Sunday, September 9, 2007

Primal Therapy Science or Pseudoscience?

Is Primal Therapy Science?

This is an important question because advocates of primal therapy, including Arthur Janov have claimed that it is indeed science. “It may seem that Primal Therapy is miraculous, but it is not magic, it is science at work” Janov claimed. Indeed his second book The Anatomy of Mental Illness (1971) was hailed as “the scientific basis of Primal Therapy” which appeared on the back cover. Similarly, Janov’s more recent books also lay claim to a scientific basis as demonstrated by the title and contents in “The Biology of Love” (2000). This is further illustrated on the Primal Center’s website in which the subtitle to the main page is “where primal therapy is a science” (as of December 2006).
First of all, to answer this question, we have to know what science is.
Do most people think they know what science is?
Usually yes.
How many actually do know it?

How many could say what the necessary elements of scientific study are?
Think about it before reading on; see if you can list them yourself.

You may be surprised, as I was. I found I didn’t actually know it and I was sure I did (I had studied science at undergraduate level and it turned out I didn’t even know what it is! I wonder how common this is).
Bear with me as we go through these essential parts of science, any one of these may seem irrelevant at first, but each element is important information that shouldn’t be left out to get a whole picture.
What is science, is it subject matter or equipment?
Science is NOT defined by subject matter or by the equipment used. Rather it is a way of thinking about and observing the world that leads to a deep understanding of its workings. This is important because this means human behavior, cognitions and emotions CAN be studied scientifically, but it is only classified as science if it is done according to the rules of science. Related to this is the important point: A scientist is only a scientist so long as he continues to do science. So, for example, if a physicist starts doing astrology instead of astronomy, he or she is no longer doing science.

Systematic Empiricism.
“Observation is fine and necessary, but pure unstructured observation of the natural world will not lead to scientific knowledge”…”Scientific observation is termed systematic because it is structured so that the results of the observation reveal something about the underlying nature of the world.” Stanovich1 p10 (2001)

Briefly On Experiments
To qualify as an experiment, you need to manipulate one variable, while keeping others constant, and you need random or representative sampling. In psychology (and medicine), random assignment to the various experimental groups (which is different from random sampling) is an essential necessity in experiments, and clinical tests. My Personality Psychology lecturer told me: without random assignment it is NOT a scientific experiment.

1How to think straight about Psychology. Keith E. Stanovich
In order for a theory to be useful in science it needs to be falsifiable, in other words it needs to be possible for some theoretical experimental result to prove it wrong. Put another way it needs to be testable. However the concept of falsifiability is larger than just this simple definition, it is a subtle concept, that is further explained with the example below. It is important, because if you have a theory in which NO MATTER WHAT THE OUTCOME of an experiment or study or therapy, if all these possible outcomes can be explained by the theory, then you have a problem.
Consider the case of Benjamin Rush:
“In 1793, a severe epidemic of yellow fever struck Philadelphia. One of the leading doctors in the city at the time was Benjamin Rush, a signer of the Declaration of Independence. During the outbreak, Rush was one of the few physicians who were available to treat literally thousands of yellow fever cases. Rush adhered to a theory of medicine that dictated that illnesses accompanied by fever should be treated by vigorous bloodletting. He administered this treatment to many patients, including himself when he came down with the illness. Critics charged that his treatments were more dangerous than the disease. However, following the epidemic, Rush became even more confident of the effectiveness of his treatment, even though several of his patients had died. Why?
One writer summarized Rush’s attitude this way: “Convinced of the correctness of his theory of medicine and lacking a means for the systematic study of treatment outcome, he attributed each new instance of improvement to the efficacy of his treatment and each new death that occurred despite it to the severity of the disease” (Eisenberg, 1977, p1106)” In other words, if the patient got better, this improvement was taken as proof that bloodletting worked. If the patient dies it merely meant that the patient had been too ill for any treatment to work. We now know that Rush’s critics were right: his treatments were as dangerous as the disease.
Benjamin Rush fell into the fatal trap when assessing the outcome of his treatment. His method of evaluating the evidence made it impossible to conclude that his treatment did not work…He made it impossible to falsify his theory.” Stanovich p23-24.
“If a theory is not falsifiable, then it has no implications for actual events in the natural world and hence is useless. Psychology has been plagued by unfalsifiable theories, and that is one of the reasons why progress has been slow.”
For example “Freudian theory uses a complicated conceptual structure that explains human behavior after the fact but does not predict things in advance. It can explain everything, but Karl Popper argued it is precisely this property that makes it scientifically useless. It makes no specific predictions. Adherents to psychoanalytic theory spend much time and effort in getting the theory to explain every known human event, from individual quirks of behavior to large scale social phenomena, but their success in making the theory a rich source of after –the fact explanation robs it of any scientific unity.” Stanovich (2001, p26)
Stanovich in his book said "remember Benjamin Rush" and those words haunted me like a Dickens novel!
Not only is Freudian theory unfalsifiable, but so are many of the neo-Freudian adaptations, such as Jungian theory. In fact the rivalry between Jung and Freud can be characterized by Jung saying he is obviously right, and Freud replying, no it is obvious he is right. Within each framework, both were right! That is because each theory explained everything, including why the other was wrong, and himself was right.
But how does this relate to primal therapy? Janov was trained and practiced in the Freudian tradition, and although he criticized Freud’s work, he then proceeded to use precisely the same means of assumption, deduction, case studies and his own interpretation of them, as Freud, Jung and others had done. Similarly with primal theory, within the framework of primal theory, Janov is right, and he can explain everything. But it is unfalsifiable and there are many other such theories that also explain everything. The question scientists ask is: are unfalsifiable theories really religions?
So we get down to the direct question. Is primal theory falsifiable? Is their a single event or a long series of events that could disprove it? Think about it. Really think about this before moving on.

