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Review: Cure, by Jo Marchant

700x373Cure: A Journey into the Science of Mind Over Body, is an excellent new book by science journalist Jo Marchant, which explores the healing (and harming) power of the mind and emotions over the body. It succintly brings together a lot of recent evidence in areas sometimes dismissed as ‘pseudoscience’, such as the placebo response and hypnotherapy, to argue for their medical efficacy and the need for a medical model which better incoporates the mind.

Marchant argues: ‘Conventional science and medicine tend to ignore or downplay the effect of the mind on the body. It’s accepted that negative mental states such as stress or anxiety can damage health long-term…But the idea that the opposite might happen, that our emotional state might be important in warding off disease, or that our minds might have ‘healing powers’, is seen as flaky in the extreme.’  Her book succeeds in its aim of rescuing this area ‘from the clutches of pseudoscience’. 

The book is very much in line with a new research project I’m involved with at the Centre for the History of Emotions, calling Living with Feeling, which also explores the interaction between emotions and health. I’m going to summarise the main points from each chapter of Marchant’s book.

Brain scans from Benedetti’s research

Chapter One looks at the placebo response, in which fake or dummy medicine still has real healing effects on patients. Mainstream science has tended to dismiss the placebo effect as a trick or mental anomaly that mainly works for ‘unintelligent or inadequate patients’, as The Lancet put it in 1954. In fact, the placebo response has been shown by researchers such as Fabrizio Benedetti to have powerful physiological effects. For example, Jan Stoessl, a neurologist at the University of British Columbia, found that dopamine levels tripled when patients with Parkinson’s were given placebo pills. Fabrizio Benedetti has used brain scans to identify the effect of placebo – the effect of belief – on motor neuron cells, which fire more slowly in Parkinson’s sufferers following a placebo. The power of belief and suggestion appears to release natural healing chemicals in the brain such as endorphins, which help counteract some illnesses like Parkinson’s and MS, as well as psychiatric illnesses like depression. Indeed, another placebo researcher, Irving Kirsch, has suggested wonderdrugs like Prozac work mainly through the placebo effect – his book The Emperor’s New Drugs explores this. Benedetti has also found that valium ‘has no effect unless patients know they are taking it’, which surprised me.

Chapter Two explores how placebos even work when patients know they are taking a placebo. A 2010 study by Harvard’s Ted Kaptchuk – a leading researcher in this field – gave placebos to patients with Irritable Bowel Syndrome (which affects 10-15% of the population) and told them  ‘that although the capsules contained no active ingredient, they might work through mind-body self-healing processes’. They did significantly better than those who received no treatment. Marchant highlights the market in ‘open-label placebos’ like Placebo World, Universal Placebos and Aplacebo – the latter set up by Simon Bolingbroke, who manages his own pain from Lyme disease using placebos. ‘It sort of started as a joke’, Bolingbroke says. ‘But it’s a joke that’s real.’

Marchant deepens her analysis of the placebo effect in this chapter, exploring the power of ‘feeling cared for’ – patients who receive their drugs when their doctor is present apparently get 50% more pain relief. She suggests that placebos tap into ‘ancient evolved pathways’ in our brain which persuade our brain ‘that we are loved, safe and getting well’. She also begins to explore the connection between placebo, ritual and symbols – bigger placebo do better than smaller ones, two pills work better than one, coloured pills work better than white, blue helps us sleep, red is better at relieving pain, green is better for anxiety. ‘We are symbolic animals’, says Benedetti. We’re also ritualized animals, and the ritual interaction between healer and patient affects the placebo response. ‘Words, gaze, silence, body language, all are important’, says Kaptchuk.

In Chapter Three, Marchant explores another mechanism for the placebo effect – physiological conditioning. She writes about the relatively new field of psychoimmuneology (which includes QMUL’s Fulvio D’Aquisto), which has proved that our autonomic nervous system is connected to our immune system, and that the placebo effect (or beliefs) can impact immune cells through neurotransmitters. She writes about a new medical intervention called Placebo Controlled Drug Reduction, where patients are given a drug in combination with a placebo, and then subsequently the drug is reduced while the placebo remains. The physiological association between the drug’s effects and the placebo’s effects means the placebo keeps working  – a 2010 study by Adrian Sandler found PCDR to be effective in treating children with ADHD.

