Not just p-values and confidence intervals

It was actually while I was training to become a preschool teacher that I started my fascination with, and in hindsight, my commitment to psychological science. I remember learning about Milgram’s (1963) obedience studies, Zimbardo’s (1971) prison experiment, Asch’s (1951) conformity research, and, of course, Rosenhan’s (1973) “On being sane in insane places”. As a young adult I was thoroughly impressed by the way in which these studies seemed to use novel and clever procedures to powerfully demonstrate fundamental principles that were broadly applicable. Later, I came to more fully understand some of the methodological flaws and nuances to these studies but, limitations aside, they remain potent demonstrations of the learning we are afforded about human nature through psychological science.

By learning about this research, I became impressed with the power of innovation and curiosity. It seemed to me at the time that it would be an incredible privilege to have the opportunity to conduct research about an important area of human nature that produced results that were surprising or counterintuitive. Setting out on a program of systematic investigation in which the answers at the outset are genuinely unknown, and where there is some risk in what the eventual results might be, is perhaps as close as we can get in modern times to the brave explorers of centuries ago. For me, then, psychological science came to initially represent bold curiosity, innovation, and a sense of excitement at discovering something new and important. I saw psychological science as an area in which boundaries could be tested for the opportunity to learn more about ourselves and how we might be able to live together more harmoniously. It was from these pioneering studies that I also began to get some inkling of the scope of psychological science and the vast spectrum of areas in which it could be used to assist all human endeavours.

Starting out

After completing training as a preschool teacher and then, subsequently, a special education teacher, I continued to be drawn to psychological science. While working with severely to profoundly handicapped students I relied heavily on Skinner’s (1953) behavioural principles. Initially, I was enthusiastic about the principles Skinner elucidated and diligently applied these concepts to the programs I was developing with my students. It was only later, as I sought to learn more about these behavioural principles and develop greater expertise in this area, that I discovered some subtleties and caveats to Skinner’s research. For example, I learned that in order for Skinner’s reinforcement schedules to work in his studies, he had to ‘prepare’ his rats prior to engaging them in the research activities. Preparing them involved reducing their body weight to 70 per cent of their normal feeding body weight. Essentially, this meant they were hungry when they entered the research apparatus. It is probably not so remarkable that a hungry rat will press a bar to obtain food, but the more important general principle I discovered from this work was that deprivation is a necessary component of any reinforcement program. That is to say, if Person A wants to use a reward or a reinforcer to control Person B’s behaviour, Person A has to find something that Person B wants, and then has to ensure that Person B doesn’t have enough of that something and can’t get enough of the something except by doing what Person A wants.

Another feature of the behavioural principles that Skinner spent a great deal of time studying that didn’t ever receive very much attention was the phenomenon of countercontrol. Skinner (1953) stated that “Because of the aversive consequences of being controlled, the individual who undertakes to control other people is likely to be countercontrolled by all of them” (p. 321). Moreover, an individual who countercontrols “may show an emotional reaction of anger or frustration including operant behavior which injures or is otherwise aversive to the controller” (p. 321).

I was so intrigued by the concept of countercontrol that it became the subject of my PhD research. I wondered whether some children who currently attract diagnoses such as conduct disorder or oppositional defiant disorder might actually be countercontrollers. With the inspiration of some of the early giants of psychological science, I set out to investigate the extent to which 10 to 12 year-old primary school students might countercontrol their teachers. To the best of my knowledge this had never been done before and the results were unknown at the outset. I’m pleased to report that some of the results I obtained were both surprising and counterintuitive (Carey & Bourbon, 2005).

By the time I finished my PhD I had completed the same training in statistics and research methods as other psychologists which equipped me to engage in the conduct of research. My greatest discovery, however, during my postgraduate training, was to learn about the scientist-practitioner model. When I encountered this model in the first year of my PhD in Clinical Psychology I felt like I had come home. The idea of being both a scientist and a practitioner seemed to me to be the most obvious and natural way to work. The ability to simultaneously engage in practice and research was, for me, the best of both worlds. It still is.

Through my training, psychological science came to represent not some vague, nebulous concept, but something in which anyone with a curious mind, a bold spirit, and an understanding of basic psychological principles could engage. I was aware that psychological science was not perfect and was certainly no guarantee of rigour or an impartial attitude. With my shiny new PhD, however, I did think that if a sound psychological process was followed, and the findings of one’s research were available for peer-review and independent scrutiny, then the results could be judged on their merits.

