after we “fail,” the voice insisting we’re not just doing something wrong but that we ARE wrong, broken, fundamentally flawed. Brené Brown, who has spent decades studying this, draws a sharp distinction: guilt circles around what you did; shame goes after who you are. Guilt can motivate change. Shame attacks the very sense of self that would need to be intact to make that change.

Ready for this? Most of us don’t realize that shame is a habit.

It starts with doing something we feel guilty about (“I shouldn’t have done that”). Guilt triggers rumination, where we dwell on the act. Over time, the focus shifts from what we did (“I ate too much”) to who we are (“I have no self-control”), and once we’ve made that leap, we start to believe we are the mistake (“I am a failure”) rather than that we made one. That’s how shame takes hold.

From a reinforcement learning standpoint, guilt functions as punishment: it feels bad, so any behavior that prevents it gets reinforced. Shame works similarly, and then it goes a step further.

At times, shame may even feel rewarding: a strange sense of agency, control, or predictability through self-criticism. That illusion of “doing something” provides a short-term payoff, even as it deepens the habit. Once rumination and self-criticism become grooved, the harsh inner critic predictably appears whenever shame is triggered. There’s a strange comfort in that, because doing something, even judging ourselves, feels better than doing nothing.

Our brains hate uncertainty and will choose painful certainty over the unknown. Yes, this sounds odd if not downright off, but that’s how our brains work. “At least I know I’m a failure” can feel more comfortable than the vulnerability of trying something new and risking disappointment again. Shame itself doesn’t feel good, but over the years it begins to feel like a trusty traveling companion, so familiar we forget to check whether it’s weighing us down.

From a functional standpoint, our brain is the perfect incubator for shame: our thoughts can repeat endlessly without anyone knowing we’re ruminating. Brown notes that silence and secrecy are precisely the conditions where shame thrives, which is one reason it gets so much uninterrupted practice.

Unfortunately, many people are raised in environments where caregivers or institutions use shaming techniques, explicitly or implicitly, to enforce social norms and obedience. This repeated exposure from a young age conditions the internal shame response, essentially wiring it as the default, if deeply unhelpful, mode of self-regulation later in life.

Shame also corrodes the very capacity to believe we can change. The more identified we become with it, the more our worldview shifts. Like glasses worn so long we forget they’re there, we start seeing everything through an “I’m broken” lens, interpreting new information to confirm what we already believe. By then, the idea of taking them off feels genuinely threatening.

This tends to produce the behaviors that keep the cycle running: hiding, withdrawing, giving up.

Shame is remarkably sticky for exactly this reason: it’s been reinforced thousands of times in the privacy of our own heads, and each repetition strengthens the pathway. So how do you take off those glasses?

Studies on shame show that it lights up a network of brain regions involved in self-referential processing. The medial prefrontal cortex and posterior cingulate cortex, core hubs of what is known as the default mode network, activate when people imagine shameful scenarios. This same network is what my lab has spent years studying in relation to craving, worry, and getting “caught up” in experience.

When you’re lost in shame (“I’m such a failure”), you’re activating the same brain regions that fire when you’re lost in a craving or stuck in anxious rumination. The posterior cingulate cortex, that brain region I’ve studied extensively in relation to addiction, doesn’t just light up when smokers crave a cigarette or when people anxiously spin out in cycles of worry; it also activates during shame.

When we identify with shame, we’re caught in the narrative, the story, the judgment. The prefrontal cortex spins stories about our character, our worth, our inability to change. Just as people who overidentify with anxiety come to believe they are an anxious person, we can get stuck in shame-as-identity (“I am no good”) rather than shame-as-experience.

Meanwhile, our older brain networks, including the insula, which processes both our body’s internal state and emotional salience, come online as well. The insula integrates signals from inside the body (that heavy, crushing sensation of shame) with our emotional state and sense of self, likely through links back to the posterior cingulate cortex.

The brain loops take hold fast. Shame activates the insula, processing those uncomfortable body sensations, while the medial prefrontal cortex and posterior cingulate cortex keep the shame story running (“this means something about WHO I AM”). And suddenly we’re reaching for food or another distraction to make it stop.

Ironically, we often reach for the very thing that triggered shame in the first place.

So how can we free ourselves from these shame spirals? The person in my Zoom call had been spinning for forty-three years, which is a long time to be dizzy.

“Can you feel into the shame?” I asked.

“It’s heavy.”

“Ask yourself: what does this feel like in my body?”

There was a shift in her face.

“That switches me from being the shame to simply feeling it.”

She’d found the doorway in.

When she turned curiosity toward the physical sensation of shame, something shifted: she created space between herself and the feeling, moving from “I am ashamed” to “I am experiencing shame.”

When we get curious about shame as a sensation (heavy, tight, crushing, whatever it feels like for us), we activate a different system altogether. We’re observing rather than being swallowed by the narrative, stepping outside the story long enough to actually look at it.

My lab has found that when experienced meditators practice mindfulness, activity in the posterior cingulate cortex decreases. We’ve even found that in people trying to quit smoking, reductions in these brain regions after mindfulness training predict reductions in cigarette smoking. The same region that lights up during craving, worry, and shame quiets down when we bring curious awareness to our experience.

Experientially, curiosity and shame can’t occupy the same moment. Curiosity feels open and expansive; shame contracts. You can’t be genuinely curious about what something feels like in your body while simultaneously being crushed by it.

Curiosity also shows us what shame actually gets us. When we pay attention to what shame feels like (heavy, crushing, contracting) and trace where it leads (more eating, more hiding, more exhaustion), we start updating the reward value in our brain. The orbitofrontal cortex, which is always running comparisons, starts getting accurate information. Shame, looked at clearly, stops justifying itself.

And once curiosity reveals that shame feels terrible and doesn’t actually help, it tends to call in its close cousin: self-compassion.

The next time shame shows up, about food or anything else, there’s a simple experiment worth running. Before you do anything about it, get curious: what does this actually feel like in my body right now? Then try talking to yourself the way you’d talk to a good friend who was struggling with the same thing. Something like: this is hard, I’m doing the best I can. Notice what shifts in your body between those two states. Your brain is always running a comparison, and it will move toward whatever feels more rewarding. For most people, the warmth of self-compassion is a pretty clear winner over shame’s cold contraction, once you can actually feel the difference.

This is how the habit loop itself becomes the path out.

She mentioned that voice, the one that says she has to fight, that it can’t be this easy, that letting go of the battle means losing control entirely.

I hear that voice all the time, and it makes a certain kind of sense: if you’ve been white-knuckling your way through life for decades, the idea of not fighting feels genuinely dangerous.

So I asked her to check: what had she actually gotten from listening to that voice for the past forty-three years?

The answer came quickly: heartache, exhaustion, forty-three years of going to bed feeling like a failure.

The leverage point is looking clearly at what the actual behavior produces, not the behavior we wish we were doing. In her case that meant tracing the real sequence: try to follow the rules, should all over herself, give up, feel shame, repeat. When we see clearly that the strategy isn’t working, really see it and feel it in our bodies, we create the conditions for something new.

Shame thrives in silence and secrecy, which is why compassion is so disruptive to it. This may be why the group setting, where others’ raised hands demonstrated “me too,” can be so useful for healing. By inviting curiosity and sharing the experience, we transform a private battle into something recognizably human, and remind ourselves that we are not alone in it.

We can also offer compassion to ourselves, and we can use the brain’s reinforcement learning system to make that a habit. When we actually compare what rumination and self-criticism feel like against self-compassion, the brain’s verdict tends to be pretty unambiguous. This helps us become disenchanted with the old habits because we see clearly that they’re not helping. We start recognizing the shame spirals whenever they arise and bring a moment or two of self-compassion in, as simple as reminding ourselves that we are worthy, that we’re doing the best we can. Short moments of self-compassion throughout the day are how we build it into a habit.

I gave her a mission (should she choose to accept it):

Any time those old habits come up (the voice of shame, the “I have to fight,” the “I am a failure”), ask: What did I get from listening to this last time?

Then drop into the body: What does this feel like right now?

No food rules, fighting with or blaming herself. Just curiosity about what’s actually happening. And perhaps a touch of compassion for good measure.

Why the 1-2 of curiosity followed by compassion? Curiosity creates the open space to step out of the old shame spiral, and compassion offers the rewarding alternative that helps you stay out.

As Rumi, the 13th century Sufi mystic wrote:

Be empty of worrying

Think of who created thought

Why do you stay in prison

When the door is wide open?

Move outside the tangle of fear thinking.

Live in silence.

Flow down and down in always

Widening rings of being.

(“A community of spirit,” Rumi)

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Bastin, C., Harrison, B. J., Davey, C. G., Moll, J., & Whittle, S. (2016). Feelings of shame, embarrassment and guilt and their neural correlates: A systematic review. Neuroscience & Biobehavioral Reviews, 71, 455–471. https://doi.org/10.1016/j.neubiorev.2016.09.019

Becker, C. J., Vogt, K. M., & Ibinson, J. W. (2018). Human posterior insula to posterior cingulate functional connectivity is related to the subjective intensity of acute pain. bioRxiv.

Bhikkhu, T. (2013, April 30). Dealing with guilt and shame (Day 19). Wildmind.

Bhikkhu, T. (2013, May). Why shame gets a bad rap (but shouldn’t). Tricycle: The Buddhist Review.

Brewer, J. A. (2017). The craving mind: From cigarettes to smartphones to love — Why we get hooked and how we can break bad habits. Yale University Press.

Brewer, J. A., & Garrison, K. A. (2014). The posterior cingulate cortex as a plausible mechanistic target of meditation: Findings from neuroimaging. Annals of the New York Academy of Sciences, 1307(1), 19–27. https://doi.org/10.1111/nyas.12246

Brewer, J. A., Garrison, K. A., & Whitfield-Gabrieli, S. (2013). What about the “self” is processed in the posterior cingulate cortex? Frontiers in Human Neuroscience, 7, 647. https://doi.org/10.3389/fnhum.2013.00647

Brewer, J. A., Ruf, A., Beccia, A. L., Essien, G. I., Finn, L. M., van Lutterveld, R., & Mason, A. E. (2018). Can mindfulness address maladaptive eating behaviors? Why traditional diet plans fail and how new mechanistic insights may lead to novel interventions. Frontiers in Psychology, 9, 1418. https://doi.org/10.3389/fpsyg.2018.01418

Brewer, J. A., Worhunsky, P. D., Gray, J. R., Tang, Y. Y., Weber, J., & Kober, H. (2011). Meditation experience is associated with differences in default mode network activity and connectivity. Proceedings of the National Academy of Sciences, 108(50), 20254–20259. https://doi.org/10.1073/pnas.1112029108

Brown, B. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. Gotham Books.

Brown, B. (2013). Shame vs. guilt. Brené Brown. https://brenebrown.com/articles/2013/01/15/shame-v-guilt/

Craig, A. D. (2002). How do you feel? Interoception: The sense of the physiological condition of the body. Nature Reviews Neuroscience, 3(8), 655–666. https://doi.org/10.1038/nrn894

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Critchley, H. D., Wiens, S., Rotshtein, P., Öhman, A., & Dolan, R. J. (2004). Neural systems supporting interoceptive awareness. Nature Neuroscience, 7(2), 189–195. https://doi.org/10.1038/nn1176

Garrison, K. A., Santoyo, J. F., Davis, J. H., Thornhill, T. A., Kerr, C. E., & Brewer, J. A. (2013). Effortless awareness: Using real time neurofeedback to investigate correlates of posterior cingulate cortex activity in meditators’ self-report. Frontiers in Human Neuroscience, 7, 440. https://doi.org/10.3389/fnhum.2013.00440

Garrison, K. A., Zeffiro, T. A., Scheinost, D., Constable, R. T., & Brewer, J. A. (2015). Meditation leads to reduced default mode network activity beyond an active task. Cognitive, Affective, & Behavioral Neuroscience, 15(3), 712–720. https://doi.org/10.3758/s13415-015-0358-3

Janes, A. C., Datko, M., Roy, A., Barton, B., Druker, S., Neal, C., Ohashi, K., Benoit, H., van Lutterveld, R., & Brewer, J. A. (2019). Quitting starts in the brain: A randomized controlled trial of app-based mindfulness shows decreases in neural responses to smoking cues that predict reductions in smoking. Neuropsychopharmacology, 44, 1631–1638.

