Expectations, with David Robson

HILARY SUTCLIFFE: Hello and welcome to From Another Angle, a Carnegie Council podcast. I am Hilary Sutcliffe, and I am on the Board of Carnegie Council's Artificial Intelligence & Equality Initiative. In this series I get to talk to some of today's most innovative thinkers, who take familiar concepts like democracy, human nature, regulation, or even the way we think about ourselves, and show them to us from a quite different angle. What really excites me about these conversations is the way they challenge our fundamental assumptions. Their fresh thinking makes me—and I hope you too—see the world in a new way and opens up a whole raft of possibilities and ways of looking at the future.

Today I am delighted to welcome David Robson, who is an award-winning science writer for BBC, The Atlantic,Popular Science, and many more, and he specializes in the extremes of the human brain, body, and behavior. We are going to talk about expectation from another angle.

You may know a bit about the effects of positive expectations, like the placebo effect, or how negative expectations of our own abilities may be limiting, but in his new book, The Expectation Effect: How Your Mindset Can Change Your World, which was a Financial Times best book of 2022 as well as a Sunday Times best paperback of 2023, and British Psychological Society Book Award for 2022, among many other accolades, David takes our understanding to another level with a scientific view of the mental and physical impacts of our expectations, and he shares some truly astonishing examples of its life-changing effects.

Today we are also going to look beyond the book to reflect on how this understanding of the positive and negative implications of our expectations can be applied to some of the thorny problems of our day, how expectations may be limiting or powering our response to climate change, for example, or even tech development.

Welcome, and thank you very much for joining us.

DAVID ROBSON: It is my pleasure. Thanks for having me on the show.

HILARY SUTCLIFFE: This idea of positive thinking has been around for decades, and "manifesting" is very popular right now, but this book is not like that at all. Perhaps you can start by talking us through what makes your book different from this other genre of self-help books.

DAVID ROBSON: I was very conscious right from the beginning of writing the book of differentiating it from this huge literature on positive thinking and then the recent trend in manifestation.

I am sure lots of people do find those kinds of books useful, but in my opinion they are pseudoscientific. They are not really based on solid research, and they often draw on these ideas of a cosmic "law of attraction," where you are sending out positive energy and hoping that you will then draw positive things in as well. These writers might talk about that as being an effect from quantum mechanics, but I feel like they are misinterpreting the rules of reality there whereas The Expectation Effect is very much grounded in good, peer-reviewed science, and is looking at all of these very plausible mechanisms through which our mindsets do have a powerful impact on our lives, and they do that through three main mechanisms.

Our beliefs can create self-fulfilling prophecies by changing our perception, our behavior, and our physiology. Even though it cannot perform a miracle in the way that you can imagine yourself becoming rich and then lots of money just happens to come your way through something like a lottery win, the effects are still incredibly profound.

My favorite example and the most powerful one that comes from the scientific literature, is that your views of aging can shape how long you live. People who have a positive view of aging, who see old age as being a time for growth and opportunity and they see their skills crystalizing as they reach their 60s and 70s, actually live seven-and-a-half years longer than people who have a negative view of aging and see it only as a time of decline and disability.

It is not magic. I am not claiming that they are changing their DNA or something, but we do know that they are producing biological change there. We know that the outlook you have of aging changes things like your stress response, and then day after day after day the small benefits that you might have from the positive mindset accumulate, or conversely the negative effects of always seeing your environment as being increasingly dangerous because you feel you are becoming more vulnerable, that actually accumulates and can damage your tissues and predispose you to illness. The mechanism here is very well documented. It is all through these pathways that we have known about for decades, and it can all be held under this umbrella of mindset, and by changing that mindset you can switch from one mode of being to another and have those benefits of having that positive view.

That is just one example of the expectation effect, but I think it encapsulates what I want to say about the expectation effect, which is that it can be profound but is not some kind of miracle or magic. It is all grounded in very real science.

HILARY SUTCLIFFE: I must admit I am little bit nearer that aging end of the spectrum than you, David, but I can see that among my peers, people who think they are on the downhill now. Luckily I am not one of those people; I am going to work until I am 112.

