With the British Psychological Society Annual Conference underway, we checked in with Susan Llewelyn, Professor of Clinical Psychology at the University of Oxford, and David Murphy, Joint Course Director for Oxford Doctoral Course in Clinical Psychology. We spoke to the co-editors of What is Clinical Psychology? about psychosis, provision of care, and careers in clinical psychology.
When did you first become interested in clinical psychology?
Sue: When I was an undergraduate studying psychology, I realised clinical psychology was by far the most interesting aspect of psychology. I was particularly interested in psychosis and what “madness” was.
David: Although I covered aspects of mental health in my undergraduate degree, I don’t think I really decided to pursue clinical psychology as a career option until I began working as an assistant psychologist and saw the range of different roles for clinical psychologists in the NHS. I worked for a while in a residential centre for people with epilepsy and became fascinated with the relationship between the brain and behaviour.
What do you think has been the most important development in clinical psychology in the past 100 years?
Sue: Probably the articulation of the cognitive, or information processing model of human behaviour and emotion, to balance the biological or the psychodynamic.
David: Clinical psychology is still such a young discipline that almost all the developments were within the last 100 years and most within the last 50 years. I think the pioneering work in behaviour therapy by Vic Meyer and others, helped open up the notion that psychological therapy could be effective in severe and intractable psychiatric problems like OCD and really changed the role of the clinical psychologist.
What is the most pressing or controversial issue in clinical psychology right now?
Sue: How we can deliver high quality clinical psychology services to meet all the so far unmet need.
David: I agree with Sue, we know from epidemiological surveys that there are large numbers of people with mental health problems who don’t or cant access services. We need to be better at using the resources to provide the most effective and responsive services we can; this often means trying to intervene early.
How might your current research have an impact on the wider world?
Sue: I am not sure I can be that grandiose! But our work tries to show how psychologically grounded ideas can make a big difference in people’s lives, and how taking the psychological realm seriously can improve the nature of the health care that can be offered to people in distress.
David: I agree with Sue; hopefully reading about the applications of psychology in practice across a diverse range of settings might inspire the next generation of clinical psychologists to pursue what is quite a long and challenging path into the profession.
Which famous psychologist has been most influential to you?
Sue: My friend and colleague Professor Glenys Parry in Sheffield has helped me to understand two important areas of psychological functioning: first how broad social and political influences shape the psychological (particularly how social and political gender issues become internalised and intimately lived by individuals), and second, how both the insights of psychodynamic, interpersonal therapies and CBT therapies can be effective combined to maximise how much we can help people.
David: That’s a really tough one! I’ve been lucky enough to work with a number of really inspirational psychologists through my career to date and, of course, many psychologists I haven’t met have influenced me through their work. One person who stands out on a personal level to me is Padmal De Silva who was my clinical tutor during training in London. Padmal was an internationally renowned expert in an array of areas; obsessive compulsive disorder, sexual and marital therapy, post-traumatic stress and Buddhist psychology. One of the most intelligent people I have ever met, he was also one of the most kind and humble. He always seemed to have time for people, even us trainees, and was genuinely interested in what they had to say. I feel very privileged that now in Oxford I have responsibility for training the clinical psychologists of the future and I am fortunate to have Padmal and others as role-models to aspire to.
What advice would you give to someone wanting to specialize in your field?
Sue: Try to be open minded about ideas: you can gain insights about the human condition from so many places including the newspapers, politics, art and literature, and conversations with friends, as well as psychology textbooks.
David: Read my OUPblog post “Five top tips to getting into Clinical Psychology” tomorrow!
What do you see as being the future of research in your field in the next decade?
Sue: We may be able to track more carefully what are the important components of our interventions, so that we can tailor what we offer more precisely to our clients
David: Wow, there are no easy questions, are there! I think research in psychological therapies, at least, will need to be not only carried out with larger sample sizes with longer follow ups but also with very detailed analysis of individual factors and therapy process factors to really enable us to answer the question “what works for whom”.
If you weren’t teaching clinical psychology, what would you be doing?
Sue: Reading really beautifully written literature, and also walking with friends and family in the mountains
David: Learning about clinical psychology! I’ve always found teaching to be just a natural extension of learning and practicing, if I can pass on what I’ve learned to trainees then hopefully I will hopefully have contributed in some way to them going out and generating more knowledge and innovative practice. I do have a life outside Psychology though, and in that life I enjoy playing football (even though I’m still not very good at it) and travelling to new places with my family.
Susan Llewelyn is Professor of Clinical Psychology at Oxford University, and Senior Research Fellow, Harris Manchester College, Oxford. David Murphy is the Joint Course Director of the University of Oxford Clinical Psychology Doctoral Training Programme. They are co-editors of the new edition of What is Clinical Psychology?
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By David Murphy and Susan Llewelyn
Psychology must be one of the most diverse disciplines there is; it encompasses understanding language development in infants, techniques to help sports competitors improve performance, the psychology of conflicts, therapy for mental health disorders, and selection techniques for business amongst many others. The BPS Annual Conference is probably the best chance to witness the breadth of the discipline each year in the United Kingdom.