Khalsa, S. S., Adolphs, R., Cameron, O. G., Critchley, H. D., Davenport, P. W., Feinstein, J. S., Feusner, J. D., Garfinkel, S. N., Lane, R. D., Mehling, W. E., Meuret, A. E., Nemeroff, C. B., Oppenheimer, S., Petzschner, F. H., Pollatos, O., Rhudy, J. L., Schramm, L. P., Simmons, W. K., Stein, M. B., . . . Zucker, N. (2018). Interoception and mental health: A roadmap. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 3(6), 501–513. https://doi.org/10.1016/j.bpsc.2017.12.004

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Wagner, U., N’Diaye, K., Ethofer, T., & Vuilleumier, P. (2011). Guilt-specific processing in the prefrontal cortex. Cerebral Cortex, 21(11), 2461–2470. https://doi.org/10.1093/cercor/bhr016

Last week, those words came back to haunt Facebook in a Los Angeles courtroom.

After nine days and nearly 44 hours of deliberation, a jury found Facebook (now known as Meta) and YouTube (owned by Google) liable for addicting a young woman, worsening her mental health, and failing to warn her of the risks. It’s the first time an American court has effectively declared that these platforms are products engineered to exploit the developing brains of children.

As a neuroscientist doing addiction research for over 20 years, this surprised me, but probably not in the way you think. I’m surprised that it’s taken this long for the legal system to catch up to something that’s been obvious to scientists for years.

The neuroscience being argued in that Los Angeles courtroom, the way unpredictable rewards hook us harder than predictable ones, has been in the peer-reviewed literature for nearly a century. B.F. Skinner described the mechanism in the mid-twentieth century. Eric Kandel found it operating in sea slugs with 20,000 neurons, work that earned him a Nobel Prize in 2000. My own lab has been publishing on how these same loops drive everything from smoking to anxiety to compulsive eating since I was a psychiatry resident at Yale.

None of this was a secret. And while lawyers are paid to claim that it ain’t so, they knew it was so, because they explicitly designed it that way. Sean Parker said that he and Mark Zuckerberg understood the risks, and did it anyway. This was less of a confession and more of a brag. A brag about how they had hacked the human brain, a “breakthrough” that had made him wildly rich, to the tune of $2.6 billion, and made Mark Zuckerberg one of the five richest people in the world.

Another direct quote from Parker: “God only knows what it’s doing to our children’s brains.”

So the verdict makes sense. And it is a big deal, because this is social media’s tobacco moment. The tobacco industry ran for decades claiming cigarettes weren’t addictive or bad for your health, knowing full well they were. It took hauling their executives in front of Congress and putting the science plainly in their faces before anything changed. We’re watching the same reckoning, just with screens instead of cigarettes.

Perhaps just as interesting is Meta’s response. “Teen mental health is profoundly complex,” Meta said after the verdict, “and cannot be linked to a single app.”

Go ahead, roll your eyes. Lawyers getting paid to defend their clients. But they’re also not entirely wrong.

Teen mental health is profoundly complex. Before we point the finger at social media alone and say “case closed”, it’s important to note that the documented rise in adolescent depression, anxiety, and self-harm (seen across multiple countries) has a long list of contributing causes, including economic precarity, increasing academic pressures, the collapse of unstructured time, family instability, and more. Rates of mental health decline were climbing before Facebook and Instagram became ubiquitous.

And, per what I could gather from the reports, the plaintiff had a genuinely difficult childhood. In fact, Meta’s defense leaned into this: her struggles, they argued, preceded Instagram and stemmed from family trauma, not scrolling.

But after more than a week of deliberation, the jury rejected this. From a scientific standpoint, I absolutely agree.

But I also want to be precise about why, because “she had a hard life” is not the exculpatory argument Meta thinks that it is. In fact, it’s the exact opposite - even more of a reason why they should be held accountable.

For example, one of my patients who came to me after a 40 year tobacco habit (roughly 293,000 cigarettes!) didn’t start smoking because everything was going well. In fact, most of my patients who are addicted to cigarettes start smoking around the age of 12, which is an extremely stressful part of adolescence (it certainly was for me). People usually pick up the things that become addictions when they’re already hurting. Stress triggers the urge to reach for something that makes us feel better, even temporarily. That’s the basic architecture of reward-based learning operating exactly as evolution designed it, in a brain that can’t tell the difference between genuine threat and a notification chime that someone liked your post.

Vulnerable kids in difficult circumstances are not evidence against the harm of addictive design. They are the mechanism through which it works most efficiently. This is why Instagram (and others) have been targeting teens for so long. They are the perfect market given their vulnerability.

The argument that “she was already struggling” is, from the perspective of the neuroscience of habit formation, an important argument for holding these platforms accountable, not an argument against it.

Another interesting point: by focusing on platform design rather than platform content, the plaintiffs’ lawyers successfully sidestepped Section 230, the law that has historically shielded tech companies from liability for what users post on their services. The tobacco cases cracked in a similar way; not when people argued smoking was bad, but when litigation reframed cigarettes as nicotine delivery systems engineered to maximize dependence. The product is the problem.

Yet, this is only a small victory in my mind.

The dollar amount of the verdict is a rounding error for a company that is worth trillions. Even a thousand similar verdicts at this scale wouldn’t threaten Meta’s business model. Looking back, the tobacco settlements eventually exceeded $200 billion and took decades to meaningfully reshape the industry. Even then, people kept smoking, and still do today. The 1,500 pending lawsuits that this verdict will influence are certainly important, but the legal mechanism alone is a slow and blunt instrument.

What could actually change things isn’t damages. Instead, it’s design. Thanks to pioneering scientists on whose shoulders we stand, we now know exactly what to look for and can measure which features drive the addictive loop, such as algorithmic feeds optimized for engagement over wellbeing, the advent of the infinite scroll, the random ding-ding-ding of intermittent reinforcement notifications, and no natural stopping points. We also know there are (albeit imperfect) alternatives such as chronological feeds and notification batching. None of these require new technology. They just require accepting lower engagement metrics, which means lower ad revenue, which is probably why they haven’t been implemented voluntarily.

Who said doing the right thing is easy, especially when your yearly bonus depends on the opposite?

For the parents and kids reading this who’ve been trying to sort out for years whether the frustration they feel about their relationship with these platforms is justified, well it is. Just like the diet industry has told people for decades that their willpower is weak, and it’s their fault that they can’t stop eating the addictively designed food, parents and kids are justified in knowing that it isn’t them. These social media systems were designed and built this way.

In my clinic and in our research programs, the single most consistent obstacle to change isn’t willpower. It’s the story people tell themselves about why they can’t change, which is again, usually some version of there’s something wrong with me. That story is exhausting to carry, and it distracts and deflects energy away from focusing it toward that which actually drives habit change. You can’t get genuinely interested in learning how your mind works when you’re too busy blaming yourself for how your mind works. Which, of course, keeps you from then learning how to work with your mind.

At the end of what to me, given all that is going on in the world, seems like a very long week, at a minimum, this verdict retires that its-not-the-platform-its-you story. You are not defective or fighting a character flaw. You are fighting a very large and well-paid (with bonuses!) engineering team with your behavioral data, a decade of iterative testing on hundreds of millions of users, and a financial model that requires your continued, compulsive attention. That’s what an attention economy is all about.

To me, this verdict gives several rays of hope: 1) these platforms are culpable for their actions, 2) we can redirect the blame and shame energy toward learning how to get our brains back.

Get curious. When the next notification pings, what does the urge feel like right before you pick up the phone? What specifically is hooking you? What itch are you scratching? What are you actually getting from opening your social media, effectively scratching that itch. And is that reward still worth what it costs?

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Arnsten, A. F. T. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10, 410–422.

Arnsten, A. F. T. (2015). Stress weakens prefrontal networks: Molecular insults to higher cognition. Nature Neuroscience, 18(10), 1376–1385.

Brewer, J. A. (2017). The craving mind: From cigarettes to smartphones to love—why we get hooked and how we can break bad habits. Yale University Press.

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 198–203.

Kandel, E. R. (2000). The molecular biology of memory storage: A dialogue between genes and synapses. Nobel Lecture. Nobel Prize Committee.

Solon, O. (2017, November 9). Ex-Facebook president Sean Parker: Site made to exploit human “vulnerability.” The Guardian.

Truth Initiative. (2023). The Master Settlement Agreement: 4 ways the landmark tobacco settlement changed tobacco control. https://truthinitiative.org/research-resources/tobacco-prevention-efforts/master-settlement-agreement-4-ways-landmark-tobacco

The experiment: researchers at UCSF and UC Berkeley trained thirsty mice to associate a brief tone with a sugar water reward, varying how long the gap was between each pairing. One group got pairings every minute, which equates to about fifty rounds in an hour-long session. Another group got pairings every ten minutes, which works out to six in the same hour. Standard thinking would predict the fifty-trial group learns faster. That’s more practice, more signal, more dopamine firing at the right moment to lock in the learning. That’s how I learned the neuroscience of reward-based learning back in the day.

Ready for the results? Both groups took roughly the same total amount of time to learn the association, BUT the mice with ten-minute gaps learned the association in one-tenth the number of trials (9 vs 94 trials)! So, you could pull nine out of ten training experiences out of the sparsely-spaced group and their brains would learn just as fast, measured in minutes, as mice who’d done it fifty times per session.

The senior author, Vijay Mohan Namboodiri, put it plainly in an interview: “total learning is determined by time, not count.”

WOW!

What the brain appears to be computing is something closer to cause-and-effect than prediction. Rather than asking “how often does this tone precede a reward?” the brain seems to be asking, retrospectively, “did that tone actually cause that reward?” (with the spacing between rewards providing essential data for answering the question). When rewards arrive rarely, each one carries more signal, more weight, more gravitas so to speak. The dopamine response in the nucleus accumbens, which the team measured directly using fluorescent sensors, backed up the behavior: it wasn’t tracking how many pairings had occurred but instead, how much time had passed between them.

There’s another finding in the paper that is also worth mentioning. When mice received a reward only fifty percent of the time, just unpredictable delivery, they learned in about half the number of rewarded trials compared to mice who got rewarded every time. They received fewer actual rewards, but learned just as fast. This can be interpreted as the less predictable the schedule, the more the brain weighted each occurrence.

You probably already know where this goes. Intermittent reinforcement is the mechanism that makes slot machines so difficult to leave, social media so hard to put down, and that relationship with someone who runs alternately hot and cold is very hard for some people to stop thinking about. We’ve known for decades that unpredictable rewards are more motivating than predictable ones. This paper backs this up nicely, and adds a precise mechanistic story: when your brain can’t predict when the next reward will arrive, it treats each occurrence as especially informative about causation, and it learns accordingly. Gravitas again.

So why am I so excited about this paper? Yes, I love reading and learning from well-designed neuroscience papers, but mice aren’t the end of the road. These are mouse data on a simple Pavlovian conditioning task. The precise proportional scaling the paper demonstrates in a controlled animal paradigm will not port directly into a clinical recommendation that I can give to someone at their next clinic visit.

What does it mean for what we do as clinicians?

I think the paper meaningfully sharpens something we’ve been saying in an imprecise way.

I’ve instructed patients and participants in my programs that mindfulness doesn’t have to take a lot of time, it just has to be real. I use the following saying as shorthand: “short moments, many times.” Habits form through repetition. What this paper offers beyond my bumper sticker saying is a mechanistic reason to think that the spacing of each learning moment may actually matter more than the frequency. If the brain is running something like a retrospective causal computation when it assigns learning to a reward experience, then cramming practice moments together just to get the reps in might dilute the signal (or at least needlessly waste time and energy) rather than amplifying it. The brain needs space to ask whether what just happened was actually caused by what came before.

