More about the success and failure of primal therapy...

spring picture: bumblebee (humla) - a social insect?!

Have been to the veterinary after lunch (3 hours) with a dog peeing blood... And in the morning I drove mom to the General Practitioner for test-taking. My youngest brother borrowed her car and she didn't want to drive another ones car.

Yesterday when we were to town we took my youngest brother's car, a four-wheel driven Subaru, fairly new (fun to drive :-))... When we parked at the market garden (handelsträdgård) I couldn't pull the key out of the ignition lock!!! There we stood! I had to phone my brother in Stockholm!!! He sounded a bit irritated, as I was the most stupid of the stupid! "Have you pushed?" he asked. "Pushed??" I thought for myself "But one use to pull!??" And he added "I haven't time more!" I got the key out (yes, one should push it first and then pull!!) and we could lock the car and leave it!! Watch this market garden! Or this! Both in Stockholm.

I am a bit tired after everything! The worries for the cute dog...

I was tipped about this article, thought it was interesting, “The Success and Failure of Primal Therapy: a Critical Review” by Stephen Kamsi. This posting is NOT short!! The original article was longer...

Addition March 29: this article was published 1988. And the book referred to by Tomas Videgård came already 1984. And Vikegård seem to be active here in Sweden still, as teacher for therapists in training!! See link to this in the text below.

“Primal theory and object relations theory are in agreement that infants become neurotic because of ‘defective relationships,’ not because of asocial drives (p. 4). This is the basis for Videgard's dichotomy between the drive-oriented and the trauma-relations oriented perspectives (p. 9)./…/

In discussing the various disciplines that comprise the trauma-relations perspective, Videgard (1984a) notes that 'they all seem to participate in a common cause against traditional psychoanalytic drive-explanations and for the uncovering of the more or less subtle traumatization processes that, according to them are the real agents in creating neuroses' (p. 4). Neuroses, then, results more from environmental influences, especially human relations and psychological traumas, than from the frustration of instinctual drives./…/

[Videgårds critique of Primal Therapy:]

Videgard (1984a) credits Janov with sensitizing the psychotherapeutic community to the subtleties of childhood trauma and with developing effective expressive techniques, but hastens to add that the consistent application of Janov's 'discharge model' leads to therapy failures. Videgard argues that primal theory is insufficient and needs to be replaced (p. 296).

Primal theory, according to Videgard (1984a), is misguided with respect to human relationships. Primal theory suffers from an inadequate and underdeveloped model of personality development (p. 293), and Primal Therapy lacks an appropriate therapist-patient relationship Videgard, 1984a (p. 287).

The therapeutic relationship, in Janov's opinion, is of minor importance (p. 287). The role of primal therapist consists primarily of being a catalyst for the emergence of stored historic pain. From the object relations perspective, however, the reliving of traumas is therapeutic only in the relational context of being heard and accepted (p. 294).

Research. Videgard (1984a) notes a serious discrepancy between Janov's claims of success and his own actual research findings. Videgard believes that ‘the published data are likely to represent an overestimation of the positive effect of Primal Therapy’ (p. 254)./…/

The Results /…/

13 subjects were considered to have had satisfactory outcomes, while between 14 (p. 295) and 19 (p. 303) had unsatisfactory outcomes.

How does Videgard (1984a) interpret these findings? ‘The main result is that about 40% of the primal patients achieve a satisfactory result within 15 to 25 months’ (p. 249). This statistic may be figured in many different ways, and various calculations of satisfactory results range form 39% for the random sample to 50% of the total sample (exclusive of subjects who could not be post-tested).

Which subjects benefitted most from Primal Therapy? Videgard correlated prognostic outcomes with several subject variables including (1) age, (2) sex, (3) marital status, (4) nationality, and (5) initial prognosis (i.e., the diagnosis). Several correlations were clearly evident between outcome categories and subject background variables. Although the small sample size allowed for only one statistically significant finding, some of the others are clinically significant and should be considered in future research.

1. An obvious correlation, suggesting a curvilinear relationship, exists with respect to age and outcome: Subjects between 30 and 40 (n=11) were more successful that subjects under 30 (n=15) [64% and 40% respectively], and no subject over 40 (n=5) was successful (Videgard, 1984a, p. 247). Perhaps there is an optimal age range for success in Primal Therapy (i.e., 30-40); in any event, the outcomes of the therapy were different for different age groups.

2. Are the results of Primal Therapy different for men and women? This study suggests not. Men (n=21) and women (n=10) showed very similar rates of success [43% and 40% respectively] (cf. Videgard, 1984a, p. 246).

