From American flags to models of the spine – linking the impossible?

I have just come across an intriguing paper in Psychological Science by Travis Carter and his mates in Chicago.  They did an experiment in which Americans who were filling out political surveys did so with either a small American flag in the corner of the screen, or nothing in the corner of the screen. They analysed the participants’ responses to the survey, assessed explicit attitudes and beliefs via direct questions (eg How much do you like Obama?) and they assessed implicit attitudes and beliefs using the implicit association task (IAT). They reassesed participants up to eight months later.  Their data are pretty compelling – on all measures those who saw the American flag during the initial survey were more ‘Republican’ than those who did not.  More Republican in their attitudes, beliefs, fondness for politicians and evaluation of their political performance. This single exposure even seemed to change the way they voted!  Travis and his team then replicated the effect with a different party in power, which means it is about Republicans not the party in power.

Now there is no doubt in this Australian’s mind that the American flag is as sacred to Americans (I always feel a bit dodgy calling the USA America – on what continent is Canada? Peru? Brazil? Chile……nonetheless, I will follow what seems to be convention. Is it also convention in Canada? Peru? Brazil….) I, yet again, digress.  So, people from the USA seem to LOVE the Stars and Stripes – Old Glory – The Star-spangled Banner (so much so these nicknames get proper noun status!)  I am always impressed by the number of cars, buses, houses, bicycles, t-shirts and shops that proudly fly the flag.  Australia and England seem to only approach this level of flag-wavingness if their team is competing in something they have a faint chance of winning. Perhaps the USA is always competing in something, somewhere, with a better than faint chance of winning.

Anyway, that the meaning of the flag seems to permeate so deeply the workings of an American brain has clear implications for one of the bees in my bonnet – those anatomically inaccurate models of the lumbar spine. I know they hold none of the ‘meaning-power’ of the American flag for most of us, but what meaning-power do they hold for someone whose back pain is ruining their life?  We have shown that seeing a red light when you get a very cold noxious stimulus makes it hurt more than if you are shown a blue light – there is clear meaning there – and marketing people are pulling a semiotic swifty on us most of the time I imagine. What happens when someone with back pain, who is primed up to look for clues as to the meaning of their back pain, walks past your desk and sees the LAFT (living adaptable force transducer), formerly known as an intervertebral disc (see: Butler, DS & Moseley, GL, Explain Pain. Noigroup publications 129 pages), all red and swollen and slippable. Could that visual image change attitudes, beliefs and behaviour in people with back pain like the American flag seems to in Americans?  Indeed, could the very notion of a slippable disc modulate those variables in people with a back?  Keep a look out for Adriaan Louw because he is doing a project on this very type of thing, as part of his PhD.

Flag Face Tattoo

Finally, I can’t help but spare a thought for the Democrats – how do they get around this curly one? Tattoo an American flag on their forehead? Hang on – that’s already been done

About Lorimer Moseley

Lorimer is NHMRC Senior Research Fellow with twenty years clinical experience working with people in pain. After spending some time as a Nuffield Medical Research Fellow at Oxford University he returned to Australia in 2009 to take up an NHMRC Senior Research Fellowship at Neuroscience Research Australia (NeuRA). In 2011, he was appointed Professor of Clinical Neurosciences & the Inaugural Chair in Physiotherapy at the University of South Australia, Adelaide. He runs the Body in Mind research groups. He is the only Clinical Scientist to have knocked over a water tank tower in Outback Australia.


Carter TJ, Ferguson MJ, & Hassin RR (2011). A Single Exposure to the American Flag Shifts Support Toward Republicanism up to 8 Months Later. Psychological science PMID: 21742933


  1. Fascinating stuff…our unconcsious thinking. I was just reading about it in Blink by Malcolm Gladwell. We can test our own at using the IAT. Apparently our unconscious first impressions can be managed.
    If we believe Nortin Hadler in Occupational Musculoskeletal Disorders (2005) and Worried Sick (2008) it is normal to have regional pain from time to time. What is not normal is what some think and do about it. For Hadler there are care seekers and there are those that work it out and stay in control. The traditional medical care path (including lots of what we say and do in PT) is fraught with problems.
    Perhaps we need a Pain IAT to test our first impression about what pain and then test interventions that change our coping.