Here’s a real-world example: one of my patients, working through an anxiety habit loop, did what many motivated people do: she started catching anxiety moments throughout her entire day, as many as she could, every time they arose. She said it felt like she was practicing constantly but that nothing was landing in a way that felt like progress toward change. We slowed it down. Fewer intentional moments, more gravitas to each one. It didn’t take that many reps yet something started to shift in the right direction within a few weeks. I’m not claiming this as evidence for the Burke findings. It’s an anecdote, and I’m well aware that any number of factors could explain it. But the paper at least gives me a more principled reason to take that clinical observation (and others like it) seriously.

Yet, there may be even more to the story.

Let’s circle back to something that may be more important than timing. What the paper can’t tell us is whether the quality of each learning moment matters alongside its timing. In the mouse paradigm, quality is held constant, essentially baked out of the experiment. A head-fixed mouse with a lick spout in front of its face and nothing else to do is, by design, fully present for each tone-sucrose pairing. It can’t half-attend, go through the motions, or note the cue while mentally drafting its grocery list. The learning moment is the learning moment. Whether a ten-minute gap between fully-present experiences produces the same result as a ten-minute gap between distracted or perfunctory ones, the experimental design simply can’t answer that.

My guess, based on my clinical work, is that the quality of attention during whatever we’re trying to learn matters quite a lot. The orbitofrontal cortex can only update the reward value of a behavior that it actually registers. This is hinted at by some of my lab’s previous research showing that it only take 5-15 times of paying attention when we overeat for the reward value to drop below zero (eg. Taylor et al 2021). Notice how overeating naturally forces spacing. We can’t overeat ten times in a row in an hour or even a day.

Which brings me to Vince Lombardi, the legendary Green Bay Packers coach after whom the Super Bowl trophy is named, who put it better than I can: “Practice doesn’t make perfect. Perfect practice makes perfect.” The Burke finding may support and even augment it. It’s not just how perfectly you practice, and it’s not just how often. It may be a combination of both: how much you’re paying quality attention during the task, and whether you’re giving your brain enough time between reps to actually compute what just happened. Time and quality, together. Not mindless reps.

And that’s an experiment that we all can try for ourselves, whether it’s breaking free from the worry habit, or learning a new habit: pay attention with each rep, and see how quickly you learn.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

References:

Burke, D. A., Taylor, A., Jeong, H., Lee, S., Zsembik, L., Wu, B., Floeder, J. R., Naik, G. A., Chen, R., & Namboodiri, V. M. K. (2026). Duration between rewards controls the rate of behavioral and dopaminergic learning. Nature Neuroscience. https://doi.org/10.1038/s41593-026-02206-2

Taylor, V., Moseley, I., Sun, S., Smith, R., Roy, A. H., Ludwig, V. U., Brewer, J. A., (2021) “Awareness drives changes in reward value and predicts behavior change: probing reinforcement learning using experience sampling from mobile mindfulness training for maladaptive eating.” Journal of Behavioral Addictions 10(3): 482-7.

As a psychiatrist and behavioral neuroscientist, I’ve spent years studying why this happens. It starts with fear, which is the oldest survival mechanism we’ve got, helping us learn to avoid dangerous situations through a process called negative reinforcement. If we step out into a busy street, turn our head, and see a car coming right at us, we instinctively jump back onto the sidewalk. That fear reaction helps us learn quickly that streets are dangerous, through a simple three-part sequence: an environmental cue, a behavior, and a result.

We share this survival tool with essentially all animals. Even the sea slug, with only twenty thousand neurons in its entire nervous system (compared to roughly a hundred billion in the human brain), uses this same learning mechanism.

Sometime in the last million years, humans evolved a new layer on top of this more primitive survival brain, called the prefrontal cortex (PFC). Involved in creativity and planning, the PFC predicts what will happen in the future based on past experience.

Critically, though, the PFC needs accurate information to make good and accurate predictions. When information is lacking, our PFC plays out different scenarios about what might happen, running simulations based on the most similar events it can find in memory to choose the best path forward.

Enter anxiety.

Defined as “a feeling of worry, nervousness or unease, typically about an imminent event or something with an uncertain outcome,” anxiety arises when our PFCs don’t have enough information to accurately predict the future. Without accurate information, it’s easy for our brains to spin stories of fear and dread based on the latest headlines we’ve seen. And because of the way our brains are wired (the more shocking the news, the more it amplifies our sense of danger), the more likely we are to remember it.

In addition to being fueled by uncertainty, anxiety is also contagious.

In psychology, the spread of emotion from one person to another is called social contagion. Our own anxiety can be triggered simply by talking to someone else who is anxious. Their fearful words are like a sneeze landing directly on our brain, emotionally infecting our PFC and sending it spinning as it worries about everything from whether our family members are safe to how our jobs will be affected.

For example, in a large-scale study, researchers at Facebook manipulated the emotional content of nearly 700,000 users’ news feeds (without their knowledge) and found that people who saw more negative posts subsequently wrote more negative posts themselves, and vice versa. In other words, emotions can spread through text alone; no face-to-face contact is required. Wall Street has long understood this: financial markets function as a collective anxiety thermometer, and the so-called Fear Index (VIX) spikes predictably every time uncertainty surges.

What’s changed in recent years is the virulence of the pathogen itself.

Epidemiologists measure how quickly a virus spreads using something called the basic reproduction number, or R0. Basically this is how many new infections one case generates on average. An R0 above 1 and a virus spreads exponentially; below 1 and it dies out.

While we can’t put a precise R0 on a feeling, emotional contagion follows a similar dynamic, and the platforms that transmit it have gotten dramatically more efficient. Think about 2020, when TikTok was mostly people doing silly dances and stress-baking sourdough. The emotional content was relatively benign. Five years later, the algorithm has had billions of data points to learn from, and what it has learned is that outrage, fear, and moral urgency keep people watching longer than joy or curiosity. Each of our individual feed experiences has become a finely tuned emotional amplifier. The TikTok virus has evolved.

It isn’t limited to TikTok. We carry that same infectious dynamic around in our pockets, all hours a day. And we put it next to our pillow at night when we go to sleep. We scroll through posts about wars, economic uncertainty, climate tipping points, and whatever political crisis landed this morning, each one a kind of micro-exposure. When we can’t contain our anxiety, that emotional fever spikes into panic, which is defined as, “sudden uncontrollable fear or anxiety, often causing wildly unthinking behavior.” Overwhelmed by uncertainty and fear of the future, our PFCs (the rational thinking parts of our brains) go offline.

Remember the pandemic, when there was a run on toilet paper that had nothing to do with diarrhea?

Logically, we know we don’t need to stockpile a six-month supply of toilet paper in our basement, but when we’re running through the grocery store and see someone’s cart piled high with it, their anxiety infects us and we go into survival mode. Our PFC only comes back online once we’re standing in the parking lot trying to figure out how we’re going to fit all that toilet paper into the car.

So how do we keep our PFCs online in uncertain times? How do we not panic?

Too many times, I’ve watched my anxious patients try to suppress or think their way out of anxiety. Unfortunately, both willpower and reasoning rely on the PFC - which isn’t available at these critical moments. So I start by teaching them how their brains actually work, so they can see how uncertainty weakens the brain’s ability to handle stress and primes it for anxiety when fear hits. Learning that uncertainty triggers anxiety, and that anxiety can cascade into panic, is genuinely useful. It lets people be on the lookout and protect themselves, rather than blindsided.

But this is only the first step. Our brains are constantly asking “what if?” When we go to social media looking for answers, what we find is more speculation and more contagion, now arriving simultaneously from all over the world. The social algorithm doesn’t know the difference between a genuinely dangerous threat and a perfectly crafted piece of outrage bait - it just knows what gets us to keep scrolling. To override this, we need something more reliable than “just stop checking your phone.”

The antidote, somewhat ironically, lives inside the same survival system that creates the problem in the first place.

To interrupt the anxiety cycle, we need to become aware of two things: that we’re getting anxious or panicking, and what the actual results of that anxiety are (not the feared-in-the-future results that haven’t happened yet, the real ones). This helps our brain’s learning system recalibrate how valuable anxiety actually is. Because the brain places more rewarding behaviors higher in its hierarchy and reaches for them more automatically in the future (that’s why we reach for cake over broccoli), clearly seeing that anxiety is both acutely unpleasant and genuinely unhelpful starts to update its reward value.

Once we’re aware of how unrewarding anxiety is, we can bring in what I call the “bigger better offer.” Because our brains will naturally move toward more rewarding experiences, we can practice replacing worry and panic with states that are intrinsically more rewarding - curiosity being the most powerful one I’ve found clinically. Curiosity feels open where anxiety feels contracted, and it doesn’t run out. Unlike checking your phone for reassurance, which requires an ever-larger dose to produce the same effect, curiosity is self-sustaining.

Learning to be curious is how we immunize ourselves against emotional contagion: not by quarantining ourselves from the world, but by making our internal state a less hospitable environment for anxiety to replicate in.

How do I know this works? My lab has studied these mechanisms for years. We’ve found that simple awareness training can reduce anxiety by 57% in physicians and 67% in people with Generalized Anxiety Disorder, in two to three months.

Understanding how anxiety spreads, and why the current media environment is so extraordinarily good at spreading it, doesn’t fix anything on its own. But it does something I find consistently undervalued: it makes the experience less mysterious.

When you can recognize that your anxious spiral after reading the news is not a sign that something is catastrophically wrong with you, but rather that a very old survival system is responding to a very well-engineered trigger, you create just enough space to do something other than keep scrolling and feeling helpless.

That space gives you some distance from that sneeze of social contagion. Curiosity is what immunizes you so that you’re back in the driver’s seat of your own life..

If you’re a visual learner, here’s a short animation we put together during the pandemic that is still relevant today.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Copyright © 2026, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Arnsten, A. F. T. (2009). Stress signalling pathways that impair prefrontal cortex structure and function. Nature Reviews Neuroscience, 10, 410–422. https://doi.org/10.1038/nrn2648

Arnsten, A. F. T. (2015). Stress weakens prefrontal networks: Molecular insults to higher cognition. Nature Neuroscience, 18, 1376–1385. https://doi.org/10.1038/nn.4087

Brewer, J. A. (2019). Mindfulness training for addictions: Has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 198–203. https://doi.org/10.1016/j.copsyc.2019.01.014

Hatfield, E., Cacioppo, J. T., & Rapson, R. L. (1993). Emotional contagion. Current Directions in Psychological Science, 2(3), 96–100. https://doi.org/10.1111/1467-8721.ep10770953

Kramer, A. D. I., Guillory, J. E., & Hancock, J. T. (2014). Experimental evidence of massive-scale emotional contagion through social networks. Proceedings of the National Academy of Sciences, 111(24), 8788–8790. https://doi.org/10.1073/pnas.1320040111

If you’ve been subscribing for a while, you know that’s unusual. I typically love showing up here each week — sharing what’s coming out of the lab, what I’m seeing in clinic, what’s actually working for people. Here’s what happened.

The honest version: I got hooked.

Not on anything I’d warn you about. But the same reward-based learning that pulls someone toward their phone at 2am? It pulled me toward this work. Three things converged at once, each one feeding the next, and before I knew it I was deep in a habit loop of the best kind — the kind where you look up and realize months have passed and you haven’t minded at all.

Let me tell you what happened.

My lab just finished a three-year study on a surprisingly simple practice for working with anxiety. The brain imaging data are in, the team is buzzing, and we’re now preparing to publish. I can’t share specifics yet (peer review has to run its course), but I’ll say this: I’ve spent my career trying to be appropriately skeptical of my own results. This time that’s been harder than usual.

If you read my earlier post What If Anxiety Is a Habit, Not a Disorder?, you’ll have a sense of the foundation this builds on. More on that when the paper’s out.

At the same time, something clicked with how we teach the Gears. For years, helping people shift out of anxiety habit loops and into curiosity and kindness took weeks of gradual skill-building. (I covered some of the brain science behind this in When Your Brain Needs a Hard Reset.)

