Transforming the placebo effect in art therapy

The placebo effect is an unacknowledged self-healing process that uses mimicry, an instinctive, preverbal mechanism of the brain. This same preverbal mimicry mechanism is involved in emotion, nonverbal communication, the transitional object effect, empathy, and the esthetic response. Art therapy mobilizes the same nonspecific healing as does the placebo effect because it assesses or explains the client's condition and involves a task that relies on the patient's involvement to perform. It is possible to test whether specific art therapy techniques might replace the mysterious placebo effect with a high rate of success and predictability.

Introduction
The modem physician would be skeptical of the notion that artmaking might be used to influence specific physiological healing. Though the idea is not new to the art therapist who sees such healing occur, the process remains mysterious. I contend that such healing occurs in art therapy for the same reason that the placebo effect has been observed to occur throughout medical history: the brain has frequently-untapped capabilities which can, nonetheless, be intentionally stimulated. There are art therapy techniques suited to providing such stimulation. My goal here is to demystify both the placebo effect in general and, in particular, the related role art therapy can play in medicine. The placebo effect is important to, and perhaps the basis for, the effectiveness of numerous methods of psychotherapy (Shapiro, 1970). Placebo is found to be effective for pain in 30% to 50% of medical cases (Beechef, 1959) and its effect gives 55% to 60% of the relief that morphine does (Evans, 1985). Every type of personality or illness is responsive to placebo. Any person with any medical or psychological condition might get well, despite the absence of the medical or psychological treatment the patient believes he or she is receiving.

Jerome Frank (1973) compared the placebo effect with healing by psychotherapy, faith healing, shamanistic healing rituals, and religious revivalism. He contended that there were certain shared elements explaining the efficacy of the various approaches. He listed four features common to all:

* The patient's confidence in the therapist's ability and desire to help.

* A socially sanctioned healing locale, especially where the patient can behave in ways that would not be acceptable elsewhere.

* A "myth" or basic conceptual paradigm to explain the patient's symptoms.

* A task to perform that involves the patient's activity.

In 1980, Brody also found that these features may produce the placebo effect, and in 1985 William Plotkin emphasized the patient's activity and faith in treatment:

A placebo effect is the occurrence of any therapeutic change that is caused and/or expressed by the patient's own intentional actions when the decision to engage in those actions is an expression of his or her faith in a therapeutic procedure whose mode of effectiveness is not [fully] understood or is misunderstood by the patient. (p.242)

This defines behavior as an intentional, voluntary action, as opposed to merely mechanistic reaction (Ossorio, 1973). Although the action is intentional, the patient is not aware that the action, itself, is the cause of the therapeutic change.

Although the patient's faith appears to play a role in the placebo effect, I believe that further understanding of the physiology of the brain will show that faith is not the central force. My alternative definition presumes that the placebo effect is an unacknowledged self-healing that is attributed to non-specific or incidental effects of a treatment. People heal themselves, exercising a discrete ability which they are unable or unwilling to acknowledge. Faith simply permits the patient to engage in the activity necessary to exercise that ability.

Models of the Placebo Effect
Though explanations have been attempted, the exact mechanism of the placebo effect has remained unknown. The placebo effect has been equated with the solacing effect of the transitional object. Horton, Gewirtz, and Kreutter (1988) claimed that the capacity or competence for solace plays a major role throughout life. Although the child gives up the treasured blanket, the capacity to respond to substitute objects with internal soothing survives. The sugar pill's power resides in its becoming a transitional object.

Krystal (1988) considered the placebo to be a transitional object that removes psychological blocks to self-healing. Failure to acknowledge self-healing is due to an Anglo-European cultural prohibition in which the whole scope of self-regula-tory, self-caring, and self-soothing functions is experienced as controlled by external superior authorities. The individual tends to attribute the ownership of and control over these functions to the mother-object and to feel that the functions are forbidden to the self. The placebo allows the individual to perform these functions without violating the self-healing taboo.

Many other models have been proposed: Gleidman, Gantt, and Teitelbaum (1957) and Wickramasekera (1985), for example, offered classic conditioning models that relate placebo reactivity to established learning concepts. Evans (1974) favored an anxiety-reduction hypothesis while Shapiro (1970) and Barber (1959) supported a suggestion hypothesis. Frank (1973) stressed the role of expectancy in therapeutic response. These models emphasize various conditions that influence the placebo effect but none of them fully explain the psychological and physiological processes involved.