Could poor results of therapy falsify Primal Therapy?
What if people don’t get well as a result of primal therapy, in the same way as was suggested in the Janov’s books? What if their eyesight doesn’t improve, what if their cancer doesn’t disappear after primal, what if they commit suicide, what if they get depressed, and what if many quit their jobs or studies? Would any of these things falsify primal theory?
No, they can be explained, “They just had too much Primal Pain” would be one a possible explanation (I heard that judgment repeated many times in various forms during my time out in the primal community, usually with regard to somebody not present or in another clique). “They just did not feel enough of their pain” is another. Or "they did the therapy wrong". So, no, poor outcomes does not deter primal believers. It is set up so that poor results do not falsify the therapy. So long as primal therapists avoid measuring the therapy as indicated in my section "A Challenge to Primal Therapy" the therapy pretty much is unfalsifiable.
The labelling of primal therapy "failures" as deviants, sociopaths, paranoids, psychopaths, borderlines, parasympaths, LSD users, too repressed, etc, is a good example of how primal theory can be stretched to explain any negative result. That most people don't benefit from primal, and most go on not to recommend it to their loved ones, can be explained with words like "Primal therapy attracts borderlines like flies". I actually heard someone say that when he/she was talking about the problems they faced previously, in the 1990s. By the way, that was wrong, the complainers of the 1990s were not borderlines at all and they had valid criticisms in my opinion. About the early nineties I heard someone say "everybody was abreacting, it was horrible" [abreaction means false feelings in primal lingo]. This also explains away complaints or poor outcomes, and protects primal theory and primal therapy. I hope I am making it clear how no matter what the outcome of therapy, even if they are majority poor or moderate, it always get interpreted in a way that preserves primal theory. This is the essence of unfalsifiability.

Now consider a way to falsify primal theory.
Let’s say a person who remembers no abuse or severe overwhelming pain in early childhood still reports some physical or mental problems. For example if they still developed muscle tension, cancer or depression. Wouldn’t that falsify the theory?
No, because a primal theorist would say that overwhelming pain is the cause, and therefore the patient must have repressed and forgotten about it. The challenge now would be to uncover those terrible hidden pains, in order to cure the patient of whatever. However, since the pains don't exist would they end up creating them, or exaggerating them?
Here is where it may become unethical, because almost all human afflictions and even natural activities (often called “act outs”), even when relatively normal, can be interpreted as being driven by pain. So someone without a psychological disorder may be persuaded they need primal therapy in order to become “real” or healthier physically. Arthur Janov’s books were and are particularly persuasive in this way.
Consider the opposite, say somebody was abused, and is doing fine now in adulthood, does that falsify the theory? No, because by definition, the person must be pretending to be okay in some way, and they really need to do primal therapy to become what they were before the abuse. Using primal theory as self evident truths leads the theorist to interpret that persons report of a good present life as just a pretence.