Well, we figured out how to do it faster (much faster). I’ve been using this rapid induction approach in my clinic, and watching people get unstuck quickly has reminded me why I got into this work in the first place. That breakthrough led us to build a new skills-based program specifically for anxiety, which I’ve been spending a lot of time pilot testing and tweaking.

But the thing that’s really had me heads-down? I’m writing a new book.

The patients I work with kept asking a question I didn’t have a good answer for: okay, I’m out of the anxiety loop — now what? And it turns out that’s a genuinely interesting question. Because the same framework that helps us stop drowning also, it turns out, helps us learn to swim. Not just getting back to baseline. Actually flourishing.

When I started exploring the now what question, I realized that there was a lot of territory to cover. So much that it deserved its own book. So I signed with Penguin/Random House, and I’ve spent the last several months writing. I now have a draft of a 42-chapter book that walks people from stuck to flourishing. And writing it has been its own fun, wild and weird experiment in flow states.

The book comes out spring 2027. I’ll share more here as it takes shape (including some of the ideas I’m most excited about).

For now: I’m back. Every Saturday, in your inbox, starting now. There’s a lot of science I want to dig into, some surprises from the clinic, and a few ideas from the book that I want to share before it’s even finished.

It’s good to be back.

— Dr. Jud

If you or someone you know is looking for practical, science-based support for anxiety, my team has built a new program based on the rapid induction techniques I mentioned above. I’ll share more details in a future post, or you can check out Going Beyond Anxiety to learn more.

Subscribe now

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

When I first encountered this teaching years ago, I thought, “Yeah, sure. Easy to say when you’re sitting on a meditation cushion in a monastery. Try being grateful to the guy who just cut you off in traffic.”

Now, decades later, I still think that response was pretty reasonable. Gratitude has become another trending item on the never-ending self-optimization to-do list. Journal about three things you’re grateful for every morning. Send gratitude texts. Keep a gratitude jar. Gratitude has become the next set of $100 yoga pants; It’s everywhere, from Instagram influencers to corporate wellness programs.

But does any of it actually work? And more importantly, why would being grateful to the jerk who cut you off in traffic do anything except make you feel like you’re gaslighting yourself?

Let’s dig into what’s actually happening in your brain when you practice gratitude, and why the current culture might be missing the point.

Is Gratitude Good for Us?

Let’s start with the good news. There has been an explosion of research on gratitude over the past decade. In short, gratitude works. Studies consistently show that gratitude practices can increase wellbeing, improve relationships, and even boost physical health. For example, a meta-analysis of 27 studies found that gratitude interventions led to significant improvements in wellbeing. As an example, one study found that keeping a gratitude journal increased happiness levels for months afterward. Granted, there are still way too many of these studies being done with college students, making them hard to generalize to IRL, but the signal seems solid enough.

If this is true, why do so many people start gratitude journals and then abandon them after a week?

The answer lies in understanding how our brains actually learn. Specifically, this relates to how reward-based learning drives behavior change. Remember that our brains are essentially survival machines, wired through evolution to seek rewards and avoid threats. Every time you do something and get a reward, your brain strengthens that neural pathway. Do it enough times, and it becomes automatic. A habit.

This is how we learn everything from finding food to checking our phones when we’re bored. Trigger, behavior, reward. Simple, elegant, and evolutionarily ancient.

So why can’t we simply form a habit of being grateful?

Gratitude Lists: Potential or Problem?

Most gratitude practices ask you to think about what you’re grateful for. Make a list. Reflect on the good things in your life. And there’s nothing wrong with this as an exercise, except that it’s operating at the wrong level.

When you sit down and think, “Okay, I should be grateful for my health, my family, my job,” you’re engaging your prefrontal cortex, the thinking, reasoning part of your brain. You’re creating a cognitive framework. Two things are often at play here: 1) We saw on our newsfeed that some new science study showed that gratitude was good for us, so we put it on our to-do list as yet another thing to do; and, 2) The “shoulds” come in. I should do this, I should do that. As the joke goes, “we should all over ourselves.”

Doing something that we think should be good for us makes our to-do list longer (which usually adds to our anxiety instead of alleviating it). And we get stuck in our heads. We might even throw in some good, old-fashioned self-judgment when we wonder what’s wrong with ourselves when we can’t do something as simple as going to bed every night thinking of three things that we’re grateful for.

You can probably see how these don’t make a magic formula for creating a gratitude habit.

To make or break a habit, there’s a specific brain region called the orbitofrontal cortex (OFC) that is critical for assigning reward value to different behaviors and experiences.

The OFC doesn’t care about your carefully reasoned list of things you should be grateful for. It cares about how things actually feel in your direct experience. It’s taking in sensory information, integrating it with your emotional state, and assigning a reward value: more of this or less of this?

This is why you can intellectually know you should be grateful for your health or your friends or whatever, while simultaneously taking it completely for granted. Your thinking brain knows it’s important, but your OFC, the part that actually drives behavior, hasn’t registered the reward value. That comes from your body; your direct embodied experience.

Notice how a part of your brain helps you get out of your head. I love irony.

What Makes Gratitude Actually Rewarding?

Ready for this? In a study that my lab conducted, we asked hundreds of people to rank their preference for different mental states. The results were remarkably consistent: people strongly preferred states like feeling kind, curious, and connected over feeling anxious, fearful, and angry.

Here’s the important part: these preferences weren’t just intellectual. When we asked people to describe how these states felt in their bodies, they consistently reported that positive states felt more open and expansive, while negative states felt more closed and contracted.

This maps directly onto neuroscience research showing that different mental states correlate with distinct patterns of brain activation. When people are in states of craving or self-referential thinking (like rumination or worry), we see increased activation in self-referential network regions, including the posterior cingulate cortex. When people shift into states of meditation, open awareness, or curiosity, that same region quiets down.

And here’s the kicker: people consistently report that the open, aware states feel better. They’re more rewarding at a felt, embodied level, not just as an idea in their heads.

So it’s possible, even likely, that people get stuck at the superficial “make a list” level, way up in their heads. Not much action can happen in that brain of ours when it can’t feel a thing. To wit, it doesn’t even have sensory neurons!

And this would also suggest that to form a gratitude habit we have come to our senses so to speak, by listening to what our body tells us. Yes, we have to feel the results of being grateful. That’s where the action is.

From the Head into the Body

When you shift from thinking about gratitude to being curious about what you experience from being grateful, something changes. Instead of trying to convince yourself that you should be grateful for things, you’re investigating what it’s like to appreciate something directly. You’re noticing the results of gratitude as a behavior. Remember, reward-based learning gets its name because behaviors that are rewarding get reinforced.

What does gratitude actually feel like in your body? Where do you feel it? How does it compare to thinking that we should be grateful?

And when you do this, you might notice something that shouldn’t be surprising at all: genuine appreciation feels good. Not in a “this will be good for me” way, but in a direct, embodied way.

It feels open rather than contracted. Expansive rather than tight. Connected rather than isolated.

And remember, through all of this exploration, your OFC is taking notes. When you directly experience the reward value of appreciation versus the intellectual exercise or “shoulding,” you’re not trying to convince yourself of anything. You’re just seeing clearly what’s actually more rewarding.

This is where gratitude can become a true habit:

Trigger: heading off to sleep.

Behavior: think of three things for which you are grateful.

Result: warm, expanded glow of gratitude.

Practicing Gratitude

So, what does this actually look like in practice?

Start with something simple. Your next meal, for example.

Instead of thinking about how you should be grateful for food, get curious. What does it actually feel like to appreciate this meal? The taste, the texture, the fact that you’re not hungry right now?

Notice where you feel that appreciation in your body. Does it feel open or closed? Expanded or contracted?

Now, contrast that feeling with the feeling of eating while scrolling through your phone, barely tasting the food. Or eating while ruminating about something that happened earlier. What’s the felt difference?

You’re not trying to force yourself to feel grateful. You’re investigating what gratitude actually feels like compared to its absence. You’re collecting data.

And here’s a bonus: when you’re genuinely appreciating something, you’re also present to it. You’re actually tasting your food instead of lost in thought. You’re actually feeling into the connection that you have with another person instead of being disconnected while, for example, scrolling on your phone or eating in a hurry while answering emails.

Those gratitude data points are also actionable: once you notice what it feels like to be grateful, you can supercharge it by acting on it. If you’re grateful for a friend or family member, tell them (even a text will do). If you appreciate your team at work, go get coffee for everyone. Expressing your gratitude through action marries it with generosity, no matter how small the act. [See my previous article on generosity to learn about the three different types of generosity]

Ready to level up?

Level 1 and Level 2 Gratitude

So far, I’ve been describing what we’ll call Level 1 gratitude. Level 1 gratitude is pretty straightforward: you appreciate the good things in your life. Your health, your relationships, your morning coffee. This is what most gratitude journals focus on. And it’s a fine starting point. Start where you can, which is with the stuff that is relatively easy. It helps you get a feel for gratitude, and for it to start taking shape in your life. Because it feels good, you can more easily form a habit of gratitude.

What about Level 2 gratitude?

Back to that slogan: “Be grateful to everyone.”

The slogan isn’t suggesting you should be grateful that someone cut you off in traffic. That would be absurd.

Here’s what I think it may be pointing to. It’s not about convincing yourself that everything is wonderful or that difficult people aren’t actually difficult. It’s about recognizing that every interaction, every situation, pleasant or unpleasant, is an opportunity to see your mind more clearly.

Be grateful to everyone is pointing to something that can be subtle or not-so-subtle: can you be grateful for the opportunity to notice your reaction? To see how quickly anger arises? To practice working with a difficult emotion in real time?

The person who cuts you off in traffic shows you how quickly anger arises. The friend who disappoints you shows you what your expectations are and where you’re attached to things being a certain way. Someone else’s success that triggers comparison shows you the habit loop of jealousy or envy.

Without these triggers, how would you ever see these patterns? How would you learn to work with them? How would you learn about your own mind, and have the opportunity to train it?

This isn’t about being grateful that bad things happen. Bad things are going to happen regardless of your gratitude practice. It’s about being grateful that you have the capacity to wake up in the middle of your habitual reactions and choose something different.

This capacity—the ability to be aware, to get curious, to meet your experience with openness instead of reactivity—this is the real practice.

Yes, how could we learn about ourselves, about how we interact with others, and about how we meet the world without seeing our reactivity clearly? Level 2 gratitude helps us lean into unpleasant experiences and situations so that we can learn and grow. [See my previous articles on Growth Mindset and The F**king Growth Opportunity for more on this.]

At first, Level 2 gratitude can feel really challenging. We’re going against our basic instincts to move away from the unpleasant places, because our brains read this as danger. But, when we lean in a few times and see that this is our growth zone, not our danger zone, it gets easier. Seeing the unrewarding results of our habitual reactions help us to let go of them. More importantly, growth feels good, so focusing on that result can help reinforce the fact that growing pains may be painful at first, but are indications of growth.

So, see if you can shift from shoulding (I should be grateful, I should practice gratitude) to getting into the habit of practicing Level 1 gratitude: notice how good it feels to be grateful for something. Once you get the hang of it, see if you can level up: open to the F**king Growth Opportunity that comes when you are grateful to everyone, no matter how mean or nice they are.

