We’ve known for some time that our expectations can profoundly influence the experience of our world,even our physiology.1 This, after all, is what the placebo effect is all about. But we hadn’t really understood the nitty-gritty of why and how expectation works until the advent of the neuroscientific field called interoception, and its central idea of predictive processing or predictive coding.
What Is Interception?
Interoception, as I’ve mentioned in previous posts, is the brain’s ongoing monitoring of sensory signals streaming from all over our inner body to maintain the homeostatic condition of our body. Our survival depends on it. Having a felt sense of the positive or negative quality of our bodily sensations allows us to quickly detect and correct any potentially dangerous physiological changes, like thirst or overheating. These same sensory signals also create our emotional awareness, our sense of well-being and even our sense of self. This amazing process creates our experience of how we are and who we are.
The Prediction Machine
Our brain, which has been called a prediction machine, creates our ongoing experience through a complicated, computational process of predicting what will happen at any given moment. The brain makes inferences about the likely cause of our body sensations by testing them against prior experiences. When our brain makes a prediction error, it has to update that prediction based on new input. In this way we are continuously creating our own internal working model of the world. As Ram Das said, we create our own reality.
The interoceptive concept of predictive processing syncs nicely with basic psychoanalytic theories of transference. We expect people to behave the way important people around us behaved when we were very young. Indeed, one way of looking at psychoanalysis or psychotherapy is that it works by helping us update our tired, old inaccurate predictive models based on new experience. Stubborn negative predictions based on past experience can actually create the feared negative outcome, the so-called nocebo effect, which is so powerful it can even change our bodies physiologically.
Another reason I appreciate the notion of prediction is that my patients really get it: They often light up when I first bring it up. Why? Because prediction conjures something active, present-tense, and dynamic. We can almost feel our brain doing it. Concepts like transference or organizing principles don’t really capture the surreal phenomenon that our brains are always, busily, actively trying to decide what to do with vast amounts of raw information being sent from our bodies.
How Therapy Works
When my client, Bob, age 49, first came into my office, he surprised me by asking question after question about how I worked and how therapy worked. He showed tremendous interest and curiosity. I got hooked and engaged in much more conversation than usual and realized, only after he left, that I had learned very little about my client. In subsequent sessions, of course, I made a point of asking about him—his history, complaints, aspirations, and so forth—but again I kept getting pulled in to tell him about my ideas. I was also having the unusual experience of forgetting what he had told me about himself.
It was only after some months that I began to make sense of what was going on. Bob was the youngest child in his family, had three very loud and extroverted older siblings and distracted parents, and he had simply disappeared. What made it even worse was that he had decided early on that it was preferable and to his advantage to fly under the radar.
Bob said he still found it most comfortable (and preferable) to draw out other people because “that’s what they want” and, in groups, to play what he called a moderator function. I told him finally that, underneathhe too wanted to be seen and known, But it was only after much pooh-poohing on his part and much conviction on my part and my finally telling him directly, with a lot of feeling, that I was interested in him and wanted to know more about him that he finally wept with what we decided must be relief.
He had arrived in my office with the expectation that I would not be interested in him, which contributed to my responding in a way that confirmed his prediction. When I first challenged his prediction, he didn’t believe me, and it was only after testing me again and again and experiencing my genuine interest, prediction error, many times over that he could begin to revise his faulty expectation. His painfully sad prediction, which had bedeviled him for almost five decades, could now be slowly and carefully updated.
I remember the first time I used the word prediction to describe his belief that no one was interested in him. I told him I thought he had unconsciously brought this prediction into therapy so we could work on it together. Bob looked astonished, then excited, then said he got it. “This is the first time I see what I’m doing,” he told me. From this new vantage point, he could begin to see how revising his prediction (and his behavior) could change his world.