Debunking Primal Therapy

(Continued from part 2, the essentials of science continued:)  

Falsifiability

In order for a theory to be useful in science it needs to be falsifiable, in other words it needs to be theoretically possible to prove it wrong.  Put another way it needs to be testable.   The concept of falsifiability is larger than just this simple definition, and it can be applied to treatments, theories and even is crucial in diagnosis. It is important, because if you have a theory in which no matter what the outcome of an experiment or study or therapy, if the complete set of possible outcomes can be explained by the hypothesis or theory, then you have a problem.  The problem is either the theory is not taking risks, and is in fact an ideology, or perhaps the experiment itself is not a “risky experiment” – a crucial consideration in scientific research.

Consider the case of Benjamin Rush, as explained by the psychologist Keith E. Stanovich:

“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, p. 1106) 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…

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…

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.” ¹ 

How to Think Straight About Psychology, Stanovich (2001, p. 26)

Stanovich in his book writes “remember Benjamin Rush” and those words haunted me like a Dickens novel, because at the time I was still in part believing in primal theory!

Not only are most aspects of Freudian theory unfalsifiable, but so are many of the neo-Freudian adaptations, such as aspects of 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. Similar to the Jung or Freud example, 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 in a similarly vague way.  The question scientists ask is: are unfalsifiable theories really religions?

So we get down to the direct question.  Is primal theory falsifiable? Is there 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 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 in a way that would risk falsifying it (the section “A Challenge to Primal Therapy“ suggests a way) the therapy pretty much is unfalsifiable.  These so called ‘risky experiments’ are necessary in science.  (“Risky” here means that there is some risk that the experiment could conceivably produce falsifying evidence to the theory – it does not mean the experiment is risky or dangerous to participants.  It is only risky to the theory.)

The labeling of primal therapy “failures” as being too repressed, paranoids, psychopaths, borderlines, parasympaths, or LSD users etc, is a good example of how primal theory can be stretched to explain any negative result.  This is another aspect of what makes it unfalsifiable.  Sadly, this makes primal therapy more similar to scientology than to science.

The fact that most people don’t benefit from primal, and most go on not to recommend it to their loved ones can be explained.  One such explanation was: ”Primal therapy attracts borderlines like flies” someone explained to me when he was explaining the problems they had faced previously, in the 1990s.  In fact, the complainers of the 1990s were not borderlines at all and they had valid criticisms.  Regarding the early 1990s I heard someone at the Primal Center explain: ”everybody was abreacting, it was horrible” [abreaction means false feelings in primal lingo].  This also explains away complaints or poor outcomes, and it protects primal theory and primal therapy.  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.

Is primal therapy testable? 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 (they do not allow independent testing). 

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 because the isolation requirement increases suggestibility and exerts social influence.  There should be representative or random sampling and random assignment of NON-PRIMAL believers suffering from a real DSM IV diagnosed problem.  To eliminate social influence factors, the requirement for reading Janov’s books would have to be abandoned. 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 therapy 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,” claiming that 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” (before the fact) know it is true, it is taken to be self evident, and they may not want some “repressed” intellectuals spoiling it.

Can you possibly 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.

Now 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 person’s report of a good present life as just 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 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.

Primal theory makes sense.  It explains everything.  That may explain why Janov and others, including myself, got 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. It needs to be exposed to ‘risky experiments’ that at least have a chance of failure.

            {Sidenote: Just a thought: The philosopher of science Karl Popper pointed out that both Marxism and Freudian theory are unfalsifiable. Primal theory is a beautiful idea, and I think Janov believes there would be beneficial social effects if it were believed.  Communism is a beautiful idea.  Communism didn’t work, and perhaps became authoritarian as a result of people not accepting that.  Primal theory (and therapy) doesn’t work in practice, and perhaps became authoritarian in a different way 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.  They are sufficiently vague in there predictions in the same way astrology is. 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 above).  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 labeled “Pain”.  Then when correlational studies revealed the fetal environment can alter growth and function, that then became “Pain.”