When you welcome the honk or bow to that person who cut you off in traffic, truly thanking them for being your teacher, that’s next level. And truly something to be grateful for.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Brewer, J. A., & Garrison, K. A. (2014). The posterior cingulate cortex as a plausible mechanistic target of meditation: Findings from neuroimaging. Annals of the New York Academy of Sciences, 1307(1), 19-27. https://doi.org/10.1111/nyas.12246

Brewer, J. A., Worhunsky, P. D., Gray, J. R., Tang, Y. Y., Weber, J., & Kober, H. (2011). Meditation experience is associated with differences in default mode network activity and connectivity. Proceedings of the National Academy of Sciences, 108(50), 20254-20259. https://doi.org/10.1073/pnas.1112029108

Dickens, L. R. (2017). Using gratitude to promote positive change: A series of meta-analyses investigating the effectiveness of gratitude interventions. Basic and Applied Social Psychology, 39(4), 193-208. https://doi.org/10.1080/01973533.2017.1323638

Emmons, R. A., & McCullough, M. E. (2003). Counting blessings versus burdens: An experimental investigation of gratitude and subjective well-being in daily life. Journal of Personality and Social Psychology, 84(2), 377-389. https://doi.org/10.1037/0022-3514.84.2.377

Garrison, K. A., Zeffiro, T. A., Scheinost, D., Constable, R. T., & Brewer, J. A. (2015). Meditation leads to reduced default mode network activity beyond an active task. Cognitive, Affective, & Behavioral Neuroscience, 15(3), 712-720. https://doi.org/10.3758/s13415-015-0358-3

Kringelbach, M. L. (2005). The human orbitofrontal cortex: Linking reward to hedonic experience. Nature Reviews Neuroscience, 6(9), 691-702. https://doi.org/10.1038/nrn1747

Kringelbach, M. L., & Rolls, E. T. (2004). The functional neuroanatomy of the human orbitofrontal cortex: Evidence from neuroimaging and neuropsychology. Progress in Neurobiology, 72(5), 341-372. https://doi.org/10.1016/j.pneurobio.2004.03.006

Malouff, J. M., & Meynadier, J. (2023). The effect of expressed gratitude interventions on psychological wellbeing: A meta-analysis of randomised controlled studies. International Journal of Applied Positive Psychology, 8, 941-960. https://doi.org/10.1007/s41042-023-00086-6

O’Doherty, J., Kringelbach, M. L., Rolls, E. T., Hornak, J., & Andrews, C. (2001). Abstract reward and punishment representations in the human orbitofrontal cortex. Nature Neuroscience, 4(1), 95-102. https://doi.org/10.1038/82959

Portocarrero, F. F., Gonzalez, K., & Ekema-Agbaw, M. (2023). The effects of gratitude interventions: A systematic review and meta-analysis. Einstein (São Paulo), 18, eRW4888. https://doi.org/10.31744/einstein_journal/2020RW4888

You might think, “No way. Giving is good! It’s altruism, not addiction.” And you’d be right... mostly. But let’s look more closely at the holiday scramble, the wedding registry anxiety, or the moment after a “good deed” when maybe you refreshed your social media a little too often to see if anyone noticed your benevolence. What’s going on here? Maybe we’ve lost focus on the act or the recipient, and gotten more focused on the return.

We often treat generosity like a singular virtue, but our brains see it differently. Our minds are wired for reward. That’s how we’ve survived as a species. Yet, where we set the finish line for that reward determines if we’re building a healthy, sustainable habit, or if we’re just hooked on a fragile, external feedback mechanism.

Knowing the difference between these different types of generosity can help us let go of giving that might be hurting us in the process, and lean into one that helps us grow in the process.

I see three distinct types of generosity running in parallel in our lives:

1. The Transactional Loop: Giving because our old, impulse-driven brain expects a dopamine hit back (expectation, praise, status, a reciprocal gift).

2. The Guilt Loop: Giving because we “should” or feel guilty when we don’t.

3. The Selfless Loop: Giving where the reward is instant, internal, and non-contingent.

Using the framework of reinforcement learning, the same way we break down food or smoking cravings, we’ll see that transactional and guilt-based generosity relies on a fragile, external dopamine signal. Selfless giving, however, uses an ancient system that generates a purer, more sustainable internal reward, potentially bypassing the craving cycle entirely.

Generosity Type 1: The Transactional Loop

We’ll call this the “Give to Get” model. This is giving as social currency, debt repayment, or status/virtue signaling. This is an exchange, where deep down, you’re holding a receipt.

We see this everywhere: the networking where you “generously” offer help, secretly hoping for a big favor back, working late to help your boss out to show that you’ll sacrifice or “take one for the team.” It can be as small as holding the door open for someone and expecting a thank you or a smile in return. You get the idea.

How does our brain learn this transactional loop? Through the same mechanism that teaches us to crave cookies or check email: the Trigger -> Behavior -> Reward (T-B-R) Cycle. These are the components that set up any habit.

1. Trigger (T): A social cue, like a friend’s birthday invitation or upcoming holiday, or an internal fear, like the desire to avoid looking cheap.

2. Behavior (B): The act of giving the gift or making the donation (or holding the door).

3. Reward (R): The external payoff: the immediate “thank you,” the warm social glow, or the reciprocal gesture.

Here’s the critical part. Dopamine, the brain’s “wanting” chemical, doesn’t fire for the good deed itself. It fires when something that we neuroscientists call the reward prediction error is positive. And here’s how it works: Your brain has a prediction: If I give this, I will get X praise etc. If the actual reward (the praise) meets or exceeds that prediction, the reward prediction error is considered positive, and dopamine floods the reward circuitry, strengthening that loop. The brain learns: Giving for external validation works. But this external validation is a contingent, and importantly, incredibly fragile reward.

To put it simply, give-to-get is positively reinforcing because we learn to do behaviors that get us positive things in return. Yet, it ain’t all positive, as there’s an itchy urgy quality that comes with expectation and contingency. We’ll return to this shortly.

Generosity Type 2: The Guilt Loop

We’ll call this the “Give to avoid Guilt” model. This is giving as expectation, but from a different source. Instead of you expecting something in return, someone else is heaping the expectation on you. This comes in a number of forms, including the holiday gift-giving driven purely by obligation, donating to a homeless person or at the grocery store register and so on.

Type 2 of generosity is put in my face every time I go to the pet store to buy cat food. When I’m at the checkout counter, before I can complete my payment, the screen stops me with a pop up asking if I’d “like” to donate $1-10 to save a pet in need. Come on!? Maybe I’m projecting, but what pet owner wouldn’t feel guilty about a sad, hungry-looking pet?

How does the shame/guilt generosity feel? It shares some of the same qualities as the give-to-get generosity in terms of itchy, restless urgy, feel, yet also has a get me out of here quality to it. This is negative reinforcement because we’re doing something to avoid or lessen an unpleasant feeling or situation.

Notice how neither Type 1 or 2 generosity feels great. Where did feel-good giving go? Hint: dopamine is a motivation, not a feel-good molecule.

With Type 1, give-to-get generosity, what happens if you go above and beyond for a friend, but they forget to thank you or they fail to reciprocate? The expected reward is delayed or missing the reward prediction error becomes negative which means that the dopamine system registers this as an error—a failure in the prediction.

The readout in your body from this prediction error is not subtle. The feeling you get isn’t warmth; instead of mocha-chocolate-peppermint-bliss, it comes in flavors of resentment, disappointment, and sometimes even a sense of being used. You give grudgingly or sometimes stop giving altogether. With Type 1 generosity, your old brain learns the wrong lesson: Giving is painful when the external reward fails to materialize. You become stuck in a cycle of clinging to the outcome, which is the very thing that prevents true generosity.

With Type 2 giving, because it has that guilt or shame or expectation quality to it, your brain also learns that giving doesn’t feel great. Whether it’s the homeless person or the pet store clerk, it’s the give quickly, avoid eye contact and get out of here mentality.

Hardly rewarding.

Generosity Type 3: Selfless giving

Transactional and guilt giving share one thing: the self. With Type 1, we want something in return. With Type 2, we give to avoid something unpleasant. They’re both about us.

So what’s the alternative?

Giving without expecting anything in return. In other words, no strings attached.

In Buddhist psychology, the concept of selfless generosity is called dana (Pali for generosity or giving). It’s one of the paramitas, or practices of perfection. Dana is a radical practice: giving with no expectation of return. That’s right. It’s not about us. It’s about the act of giving itself.

This doesn’t just mean letting go of the item you’re giving; it means letting go of the expectation of outcome: the praise, the favor, the pat on the back. It’s also not giving to get away from some unpleasant feeling. And selfless giving has a different flavor to it.

Here’s a taste of the results of selfless action. As Dale S. Wright wrote:

“The practice of generosity is the practice of freedom, and it carries with it all the joy and pleasure that are associated with liberation [from self-centeredness]... Indeed, there may be no greater sense of fulfillment in life than the simultaneous feelings of human interconnection and pure freedom that arise from an authentic act of selfless generosity.”

Why would our self-serving, survival-focused “old brain” bother with this kind of giving if there’s no visible return? At first blush, it hardly seems logical. Why trade a tangible, external reward for nothing?

The answer may be counterintuitive: nothing is something. And that something may be more rewarding than the tainted types that come with Type 1 and 2 generosity. But as we’ll explore in a bit, it brings with it a paradox.

Selfless giving shifts the reward from the contingent outcome (a “thank you” you can’t control or lessening guilt) to a reliable process (an internal feeling that is intrinsic, autogenerated). Here, we’re leveraging the reinforcement learning system to access a purer, more sustainable source of reinforcement.

And, it feels better. More of a mocha-peppermint-bliss flavor.

The Selfless Generosity Circuit

Two and a half millennia ago, Buddhist teachers mapped out the neurobiology of true generosity with shocking precision. The Anguttara Nikaya, an ancient text from the Pali Canon, describes the internal reward sequence of generosity:

“The donor, before giving, is glad; while giving, his/her mind is inspired; and after giving, is gratified. These are the three factors of the donor….”

When I first read this, my eyes almost popped out of my head. As a researcher who studies habit formation, this showed a beautiful twist on habit formation: a reward circuit that consisted of a three-stage, self-contained, non-contingent reward loop.

1. Before Giving (trigger): “The donor... is glad.”

In ancient times, monastics would give sermons or teachings to the lay people. If the teachings were helpful and useful, the recipients felt glad. In modern day with fewer monastics wandering around (especially in the West), we might be gladdened when we read about an organization’s cause or see how someone is helping others.

2. While Giving (behavior): “while giving, his/her mind is inspired.”

When we give selflessly, the process itself becomes simplified. Without strings attached, we can lean into the act itself, instead of looking to make sure someone is noticing (Type 1) or feeling the judgmental look (Type 2).

3. After Giving (reward): “and after giving, is gratified.”

The reward is instantaneous and simultaneous with the behavior. Because there is no contingency, there is no delay. The reward is completely divorced from the recipient’s reaction, and thus reinforces a new self-identity that ironically, is less self-focused or selfish. And with no strings attached, there is a purity to the action itself which gives a totally different taste and feel to the reward: instead of the urgy contraction that comes with expectation or guilt, there’s a lightness, an expansion as we connect on a deeper level. Yes, the joy of giving for giving’s sake.

This generosity loop is immediate, reliable, and unconditional. It’s an efficient learning system that consistently generates its own fuel, making it highly sustainable. This may be where the saying “pay it forward” comes from. Paying it forward feels good so it builds momentum and perpetuates the process.

What makes giving for the sake of giving so sustainable? You probably already know the answer. Compare all three types of generosity against each other. Which feels better: Type 1, Type 2, or Type 3 generosity? Yes, both Types 1 and 2 can have a bittersweet quality: you’re giving (how sweet!) but in order to get or avoid something (a bit bitter).

Type 3 is all sweetness. Notice how all three elements, the trigger, the behavior and the reward are rewarding. We feel good. We’re inspired to give. And there’s no giver’s remorse because the act of giving is the reward unto itself. Mocha, peppermint, and bliss all in one with no saccharine aftertaste!

Yes, when the generosity is genuine, not about us, it feels pretty darn good. Full stop.

If you’re not getting those three internal rewards—the gladness, the inspiration, and the gratification—it may be a sign of selfish giving (Type 1 or Type 2). As the American meditation teacher Gil Fronsdal noted:

“When we are practicing generosity, and it does not bring happiness and joy, we should pay close attention to our motivations for giving...”.

The absence of this internal reward signal may mean that you are still waiting for an external reward, and your brain is giving you some (bitter) feedback to let you know.

Before we get to the practical steps, let’s first address what may seem like a paradox. I’ve just argued that the most rewarding form of giving is the one where you don’t seek rewards. If you now pursue Type 3 generosity for those bigger, better but internalized rewards that are more rewarding, haven’t I just created a more sophisticated form of give-to-get?