The irony in explaining this unknown process is that once an explanation is accepted, the placebo phenomenon will cease to exist. By definition, the placebo effects are nonspecific; when the mechanisms become known, their therapeutic use will become a specific treatment.

The Mimicry Model: A Physiological Mechanism for the Placebo Effect
Individuals can regulate specific physiological systems and processes, such as stomach motility (Steinbach, 1964), dermatitis (Ikemi & Nakagawa, cited in Plotkin, 1985), hypertension (Graham, Kabler, & Graham, 1962), visual acuity (Graham & Liebowitz, 1972), and other physical ailments and experiences including adrenal gland secretion, angina, blood cell counts, common cold, cough reflex, fever, gastric secretions, headache, insomnia, contraception, pain, pupil dilation and constriction, respiration, rheumatoid arthritis, vaccine response, vasomotor function, and warts (Haas, Fink, & Hartfelder, cited in Evans, 1985). The precise mechanisms used by the brain in effecting such control, however, have not been understood. To understand these mechanisms, and therefore the power at the individual's disposal, it is essential to examine the brain's development and physiology.

One consequence of the brain's evolution is that even our highest mental functions are adaptations of primitive neural structures. Emotion, empathy, and esthetic sensibility, three highly esteemed human attributes, are rooted in the lowest of the brain's organizations, the "reptilian" brain, and use one of its more primitive behaviors, reptilian mimicry (MacLean, 1990). The process is an ancient, neural communication using the same mechanisms as the color response of the chameleon. It involves communication between the separated brain hemispheres that follows a primitive route, bypassing the corpus callosum which connects them.

During human infancy this bypass route is the only line of communication between the cerebral hemispheres because the immature corpus callosum, the only direct link, does not transmit information until the child is about 3 years old (Tinnin, 1989). The infant would have two separate minds if not for this extra-callosal linkage between the hemispheres.

This mimetic functioning is significant. Human communication begins with mimicry. The newborn infant responds to faces with mirrored expressions. One can stick out one's tongue to a newborn and get the same salute in return (Meltzoff & Moore, 1977). Babies imitate a multitude of facial expressions within the first few days of life (Field, T., Woodson, R., Greenberg, R., & Cohen, D., 1982). Long before language develops, the growing child learns about the parent's state of mind by mimicking the parent's associated facial expressions (Stern, 1985).

The infant's imitation of the smiling face is a reaction initiated by the brain-stem. This reaction is expressed through the autonomic nervous system, which acts internally as well as through the facial muscles. Although the divided brain cannot exchange messages across the corpus callosum, each half will perceive the facial, visceral, and skeletal activation generated by the other, and each half will then assume the state of mind that has come to be associated with that pattern of activation in the past. This process of internal communication by way of bodily activation is the major source of volitional coordination until the corpus callosum matures.

This process makes it possible for the child to soothe itself in mimicry of the mother's soothing. This self-soothing is learned in a reciprocal cycle of comforting, mimicry, and pleasure, a process that requires mutually empathic responses. The capacity for empathy originates in finding and giving solace (Adams-Silvan & Silvan, 1988). In time, the child can find solace without the mother by soothing a substitute object. Note that the transitional object is not the soother, but that which is soothed. The child strokes the blanket in mimicry of mother's soothing and thereby activates the internal process of autonomic calming and repair.

Once the corpus callosum matures, the newly dominant verbal self claims that all of the body's feelings and actions are generated by itself, including the preverbal affect and actions that are communicated along the extra-callosal route. The verbal mental module denies the a posteriori nature of emotional experience which, in reality, is initiated outside the brain's language areas (Tinnin, 1990). Despite the denial by the conscious self, this callosal bypass continues to process nonverbal communication outside of conscious awareness. The infant's sequence of external imitation of another's facial expression, followed by internal autonomic mimicry, continues throughout life.

With the addition of the phase of conscious interpretation and owning of the experience, this sequence constitutes the three phases of emotion as described by Nathanson (1992): The affect phase consisting of the preverbal motor activation of facial, visceral, and body movement; feeling, the sensation of that activation; and emotion, the cognitive interpretation and owning of the feeling. Affect in animals is the precursor of human will and speech. As the precursor of will, it is the intention to act. As the precursor of speech, affect evokes mimetic behavior in others and thus conveys intentions and states of mind.