Things to do at the conference
This year’s conference in Birmingham has some fantastic highlights. The session on psychology in the military is highly topical and has some leading figures in the world speaking such as Keynote speaker, Professor Simon Wessely. There is a great deal of research looking at aspects of parenting throughout the conference as well as sessions covering a range of areas including mental health, diet, managing physical illness and educational attainment among others. Professor Sergio Della Sala is a neuropsychologist who has a great ability to communicate information about brain functioning in an easily understandable and entertaining fashion; his talk is sure to be a high point.
However, sometimes at the BPS conference its worth just going with the flow and attending talks in areas that you aren’t very familiar with, you will hopefully find them very interesting, and they may well give you new ideas which could even be a turning point for your career to go off in a new direction, or help you think in a new way about your own area of research or study.
Things to do in Birmingham
Birmingham has a range of extraordinary heritage, so the Museum & Art Gallery should be top of the list for those wanting to fully appreciate the scope of the city’s history.
It is also thought that some of Birmingham’s sights and history inspired the works of J.R.R. Tolkien. The Hobbit fans among us might want to take the Tolkien Bus Tour the weekend after the conference.
We hope to see you at the conference this year, do come up and say hello if you are attending.
Susan Llewelyn is Professor of Clinical Psychology at Oxford University, and Senior Research Fellow, Harris Manchester College, Oxford. David Murphy is the Joint Course Director of the University of Oxford Clinical Psychology Doctoral Training Programme. They are co-editors of What is Clinical Psychology?
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By Huw Llewelyn
In medicine, we use two different thought processes: (1) non-transparent thought, e.g. slick, subjective decisions and (2) transparent reasoning, e.g. verbal explanations to patients, discussions during meetings, ward rounds, and letter-writing. In practice, we use one approach as a check for the other. Animals communicate solely through non-transparent thought, but the human gift of language allows us also to convey our thoughts to others transparently. However, in order to communicate properly we must have an appropriate vocabulary linked to shared concepts.
‘Reasoning by probable elimination’ plays an important role in transparent medical reasoning. The diagnostic process uses ‘probable elimination’ rival possibilities and points to a conclusion through that process of elimination. Suppose one item of information (e.g. a symptom) is chosen as a ‘lead’ that is associated with a short list of diagnoses that covers most people with that lead (ideally 100%). The next step is to choose a diagnosis from that list and to look for a finding that occurs commonly in those with that chosen diagnosis and rarely (ideally never) in at least one other diagnosis in the list. If such a finding is found for each of the other diagnoses in the list, then the probability of the chosen diagnosis is high. If findings are found that never occur in each other possibility in the list, then the diagnosis is certain. However, if none of this happens, then another diagnosis is chosen from the list and the process is repeated.
Probabilistic reasoning by elimination explains how diagnostic tests can be assessed in a logical way using these concepts to avoid misdiagnosis and mistreatment. If clear, written explanations became routine, it would go a long way to eliminating failures of care that have dominated the media of late.
Reasoning by probable elimination is important in estimating the probability of similar outcomes by repeating a published study (i.e. the probability of replication). In order for the probability of replication to be high, the probability of non-replication due to all other reasons has to be low. For example, the estimated probability of non-replication due to poor reporting of results or methods (due to error, ignorance or dishonesty) has to be low. Also, the probability of non-replication due to poor or idiosyncratic methodology, or different circumstances or subjects in the reader’s setting, etc. should be low. Finally, the probability of non-replication by chance due to the number of readings made must be low. If, after all this, the estimated probabilities are low for all possible reasons of non-replication, then the probability of replication should be high. This assumes of course that all the reasons for non-replication have been considered and shown to be improbable!
If the probability of replicating a study result is high, the reader will consider the possible explanations or hypotheses for that study finding. Ideally the list of possibilities should be complete. However, in a novel scientific situation there may well be some explanations that no one has considered yet. This contrasts with a diagnostic situation where past experience tells us that 99% of patients presenting with some symptom have one of short list of diagnoses. Therefore, the probability of the favoured scientific hypothesis cannot be assumed to be high or ‘confirmed’ because it cannot be guaranteed that all other important explanations have been eliminated or shown to be improbable. This partly explains why Karl Popper asserted that hypotheses can never be confirmed – that it is only possible to ‘falsify’ alternative hypotheses. The theorem of probable elimination identifies the assumptions, limitations and pitfalls of reasoning by probable elimination.
Reasoning by probable elimination is central to medicine, science, statistics and other disciplines. This important method should have a central place in education.
Huw Llewelyn is a general physician with a special interest in endocrinology and acute medicine, who has had a career-long interest in the mathematical representation of the thought processes used by doctors in their day to day work during clinical practice, teaching and research. He has also been an honorary fellow in mathematics in Aberystwyth University for many years and has had wide experience in different medical settings: general practice, teaching hospital departments with international reputations of excellence and district general hospitals in urban and rural areas. His insight is reflected in the content of the Oxford Handbook of Clinical Diagnosis and the mathematical models in the form of new theorems on which that content is based.
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