What I liked about your book too and what I have not seen before is that you talk about the mind as a "prediction machine." Talk us through the scientific approach of how our mind uses what we find in the outside world to make predictions.

DAVID ROBSON: This is the theoretical bedrock of The Expectation Effect. It helps us to understand why we evolved for expectations to shape our well-being in the way that they do, and it can help us to understand the specific mechanics of the expectation effect.

Essentially this theory, which has been gaining a lot of ground in neuroscience, is that the brain is constantly building these simulations of the world around us. Every second of every day it is doing this. That is important for shaping our perceptions first of all because the truth is that the sensory data that is coming into our bodies is often quite poor. What we see, the conscious experience of seeing, is not a true reflection of the data that is hitting our retinas. That can be very messy and very ambiguous, and the brain does a lot of processing to tidy it up, and it does so through these simulations that it has built.

It has all these past experiences of similar situations, it knows the context, which helps to refine those simulations, and then it is using the data hitting your eyes to tweak the simulations. It is almost simulations that we are experiencing rather than the real world. Some neuroscientists even go as far as to say that reality is really a "controlled hallucination" for this reason.

The fact is that these simulations often are very accurate, but sometimes they can be wrong, which is why we have those visual illusions that you might see where you might mistake something in your field of vision, you might mistake a stranger for a familiar person because of the expectation that you would see them. It is wrong a fair amount of the time, but mostly it works very well.

What these simulations are doing besides shaping our perception is that they are also then changing our physiology because we have to be very adaptive. As animals we have to respond to our circumstances, and those simulations are just helping you to predict what you need to do next, how the body could prepare for a fight, prepare for the food it is about to eat, or prepare for a period of starvation. That in turn is changing things like the hormonal balance in your body, the actions of your digestive system, your blood pressure, and the actions of your immune system, whether you are going to be releasing lots of inflammatory molecules that can help to be the first line of defense against infection if you become wounded, for example. All of this is happening.

The prediction machine is working basically 24 hours a day. When we sleep our dreams are a product of the prediction machine to a certain extent. Especially when we are conscious our perception, our behavior, and our physiology is constantly being tweaked and changed by this prediction machine. What we need to remember when we are thinking about the expectation effect is that we are trying to optimize those simulations to make sure that they are working in the best way for us.

HILARY SUTCLIFFE: When I was reading the book I was astonished by the physical symptoms that the expectation effect generates. This is not just about mindset necessarily. This actually results in changed physical symptoms. Give us some examples of that, because it is fascinating.

DAVID ROBSON: Exactly. It is not imagined at all. I would really emphasize that. We are not just telling ourselves that we are getting better and feeling happier because of that. We are actually seeing in many cases some real physiological changes.

If you take a placebo of a painkiller, a dummy pill that you believe to be an opioid drug, for example, your brain actually starts to produce its own endogenous opioids. We know that from brain scans. We know from clever experiments where people have taken chemicals that block opioid signaling what you see is that when you block the opioid signaling people no longer have the benefit of the placebo because they are not able to benefit from those endogenous opioids being released. I think there is very strong causal evidence that the expectations are actually changing the chemistry within your brain.

We know that is also true for lots of other symptoms that you might be experiencing, things like inflammation, which is what basically leaves us feeling poorly when we have an infection and what causes rashes to start to look very hot and angry. This is caused by these inflammatory molecules, and we know that if you take a placebo that you think is going to reduce inflammation, then often it does reduce the levels of those inflammatory molecules. Conversely if you expect to become sick it can cause the body to ramp up the production of those molecules as it prepares to fight some kind of infection. Like you said, it is a very physical result that is coming from your subjective beliefs.

HILARY SUTCLIFFE: To the point of death. Tell us the story that you use at the beginning of your book of the tribe that came over to America, and the unexpected deaths that were psychological and not physical.

DAVID ROBSON: These were immigrants from Laos. They were moving to the United States in the 1970s and 1980s. Suddenly the Centers for Disease Control and Prevention started noticing that there was a high proportion of deaths among the young men who had come over, much higher than you would expect for that age group. It was actually the leading cause of death for these young to middle-aged men. It was a medical mystery. In the middle of the night they would start gasping for breath and then die of heart failure.