From a neuroscience perspective, the paradox is real. Your brain learns from rewards. Once you discover that selfless giving feels better than transactional giving, your orbitofrontal cortex, a part of your prefrontal cortex, encodes that value. You can’t unknow it. That’s how reinforcement learning works.

Buddhist philosophers and teachers have wrestled with this for millennia - yes, you can make letting-go itself into an object of grasping, when it’s about you letting go.

So what’s the way forward? Two things can be simultaneously true:

First: This is real progress. Moving from external, contingent rewards to internal, non-contingent rewards makes you less fragile, less dependent on others’ validation, less subject to your expectations. That’s not nothing.

Second: Yes, it can still be rewarding to you, even if it’s not about you. The joy of Type 3 generosity has a clean and pure taste. And it can be pretty easy to get attached to that, if you’re not paying attention.

Here’s the key distinction: there’s a difference between experiencing a reward and wanting a reward. Buddhist psychology calls this taṇhā - the craving or wanting for pleasant experiences to continue, or for unpleasant experiences to go away. Great work by Kent Berridge and others has shown a clear delineation between liking and wanting, as they activate different neurotransmitter systems and networks (e.g. opioid vs. dopamine).

Here’s what I’ve found over the past decades of working with patients: the more clearly you see your mind’s grasping, the less attractive it becomes. Not because grasping is “bad,” but because the restless, calculating quality of “Am I getting my reward?” feels unpleasant when you pay close attention. There’s a contracted, clenched feeling to it. That’s the bitter taste of self-centeredness that is hard to ignore once we’ve noticed it.

In contrast, giving while the inner calculator is quiet feels tangibly different. When there is less of you in the equation, there is more connection with others. This feels lighter, freer, more expanded.

So yes, your brain gets rewarded in Type 3. But where you place your attention determines whether you’re reinforcing grasping or freedom from grasping. Are you attending to the direct experience of giving? Or are you checking if you are getting something from giving?

Rewiring Generosity

We can’t simply flip a switch from transactional or guilty to selfless. Generosity, like any skill, is something we learn over time. Dale Wright reminds us that:

“The movement from ordinary states of self-concern to selfless giving always involves a gradual transformation of character, not a sudden leap.”

So, how do we train our brains to favor the robust “generosity circuit” over the fragile craving loop?

It begins with getting a taste of it.

1. Awareness/Curiosity: What am I craving or avoiding?

This is straight from our addiction research playbook. Before you give, stop and notice the T-B-R loop in action. Is the trigger fear of shame? Is the expected reward praise? Get curious. Ask: “What is my real intention here? Am I looking for something in return? Am I aiming to avoid something unpleasant?” Simply noticing the motivation or drive to give often loosens its grip if it is bitter, and strengthens it, if it is sweet.

2. Gratitude as a Launchpad

Generosity requires us to relinquish something, and you can only do that if you’re in a place where you are content with what you have. Sallie Tisdale nailed this idea when she wrote:

“Gratitude... is the foundation of all generosity. I am generous when I believe that right now, right here, in this form and this place, I am myself being given what I need. Generosity requires that we relinquish something, and this is impossible if we are not glad for what we have. Otherwise the giving hand closes into a fist and won’t let go.”

If your hand is a fist, start with gratitude. Gratitude is a great way to remind ourselves of all that we have. Sometimes all we have to give at any moment is a smile or a kind gesture. And that’s fine. It’s more than fine, as it’s not about the size of a gift, it’s the selfless intent that makes Type 3 generosity sweet.

3. Short moments, many times

Any new habit is formed through repetition. Here we can practice small, anonymous acts over and over. Check your ego at the very door that you hold open for someone. Pay for the person behind you in line or at the subway stop without waiting for their reaction. Make eye contact and smile at strangers early and often. Find other creative ways to practice random acts of kindness. Rinse and repeat.

Remember, true generosity isn’t about some lofty moral ideal. In fact, it’s not about you at all! The more you selflessly give, the more you get to be your own greatest benefactor, generating joy and “pure freedom” from the inside out. The rewarding quality of the process will make it self-perpetuating.

This quote from the Persian mystic Hafiz sums up the selflessness of Type 3 generosity beautifully:

“Even after all this time, the sun never says to the Earth, ‘You owe me.’ Look what happens with a love like that. It lights the whole sky”

That’s pure sweetness, through and through.

Your mission should you choose to accept it: Try one act of selfless giving today. Or throw caution to the wind and do more than one. Pay attention to the feeling before, during, and after. Did you feel the warm glow, the sweet taste of not needing anything in return? If not, investigate the motivation, and see what you can learn simply by exploring how rewarding the different types of generosity are. Find that hint of bitter so that you are less likely to add it to the mix next time.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

References

Anguttara Nikaya 6:37. (n.d.). In The Book of the Sixes (Aṅguttara Nikāya, 6th Collection, Sutta 37). [Religious Text].

Berridge, K. C., & Kringelbach, M. L. (2015). Pleasure systems in the brain. Neuron, 86(3), 646–664. https://doi.org/10.1016/j.neuron.2015.02.018

Brewer, J. A. (2019). Mindfulness training for addictions: has neuroscience revealed a brain hack by which awareness subverts the addictive process? Current Opinion in Psychology, 28, 268–273.

Gore, C., Chaminade, T., & Dubios, M. (2017). Dissociating neural networks for altruistic choice and moral judgment. Cerebral Cortex, 27(1), 116–131.

Hare, T. A., Camerer, C. F., Knoepfle, D. T., & Rangel, A. (2010). Neural evidence for a unitary value scale in human choice. Nature Neuroscience, 13(2), 209–216.

Zaki, J., & Mitchell, J. P. (2011). Neural processing of the selfish pleasure of giving. Psychological Science, 22(1), 19–23.

“Sometimes it’s just a bad day. It’s a bad mental day,” one of my Going Beyond Anxiety participants said during a recent session. “Once I feel like I’ve kind of gone off the tracks…I really need a hard reset. And typically what works is the next day. Once I’ve slept it off, I can start again fresh. But usually I’m in the middle of my day and I know that I need a hard reset. And I’m not sure what to do about it. I can’t just go to bed at noon and be like, today is a loss. That doesn’t work. I’d like to have something that I can do—almost like turning that computer off and turning it back on again.”

I asked her what “off the rails” looked like.

“When I really notice it,” she said, “I’ve learned in this program that I tend to eat my feelings. I eat my anxiety. So when we’re into the Halloween candy, it’s like—pardon my language—‘to hell with it.’ We’ve started, and now it’s Snickers from here on out. I don’t want to be in that place … So is there something you would recommend at that point?”

I smiled. “So, a grounding reset practice that’s not a Snickers bar?”

She laughed. “Exactly. Something that can halt me when I’m already starting to [go off the rails].”

That’s when I introduced her to five finger breathing.

Why breathing sometimes isn’t enough

Here’s what’s going on in your brain: when we’re anxious, our brain’s key thinking center, the prefrontal cortex, starts short-circuiting. The dorsolateral prefrontal cortex (dlPFC), the part of the PFC that helps us plan, regulate, and remember, gets swamped. Stress and worry hijack its bandwidth, leaving you with that revved-up, scattered feeling that makes it hard to focus and concentrate, let alone make good decisions. It’s not that you’ve lost your ability to think; it’s that your RAM is maxed out.

The practice: Five finger breathing

Five Finger Breathing (FFB) is a perfect pattern interrupt whenever you are feeling disconnected, ungrounded, anxious or even panicked. You probably know or at least have heard of the basics of mindful breathing. But here’s why Five Finger Breathing works differently: it keeps your brain too busy to spiral.

Five Finger Breathing is like hitting Control–Alt–Delete for your brain. It interrupts the anxiety loop from both directions: top-down and bottom-up. Cognitively, it forces your executive brain to focus on a multisensory, structured task. Physiologically, it calms your body through paced breathing, which likely activates your parasympathetic nervous system and flips your system from fight-or-flight into rest-and-digest.

Five Finger Breathing is simple. Here’s how I teach it to my patients: Start by placing the index finger of one hand on the outside of the pinky finger on your other hand. As you breathe in, trace up to the tip of your pinky. As you breathe out, trace down the inside. Keep going—up the outside of the ring finger on the inbreath, down the inside on the outbreath. Continue until you’ve traced your whole hand, over the course of five breaths. Then reverse it, from thumb back to pinky for five more. What’s it like to even trace a few fingers? Better than getting caught up in worry, no?

Neuroscientifically speaking, this simple tracing move is doing a lot of heavy lifting. You’re using sight, touch, movement, and breath all at once. This is called a multimodal load. That fancy term basically means that you’ve loaded up your brain with a task that is complex enough to fully occupy your dlPFC, redirecting bandwidth away from verbal rumination (that endless inner monologue) toward non-verbal sensory processing. It’s like giving your brain a more useful puzzle to solve.

Meanwhile, your breathing is doing the quiet physiological work. Slow, steady inhales and exhales stimulate the parasympathetic nervous system (led by the very pop-psychology popular Vagus nerve). You can broadly think of this system as your body’s built-in brake pedal. The system shifts from sympathetic (“get ready to fight or flee”) to parasympathetic (“you’re safe now”). And when your body signals safety, your brain follows.

The neuroscience behind the reset

Researchers have a name for what’s happening here: dual-pathway regulation. One pathway runs top-down (your dlPFC directing focus), the other bottom-up (your vagus nerve dialing down arousal). In fact, studies show that high cognitive load tasks reduce anxiety-driven rumination, while paced breathing increases vagal tone and heart rate variability. Put together, these create a neurobiological “hard reset.”

When these top-down and bottom-up pathways work together, something powerful happens: your anxious thoughts lose their emotional charge. The worry thoughts don’t disappear. Instead, they become less amped up. This process can be called affective decoupling. Once your physiology calms, those same thoughts don’t carry the same emotional charge. They show up, but they aren’t as electrifying, and as such, are less likely to suck you in, or stretching the metaphor a bit, be staticky: they don’t cling so much in your mind. And with this reduced charge, you don’t get as shocked in the process; you can see them for what they are: passing bits of cognition, not emergencies demanding action.

The reset button

When life spins too fast, we all need that reset button. We all need a way to reboot right now, without having to wait for tomorrow. Five Finger Breathing combines complex sensory engagement with vagal activation to calm your body and re-engage your executive brain. It interrupts the “to hell with it” cascade before it turns into a full-blown Snickers spiral, not through willpower, but through awareness that reclaims your attention, one fingertip at a time. In those traced breaths, your physiology resets, your prefrontal cortex comes back online, and what felt like chaos becomes workable again.

So the next time you are feeling ungrounded, overwhelmed or so stuck in your head that you can’t think straight, let your fingers do the feeling, bringing you back to earth through this simple embodied practice, one breath at a time.

Here’s a short video that I put together a little while ago that walks you through the five finger breathing practice.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

Eysenck, M. W., Derakshan, N., & Santos, D. (2013). Cognitive load eliminates the effect of emotional valence on task performance in high-anxious individuals. Frontiers in Human Neuroscience, 7, 188.

Eysenck, M. W., Derakshan, N., Santos, D., & Calvo, M. G. (2007). Anxiety and cognitive performance: Attentional control theory. Journal of Research in Personality, 41(3), 570–588.

Johnson, K. V.-A., & Steenbergen, L. (2022). Gut feelings: Vagal stimulation reduces emotional biases. Neuroscience, 494, 119–131.

Johnson, D. C., & Wager, T. D. (2019). The content domain framework for the dorsolateral prefrontal cortex. Psychological Bulletin, 145(10), 969–994.

Johnson, E. L., & Moran, R. J. (2020). Reduced efficiency of working memory in anxiety patients: A functional magnetic resonance imaging study. Biological Psychiatry, 88(4), 382–391.

Johnson, V. K., Mclaren, K. A., & Chen, J. (2022). Multimodal assessment of obsessive-compulsive disorder severity in a clinical trial of deep brain stimulation. IEEE Transactions on Biomedical Engineering, 69(1), 324–334.