3. The relationship between marital status and outcome revealed a highly significant finding (p < .01): married subjects (n=9) were more successful than divorced (n=5) or unmarried (n=17) subjects [67%, 60%, and 24% satisfactory prognostic outcomes, respectively] (Videgard, 1984a, p. 247). It should be added, however, that unmarried and divorced subjects actually came to Primal Therapy with more severe disturbances than married subjects: none of the married subjects (n=8) entered therapy with a ‘severe disturbance, although 71% of unmarried (n=17) and 67% (n=6) subjects did so. [Note: there is a discrepancy between the number of married (9, 8) and divorced (5, 6) subjects in the original Tables 4 and 5, respectively (cf. pp. 246-248)].

4. The correlation between nationality and outcome revealed that (1) Europeans (n=15) and (2) Scandinavians (n=12) were more successful than (3) American and Canadians combined (n=16) [53%, 50% and 31% respectively] (Videgard, 1984a, p. 247). As Videgard correctly notes, this may be a chance finding. Another plausible hypothesis is that (a) Europeans and Scandinavians were somehow different than North Americans--perhaps more highly motivated, since they had to overcome greater obstacles to obtain treatment, or (b) Primal Therapy is somehow more effective on the character structures of Europeans and Scandinavians than Americans and Canadians.

5. Subjects entering therapy with a ‘severe disturbance’ (n=16) are less successful than those entering with a ‘moderately severe disturbance’ (n=15) [25% and 60% satisfactory outcomes, respectively] (Videgard, 1984a, p. 248). 'The difference in outcome between the severe and the moderately severe groups is significant (p < .05). . . . Patients with deep disturbances are less likely to benefit from Primal Therapy than those with milder disturbances’ (p. 249).

6. An important but unreported correlation is that subjects with no previous therapy (n=11) were more successful than those with previous therapy (n=17) [55% and 41%, respectively] (cf. Videgard, 1984a, p. 246).

The following were reported by Videgard, but seem to have been derived in a less systematic fashion.

7. New memories (i.e., a reappearance of previously forgotten scenes) were reported by only a few subjects. This finding, however, should be qualified in at least the following ways. First, well-known childhood scenes reportedly took on new meanings. Second, many subjects reported strong feelings and bodily sensations which they associated with very early events but were unaccompanied by images or memories ‘in the common meaning of that word’ (Videgard, 1984a, pp. 274-275). In light of findings from Primal Therapy and other experiential psychotherapies, perhaps we need to expand the common meaning of the word ‘memory’ (cf. Khamsi, 1985, regarding ‘memory’ and the primal process). Third, it is probable that repression intervened between the time of memories experienced in therapy and the time of the posttest interviews. As a therapist, I have often seen the pernicious effects of repression; it is not at all unusual for a person to have deep experiential memories one moment, and literally be unable to recall them the next.

8. Videgard (1984a) reports that only three subjects had ‘connected’ birth feelings (p. 275), and that ‘integrated experiences,’ an undefined term, were rare before the ages of three or four. The reader may receive a false impression, however, since many more of these subjects reported having had numerous nonverbal, perhaps ineffable experiences--many of which were explicitly reported to be birth-related (cf. Khamsi, 1985, for a qualitative account of birth feelings in Primal Therapy). Videgard, then, appears to be extremely conservative in accepting nonverbal and birth feelings as ‘connected’ or ‘integrated,’ and thus as legitimate objects of scientific inquiry.

Videgard (1984a) believes that most, but not all, of his subjects may have done as well or better in more conventional therapies. ‘Except for the . . . three to four subjects who had been both 'desperate and integrated' and who had relived their birth-traumas, it seems the rest of the successful patients, at least in principle, could have achieved their results in good insight psychotherapy’ (p. 280). This is speculation, and I disagree. Videgard's own book, in fact, has innumerable statements of subjects that contradict the notion that other approaches would have worked as well for them. But it does indicate Videgard's unstated respect for the power of birth feelings--for certain subjects.

9. None of the subjects considered themselves cured (Videgard, 1984a, p. 275; cf. the ‘Failure Rate’ section in the ‘Discussion’ below).

10. Thirteen subjects reported improved relations with the opposite sex, and two reported improved relations with the same sex (Videgard, 1984a, p. 276). One-third reported a better sex life, one-third were unchanged, and three or four were ‘aggravated.’

In addition to the above findings, Videgard reported the following impressions from his research.

11. ‘A great majority of the patients found the Primal Therapy slower and much more difficult than expected’ (Videgard, 1984a, p. 273).

12. ‘Most of the successful patients had positive feelings for at least one or two therapists [while] none of the five least successful patients had developed strong positive feelings for any therapist’ (Videgard, 1984a, p. 273). Related to this is the impression that ‘about 50% of the patients wanted more individual contact with the therapists’ (p. 277). These findings provide strong support for Videgard's argument to rethink the therapeutic relationship in Primal Therapy.