As an analogy, let’s 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 according to how bad is the problem, that’s 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. (The idea of the little green men analogy was inspired by the much recommended book How To Think Straight About Psychology, Stanovich)

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  psychology that proves primal theory wrong?  I did see evidence that contradicts primal theory in EVERY psychology class I have attended, but it is indirect evidence usually. It is the sheer amount of the little bits of indirect evidence that casts the doubts over primal theory; and it makes it difficult to have a simple one-sentence knock down argument.  The best advice one can give someone is to learn how to weight the evidence and to start looking at a vast array of evidence in the field of psychology. The problem is, with each small snippet of evidence that contradicts primal theory,  the basic concepts of primal theory can be used and twisted to explain the results.  Primal people may also not follow psychological science, or trust science or the results of psychological experiments (“you can’t measure the mind” arguments, or “you just know it from your feelings”), or they simply may say it is all too “left brain”, so their attitude makes it double hard to test. 

Let’s take the Primal Pain based explanation for all psychological problems, for example.  As science has developed since the early 1970s, it became clear that it was not so much the pain killing neurotransmitters (endorphins) that were important in depression, for example.  Serotonin and norepinephrine, which are not specifically pain killing, started to stand out as more important, NOT endorphins.  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 and vague the basic theory is.

Falsifiability in Diagnosis

So far we have discussed primal therapy and theory with respect to to falsifiability, but there is a third consideration that is a problem in Primal Therapy, some other therapies and movements such as scientology.  It is the use of unfalsifiable thinking in the process of diagnosis (the labelling of patients into categories).  Labelling is not always a bad thing, but it has to be done in a falsifiable way – something that is not understood by many therapists, clinical psychologists or psychiatrists.  Without falsifiability in diagnosis you get a inbalance of power in the patient-therapist relationship, and in some more severe cases just downright cultic insanity. It also creates circular thinking that can have a damaging effect on the patients life.  The therapist can in effect invent problems in the patient and thus create a need for their therapy. Social psychologist Carol Tavris describes an example of diagnosis without falsifiability (before you read it, it may be helpful to know that Munchausen by proxy is the disorder where parents harm there child in the context of medical treatment for their child):

“Munchausen by proxy (MBP; factitious disorder by proxy in the appendix to DSM-IV) is the latest trendy disorder to capture clinical and media attention…I watched as this clinical psychologist – I’ll call her Dr. X – revealed the pseudoscientific assumptions, methods, and ways of thinking that have become common in clinical practice, as this volume will consider in depth:

Dr. X relied on projective tests to determine that the mother had psychological problems. Quite apart from the problems of reliability and validity with these tests, no one has any idea whether real MBP mothers have any characteristic mental disorder…

Dr. X knew nothing about the importance of testing clinical assumptions empirically, let alone operationally defining her terms.  What does “in collusion” mean?  How does a MBP mother’s behavior differ from that of any mother of a chronically sick child, or, for that matter, from that of any loving mother?

Dr. X knew nothing about confirmational bias or the principle of falsifiability, and how these might affect clinical diagnosis.  Once she decided this mother was a “classic Munch.,” as she wrote in her notes, that was that.  Nothing the mother did or said could change her mind.  This is because, she testified, Munchausen mothers are so deceptively charming, educated, and persuasive.  Nothing the child said could change her mind.  This is because, she said, he naturally wants to remain with his mother, in spite of her abusiveness.  No testimony from immunologists that the child really did have an immune disorder could change her mind.  This is because, she explained, Munchausen mothers force doctors to impose treatments on their children by interpreting “borderline” medical conditions as problems needing intervention.

Dr. X understood nothing about the social psychology of diagnosis: for example, how a rare problem, such as “dissociative identity disorder” or “Munchausen by proxy” syndrome, becomes overreportedwhen clinicians start looking for it everywhere and are rewarded with fame, acclaim, and income when the find it (Acocella, 1999).

Dr. X understood nothing about the problem of error rates (Mart, 1999): that in their zeal to avoid false negatives (failing to identify mothers who are harming their children), clinicians might significantly boost the rate of false positives (mistakenly labeling mothers as having MBP syndrome).  “This disorder destroys families,” she said, apparently without pausing to consider that mistaken diagnoses do the same.

In short this clinical psychologist received a PhD without having aquired a core understanding of the basic principles of critical and scientific thinking.”

 Science and Pseudoscience in Clinical Psychology, (2004) (page ix to xi), ISBN 1-59385-070-0. New York: Guilford Press.