Li, Z., Huang, S., Chen, Y., & Wang, Q. (2024). A systematic review of machine learning applications for multimodal detection of mental health disorders. Sensors, 24(2), 348.

Logue, S. F., & Gould, T. J. (2014). The effect of stress on executive function: Focus on working memory, attention, response inhibition, and cognitive flexibility. Current Molecular Pharmacology, 7(1), 10–21.

Roldán, A., Del Moral, L., de La Muela, A., & Ruiz-Vargas, J. M. (2024). Paced Breathing With a Prolonged Inspiratory Period Increases Sympathetic Activity: A Heart and Brain Analysis. bioRxiv. https://doi.org/10.1101/2024.02.23.581710

Vytal, K., & Grillon, C. (2012). Anxiety impairs the ability to think and concentrate: A n-back study. Biological Psychiatry, 71(1), 18–26.

Williams, S. L., & Pennebaker, J. W. (2015). The role of physiological arousal in subjective emotional experience: A review. Biological Psychology, 104, 1–13.

We’ve all been there: that sudden lurch in your chest, the unsettling flutter in your stomach, or a wave of inexplicable unease that washes over you. Is it stress? Too much coffee? Or something deeper, something saying “danger danger, seek attention immediately!”

Medical school and residency beat one lesson into me over and over: never assume anxiety lives purely in the head until you’ve ruled out the body. As a physician, I want to give you the lay of the land to help you understand when “just anxiety” might be a distress signal from your body, and a few tips that might help save you a trip to the hospital.

Medical Conditions That Directly Cause Anxiety Symptoms

In this first context, anxiety is not a separate psychological disorder but a direct symptom (a “medical mimic” or “secondary anxiety”) of an underlying physical illness. The illness itself creates the physiological state of anxiety.

The endocrine and hormonal system is one of the most common causes. Hyperthyroidism (overactive thyroid) is a classic example. Excess thyroid hormone speeds up the body’s metabolism, leading to symptoms that sound a whole lot like anxiety: a racing heart (palpitations), nervousness, trembling, sweating, irritability, and sleep disturbances.

A 2021 meta-analysis on Graves’ hyperthyroidism found that the pooled prevalence of anxiety disorders in newly diagnosed patients was 31%. That’s nearly one in three! Beyond the thyroid, adrenal gland disorders like Cushing’s syndrome (excess cortisol) or a pheochromocytoma (a rare tumor producing excess “fight-or-flight” hormones) can also directly trigger intense anxiety and panic. But don’t panic, I want to reiterate that this is VERY RARE. Even common hormonal fluctuations related to premenstrual syndrome and menopause can cause significant mood changes and anxiety.

Metabolic conditions are another frequent culprit. Hypoglycemia (low blood sugar), for instance, causes the body to release adrenaline to compensate, leading to shakiness, sweating, dizziness, and a fast heart rate that all feel like an anxiety attack. Similarly, electrolyte imbalances in sodium, potassium, or calcium can affect nerve and muscle function, leading to confusion and rapid heartbeat.

The cardiovascular system itself can be a source of anxiety. Arrhythmias, or irregular heartbeats, are tricky. The symptoms, well, sound (and feel) a whole lot like anxiety: racing heart, shortness of breath, sense of doom which both mimic and cause a state of panic. According to one paper, more than half of people with supraventricular tachycardia reported that they had been told by a physician that their symptoms were “in their head.” Postural Orthostatic Tachycardia Syndrome (POTS), a condition characterized by a rapid heart rate increase upon standing, also causes dizziness and palpitations often mistaken for anxiety.

Finally, substance-related causes are critical to consider. Withdrawal from substances like alcohol or anti-anxiety medications (benzodiazepines) can induce severe anxiety and agitation, while stimulants like caffeine or amphetamines are well-known causes of anxiety, agitation, and even panic. I’ve seen this quite a bit in my clinic: my patients, especially those with alcohol use disorder, wake up in the morning after drinking too much feeling anxious as a result of withdrawing from alcohol.

Anxiety Symptoms That Mimic Medical Conditions (Differential Diagnosis)

This second area is when a primary anxiety disorder, particularly a panic attack, produces intense physical (somatic) symptoms that mimic a life-threatening medical emergency. This is often described as the body’s “fight-or-flight” system acting as a false alarm.

The most common and frightening mimic is that of a heart attack. A panic attack can cause chest pain, a pounding, rapid heart (palpitations), shortness of breath, dizziness, sweating, and a sense of impending doom. Typically the chest pain for panic are described as sharp, stabbing, or intense pain localized in a small area, whereas chest pain from a myocardial infarction is often described as pressure, squeezing, fullness, heaviness, or a tight band around the chest and can radiate to the arm (usually left), neck, jaw, back, or stomach. MIs are tricky, as they can even show up as a dull ache or even be mistaken for indigestion or heartburn.

Panic symptoms can be challenging to distinguish from a heart attack (especially for someone without medical training), which is why medical evaluation (EKG, blood tests) is generally the gold standard for ruling out a cardiac event.

How common is this? Very. A 2020 systematic review and meta-analysis found that the pooled prevalence of panic disorder in patients with non-cardiac chest pain was 22.8%. This means that nearly 1 in 4 patients who come to the hospital for chest pain and are not having a heart attack meet the diagnostic criteria for panic disorder.

Medical Conditions That Lead to Anxiety (Co-morbidity)

This third category describes anxiety as a separate, co-morbid condition that is a common psychological response to the stress, burden, and biological changes of a chronic illness.

The link with cardiac conditions is very strong. Patients with coronary artery disease (CAD) or those who have had a myocardial infarction (heart attack) have high rates of anxiety. A 2018 meta-analysis found that the pooled prevalence of anxiety among these patients was 38%. That’s more than 1 in 3! Having fear of another event is so common that it is often described as “cardiac anxiety.” Yes, fear of the future is a hallmark of worry, a critical distinction which I will get into more later in the article.

On top of this, anxiety and heart disease can feed on each other; anxiety itself is an independent risk factor for developing heart disease and worsens the prognosis for existing heart disease.

Neurological conditions also show a high co-morbidity with anxiety. For example, one systematic review calculated a pooled odds ratio of 3.95, indicating that individuals with migraine are nearly 4x more likely to also have an anxiety disorder. Anxiety is also a common non-motor symptom in Parkinson’s Disease (often preceding motor symptoms by several years). A large 2016 meta-analysis found that about 31% of patients with Parkinson’s also have an anxiety disorder. I’ve seen this personally: a large number of patients with Parkinson’s have been referred to me or have joined my anxiety program over the years because of high anxiety. To round out the neurological category, conditions like epilepsy and Traumatic Brain Injury (TBI) are also strongly linked to anxiety, as the brain’s emotional regulation centers can be damaged.

Other chronic illnesses can be deeply intertwined with anxiety. Respiratory conditions like Asthma and Chronic Obstructive Pulmonary Disease (COPD) show high rates, as the physical sensation of being unable to breathe (dyspnea) is a powerful panic trigger (duh!). For COPD patients, panic disorder specifically is noted to be up to 10 times more common than in the general population. Gastrointestinal (GI) conditions like Irritable Bowel Syndrome (IBS) are also strongly linked, believed to be related to the “gut-brain axis.”

I know this one personally. In my book Unwinding Anxiety, I detailed how I was so anxious my senior year of college that I developed IBS. Ironically, I didn’t even know what IBS was at the time, and was in total denial that I could be anxious. Fortunately, my IBS resolved after I started a meditation practice in medical school. (And my personal experience set the stage for me specializing in anxiety as a psychiatrist.)

Lastly, chronic pain and autoimmune disorders like fibromyalgia and rheumatoid arthritis are associated with high levels of anxiety, driven by the stress of chronic pain and inflammation.

The Medication Plot Twist

Sometimes anxiety is iatrogenic (fancy term for doctor-caused). Corticosteroids, which we prescribe for everything from asthma to arthritis to poison ivy, reduce GABA, the brain’s main inhibitory neurotransmitter. Less GABA basically means less brake pedal on your central nervous system. While euphoria/hypomania is most common, anxiety, agitation, insomnia and irritability are frequently reported. The higher the dose, the more likely one of these symptoms shows up.

Albuterol, the rescue inhaler for asthma, causes nervousness and tremors in about 20% of patients. It acts on beta-2 receptors, which not only opens up your airways, but because your heart also has beta-2 receptors, it also literally activates your heart. So you can breathe better, but beta-2 as a side effect you get increased heart rate (tachycardia), palpitations and shakiness. Yup, feels like anxiety.

Thyroid replacement medication at too high a dose causes anxiety symptoms. ADHD stimulants cause anxiety (I see this a lot in my clinic). Over-the-counter decongestants can even cause anxiety by increasing serotonin and dopamine.

When the Mind Won’t Stop: How Worry Sets “Real” Anxiety Apart

How can someone with anxiety figure out when it is appropriate to go to their primary care doctor (or the ED) to get a complete workup. We doctors can’t order every test on every anxious patient.

The red flags that I look for are surprisingly straightforward: anxiety presenting late in life with no prior history. Anxiety that’s refractory to multiple evidence-based treatments. Anxiety that started after beginning a new medication. Anxiety accompanied by weight loss, tachycardia, hypertension, or other physical symptoms that don’t quite fit.

And, there’s one critical thing that I assess that can be a good (but not perfect) differentiator: WORRY.

Worry may be one of the most useful clues for distinguishing anxiety from its medical mimics. While panic, restlessness, or a racing heartbeat can all come from thyroid dysfunction, cardiac arrhythmias, or even low blood sugar, worry is different. It is a behavior, not a sensation. Worry is what the mind does in response to uncertainty: rehearsing, predicting, and trying to control what cannot be controlled. Two of the seven items on the gold-standard clinical anxiety assessment (GAD-7) specifically ask about worry (“Feeling nervous, anxious, or on edge” and “Not being able to stop or control worrying”), which shows how central it is to generalized anxiety.

Any good physician knows this distinction matters, which is why they take time to explore the details when someone presents with anxiety-like symptoms. They ask when the sensations began, how long they last, what brings them on, what makes them go away etc. They listen for patterns: does it happen only at rest, after caffeine, during exercise, or before a stressful meeting? Do symptoms wake the person from sleep or come on out of the blue? They ask about medications, recent illnesses, and whether anything helps, even temporarily. The goal is not just to collect data but to understand whether the symptoms follow the body’s physiology or the mind’s illogic (planning is logical, worry is not).

One simple way to check in with yourself to see if worry is driving your anxiety is to ask, “What’s happening right now—in my body or in my mind?” If you notice tension in your chest, a racing heart, or shallow breathing, that is the physiological side of anxiety. If you find yourself mentally spinning, replaying conversations, planning for every possible outcome, or trying to think your way out of discomfort, that is worry. The body feels; the mind worries.

And if worry is the main driver of your anxiety, don’t worry, it can be treated.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce worry and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

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Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

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Your heart is pounding. That familiar pit opens up in your stomach. And right on cue, your brain helpfully chimes in: “Oh no. I’ll never get back to sleep. I’m going to be completely dysfunctional tomorrow.”

Welcome to sleep anxiety. Or as I like to call it, anxiety eating your sleep. This is one of the most common things that I see in my anxiety clinic. My patients describe it this way: as soon as their head hits the pillow, because they’re not focused on other things or distracting themselves with their phones, their anxiety takes that as a cue to start talking. And talking. And talking.

Here’s what makes this loop so frustrating for my patients: they’re anxious about being anxious about not sleeping. And the more they try to fix it—do a body scan, take deep breaths, tell themselves to relax—the more wound up they get.

My lab recently completed a randomized controlled trial on exactly this problem. We recruited 80 people whose worry interfered with their sleep and taught them mindfulness training through an app. After two months, they reported a 27% reduction in worry-related sleep disturbances compared to only 6% in the control group. We found clear evidence of how it works: increased ability not to get caught up in thoughts and emotions led to decreased worry, which led to improved sleep. When the control group got access to the app, they showed basically the same results: a 29% reduction in worry-related sleep disturbances.