The point is it is impossible to falsify the theory. Unfalsifiable theories are considered useless in science. I use the word "useless" advisedly, I found that exact term "useless" in at least three different college textbooks, it is not me being deliberately mean. I have found it echoed in many different disciplines. Philosophy, psychology, anthropology and all the natural sciences all mention this point; although it is easy to miss it sometimes (for example, recently in my chemistry course the professor skipped over the scientific method in 10 minutes, which I think is an injustice to young people).
Primal theory makes sense. It explains everything. That may explain why Janov and others, including myself, got so so excited about it. But that is not enough, a good theory is one that has many possibilities to be falsified, but has not been after much testing.
The philosopher of science, Karl Popper pointed out that both Marxism and Freudian theory are both unfalsifiable.
Primal theory is a beautiful idea. Communism is a beautiful idea. Communism didn't work, and I think became authoritarian as a result of people not accepting that. In my opinion, primal theory (and therapy) doesn't work in practice, and can become authoritarian as a result of people not accepting that.

The concept of Pain, need and repression in primal theory are stretchable ones that cannot be pinned down or ever proved wrong. But the problem goes deeper than that. There have been many things primal theory didn't explain very well, and over time the theory has developed little ad hoc plugs that have filled the gaps. It has been done in such a way to make it convoluted and immune to any falsifying experimental outcome. It is unfalsifiable, yes, and I think it will always will be so (in contrast primal therapy is unfalsifiable due to the insistence of things like the 3 week intensive, which blocks testing, and other things, see section below). In fact Janov uses the concept of Pain in a way that it can be stretched into whatever causes problems later. For example, once birth primals became the consensus in the group, then anoxia at birth was labelled "Pain". Then when correlational studies reveal the fetal environment can alter growth and function, that became "Pain".
As an analogy, lets say I think up a theory that there are little green men in people's heads that control the whole psychological system. When psychological problems arise, maybe the theory says there are too many little green men (LGM) in that part of the brain (an overload). So, that is why we have the problem, it was a LGM overload. Everything is explained. How can you measure LGM?, well how bad is the problem, thats how. But we can't observe LGM directly, isn't that a problem? No the theory states that when you try and observe them, they disappear. Okay, that's explained then.
So if everything is explained, it's a good theory, right? NO!!!!!, because it is untestable and useless as a scientific theory. The theory didn't come out of experiment, and it predicts nothing. It's made up, and because it explains everything, and because it is IMPOSSIBLE to prove it wrong, it persists like a religion.
But isn't there evidence in child development science that prove primal theory wrong? I did see evidence that contradicts primal theory, but the basic concepts of primal theory can be used and twisted to explain these results. Primal people may also not follow psychological science, or trust the results of psychological experiments("you can't measure the mind" arguments, or "you know it from your feelings"), so their attitude makes it double hard to falsify.
Lets take the pain based explanation for all psychological problems, for example. As science has developed, it became clear that it was not so much the pain killing neurotransmitters (endorphins) that were important in depression, for example. Serotonin and nor epinephrine, which are not specifically pain killing, started to stand out as more important, NOT endophins. Similarly, the neurotransmitter involved in deep chronic pain was found to be "substance K", yet this substance does not seem as relevant to depression or anxiety as say serotonin or gaba. Yet primal theory has gobbled up these problems, explained it, and remained unchanged basically. This is one of many examples that show how stretchable the basic theory is.