It actually took a medical anthropologist to find out what was causing this. Her name was Shelley Adler, and she noticed that these men had carried a cultural belief from Laos about this devil called dab tsog, who would visit people in their sleep, sit on their chest, and suffocate them. Back in their homeland these people would have been able to call on a shaman or could have performed certain rituals that would have protected them from the dab tsog, but these men in America lacked these cultural practices. They were integrating with American life, and they had left some of those behind, and that seemed to be contributing to this state of panic. When it was combined with an existing genetic weakness in the heart it was actually precipitating their deaths. The idea was that these people could have lived with that weakness in the heart for decades, but then the panic that was coming from this belief was leading them to die a lot younger than they should have done.

I think a lot of the newspaper coverage at the time was quite racist I would say and was quite patronizing about these people, as if we in the West do not have any irrational beliefs. Obviously we do, and there have been similarly recorded cases of death through negative beliefs amongst certain people in the West as well. What I think we need to recognize is that so many of our widespread beliefs are doing exactly the same thing.

One that I think is relevant is our attitude to stress in general. We have been led to believe for about a century now that stress is in itself debilitating, dangerous, and must be avoided, so people are not only feeling the stress of their jobs, which is substantial, but they are also feeling the fear of that stress as well. There are longitudinal studies suggesting that it is actually the fear of stress that is amplifying the terrible effects of people's stress, and that combination is then leading to cardiovascular disease and the heightened risk of death.

We think of it as being total scientific proof that stress is dangerous. Stress can be dangerous, but it can also be enhancing, and it is very much our beliefs that determine which one is true. That is a self-fulfilling prophecy that I think we could combat in the West.

HILARY SUTCLIFFE: I like as well your approach, looking at the reframing of stress from one perspective to another perspective, a more positive perspective, that has quite quick and profound implications for people.

DAVID ROBSON: It does. I talk about these kinds of headline results, but there is a huge amount of evidence behind this in the short and long terms. To give a few examples of the short-term benefits of reframing your attitudes to stress, scientists were looking at students taking a difficult GRE (Graduate Records Examination). Students were especially stressed about the maths component of that exam.

They told these students: "You know, you will feel anxious probably in the exam, that is natural, that your heart is going to be racing, you might feel a bit short of breath like you need to bring in more oxygen, but you do not have to worry about that." That physiological reaction evolved for a reason because when the heart is racing it is pumping all that oxygen to your brain, is helping it to function, and helping it to think more clearly.

Similarly, that feeling that your nerves are jangling is coming from cortisol. Over the long term if you have too-high levels cortisol that can be damaging, but for a short-term event it can be enhancing to have that because it keeps you alert and makes sure that you are focused. No one wants to go into an exam feeling drowsy.

The research has found that just teaching these students about those benefits improved their performance. It also changes how people recover after the stress. I think this is what is important to remember. It is not just about doing well. It also helps you to relax more quickly afterward so the cardiovascular system goes back to normal, the body can start to divert more resources to things like digestion—which we call the "rest-and-digest" state—and it can go back to doing the things it has to do to maintain your health.

It is through that kind of improved recovery that I think the long-term benefits of having the more positive stress mindset comes in. If you are facing regular stresses with work—if you are having to do stressful meetings every day or meet tight deadlines—if you can isolate the stress to just that one moment in the day and then have lots of downtime where you can disconnect from it, you are not going to have long-term health problems. But if that is accumulating, if the levels of cortisol are staying constantly high day after day and month after month, that is going to cause wear and tear to your organs and is eventually going to lead you to have a shortened lifespan.

I find this very compelling evidence. We have the short-term interventional studies, we have the long-term longitudinal studies, they all tie together, and they all point in the same direction, that our attitudes to stress are shaping how it affects our health and well-being.