13. Those patients whose childhoods had been characterized by a general lack of emotional contact with both parents seem to have very small chances of benefitting from Primal Therapy (Videgard, 1984a, p. 282). This finding underscores Videgard's concern about the importance of human relationships, both in development and in therapy.

14. No patient claimed to have experienced the complete sequence of events by which Holden (1976) describes a ‘primal’ (Videgard, 1984a, p. 274). So-called ‘primal screams’ were reportedly rare, and even screaming was an exception. According to Videgard, ‘most patients preferred to talk about feelings instead of primals.’ (p. 274)

There appears to be a chasm between Primal Therapy experiences as they are (a) lived and (b) described in the literature. Moreover, ‘primals’ and their neurophysiological correlates are apparently most intriguing to patients before their therapy, not after.

15. Most subjects had one or two key scenes, but crying was more often about generalized feelings than about specific scenes (Videgard, 1984a, p. 275).

Generalized feelings have been denigrated by Janov because his theory is based on the importance of reliving specific ‘primal scenes.’ According to these reports from Janov's own clientele, however, most feelings in Primal Therapy are in fact generalized and not specific./…/

The primal sense is a literal sixth Aristotelean sense, related to but different than the vestibular, kinesthetic and cutaneous ‘body senses.’

16. Improved work capacity was the only area of perceived progress for several subjects (Videgard, 1984a, p. 276). Obviously, these were subjects with unsatisfactory outcomes.

17. Videgard (1984a) discovered that ‘patients who did not perceive the threat in the last exposure of the DMT before therapy fail significantly more often than those who perceive the threat’ (p. 282). This is an important finding, and is deserving of future research attention.

Discussion

Videgard is clearly in favor of replacing the psychoanalytic paradigm. He has leveled a massive attack on orthodox ‘drive-oriented’ psychoanalytic theory and, drawing firepower from ORT [Object Relation Theory?] and Primal Therapy, has proposed as alternative--the "trauma-relations" orientation. In resurrecting the psychoanalytic paradigm, Videgard argues in favor of incorporating the theory and relational therapeutic context of ORT with many of the therapeutic techniques of Primal Therapy. In order to strengthen and further elucidate the trauma-relations position, Videgard has conducted an empirical outcome study of Primal Therapy./…/

Videgard (1984a) might also conduct one or more follow-up studies of these same primal subjects sometime in the future. This meritorious undertaking would begin to chart the long-term effects of Primal Therapy. ‘Cindy’ (pp. 39-43), interviewed seven years after beginning the therapy, shows that Primal Therapy outcomes may appear very different when evaluated over a longer period. Videgard could fairly easily expand his original project into a longitudinal study, retesting and/or reinterviewing the subjects periodically, perhaps once every five or ten years. Given the huge amount of work already invested, and the importance of the findings thus far, it may well be advisable to expand the research in this way./…/

Videgard concluded that the results of the psychoanalysis and pychoanalytically-oriented therapies at the Menninger clinic seemed less successful than his primal sample (p. 266). The Primal Institute, then, was considered to have slightly better outcomes than either the Tavistock or Menninger clinic.

The failure rate of Primal Therapy. Carlini and Bernfeld ('Questionnaire,' 1979) conducted a pilot study of 200 Primal Institute patients. They estimated an overall "failure rate" of Primal Therapy from the following: (1) 21% of their sample claimed to be unable to primal as described in the literature, (2) 24% claimed they had not reexperienced a repressed feeling or event, and (3) 19% stated that they were unable to feel previously-repressed feeling (p. 5). From their large sample, Carlini and Bernfeld estimated the failure rate of Primal Therapy to be approximately 21% (p. 5).

In Videgard's (1984a) study, however, ‘almost one-third (9 out of 31 patients) had either left the therapy prematurely (including one suicide) and/or expressed strong dissatisfaction with their own development and follow-up’ (p. 267). In all, 40% of Videgard's subjects were judged to have reached a satisfactory result (p.267); this contrasts sharply with Carlini and Bernfeld's explicit success rate of 79% and with Janov's implicit success rate of 90-98%.

How can such major discrepancies exist between these postulated rates of success in Primal Therapy? Clearly, part of the answer is that Videgard employed more exacting methods to determine therapeutic success and failure than either Carlini and Bernfeld or Janov; Janov's estimates have been impressionistic, while Carlini and Bernfeld's was based on data from self-reports. In any event, the primal community must continue to examine its therapy outcomes. There is a need to examine what 'success' and 'failure' mean in Primal Therapy, as well as how and why they do or do not occur. This is a deep and complex issue that deserves much future attention.