With this replication of the results, the science seems pretty solid. But to get these results, it requires doing something that sounds completely counterintuitive.

You have to stop trying to sleep.

The Sleep Anxiety Habit Loop

The top 5 themes that I’ve seen in my clinical programs over the past decade are: #1: Waking up in the middle of the night and not being able to fall back asleep; #2: Early morning anxiety; #3: Difficulty falling asleep; #4: Racing thoughts/worry loops; #5: Panic (and other physical symptoms).

One of my patients, I’ll call her Amy, described a mixture of these themes perfectly: “I wake up at 4:30 and immediately think, ‘Oh no. I will never get to sleep again and I won’t be able to function.’ That tape has been going off in my head this whole week as I lie awake hoping to go back to sleep and getting increasingly frustrated.”

This is reward-based learning in action. The same process that helps us remember where to find food also keeps us stuck in anxiety loops. We only need three elements to form a worry habit: trigger, behavior and result. For Amy it looked like this:

Trigger: Wake up at 3:30 AM.

Behavior: Panic thoughts (”I’ll never get back to sleep”), check the clock, mental math about remaining sleep time, try to force relaxation, catastrophize about tomorrow.

Result/Reward: More anxiety. Heart racing. Wide awake. Self-fulfilling prophecy confirmed.

All habits need to have some reward from a brain standpoint to get set up as a habit in the first place. That’s why it’s called reward-based learning. So what’s the reward for Amy or anyone else who gets stuck in this cycle? When you worry, your brain feels like it’s doing something. It feels productive, like you’re addressing the problem. That’s the illusory reward that keeps the worry loop going.

Amy asked me: “What is the reward for worrying that I won’t get back to sleep?”

She later figured it out herself: “I get nothing from this.”

What’s Going on in Your Brain?

The relationship between anxiety and sleep runs both ways. Persistent sleep disturbance predicts the development of anxiety disorders, and worry plays a major role in increasing bedtime arousal and perceived sleep disturbances. In fact, there’s about a 70% overlap between generalized anxiety disorder and insomnia, and roughly three-quarters of primary care patients with anxiety report sleep problems.

Here’s how anxiety and sleep feed on each other: High levels of worry predict more sleep problems such as increased nighttime awakenings, and lower sleep efficiency. Stress-related worry exacerbates something called sleep reactivity, which means your sleep system becomes hypersensitive to stress. Eventually your body starts having consistent sleep responses to stress regardless of what’s actually happening. Your bed itself can become a conditioned stimulus that triggers worry, leading to maladaptive behaviors like staying in bed despite not being able to sleep.

Yes, unhelpful sleep habits that you didn’t even know that you had. Now add in worry.

The mental processes of worry and rumination create additional stress surrounding poor sleep. Your brain gets stuck in cycles of “What if I never fall asleep? What if I’m exhausted tomorrow? What if this becomes chronic?” These thought patterns contribute to the very sleep disturbance you’re trying to avoid.

Meanwhile, your prefrontal cortex. where all that rational thinking happens, goes offline when you’re stressed and tired. The neural structures associated with cognitive control shut down exactly when you need them most.

So, ironically, your “willpower” isn’t available when you actually need it. And the PFC isn’t exactly at full capacity in the middle of the night anyway…

Watch Out for the Expectation Trap

A lot of my patients try to use mindfulness techniques such as the body scan to GET to sleep. I’ve used this myself years ago, and it really helped.

But these practices don’t work as an “if I do X, then I get Y” tool.

The moment you do a body scan in order to fall asleep, you’re still in fix-it mode. You’ve added another layer: “If this doesn’t work, I’m really screwed.” Just like high performance situations on stage and in sports, the higher the expectation, the more pressure you put on a practice to get a result, the less likely it is to work. So, too, with doing things in order to get to sleep.

Amy discovered this when doing a body scan didn’t make her fall asleep but instead turned into a distraction technique. She noted, “After the body scan, I listened to an audio book and fell asleep.” Then she astutely wondered, “Am I feeding a habit loop by listening to the audio book with the hope that I will drift back to sleep?”

Yes. Any “in-order-to” behavior, like listening to audiobooks, still feeds the underlying loop.

So, I pointed this out to Amy, and then suggested to her something radical: “Let go of the goal of getting to sleep.”

One More Problem: Measurement

In general, I’m not anti-wearables. And personally, I wear a watch at night that measures my sleep duration and stages to an accurate-enough degree that I can see how things like how late I eat dinner and how sugar and alcohol intake affect my sleep.

My wife takes sleep-tracking a little too seriously: she set up some arbitrary competition in her head about our sleep scores, always asks what mine was, and seems disappointed when she doesn’t get a “good” score (whatever that is). Sometimes when we wake up in the morning, she’ll even check her watch before our usual good-morning kiss.

A patient, I’ll call her Natalie, got caught in this tracking mentality: “I wake up and want to know what time it is. As soon as I look at my watch it wakes me up completely. If it’s too early I start panicking. If it’s not too early, I still can’t fall back asleep. If I don’t look at my watch, I get very anxious about not looking.”

Sleep diaries, wearables, tracking apps, whatever it is, if we aren’t careful, these can all feed the anxiety loop.

Once we notice that we’re falling into these habits, we can step out of them. Another patient reported on her simple solution: “I stopped doing sleep diaries altogether. The tracking was causing more stress than helping. I turned my clock completely away.”

So, if wearables are giving you useful information, great, keep using them. If, paradoxically, they are making your sleep worse, it might be helpful to place them off to the side for now.

A Paradox as a Solution: Let Go of the Goal

What if trying is the problem? What if you just didn’t care whether you slept or not?

I know this sounds a bit wacky, especially if we’re half-awake at 3:30 AM. But this is what fits with the science, and works in my clinic: letting go of the goal of sleeping is what allows sleep to happen. Here’s what I mean by this.

Map What You Can Control

You can’t control waking up. That’s just something that happens.

You CAN control how you respond: worrying, catastrophizing, trying to force sleep. And by working with the worry, you change the result, and step out of the loop. The key is to not feed the worry beast. This is where reinforcement learning comes in: by seeing that worrying only amps us up and makes it harder to sleep, we can become disenchanted with it.

Get Disenchanted with Worry

When you see clearly–and by this I mean experientially, not intellectually–that worry gets you nothing and, in fact, makes your sleep worse, your brain starts to wake up to this reality. This helps you become disenchanted with worrying, which in turn, helps you let go of that habit. [See my previous articles for more on this]

Find the Bigger Better Offer

Our brain’s reward system is relative. By this, I mean that they are always comparing A to B to decide which one is better. Disenchantment helps drop the value of worrying. But this is a relative drop, meaning that if you compare it to something else that is better, that disenchantment can feel even stronger. What can you compare worrying to? Curiosity.

My lab has found that worry and anxiety correlate with feeling closed down or contracted, while curious awareness correlates with feeling open and expanded. In our studies, people reported that the expanded feeling has higher reward value. You can do this experiment yourself. Which feels better? Worrying or being curious?

When worry comes up—”Oh no, I’ll never get back to sleep”—get curious: “Hmm, that’s interesting. There’s that thought again.” Getting curious helps bring in the observer effect so we can notice worry thoughts without being swept away by them.

You can also get curious about what anxiety feels like in your body. Where is it? Right or left? Front or back? Tight? Hot? Pressure? What happens when you turn toward your experience rather than the habitual reaction of running away from it? Do the sensations change the more curious you get?

One patient described developing the new habit of curiosity this way: “I felt a wave of panic, and instead of immediate dread, my automatic response was, ‘Hmm, that’s interesting.’ That took the wind right out of its sails!”

Any time you’re worrying, whether in the middle of the night or in broad daylight, you can leverage your brain’s reward system to develop the habit of curiosity too.

One practical thing to note here is that curiosity is often energizing. A number of people in my Going Beyond Anxiety have pointed this out: when we’re interested in something, we naturally lean in and wake up a little more, whether it’s day or night.

So if you find yourself moving in the opposite direction of sleep when bringing in curiosity, that’s normal, even expected. Here, you can teach yourself to use curiosity to unhook and step out of worry habit loops (which are both energizing and agitating), and then switch to a practice like the body scan or breath awareness that might be more calming. Then, see if your body naturally drifts off to sleep. If not, it’s all good: you can simply let your body rest while you meditate, and see what happens next.

Remember to keep an eye out for expectations or trying.

Practical Tools

A very common practice that I teach my patients to help them disengage with worry habit loops uses the acronym RAIN.

Recognize what’s here right now

Allow it to be here without trying to fix it

Investigate what it feels like in your body by getting curious

Note and nurture - note or label what you’re experiencing, with an attitude of kindness toward yourself.

Just get curious. Don’t try to change it. Use this to awaken your curiosity. And then you can leverage the observer effect by simply noting or labeling your thoughts, emotions and sensations moment to moment. For example, noting “future thinking,” “Catastrophizing,” “Worrying,” “Planning” and so on.

Remember, this isn’t about stopping thoughts. It’s about leveraging the observer effect. By observing, you’re creating space between you and the thought.

Amy put it this way: “I don’t have to be anxious about being anxious. With curiosity, body scans and RAIN, I am now getting better at observing the anxious thoughts and associated body sensations and I can ride them out.”

Patience and Practice

After a few months in my anxiety program, Amy sent me a note stating, “This morning, at 4am, I could not get back to sleep and I noted all the worry thoughts around not sleeping. I also noted my body sensations of rapid heart beat and fatigued eyes. I also got very curious about my body sensations and I saw that I was getting nothing from worrying. The heart beat and the worry thoughts passed with my doing RAIN. I also did a body scan and a breathing meditation. And yet, I could not get back to sleep. So I feel that I am winning the battle and losing the war.”

I wrote back, “Have you played with separating the behaviors over which you have no control (waking up early) from those that you might be able to not feed (worry)? For example, focusing on driving in 2nd gear with worry (not the waking up bits), and when thoroughly disenchanted, shift into 3rd gear and play with exercises such as the body scan. Even if you’re not able to get back to sleep, you might notice a difference in being rested if you’ve practiced the body scan vs. being frustrated or worried.” (The gears are the framework that we use in our Going Beyond Anxiety program)

She took this suggestion to heart. By March, breakthroughs, including seeing old habits of feeling like she had to get up very early to be productive and successful, but that these were not helpful in the long run. By May, real progress with disenchantment with worry and improvements in sleep. It took months. But it worked.

Someone else in the program put it nicely: “Well I totally failed at accepting being awake last night. Lol. I got frustrated and definitely fell into my old habit loops. But unwinding habits takes time and setbacks are all a part of it.”

Practice and progress, not perfection.

Don’t Try This Tonight (Play With it)

To sum it up, remember these key takeaways. Let go of the goal of sleeping. See how much you can notice and let go of expectation, and instead use curiosity to loosen up so that you can play with practices such as RAIN and the body scan. When anxiety or worry comes up, be curious about what’s happening at that moment. What a great time to meditate! You’re already awake, lying down in a quiet place. Make the best of it.

As Amy wrote after months of practice: “This program is definitely helping me to unwind the stress during the day. Slowly, I am having a few nights of good sleep. I am noticing all the times when I contract. I have been using my mantra, ‘Let it Flow’ when I feel contracted and I then breathe through the contraction until I feel more expanded. This is good evidence that the program is helping me to change my old ingrained habits one day at a time.”

One day at a time. One night at a time. One moment at a time.

Judson Brewer MD PhD is a psychiatrist and neuroscientist and professor at Brown University. He is the author of Unwinding Anxiety (NYTimes bestseller), The Craving Mind, The Hunger Habit and The Unwinding Anxiety Workbook. He co-founded MindshiftRecovery.org which provides free support for people with any type of addiction.

If you are struggling with anxiety, Dr. Brewer’s Going Beyond Anxiety program brings together his research and clinical experience to help people build effective skills to reduce anxiety and cultivate calm (www.goingbeyondanxiety.com).

Subscribe now

Share

Copyright © 2025, Judson Brewer, MD, PhD. All rights reserved.

REFERENCES

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