HILARY SUTCLIFFE: What I loved about that chapter and that story as well is the power of explanations. I did a bit of work on trust recently, and an explanation is a big driver of trust. I am working for a European health service looking at how explanations matter between doctors and patients. You have a fantastic study where you talk about how the explanations about what is going to happen with this drug and what is not and explaining how they may feel transforms their life expectancy and the time in hospital. Could you give us that case study?

DAVID ROBSON: Absolutely. There are quite a few of these now, and I find it exciting because for decades doctors knew about the placebo effect, but they did not know how we could use it ethically because you cannot deceive the patient into thinking they are taking a real drug when they are not, but what you can do is, like you said, you just explain why the treatment is beneficial.

We saw this with people with extreme anemia, for example, who were receiving iron transfusions to boost their energy levels, and just explaining to them why it was going to help and to show them what they could expect to happen over the days ahead led them to have longer-term benefits from that transfusion. They did not need to go back so often to get it because it was helping to enhance their experience of that treatment.

The most profound case study I think came from Malberg in Germany. That was looking at people who were recovering from cardiac surgery. As you can imagine, it is very serious surgery, and lots of people have a huge amount of anxiety about what is going to happen, and they can often build a worst-case scenario into their thinking. The doctors assumed that maybe that was going to harm their recovery, their negative expectation of things.

They gave half of their patients psychological therapy, just four sessions, an hour long each, where a health psychologist spoke to them about what their fears were and then tried to explain that actually there might be this risk but it does not need to be as bad as you are expecting and then also explaining why the surgery was going to help them, physically what was happening in the surgery and why that was going to improve the function of the heart. And then they set out this plan for the next month of when they might expect to reach certain milestones in their recovery. The other patients were just given treatment as usual, all of the good care that you would get in the hospital, but they were not given this extra psychological help as well.

Like you mentioned, these patients actually left the hospital days earlier, a difference that in itself is enough to easily pay for the cost of the psychological therapy. If you consider how expensive it is to have a hospital bed, four hours of therapy is nothing in comparison.

It improved the patient's comfort in that short period of time, but then the benefits kept on accumulating. They had lower disability scores after the operation, they were able to go back to work more quickly, go on holiday, and do all the things that they wanted. We even saw changes in the levels of inflammation within the body, and that is important because if you have too high levels of inflammation after an operation that might make the healing a lot slower and could even undo some of the good that you are getting from the surgery. In all these ways the positive expectations were benefiting the participants. The important thing was that there was no deception there at all. It was just giving them better understanding of what was happening in their bodies. Knowledge was power.

HILARY SUTCLIFFE: Astonishing. As you say, a very cost-effective way of treating people for our strapped health services.

Let's move out for a second now because one of the things I was struck about reading your book was the power of positive and negative framing. Obviously with Carnegie Council we are looking at very large-scale issues, issues that are thorny, the problems of our age—climate change and technology development. It did strike me that a lot of the articles that I read on LinkedIn and in academic literature are all about describing the problem and "catastrophizing" the problem.

The problems are worth catastrophizing. Let's be honest. I am not minimizing the problems, but it struck me that it is easier to talk about problems than it is about solutions. It is certainly in our nature to do that. But there may be negative issues associated with that, not least a sort of fatalistic feeling that we cannot change anything. I wondered if you could extrapolate your research into this higher-level thinking and see what you think is happening and what we could do differently in terms of expectations and communications.

DAVID ROBSON: I think our expectations are hugely important in how we deal with big issues as well as our personal challenges, and I say that thinking that we cannot minimize the dangers that we are facing. With climate change I think we have to be absolutely honest about the level of threat and the timelines that we are looking at. It is urgent, and we need to acknowledge that. People need to take action as quickly as possible. I do not think that sugarcoating the message is going to help there, but I do think in much the same way with those patients undergoing the heart surgery you are not pretending that they are not going to experience discomfort or that it is not going to be difficult. The framing is important still, and like you said we do not need to catastrophize too much, and by "catastrophize" I do mean that chain of thinking where it seems so fatalistic that there is simply nothing to do. With climate change in particular I think there is emerging research showing that mindsets can be important here.