Chapter Four covers the highly contentious area of fatigue and Chronic Fatigue Syndrome. Marchant explores how fatigue used to be understood as an automatic physiological response, but which some researchers argue is actually more like an emotion. Sports psychologist Tim Noakes of the University of Cape Town has ‘proposed that the feeling of fatigue is imposed centrally, by the brain’. A ‘central governor’ in the brain makes us feel tired before our body gets damaged, as an early-warning system, Noakes argues. However, the central governor can get it wrong, and can be modulated through training, and through belief – Chris Beedie at Aberystwyth University found cyclists given a pill they believed was performance-enhancing could cycle 2-3% faster.

Marchant then highlights the research of QMUL’s Peter White on Chronic Fatigue Syndrome. White’s research argues that CFS can be treated with a combination of Cognitive Behavioural Therapy and Graded Exercise Therapy. A 2011 study found that 22% of patients recovered after a year of CBT and GET, while patients trying ‘adaptive pacing therapy’ (in which you adapt to the new circumstances of having CFS) did no better. CBT and GET appears to be a way to re-train the ‘central governor’ of your brain when it gives you the false information that your body has reached its fatigue limit. The suggestion that CFS involves the mind is, however, hugely unpopular with some sufferers of ME (Myalgic Encephalopathy, patients’ preferred name for the condition) , who have been stigmatized for decades as suffering from ‘yuppie flu’ or ‘Raggedy Ann syndrome’. A Guardian article by Marchant on CFS has already attracted the ire of ME groups. Perhaps it’s the mind / body paradigm that’s at fault – it’s rarely just the mind or just the body, but a complex interaction between the two.

Franz Mesmer

Chapter Five looks at hypnosis, a medical intervention with a chequered history ever since Benjamin Franklin’s 1784 trial of Mesmer’s animal magnetism dismissed it as ‘imagination’. The Lancet was initially a fan of John Elliotson’s early research into animal magnetism in the mid-19th century, but then rapidly and publicly dismissed it as mere ‘suggestion’. But can suggestion still be very healing? Part of the problem is there is still argument over what hypnosis actually is and what it does. On one side are those who argue it induces a hypnotic ‘state’ in the brain – a trance or altered state. On the other side are those who argue it is simply role-play, people going along with suggestions, particularly if given by a high-status figure. It’s probably both. In support of the ‘state’ theory, neuroscientist David Spiegel has found that brain scans of people hypnotized to see black and white as colour show the colour-processing parts of their brain are activated – if this is just ‘make-believe’, then it’s make-believe at a neurological level.

Marchant highlights the research into the healing power of hypnotherapy visualization for sufferers of Irritable Bowel Syndrome, which helps 70-80% of IBS sufferers, according to the research of Peter Whorwell. Visualizing and imagining apparently affects our physiology – a study by Karen Olness found that children who imagined heat going to their hands really did heat up their hands. I find that fascinating, considering the importance of ‘warm healing hands’ in charismatic Christianity and alternative medicine. It also reminds me of how people using Tibetan Tummo meditation manage to heat up their body, and even endure ice baths for long periods, by visualizing a candle burning in their chest.

Chapter Six takes this idea of the healing power of visualization into the realm of virtual reality, by exploring a VR programme called Snow World, which has been found to help burn victims to cope with pain, apparently by distracting them with an interesting immersive world. VR can also be used to manipulate people’s body awareness, mitigating the symptoms of phantom limb syndrome, and even inducing out-of-body experiences. Below is a video on Snow World:

Chaper Seven deepens the analysis into the importance of caring relationships in healing, showing how mothers giving birth who have the same care-giver helping them throughout the birthing process tend to have less complications and easier births – an important finding when one third of women feel traumatized by birth. Marchant also looks at the use of Comfort Talk by medical practitioners. She takes up the importance of caring relationships in Chapter Ten as well, highlighting the Tecumseh research project, which explored the importance of social connections to the immune system.

Chapter Eight looks at how stress is bad for our immune systems and even ages us, and how growing up in poor, rough neighbourhoods affects our bodies. Stress is apparently connected to our imaginations too – we remember past adverse events and expect them in the future, so our bodies are stuck in defense mode. Chapter Nine looks at how we can counteract this with mindfulness, bringing our mind back to the present moment rather than worrying about the past and future. Marchant also discusses the Relaxation Response, first highlighted by Herbert Benson, who looked at how chanting a mantra (or any word, it doesn’t have to be Hindu) helps kick in the parasympathetic nervous system response, enabling our bodies to relax and heal.