One important aspect of any therapy success or failure concerns the issue of therapeutic technique. Videgard (1984a) believes that 'at least some of the failures in Primal Therapy can be attributed to specific shortcomings in the way the therapy is done' (p. 284). This charge deserves comment.

The technique of Primal Therapy. Videgard (1984a) approves of the sensitive use of primal techniques (p. 288). He believes that the physical setting and focusing technique of Primal Therapy allow maximum freedom of emotional expression. ‘The primal technique,’ in fact, ‘may be a help to follow the patient's natural pace’ (p. 288).

Videgard (1984a) objects, however, to the lack of an on-going therapeutic relationship. Most Primal Therapy failures can be attributed to the lack of individual therapy sessions for most patients. The discharge-model is simply insufficient, says Videgard, so primal theory needs to be replaced and ‘continuous, individual therapeutic contact’ should contextualize the primal therapeutic process (p. 296).

Videgard is correct. In 1969, after leaving the Primal Institute, therapists at the Marin Center for Intensive Therapy began offering Primal Therapy that included an explicit and defined client-centered relationship. Since commencing therapy there in 1973 I have observed Primal Therapy practiced in many ways. /…/

What is Primal Therapy?

Certain facts about Primal Therapy have been established by Videgard. Following from these facts, he has provided an interpretation of the findings and has offered a well-reasoned argument in favor of an alternative paradigm--the trauma relations perspective.

Videgard's facts have been established with proper scientific rigor and reporting, and thus represent an important new source of information for the empirical data base of Primal Therapy. These data may, however, be interpreted in other ways. While I generally accept his data as facts, my own interpretations sometimes differ.

I find Videgard's findings plausible and his arguments fairly persuasive. I agree, for instance, that ORT is superior to primal theory with respect to developmental theory and client-therapist relationships. In a prior article, however, I interpreted these same facts in a slightly different way--my argument was in favor of a ‘humanistic’ or ‘client-centered’ Primal Therapy (Khamsi, 1981). With respect to this fundamental deficiency in primal therapeutic relationships, Videgard and I have offered similar, constructive alternatives. Primal theory needs to be reworked in light of its own failings, taking into account the strengths of ORT and person-centered theory.

In attempting to get at the core of Primal Therapy, Videgard (1984a) has attempted to determine if it is a unique method, i.e., if it is the only approach that is able to help certain people (p. 279). He believes that it may have been for some of his subjects. Unfortunately, Videgard here has pursued the 'primal-is-the-only-cure-for-mental-illness' myth, which is dated both as an honest misconception and as a sales campaign. Primal is one viable approach, preferred by many; but viewing Primal Therapy as discontinuous with and/or better than other approaches keeps us from understanding and researching exactly what it is and how it relates to any larger scheme of things./…/

Through imaginative variation we can see that the essence of Primal Therapy lies neither with primal screaming, nor three-week Intensives, nor particular techniques. Primal Therapy is a way of feeling and being real. This insight has been central to my own thesis that the primal sense dimension is most essential to the primal therapeutic process.

Primal is, in essence, a way of being real or authentic. It emerges from an individual's ‘decision’ to open to what is, to feel-change-grow in spite of pain or difficulty. Nothing done to a person--such as ‘therapy’--facilitates real change. Being real come from within. Therapist and client/patient/person can work together, sharing experiences, ideas and feelings, so that both may live with greater feeling, meaning and authenticity. Being real can never be forced./…/

With respect to trauma, we must distinguish between theories of etiology and theories of therapy. A trauma theory of etiology needs to show that personality development is significantly affected by traumatic incidents, and this idea has been widely accepted. A trauma theory of therapy, on the other hand, would need to demonstrate a prevalence of subjects reliving specific traumatic scenes--which clearly was not the case in this study. There were fewer reports of new memories and specific feelings--hallmarks of reliving traumatic scenes--than of general feelings about such scenes. In general, then, the data support a relational Primal Therapy and a trauma theory of etiology but refute a trauma theory of therapy.

Theory can open or close our eyes. Just as Janov opened eyes when his insights were fresh, we can continue to open eyes and hearts and minds by researching and reporting human experience as it is lived--not theorized. Janov helped us see beyond the bounds of psychological theories extant. Now we must see beyond his.”

"Etiologi är läran om orsakssamband, eller kausalitet. Termen kommer ifrån grekiskans aitia, orsak, och logia, lära, och används inom filosofi, fysik, psykologibiologi då man diskuterar orsaker till olika fenomen.

Inom medicin används termin specifikt för anledningar och bakomliggande variabler till sjukdomar och patologiska tillstånd.

Med begreppet kan också avses en orsakslära som i sagor och berättelser söker förklara hur olika företeelser, bruk och namn har uppkommit. Ett slags etiologier är bildliga förklaringar som då John Blund sägs komma med sömnen till barnen."