To give just one example, there is a long history of research in education about the "growth mindset," the idea that if people think that their abilities can improve incrementally with effort and with perseverance, they will deal with challenges a lot more proactively than people who have a fixed mindset. These are people who assume that any talents are completely innate and are not going to get better through practice, and if they face failure it is a personal reflection on them and it says something terrible about their inability to improve. That research has had some controversies, but I think in general it is well-acknowledged now that it does bring lots of benefits to children to develop the growth mindset even if it is not this kind of cure-all for all of education's problems, which it never could be.

We have also looked at how that can be beneficial for people undergoing psychological therapy, for example. If you have a growth mindset about your personality and about your ability to regulate your emotions, you are more likely to benefit from cognitive behavioral therapy for anxiety or depression, so it can be applied in lots of different circumstances.

This new research has actually looked at how people see the world around them. Do they see it as being this fixed entity that is not going to change, that the details of the problems might change but ultimately we are going to still have the same issues, or do you see it as something that actually can get better over time? If we all work together as a society, can we make the world a better place, can we tackle these big challenges head-on?

What they found was that encouraging people to have that growth mindset about the world, to recognize that positive change is possible, and to avoid that fatalistic, fixed way of thinking, did change people's attitudes to climate change. First of all, it meant that they were more willing to accept the scientific consensus on climate change but also that people were more willing to be proactive in the way that they personally would deal with climate change.

I find that very optimistic. I am certainly not claiming that teaching people a growth mindset about the world is going to be the one and only solution to climate change. No, it is a very small piece of the puzzle, but nevertheless I think when we are communicating about these risks we do want to make sure that we bear this in mind. We do not want to reinforce that fixed mindset that is going to make people feel like they might as well give up or turn away from the problem and try to pretend it is not happening. We want to try to get them to have that kind of growth mindset and to think about even small changes they can make that might over time build up, even just with their voting intentions that might make a change eventually to some much greater transformation. That is where I stand on that.

HILARY SUTCLIFFE: Thank you, David. What a fantastic way to end. Could you give a few pointers for our listeners of what they could do in their own lives and use the expectation effect to help themselves?

DAVID ROBSON: The first thing that I would like to emphasize is that whatever positive change we are trying to bring about, I am not talking about having this Pollyanna-ish view of the world as being this wonderful, rosy place where you deny all kinds of discomfort, challenges, and stresses. We have to be realistic about the situation that we are in.

I think also we have to avoid this kind of idea that by being pessimistic we are being inherently rational. I think there is this idea that with defensive pessimism you are kind of smarter if you are always looking on the downside of things because you are not going to be disappointed. We should be aiming for this middle ground, I think, like those people undergoing heart surgery. You can acknowledge the difficulties, but you can then look at the positive side of what is going on and reframing it so that you can set your expectations based on the evidence at hand and are avoiding that extra level of stress and unhappiness that might be caused by the overly negative, catastrophic way of thinking.

If you do find yourself going in a downward spiral, there are just a few questions you can ask yourself: Am I being as objective as possible? Is there actually evidence for what I am thinking? Is what I am fearing inevitable, or can I look at it in terms of probabilities? Is there a positive outcome, a negative outcome, and a neutral outcome, and what are the relative weightings of all of those?

Finally, treating ourselves with self-compassion is important in applying the expectation effect. There is a huge amount of research showing that we tend to be overly self-critical and to beat ourselves up all the time for our failings.

We can learn from our failings and we can recognize that feelings of disappointment are valuable and are conveying useful information for how we might improve in the future, but we do not need to add to that distress by being nasty to ourselves. We should try to talk to ourselves as a parent might to a child or you might to a friend who is facing disappointment, being honest but also being encouraging. Whatever challenges you are facing and however you are trying to apply the expectation effect, I think it is important to just be kind to ourselves.

HILARY SUTCLIFFE: Fantastic. What a great way to end.

Thank you very much, David Robson. His book, The Expectation Effect, will be linked underneath the podcast here with some other sources of information and interest that he would like to share with us.

David, thank you very much indeed for joining us.

DAVID ROBSON: Thanks for such a fascinating discussion.