In Chapter Eleven, Marchant looks at the role of the vagus nerve as an important transmitter between our mind and body, particularly through Heart-Rate Variability (HRV). Those with higher HRVs are apparently better able to adapt and respond to adverse events. We can modulate the HRV through techniques like meditation, and train our response through biofeedback mechanisms – in one app, for example, as your HRV goes up, you see on an image change and the sun rise over a tree! That kind of live feedback makes training much easier. Marchant also looks at the ground-breaking research of Kevin Tracey into Vagal Nerve Stimulation, using implanted electric nerve stimulators which are controlled via iPad.  It’s been found to be helpful in treating arthitis, MS, depression and other disorders. Is electric healing the future? One more device to charge!

The faithful at Lourdes

Finally, Chapter Twelve brings these various strands together to look at the role of ritual, care, belief and faith in healing at Lourdes. Marchant visits Lourdes and takes part in the healing ceremonies. Despite her atheism and skepticism, she is struck by the physical power of the ritual, and the deep caring connections that visitors feel. ‘Quite unexpectedly, I feel a powerful sense of connectedness, as if I’m at the centre of something much, much bigger’, she writes. Exeter’s Paul Dieppe, another key researcher in this field, has also studied the Lourdes effect – I interview him here.

But do visitors to Lourdes experience  ‘miracles’? Maybe, maybe not, but it certainly unlocks many of the healing responses Marchant’s explored throughout the book. She also highlights the healing power of spiritual beliefs in HIV patients – a 2006 study of HIV patients found 50% throught their religion / spirituality was helping them live longer. Another study found that 45% of HIV patients became more religious after their diagnosis, and those who did ‘lost CD4 cells much more slowly’ over the four years of the study than those who didn’t. Religious belief isn’t always healing – those who believe in an angry or judgemental God are more stressed and heal less well.

Marchant concludes by noting the scientific community’s ‘ingrained resistance’ to much of the research she has explored, how difficult it is for the researchers to get funding, how the NHS website still says ‘there is no strong evidence’ for hypnotherapy’s effectiveness for IBS, when there actually is. She puts this down to the success of the materialist paradigm in giving rise to modern medicine, in which the physical is taken as real and measurable, while the mental / emotional / subjective is seen as slippery, hard to measure, and best ignored. As a result, we put much more faith and funding into surgical or chemical interventions than mental ones, despite the huge cost of drugs which may work mainly through the placebo effect, and despite the sad fact that half a million people die each year in the western world accidentally through psychiatric drugs. We have replaced spiritual healing with chemical healing, even though the latter is still, to some extent, a faith-system.

We need to go beyond the mind / body split and find new terms, like ‘psyche’, or mind-body continuum, or even the dreaded ‘holistic medicine’, particularly in the treatment of chronic conditions like IBS, CFS, MS, and depression. It reminds me of meeting Professor Qasim Aziz, head of QMUL’s gastroenterology unit and an expert on IBS, last month. He told me that, although it is now official NHS policy to combine mental and physical care within hospitals, in reality this isn’t yet the case at all, and many IBS sufferers are passed from department to department without proper treatment, until around 40% contemplate suicide, and some go through with it. I hope this changes, and we can reincoporate the mind into medical care. This excellent book is a hopeful step towards that change, and essential reading for those interested in the medical humanities and the fascinating interplay between belief, meaning, imagination, emotion, ritual, relationships, and our material bodies.

Religion and the arts as ‘let’s pretend’ collective improv

Cave-painting from Lascaux, from approximately 30,000 BC

I’m interested in the idea of religion and the arts as forms of collective improvisation – play-areas where people can let go of their normal ego-construction and social situation, and play at other selves and other worlds. This is, in the words of Brian Eno, ‘the central human trick’. He said in his Peel lecture last year:

If you watch children playing what they’re doing mostly is let’s pretend. Let’s pretend this stick can change you into a frog…what they’re really saying is let’s imagine. Imagining is possibly the central human trick….We can imagine worlds that don’t exist…You think about this world by imagining alternatives to it.