Not as it is set up now. It isn't, due to the three week intensive isolation requirement, the requirements to read Janov's persuasive and suggestive book(s), the requirement of a typed autobiography and selection procedures, and the attitude of the therapists to outside testing (amongst others).
It is possible for that to change, but it would mean accepting clinical type trails. This would mean for the study they would abandon the three weeks intensive, and allow for representative sampling and random assignment of NON-PRIMAL believers suffering from a real DSM IV diagnosed problem. These things are so unlikely to happen that I think it is accurate to say it is set up in a way that makes it unfalsifiable, and it has been that way for 40 years. It is unlikely to change, and even if they did do clinical trails and the results were poor, they would likely blame it on the lack of the three weeks, or the patients not reading the primal books, or the interference of the researchers, whatever etc. It would be like trying to test ESP, where the believers say that the very attempt to measure it disturbed the experiment. Whatever happens, primal will likely persist without good evidence for efficacy or safety.
(To compare with the case of Benjamin Rush, it was his attitude and way of interpreting things that made his theories unfalsifiable. Of course bloodletting could be tested for efficacy later, but things needed to change.)
Why might primal leaders NOT want to change it so it can be tested? If the results are mediocre, they no longer have "differentiation of product", a crucial selling point in primal therapy. They no longer would be able to write books called "Grand Delusions, talk therapies are no good". If the results are poor, there is a risk primal therapy might fall out of favor completely. They may never take that chance, because they "a priori" know it is true, it is taken to be self evident, and they may not want some repressed intellectuals spoiling it.

That "a priori" knowledge, the self evident truths of primal therapy which are held as axioms indicates another deep problem with primal theory, that I should write about more some time. The problem is that in science you don't create axioms so far up the knowledge tree. Axioms such as the equality axiom in math are okay, but to find knowledge in science you have to do so from systematic observation and experiment, not from declaring axioms or self evident truths. That repressed pain causes all mental problems is not a valid axiom or self evident truth. Even worse is saying reliving your pain will make you well is self evident. It is not a starting point you can assume and then build knowledge on. You first have to establish that truth itself as knowledge, then build on that.

The importance of falsifiability should not be underestimated. It can save one from embarrassment and from being labelled crazy for one's ideas. My friend made me aware of David Icke, he described his material as 'a blast'. I checked it out and it was entertaining, and I realised Icke's ideas do explain everything to him, and I think it has hurt him deeply that he has been ridiculed and laughed at for them. I don't think he is crazy actually. Although his ideas start out reasonable, he ends up claiming the world's elite may be shape shifting reptilian humans. Now believe it or not, his ideas do explain a lot of things to him and his followers, and has a emotional edge to it, and they do explain everything in a neat way. And he does have many testimonials. However he could have been saved the pain and embarrassment of coming out with such outlandish ideas by taking time to learn what falsifiability is, rather than assuming that as a famous sports presenter he already knew what science is or how to aquire real knowledge. Falsifiability is important to peoples lives, it is not a useless intellectual concept. I think it should be taught in schools. Also important in both the Icke case, and in the case of Janov is to actively look for disconfirming evidence, something I will try to discuss more at some time.

1How to think straight about Psychology. Keith E. Stanovich

Peer Review and Replication

Peer review is the checking of articles and scientific work by other scientists in the same field. Without peer review it is not science, in other words peer review is an essential element of science. It is not optional; you can’t claim to do science without it.
“Scientific knowledge is public in a special sense…scientific knowledge does not exist solely in the mind of a particular individual. In an important sense, scientific knowledge does not exist at all until it has been submitted to the scientific community for criticism and empirical testing by others. Knowledge that is considered “special”-the province of the thought processes of a particular individual, immune from scrutiny and criticism by others-can never have the status of scientific knowledge.
Science makes the idea of public verifiability concrete via the procedure of replication. In order to be considered in the realm of science, a finding must be presented to the scientific community in a way that enables other scientists to attempt the same experiment and obtain the same results. When this occurs, we say the finding has been replicated... It ensures that a particular finding is not due simply to the errors or biases of a particular investigator. In short, for a finding to be accepted by the scientific community, it must be possible for someone other than the original investigator to duplicate it…
…one important way to distinguish charlatans and practitioners of pseudoscience from legitimate scientists is the former often bypass the normal channels of scientific publication and instead go straight to the media with “their findings”. One ironclad criterion that will always work for the public when presented with scientific claims of uncertain validity is the question: Have the findings been published in a recognized scientific journal that uses some type of peer review procedure? The answer to this question will almost always separate pseudoscientific claims from the real thing…
Not all information in peer reviewed scientific journals is necessarily correct, but at least it has met a criterion of peer criticism and scrutiny. It is a minimal criterion, not a stringent one, because most scientific disciplines publish many different journals of varying quality. Most scientific ideas can get published somewhere in the legitimate literature if they meet some rudimentary standards. The idea that only a narrow range of data and theory can get published in science is false. This is an idea often suggested by purveyors of bogus remedies and therapies who try to convince the media and the public that they have been shut out of scientific outlets by a conspiracy of “orthodox science”. But consider for a minute just how many legitimate outlets there are in a field like psychology [between 100 and 200 journals are then listed on pages 12 to 14 of Stanovich’s book, although dozens more exist]. Virtually all halfway legitimate theories and experiments can find their way into this vast array of publication outlets….
..the failure of an idea, a theory, a claim, or a therapy to have adequate documentation in the peer reviewed literature of a scientific discipline is very diagnostic. Particularly when the lack of evidence is accompanied by a media campaign to publicize the claim, it is a sure sign that the idea, theory, or therapy is bogus…
The peer review process is far from perfect, but it is really the only consumer protection we have. To ignore it (or not be aware of it) is to leave ourselves at the mercy of the multimillion-dollar pseudoscience industries that are so good at manipulating the media to their own ends.” Stanovich (2001, p10-15)