The preverbal activation of the auto-nomic nervous system directly influences hormone secretion and the immune system's antibody production. The mimicry process recruits all of these preverbal motor functions and thereby provides a coordinated mechanism for self-healing. Because of the callosal bypass and the a posteriori. labeling (rationalizing and confabulating) of the output by consciousness, the self-healing process necessarily remains preverbal and inaccessible to consciousness (Tinnin, 1991). It can be mobilized by mimicry and nonverbal communication that bypasses verbal dominance and by trance states (as in hypnosis) or altered states of consciousness (as found through certain sedatives, hypnotics, and anesthetic agents), as well as by the placebo effect, but not by conscious methods.

The Mimetic Process and the Esthetic Response
The basic therapeutic approaches of art therapy satisfy Frank's (1973) universal nonspecific healing measures in terms of (1) the patient's confidence in the therapist (faith in the art therapist); (2) a socially-sanctioned healing locale (the art therapy room with its art materials and tools that facilitate expressiveness); (3) a myth or basic paradigm (the therapist's diagnosis or explanation of the client's condition that guides the treatment process); and (4) the patient's activity (the artwork to be accomplished by the client). Additionally, art therapy has a unique and specific potential relative to self-healing because of the way art affects the brain.

Human perception of nonverbal communication is an active, although unconscious, process in which the receiver creates the percept by mimicry. This is as true when the message is carried by art as when it is carried by face-to-face emotion. The primitive tendency to mimic perceived movements or dynamic postures of people and objects is experienced kinesthetically as incipient movement in the muscles. Because motor activation is intrinsic to emotion, kinesthetic sensations tend to evoke emotions (Kreitler & Kreitler, 1972). Papanicolaou (1989) believed that it is the combination of kinesthetic and autonomic mimicry that constitutes the esthetic experience when viewing art. An essential part of that experience is the unconscious mimicry of a depicted movement or posture and the imagined completion or reconstruction of the movement.

Because of this mimicry, art therapy procedures have the capacity to short-circuit the callosal bypass route and permit expression of the preverbal message prior to verbal interpretation. This permits the revelation of uncensored nonverbal information in the service of diagnosis and treatment.

Art Therapy as a Specific Medical Treatment
My hypothesis, therefore, is that an art therapy approach that makes use of the image and preverbal mimicry in the principles of the placebo effect will have a probability for success in treating a specific condition of at least 30% to 50% and the expected degree of change will be at least 55% to 60% of that obtained with a known effective medical agent.

The Interactive Technique devised by Lachman-Chapin (1983), modified to include preverbal mimicry, would serve admirably to test the hypothesis. Lachman-Chapin's technique consists of the therapist making art at the same time as the patient. Usually the therapist and the patient do not look at each other's work in progress. When both have finished, they first look at and talk about the patient's production and then they talk about the therapist's. The patient and therapist "read" each other's responses in the artwork, a process she calls "art dialogue."

In the modified procedure, the patient and therapist begin by making art at the same time with the agreed-upon goal of depicting the patient (figuratively or abstractly) and the symptom to be changed. They might sit on the same or opposite sides of a table. When they have completed their initial picture or sculpture they inspect both works and discuss how the desired resolution of the symptom might be represented. The therapist alters his or her piece to transform the symptom. The patient follows the model by erasing, reducing, or changing the symptom depicted in his or her own production. They then discuss the patient's solution and the patient makes any further modification desired.

With this technique the therapist and client first establish diagnosis and the target for self-healing. The therapist's expert modeling of transformation then inspires faith in the therapist and the activity. When the client executes the transformation, the brain's capacity for self-healing via preverbal mimicry is stimulated. All of the conditions are met to achieve the same or better results than those found in the placebo effect process.

This procedure is more directive and structured than the usual art therapy approach and is not intended to replace other art therapy procedures. These elementary features would be useful for the limited goal of testing my prediction.

Conclusion
Understanding the brain demystifies the placebo effect process. The unacknowledged self-healing process experienced unpredictably in the placebo effect can be intentionally stimulated with predictable results by using art. Because art influences existent preverbal brain processes, art therapy may be an ideal tool for medicine. A modified version of Lachman-Chapin's technique should be tested. I predict that it will produce results meeting or exceeding those produced in the placebo effect.

Requests for reprints should be directed to the author at Chestnut Ridge Hospital, 930 Chestnut Ridge Road, Morgantown, WV 26505-2854.

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By Louis W. Tinnin

Louis W. Tinnin, MD, is professor of psychiatry at West Virginia University's Chestnut Ridge Hospital.

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