Altered states are central to these shared alter-worlds – through ritual, we enter into highly suggestible hypnotic or trance states, in which our ego-constructions become fluid and alterable, we get immersed or absorbed in the collective play, in alter-selves and alter-worlds. Our imaginings seem really real.

Other animals also seek out altered states (moose get high eating fermented apples, for example). But only humans create collective alter-worlds, through words, symbols and songs. Think of our homo sapiens ancestors creating the shared otherworld of the cave at Lascaux – a decisive moment in evolution, a window into a new reality. Humans can make the imaginary collective, turn it into art / religion, and thereby make it real. It becomes real in our emotions, in our ethics, in our bodies, in our relations, in our societies.

Then the Otherworld culture becomes material for new improvisations, new riffs, new songs  – we absorb the old material into our imagination and sing new versions of the stories for our own time. For example, the 14th-century mystic Margery Kempe gorged herself on devotional literature, until finally her inner world spilled out into the outer world, Jesus appeared to her, she becomes part of the Christian story. Religion, in this sense, is a form of massive-world fan-fiction (a point made nicely by Helen MacDonald last week).

CS Lewis actually had a chapter in Mere Christianity called ‘Let’s Pretend‘, where he wrote that when we pray the Lord’s prayer ‘you are dressing up as Christ…Let us pretend in order to make the pretence a reality’. The arts are also a sort of ritualized play, which can be made real in our lives. This is what Hippolyta means in Midsummer Night’s Dream, when she says:

But all the story of the night told over,
And all their minds transfigured so together,
More witnesseth than fancy’s images
And grows to something of great constancy,
But, howsoever, strange and admirable.

The play ‘grows to something of great constancy’ because our minds are ‘transfigured so together.’

Pippa Evans (second from the right) in Showstopper
Pippa Evans (on the right) in Showstopper

I’m interested, then, in improvisation in the arts and religion, their connection to altered states of consciousness, their therapeutic power. I’ve been reading Tanya Luhrmann on charismatic Christianity as a form of collective improv, Keith Johnstone on mask-play as a means to trance states and possession by ‘other selves’ or alter-egos, and Ken Campbell on comic play as a form of catharsis, a shame-release of the madness inside us. To explore further, I interviewed the wonderful Pippa Evans, who is both a highly accomplished improviser (she stars in Showstopper! a very funny musical improv show now on in the West End), a stand-up comedian (for which she’s often used an alter-ego, Loretta Maine), and one of the founders of Sunday Assembly, the Godless church. She also runs a course, Impro Your Life, using improv workshops to help people develop their interpersonal skills.

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What makes a good improviser?

A really great improviser is open, switched on, and able to deal with pretty much anything that’s thrown at them. They’re like a footballer who’s body is a trampoline; things can just bounce off them! A great improviser listens closely to their partner. They hear everything – words, tone, silence. Improvising is 100% a social skill.
And for me, the biggest thing is being able to throw away your ideas – to have 10,000 ideas of where a scene could go, but if your partner says something that doesn’t relate to your ideas, you throw them away and never look back.

What is a ‘gift’ in improv?

A gift is when someone gives you specifics about the scene you are in, which you can then play with. So if we’re doing a scene together and I say ‘Dad, remember I only eat salad’, I’ve just given you loads of information (or ‘offers’) about the scene, rather than me coming on and saying ‘hi’, and leaving you to do all the work. We were doing an exercise called ‘QVC’ – two people have to improvise a shopping channel. And sometimes people say to their partners ‘why don’t you tell us about the product?’ That’s an empty offer – they haven’t helped their partner at all. They haven’t even named the product. At least say “Tell us about the shampoo!”

The one improv technique I’ve heard of is ‘yes…and’. What is that?

‘Yes…and’ is a building tool. It’s great for blue sky thinking. You have to agree with your partner (say ‘yes’) and add to the idea (that’s the ‘and’).
Let’s make a cup of tea!
Yes and we’ll have cake too!
Yes and we’ll share it with our neighbours!
Yes and they will high five us!
Yes and we’ll have a big group hug!
Yes and we’ll break the record for group hugs!
Yes and everyone will get a medal.

The energy of improv is obviously enthusiasm. Is that quite different to the energy of stand-up, which is often the energy of the cynical outsider?