Just a word to the wise. An appearance of peer review can be faked. Someone with a pseudoscientific psychotherapy can include accurate science in the field of neurology in their books. Neurology neither proves or disproves any psychotherapy. Psychotherapies are tested with clinical type trials, not neurology. They then can hire someone from a local university, and pay them to check the neurology science. Then they can thank the scientist for helping them write the book in the credits. THIS IS NOT PEER REVIEW.
Peer review (hopefully) would involved looking not at the neurology, but at the miraculous claims of the therapy and the quality of the efficacy testing for the therapy, the real evidence for the therapy, etc.

1How to think straight about Psychology. Keith E. Stanovich

Testimonials and case study evidence

“Case studies and testimonials are not useful at the later stages of scientific investigation because they cannot be used as confirming or disconfirming evidence in the test of a particular theory. The reason is case studies and testimonials are isolated events that lack the comparative information necessary to rule out alternative explanations.
The problem of relying on testimonial evidence is that if testimonials accumulate to support any specific remedy. All the competing remedies also have supporting testimonials. What we all want to know, of course is which remedy is best, and we cannot determine this by using testimonial evidence. As psychologist Ray Nickerson (1998) has said in his review of the cognitive processes we use to deceive ourselves: “Every practitioner of a form of pseudomedicine can point to a cadre of patients who will testify, in all sincerity, to have benefited from the treatment” (p.192).
Nickerson’s point is illustrated empirically in a study conducted by psychologist Anthony Greenwald and his colleagues (Greenwald, Spangenberg, Pratkanis, & Eskenazi, 1991). In this study, the authors tested the usefulness of subliminal self help audiotapes (tapes that use messages below hearing threshold), which are commonly advertised in magazines and on television (Moore, 1995). They tested one tape program designed to improve memory and another to improve self esteem. After taking memory and self esteem tests, the subjects were given the tape and listened to it each day fro a month (the amount of time that the advertisers of the tapes said was sufficient to produce the advertised effects). Some subjects were given a self esteem tape labeled “self-esteem tape,” and the other subjects were given the memory tape labeled “memory tape.” Importantly, however, two more groups of subjects were tested: one given a tape that was labeled “self esteem tape” but had the content of the memory tape and another given a tape that was labeled “memory tape” but had the content of the self esteem tape. These two conditions served as critical controls. What happened was that there was no improvement in actual memory or self esteem. However, there were differences in the self-perceptions (testimonials) among the groups. Here, it was the label on the tape that was important, not the content. Both groups receiving a tape labeled “self-esteem” scored higher on the measure of self-perception of improvement on self esteem (even though one group had received memory content), and both groups receiving a tape labeled “memory” scored higher on the measure of self perception of improvement in memory (even though one group had received self-esteem content). In short these tapes generated plenty of testimonials despite the fact that their content had absolutely no effect on memory or self esteem (see also, Moore, 1995)” Stanovich¹ (p.59, 2001)

