Wednesday, March 30, 2011

Bad CAM research - Dolphin-Assisted Therapy

The latest issue of Phi Kappa Phi Forum, on the theme of empathy, has a rare (for them :)*) interesting piece by Lori Marino (I’m starting to think there might be something to this name-determination business…) - “Dolphin Assisted Therapy: From Ancient Myth to Modern Snake Oil.”** Marino is a cetacean researcher who's reviewed the history of DAT (“humans swimming and/or interacting with captive dolphins with the intent of treating some mental or physical disorder,” 5) and claims of its efficacy. She argues that not only have the benefits not been scientifically demonstrated but the therapy is harmful to both humans and dolphins.

DAT, according to Marino, grows out of ancient traditions of human reverence for and attachment to dolphins, leading more recently to dolphins’ status as a “New Age icon” (5). There are DAT facilities worldwide, and she says it continues to increase in popularity. DAT - difficult to separate from recreational “swimming with the dolphins” tourism and “not regulated by any authority overseeing health and safety standards for either humans or dolphins” (5) - is said to be effective in treating any number of ailments:
Autism and similar developmental disabilities top the list of conditions touted as highly treatable by DAT. Proponents also claim it helps everything from depression and anxiety to infections to neuromuscular disorders to cancer and AIDS…Proponents also assert that DAT provides humans with enhanced concentration (a vague claim unproven scientifically); alters people’s brainwaves therapeutically via the dolphin’s echolocation, the high-pitched sounds the dolphin makes (nothing but pseudoscience); and generally enhances biophilia (a feel-good, New Age love of nature) (5).
But according to Marino’s and others’ analyses over several years, there is no scientific basis for the claims of DAT proponents and practitioners. The most recent review she mentions is one of her own:
Marino, Lori, and Scott O. Lilienfeld. 2007. “Dolphin-Assisted Therapy: More Flawed Data and Flawed Conclusions.” Anthrozoös 20 (3): 239-49. [full-text PDF available here]
(I had to search for the paper myself because, that’s right, the Forum doesn’t have any citations! Believe it or not for a publication targeted to scholars, there are no footnotes, just a box at the bottom of a page in some articles instructing readers: “For footnotes, go online to” So I did, and there aren’t even any citations or suggestions for further reading listed for this piece. This despite the fact that each article is accompanied by a long author biography and illustrated with large pictures - many not directly related to the contents - and those useless semi-abstract graphic things. The publication is of course ultimately at fault for the lack of proper citations, but I suspect they’re the more immediate problem as well, as I wouldn’t expect many authors to shy away from citing their own published work on a subject.)

The 2007 article reviews five peer-reviewed (how, I have no idea) DAT studies from the previous eight years, assessing the efficacy if DAT in: depression, anxiety, atopic dermatitis, “infantile neurosis,” autism, mental retardation, and general psychological well-being. As summarized in the abstract:
We found that all five studies were methodologically flawed and plagued by several threats to both internal and construct validity. We conclude that nearly a decade following our initial review, there remains no compelling evidence that DAT is a legitimate therapy or that it affords any more than fleeting improvements in mood (239).
It’s worthwhile to note that the five studied DAT in a range of conditions, so there really haven’t even been five peer-reviewed studies for any single condition over many years. Any claim of an intervention's efficacy in treating such diverse conditions should automatically be suspect. It’s also important to note that this is a therapeutic intervention whose alleged mechanism for bringing about significant and extended benefits in any of these conditions is, as is typical in this realm, not elaborated in any detail, and for some conditions exceedingly implausible. Wooish beliefs aside, it would be very surprising for people and dolphins – as opposed to people and dogs, for example – to have any special empathy or bond: dolphins are not domesticated and the two species haven’t had much enduring contact. And, as Marino and Lilienfeld describe, these studies are for the most part seriously weak. I’m interested in the specific issues involved, but the review article is worth discussing in a general way in that the problems Marino and Lilienfeld find in the DAT studies seem common to a good deal of CAM research, and shed light on what makes bad (and good!) research.