  2. Tim Cocks says:

    Hey Theo, I think your right, but as a trained NLP Practitioner (and a recovering Physio), well I do take umbrage at being sidelined as a “psychology spin-off”!!! All in jest….

    The ad agencies do some brilliant stuff when it comes to marketing pain medications. While I wouldn’t call it subliminal, it is very covert to the average person.

    A lot of these ads will manipulate submodalities; these are the building blocks of subjective experience. Images will vary in intensity, size, position, colour/black and white. Sounds will vary in tone, volume etc in these ads in very controlled ways. In one ad I can think of, ‘before’ images are black and white, slightly blurry and out of focus – images of people in pain and grimacing, and the accompanying sounds are a bit discordant. Enter the magic pain killer, and all of a sudden images are bright and in full colour, with people running on beaches and smiling, sounds are pleasant and musical and just as the emotional state induced is at its peak, boom, the medication name and logo are flashed up and anchored……

    But we can fight back!! There are these two blokes, wrote this book called Explain Pain, which was full of story and metaphor and reframed the whole pain experience from being something scary and ‘bad’ to something that our brains do to protect and preserve us…

    So I reckon there is hope and I think Theo and John are on to something – perhaps rather than spending a weekend learning about the latest and greatest ways to push, poke, stretch, stabilise etc etc, practitioners would be better served by learning how to be more persuasive, construct metaphors and use language and other forms of communication in ways that promote the benefits of health.

  3. Theo Jordan says:

    I recently lectured using the theme that we should be ‘selling’ health to our patients, but that we totally suck at this and should learn from our sales-person colleagues. In the businmess and political worlds, there have been billions of dollars/pounds/euros, etc. poured into discovering better ways to influence our choices, our affinities and attitudes toward products and political candidates. Nothing short of subliminal mind-control in some instances. For instance, there are clever ways of setting up rapport with someone on first meeting (mimicing their body gestures, asking them questions for which they will repeatedly reply ‘yes’; A student once told me that his previous training as a car salesperson required that he get a prospective customer to say ‘yes’ 23 times in the initial conversation – this increased the likelyhood that they would buy). There are methods in psychology and psychology spin-offs – like NLP – that can quickly change a person’s beliefs! Why aren’t we tapping into these techniques? Most of them are well researched, and are widely used to sell products and sell political candidates. We are definitely behind the curve in this arena, and should take the idea of ‘selling’ health more seriously.

  4. Luciana Machado says:

    Great post Loz! The effects of these images on patients’ attitudes and beliefs have always intrigued me. A slipping disc can be quite frightening to patients… After seeing a huge disc pressing my nerve roots, I wouldn’t walk either!hehe. But what intrigues me even more is that some of these ‘frightening’ images can be used for the good: the idea of a disc derangement that can be put back in place by simple exercises is a fantastic way of empowering patients to seek their recovery (not sure McKenzie ever thought this when he developed his treatment, but this is quite smart!). It’s the same of saying “you can cure yourself, it is all on your hands!”. There are other very nice examples that we can chat about some other time. Greetings from Brazil!

  5. Yo L,
    As a full red-blooded American Capitalist Swine who wears a blue Democratic tie, I have to say that our wise men, the advertising agencies, have been well ahead of you scientific blokes. Red has always been the dominant color of analgesic commercials, except in the age of black and white TV. Our agencies have done some fantastic artistic work where joints that start off in this non-commercial healthy pink color end up in this in this wonderful (from a commercial standpoint ) scarlet color with a great big circle around it. What better image could you find to develop a need for a product? The only blue color you might see is the color of the pill (check out the nice calming blue color of Aleve).
    Sometimes I think that we miss and fail to learn, as clinicians and scientists, from the most carefully performed and lavishly funded body of knowledge about human behavior ever performed- the world of advertising. Color, context, word/ emotional triggers, subliminal messaging are all there and have been well studied. We, as clinicians, could probably learn a lot from used car salesman/rug traders on how to produce commitment and compliance.
    Sometimes I am so in awe and frightened by what I know commercials are trying to do, that I think that I should stop reading all of this scientific stuff and spend some time clerking in an ad agencies or being mentored by a used car salesman. I might end up having better outcomes.


  6. Nicolas Sepulveda says:

    One question pop into my mind after reading this article: How can we make neurophysiological pain education to get a real meaning to those in pain?