Everybody is vulnerable to the same psychological biases that are evident in this study, even those trained in science. Imagine for a moment that one of the participants above was a MD or PhD (or imagine a celebrity like John Lennon or Tom Cruise). Imagine how convincing it would be to put that doctor’s testimonial on the self-esteem tape company’s website or on the cover of their next book.
But how is this relevant to Primal Therapy? Stanovich uses an example that is obvious to most as a bogus product so that we can think of how it applies to things that are not so immediately obvious. With regard to Primal Therapy you have to ask yourself “Why haven’t cleverly designed studies with similar critical controls been used to measure the therapy?”. In more than 30 years of Dr Janov claiming to have a scientific therapy, there has been no independent, peer reviewed and replicated studies with the same kind of ingenious designs as described above. The question is, have they been avoided? Why have the “experiments” done by Janov and his followers all been designed so as not to answer the questions the public really wants to know when choosing a therapy? As far as I can tell almost every so called study done at Dr Janov’s primal center have been controlled and interpreted by Dr Janov or his fans who also believe in primal therapy, and it is his interpretation, (his followers then adopt his interpretation), that then makes it to print in his books. Sometimes the researchers themselves turned out to be primal participants. In addition, most or all of these studies would have been explained by primal theory, no matter what the outcome. So why do those type of studies in the first place? There is an answer to this question, see if you can figure it out before you move on.

It is not that gathering case study data is wrong, what is objectionable is the misrepresentation that it is evidence or even proof of primal theory. In fact the very same data could be interpreted any number of ways from any other unfalsifiable theory.
I had an email saying:
"[name omitted] told me during the 3 weeks intensive [name omitted] went through first line feelings and [he/she] had slowed down and felt rested, also that [his/her] skin has cleared. Now that shows the truth , that the therapy works."

This is a testimonial, and although I know for sure it was meant sincerely, there are some biases and factors that affect all testimonials. To eliminate cognitive biases you have to conduct an experiment, with as many people as possible, and you repeat the experiment later. In this case it would resemble a clinical trial, where the variable you allow to change from group to group is the treatment type. You cannot eliminate bias by trying to be unbiased, or by claiming you have a superior level of feeling or consciousness, thats not how it works. Cognitive biases are natural and normal and everyone has them. Even good intelligent people have cognitive biases, and even with those people, an experiment is needed. (See "challenge to" section).
But let me address the specific testimonial above. I have the permission from the person to discuss it, and he/she has told me some further information about it. The fact they felt rested could have been due to a whole host of things. The person had been working very hard in a difficult job (to save up money for therapy) right up to the week of the flight that brought them to therapy. In the three weeks, they were not allowed to work, and being in a beautiful place, with no work, maybe that was why they felt more rested. It's not suprising the vital signs went down, especially after the nervousness of the first day. Maybe his/her skin cleared due to less bacteria, or less stress due to no work, or due to the higher strength of sunshine. Or maybe from the social support he/she felt from joining the group. Maybe the person meant that his/her skin cleared before therapy, but after reading the primal scream, and maybe it actually changed due to hormone changes in aging. Maybe the person's intense belief in primal therapy, coloured his or her testimony. There are many variables like this.
What happens is people become hyper sensitive to any change, real or imaginary, that happens in therapy. Whatever happens that is positive, we attribute it to therapy. Whatever bad happens we attribute to our childhood pain.
But think about this, good and bad things happen to everybody throughout life. With any given placebo treatment, there will be something good that happened in that time period. If the placebo taker was told that the placebo could help any of the miriad of health and psychological problems, they are going to be able to find something to point to as proof.
People change with or without therapy, the key is to doing controlled studies (as they did when comparing cognitive therapy and medication for depression, see Abnormal Psychology, Barlow 2004). Bear in mind the treatment does not in of itself have to be mechanical and scientific, in a scientific study, it can be anything, physical, emotional, primalling or talking. It is only the measurement of the efficacy of such treatments that is controlled. When we say the study needs to be controlled, we don't mean the patient has to control any feelings, the treatment is pretty much free to be whatever. It just means you control variables to eliminate all of the many cognitive biases.

1How to think straight about Psychology. Keith E. Stanovich