by Michael D. Anestis, M.S.
We spend a lot of time on Psychotherapy Brown Bag discussing treatments with varying levels of empirical support, with the central aim being to help readers learn about treatments for specific mental illnesses that have evidence indicating that they actually work. Unfortunately, for every empirically supported treatment (EST), there are a host of therapies that simply do not have evidence indicating that they produce positive effects. In past articles, we have discussed iatrogenic treatments (e.g., rebirthing therapy) and treatments that have been shown to have no significant effect (e.g., prescribing antidepressant medication to reduce repetitive behaviors in autism and autism spectrum disorders). Today, however, I would like to discuss another phenomenon, and a case could be made that this is the most dangerous of them all: treatments with faulty evidence that practitioners use to erroneously claim effectiveness. In this case, I would like to discuss Marino and Lilienfeld's (2007) review of the literature on dolphin assisted therapy (DAT).
DAT has been practiced for decades and has grown in prominence in various global locations. Practitioners claim that, by interacting with dolphins, typically in an enclosed environment, individuals are able to overcome the symptoms of a variety of mental illnesses. Admittedly, when I first heard about this, I was immediately skeptical, but my gut reaction is entirely unimportant. What matters, and what I will focus on today, is the data.
In 1998, Marino and Lilienfeld published their first review of this therapeutic approach. At the time, there had only been two published studies on DAT and Marino and Lilienfeld pointed to a variety of fatal flaws in those studies that rendered their results entirely useless. Specifically, the authors of the DAT studies did not have any control group and their ratings were entirely subjective and prone to bias on the part of the experimenters. In 2003, Humphries published a similar review of an additional five studies on DAT, all of which fell victim to the same flaws, particularly with respect to a lack of control group. Finally, in 2007, the review I will focus on today was published, focusing on an additional five studies on DAT that have been published since 1998.
Marino and Lilienfeld (2007) first examined what they determined to be the most methodologically strong of the five studies, one published by Antonioli and Reveley (2005). In this study, a group of 13 men and women with mild to moderate depression scores assessed through validated and psychometrically strong self-report measures played with, swam with, and "took care of" dolphins one hour per day, five days per week, for two weeks. The control group consistent of 12 men and women with mild to moderate depression scores who snorkeled in the barrier reef and received a similar amount of human contact, but in the absence of dolphins. The authors found that individuals in the DAT group exhibited significantly greater improvement in depression but not anxiety than did the control group and concluded that DAT is more effective than "water therapy" for treating mild to moderate depression.
The conclusions of this study are problematic for a variety of reasons. First, the control group knew that they were the control group. Imagine you are depressed and you sign up for a study only to find out that, while half of the participants get to swim with dolphins, you do not. Barring a phobia of dolphins, this is likely not good news and, as such, the control group was not actually a control group. They were, instead, the group of depressed folks who were not allowed to swim with dolphins and who, not so surprisingly, reported feeling greater levels of depression than did folks who did get to swim with dolphins. This does not mean that dolphins cure depression. It means that when you split depressed individuals into two groups and only let one group experience a novel, positive interaction, that group will feel better in the moment than the group of people who not only are not included, but are well aware of what the other folks get to do.
Additionally, as Marino and Lilienfeld (2007) pointed out, the authors did not control for the effects of interacting with other charismatic animals. Although I am quite openly skeptical regarding the utility of simply interacting with animals as a treatment for mental illness, my conclusions on the matter will be based entirely on data. In order for that data to convince me or any other scientist that dolphins have a specific importance in treatment, however, the experimenters need to demonstrate that the same effects can not be found through interactions with other animals. Why is this important? Think back to our articles the behavioral activation component of cognitive behavioral therapy (CBT). Research has demonstrated that by increasing positive, reinforcing behaviors, an individual can experience an immediate, significant decrease in depressive symptoms. As such, the question becomes whether DAT is a unique, stand-alone treatment or if it simply demonstrates the efficacy of behavioral activation - one component of CBT - in an extreme environment. Doing something novel and fun will make an individual's mood improve - this is not news. The question is whether any such improvement in mood extends beyond that moment and thus actually addresses depression.
This leads to the final and perhaps most important critique of this and other studies mentioned by Marino and Lilienfeld (2007): no effort was made to measure follow-up symptoms. All we know from this study is how people felt immediately after swimming with dolphins (or, alternatively, not swimming with dolphins when they were depressed and knew other people had the opportunity to do so). We do not know how they felt one day, one week, one month, one year, or several years later. Given that extensive follow-up data is available for other treatments for depression (see our articles on CBT as an example), it seems extremely important for proponents of DAT to demonstrate that individuals experience more than a momentary decrease in symptoms.
The other studies reviewed by Marino and Lilienfeld (2007) were full of even greater problems. Likura et al (2001) reported that DAT was an effective pain reliever in therapy; however, they provided no information regarding the nature of the sample, how the study was conducted, or what methods were used to assess outcomes. In other words, the study essentially consisted of the authors stating their conclusions without telling the reader how they arrived at that point. This is not to say that the conclusions are necessarily wrong, but rather to point out that we have no way of testing their veracity. This is quite obviously highly problematic. Other studies reported on in this review failed to provide data of any kind or based their conclusions reports by the experimenters themselves, who were not blind to condition and, as such, were likely vulnerable to their own biases.
Psychotherapy Brown Bag aims to provide education on ESTs. To do so, we hope to write as many articles as possible explaining the nature of these therapeutic approaches and the evidence behind them. Another component of this goal, however, is debunking misinformation. Today's article focused on that latter component. Given that many individuals seek out DAT as a treatment for depression, pain, autism, mental retardation, anxiety, and a variety of other ailments, it is important for as many people as possible to learn about the complete dearth of evidence for its utility, particularly given the existence of ESTs for many of those same conditions. The thought of swimming with a dolphin is likely to sound more enticing than the thought of congitive restructuring. As such, the importance of battling the allure of faulty therapiest is difficult to overstate.
DAT is a highly profitable business. Perhaps if better experiments are conducted and an abundance of data is accumulated, results will indicate that it produces as much relief from mental illness as it does profit for practitioners, but thus far, the evidence indicates this is not the case. I do not suspect that the popularity of DAT is the result of malice on the part of practitioners. In fact, I suspect that practitioners of DAT strongly believe that it is an effective approach. The problem, however, is that the evidence does not support this belief and individuals in desperate need of help are thus victimized by a blind allegiance to a philosophical stance inconsistent with objective results.
Clinical psychology is, unfortunately, plagued by situations similar to this one. I hope to cover as many of these as possible, but also invite you to comment on this and other articles proposing your own ideas for therapeutic misinformation in need of clarification.
In the meantime, we hope that you will take this opportunity to browse our online store. There, you will find an abundance of information on EST's for a variety of mental illnesses. Materials are available for clinicians, researchers, and the general public and, if you have questions about any of them, we would be more than happy to answer them.
Mike Anestis is a doctoral candidate in the clinical psychology department at Florida State University.
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