Pippa as Loretta Maine
Pippa as Loretta Maine

Yes, it’s very hard to do stand-up and suggest everything is great. People don’t want to hear that. I struggle with that sometimes, because I am quite happy-go-lucky. I think that’s how I ended up inventing this character called Loretta Maine, an American singer-songwriter. She’s like a real person, and I can slip into her really easily. She’s a fun alter-ego to have, because she’s the complete opposite of me, she’s pretty horrible, quite aggressive and really hates life. She says things everyone thinks but no one says. People love her!

So alter egos give people permission to let out other sides of themselves?

Yes. I suppose Loretta came out of an angry place. A frustrated place. She gave me permission to go on stage and connect with the worst part of everyone. I have a song called White Wine Witch, about how awful women are when drunk on the grape juice. It gets a massive response.
Character work is kind of cathartic as a performer, like a kind of masked confession.

The catharsis of shame-release. That’s a massive part of what the arts and religion can do.

What I love about stand-up is that you get 500 people in a room who don’t know each other, all laughing because they’ve all met or been the White Wine Witch. Impro is also about overcoming shame and self-consciousness. I was brought up to be good and do everything right and not upset anyone. And to suddenly go on stage and say whatever falls out of your mouth is so invigorating. So dangerous!
There’s an exercise called ‘endless box’, where you pull objects out of an imaginary box and have to name them. I always say to people ‘don’t worry, the worst thing you’re going to say is c*** and I’ve already said it’. You can see people physically worried about what they might say. It’s actually good to get all that stuff out of your mouth. We store all these weird, dirty, nasty things in our brains, and you can get them out in a little exercise, it’s good for you.
It’s great to watch people slowly shedding their hang-ups and fears that really hold them back. When people come on the Impro Your Life course, they say things like ‘I just want to be able to say what I mean in a meeting’. It’s awful that people need a class to say what they want. Impro is very good at that.

Did Loretta ever come out in real life?
Yes, there was this time a man was pestering me in the street, and I became Loretta, and just told him to back the fuck off. She’s terrifying. I felt my body changing entirely.

Did you eventually get sick of her?
Yes, I stopped doing her about a year ago. I was doing her every night, and I got frustrated. I switched to doing solo shows as myself. But I needed that five years as Loretta to get back to being myself. I learned the skills of stand-up while being someone else. And I still let her out occasionally, which means I can really enjoy her.

It seems like a lot of improvisational ability is to do with working memory. Firstly, your memory of particular musical styles and story structures. But also your memory of what has happened already, and how you weave in spontaneous occurrences into the story. Why do we get such satisfaction when a comedian does that?

When I do stand-up, I’ll often name-check someone in a song who’s been mentioned before, and they can’t believe you remember and they’re now part of the song. We’re just impressed with anyone who can remember anything. Also it’s the feeling of completion. Like I told you about an elephant in the first scene, we haven’t mentioned an elephant, then at the end an elephant saves the day. The audience goes nuts. It’s satisfying. The great circle of life, and all that.

It might go back to the roots of culture in the oral tradition – the poet or rhapsode who can remember an incredibly long poem, and who maybe weaved in new elements too.

Particularly with impro, it’s also proof that you were listening and that the show is improvised.

One thing I noticed about Showstopper was your real skill as story-tellers. You’re obviously so familiar with story structure, with the ways stories usually go. So the audience doesn’t feel it’s completely off the wall, it does feel like a story arc, and that’s satisfying.
Yes, we’ve studied story structure. We’ve read Story, Save the Cat, all these books on film craft. When we started, we’d do the Hero’s Journey quite often. Now, because it’s all so ingrained in us, it’s almost 100% done on feeling.
“It feels like now we need something bad to happen to your character”. Or “It feels like now we need the moral message”. Sometimes we know there are things we want to hit, as it were. But we’ve done shows where it’s been completely different, where we really don’t know where it’s going or going to go. That’s when you get to this flow place, this crazy, beyond-your-brain place, where you just have to be in it, and have to literally, as Frozen says, ‘Let It Go’, because if you even try to contemplate what the fuck is going on, you will destroy the hivemind magic. That’s when you have to be ‘yes and’ mentally. 
We did a Showstopper set in the Vatican, but an American senator had come to make it more glamorous. It made total sense in the end. Keith Johnstone said “An improviser is like a man walking backwards, he doesn’t know where he is going but can always see where he has been.”
During the performance, you have to trust what came before rather than trying to guess where it’s going. You can’t judge it till the end. They’re the best shows. Because you can’t phone it in. You have to be on, alert and focused the entire time.