In brief, they found major problems with internal and construct validity in these studies. The studies lacked adequate controls, blinding, and follow-up assessments. It’s a short article and can be read at the link above, but I’ll reproduce their list of the areas in which the studies were severely flawed, from Table 1 (242), here (each of the studies had major problems in one or more of these areas):

  • Placebo Effects: Improvement from expectation of improvement

  • [People have expectations of efficacy based on marketing of DAT.]

  • Novelty Effects: Effects of energy, excitement, and enthusiasm not specific to the intended treatment

  • Construct Confounding: Failure to take into account the fact that the procedure may include more than one active ingredient

  • [People were outdoors, in water, interacting with “charismatic” animals, and receiving attention from professionals. There are many aspects of the interaction with the dolphins that would need to be distinguished from one another.]

  • Resentful Demoralization: Participants aware of not receiving the active treatment may be resentful and respond more negatively than the treatment group

  • Demand Characteristics: Tendency of participants to alter their responses in accord with their suspicions about the research hypothesis

  • Experimenter Expectancy Effects: Tendency for experimenter to unintentionally bias the results in accordance with the hypothesis

  • History: Occurrence of potentially therapeutic events other than the intended treatment during the course of the study

  • Testing: Improvements due to testing itself (e.g., practice effects)

  • Regression: Tendency of extreme scores to become less extreme on re-testing

  • Instrumentation: Changes in the dependent measure at different times in the study

  • Multiple Intervention Interference: Administration of treatments other than the intended treatment during the course of the study

  • Maturation: Changes over time due to natural developmental effects

  • Informant Bias: Tendency of informants to selectively recall improvement in accord with their hopes and expectations (retrospective bias) or unintentional distortion of improvement due to effort justification (“the psychological need to justify to oneself the time, expense, and energy invested in the treatment,” 244)

  • The authors contend that people should be informed of the lack of evidence for any beyond the most transitory effects so that they can make informed decisions (248). In the Forum piece, Marino responds to the question, “Who does it hurt?”:
    Some might argue that DAT is not completely devoid of merit because, at the very least, children and adults enjoy interacting with dolphins in a once-in-a-lifetime experience. So, even if DAT provides no scientifically proven salutary benefits whatsoever, who could quarrel with putting a smile, at least temporarily, on the face of a sick child?

    There is more to DAT than meets the eye and when one becomes aware of the tradeoffs, DAT no longer seems benign. The costs are enormous, for humans (except for the practitioners) and dolphins alike, in all sorts of ways (5).
    Marino says that DAT, “[h]awked heavily” to parents of children with autism and other developmental disorders, provides false hope to vulnerable and desperate parents. In addition, it’s expensive – the standard fee, according to Marino, is $5-7000 for a few short sessions over several days and not covered by insurance (a good thing); and may take people’s attention and resources away from other, effective, forms of help. There’s also a real risk of injuries and infections from interacting with these wild animals.

    For the dolphins, captivity and work, according to Marino, “causes debilitating stress, disease and mortality to both the wild-caught and captive-born” (6). Capturing dolphins in the wild (no longer allowed in the US but allowed elsewhere) leads to mass slaughters and the reduction of dolphin populations. Having described complex cetacean social relationships – this was extremely interesting and I would like to read the best work on it, but…no citations offered – she argues (6), “We do not need to attach supernatural qualities to them, for their actual nature is much richer and multidimensional than any human mythology can provide.” I’ll have more to say about this soon….

    *This should not be taken as a dig at them specifically. I generally find the Phi Beta Kappa Key Reporter boring as hell, too.

    **Lori Marino. 2011. “Dolphin Assisted Therapy: From Ancient Myth to Modern Snake Oil.” Phi Kappa Phi Forum 91 (1: Spring): 4-6.

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