Some of impro is clearly thinking on your feet and being adept. Some of it is also unconscious – ingrained skills and patterns. And then is some of it a sort of altered consciousness?

There’s a conscious level, where you’re consciously steering and making decisions. Then there is this other level, which is where all the muscle memory is, where all the skills are ingrained. And then, when I’m working with certain people, and have worked with them a long time or have a certain connection with them, you do find yourself singing songs and you don’t know where it’s coming from, but it sounds amazing, and you can’t believe it – you feel like you’re floating above it watching this lovely moment.
It might not be the whole show, just a moment in it, where you know you’re connected with someone. It’s some combination of the freeness of your brain and the connection with the music and the character you’re playing giving you freedom…and you really believe. I remember singing a song with Andrew Pugsley, it was the last Showstopper at the Apollo, the song was called called ‘When’s My Birthday Dad?’ I was his daughter, he worked on the Bakerloo line. The line was ‘You know all the tube stops but you don’t know when my birthday is’. And it just fell out of my mouth, and the whole audience went ‘Ohhh!’. They believed this little girl, being played by a 33 year old woman, was real. They believed that my Dad, being played by a 33 year old male, was real. And our troubled relationship touched them. There was this moment of creative connection, truth connection, a realness.

It’s one of the strange things with creative performance – you get a moment of ‘realness’ when you’re on stage playing an eight-year-old. Imaginary play seems to give people a greater sense of realness and connectedness than normal life, sometimes.

Sunday Assembly
Sunday Assembly

I think it all comes back to…we want the Other, the God, the feeling there is something bigger than us. We sometimes get that in moments in Showstopper when everyone in the room feels connected together. There was a show when my mother (not in real life) was trapped in a tree – she was suddenly revealed at the end during a song. Again – the audience were hushed. We shared this moment, this shared emotion of lost parents, or family. We grieved together. And then we sang a chorus.

You don’t know quite how it happens, where it comes from.

And you don’t know if you’ll ever get that feeling again. How can we ever find this again? There’s no formula.

So is religion a form of improv? Christianity could be seen as a collective extemporisation, an ‘as if’, a collective imagining or creative play based on certain standard themes, stories, symbols, which people draw on and riff in new directions.

Seriously long-form improv?

Yeah. Or like fan-fiction – you feed deeply on the stories, then imagine yourself into them and riff off them.

Pippa with Sunday Assembly co-founder Sanderson Jones
Pippa with Sunday Assembly co-founder Sanderson Jones

When I went to church, I knew a guy who wrote worship songs, and they were really over-complicated, and I remember saying ‘your hymns are really complicated, you should write something simple’. And he said ‘God is so with you’. And I was like ‘what do you mean?’ He said ‘that’s a message from God’. And I sort of believed him, but now I think it was just us being really in tune and connected.

What they call God and the Holy Spirit, others would call being in tune with each other.

Yes, being so present and attentive. I’ve met performance artists who have the air of monks or nuns because they’re so focused on their art, they don’t care about any of the trimmings. You do feel they’re slightly on another level.

Do you find something in the arts to what you used to find in the church?

Yes. Showstopper is like a family in a way, it gives you a feeling of belonging in a group, being very honest and emotionally available with each other. It’s a very intimate group, because of the stuff just coming out of your mouth. When I used to go to church and do the Holy Spirit stuff and shake and fall over, I think that’s a very similar feeling to when we’re doing a scene and we don’t know where it’s going, and we come off stage and feel really euphoric and literally can’t sleep because we’re so excited at the mystery of what happened.
And the guidance too – the older improvisers are teaching you and you’re teaching the younger people. And, now I think about it, improv can be a bit like religions in that you have different groups insisting on different rules. You have Johnstonians, who follow the teachings of Keith Johnstone and do an improv based often in games, then you have the way of Second City, which follows Del Close. And sometimes groups fall out, which is really painful. Or choose a different path. Or split off into new groups. It’s the Judean People’s Front all over again.