An imperfect science

After my PhD, I worked in Scotland as a Chartered Clinical Psychologist in a rural primary care service of the National Health Service. Without ever planning to, I became interested – to the point of obsessed – with why we structure treatments the way we do. During my two-week orientation period in the psychology department in which I worked, my supervisor told me that it was standard to schedule fortnightly appointments. This seemed odd to me and I wondered why weekly appointments were not arranged. The important context here is that, when I first started working in this department, there was a 15-month waiting list for adults who were referred to have their first appointment scheduled. Exercising my curiosity about whether weekly or fortnightly schedules were best, I embarked on an extensive search of the literature to accumulate the available evidence. As the search continued, my curiosity expanded to include a quest to understand how the numbers for any particular protocol of treatment were derived. Why, for example, do we have 16 sessions of cognitive behaviour therapy (CBT) or interpersonal psychotherapy (IPT)?

My curiosity and lengthy searching were rewarded with nothing. In other words, what I discovered was that there was no rationale for any particular number of sessions or for any particular appointment frequency (Carey, 2005). While there were mountains of evidence demonstrating that treatments of particular lengths could be effective, on average, for different groups of participants, there were no studies demonstrating that a particular treatment length was necessary for effectiveness. I realised that an error in reasoning had developed. Indeed, that error continues to the present time with the idea that certain disorders require particular treatment lengths for effective treatment. Errors such as this can have important consequences.

In the United Kingdom, for example, the National Institute for Health and Clinical Excellence (NICE) recommends that, “For all people with depression having individual CBT, the duration of treatment should typically be in the range of 16 to 20 sessions over three to four months” (National Institute for Health and Clinical Excellence, 2009, p. 28). This is a remarkable statement given that the evidence indicates that, in routine clinical practice, people typically attend fewer than 10 sessions with average attendance of approximately five sessions (Carey, 2011). A situation has been created, therefore, in which practitioners could feel undue pressure to retain people in treatment much longer than is required for most people. There are also substantial and unnecessary costs involved in resourcing a service to be able to provide 16 to 20 sessions when less than 10 will be required for the vast majority of people accessing the service.

It was through this exploration that I first began to see most explicitly that results of psychological science could be used for different political purposes. Still, being a quite recent PhD graduate, I was naïve to the fact that all science is situated within a political context. Perhaps the importance of context explains why the ideas of deprivation and countercontrol from Skinner’s work have not become more widely known.

A patient-led model

Given that I could find no compelling evidence to suggest an ideal treatment length or treatment frequency, I wondered what would happen if I did nothing. That is, I was curious as to what might happen if patients, rather than therapists, determined when appointments occurred. Again, I found no published research or other documentation to provide advice with regard to this approach so I began to study it. Since I was working in the NHS I had the freedom to see patients as often as they wanted for as long as they wanted. So, in the GP practices within which I worked, I established systems enabling patients to book appointments to see me in the same way that they would book appointments to see a GP. At the end of an appointment, I would not know when I would see this person again. From the time I commenced this way of working, I began collecting data and I conducted a series of evaluations of this approach. I called this approach “patient-led appointment scheduling”.

As I developed the patient-led model of appointment scheduling, some colleagues recognised the merits of this initiative and joined my efforts to implement and evaluate this innovation to treatment scheduling. Over a series of evaluations we discovered that, with patient-led appointment scheduling, we had fewer missed and cancelled appointments as well as increased service capacity (Carey 2005; Carey & Mullan, 2007; Carey & Spratt, 2009; Carey, Tai, & Stiles, 2013). Patients, generally, did not overuse the service. Instead, patients scheduled appointments at times that were convenient to them to work through the difficulties they were experiencing. The outcomes we obtained were impressive when benchmarked against other studies of routine clinical practice outcomes (Carey et al., 2013).

The results of the patient-led appointment scheduling work were tangible and dramatic. In one GP practice we almost doubled the number of referrals over a six-month period while simultaneously eliminating a seven-month waiting list (Carey & Spratt, 2009). Across the district, whereas there had been a 15-month waiting list when I started, five years later there was no waiting list, even though only a small number of the staff were using patient-led appointment scheduling. As promising as this work seemed to be, it has not generated the interest that might be expected.

I learned during this time that psychological science can produce important results but whether or not those results are attended to relies on a multiplicity of factors. Psychological science is not perfect. Sometimes research conducted under the guise of psychological science can produce results that are uncomfortable or inconvenient and sometimes, rather than using research to discover something new, the mechanics of experiments and other investigations can be used to provide particular findings that the researcher had in mind before the project even started.

A science that can transform lives

Despite the fact that psychological science might not always be used for noble purposes, there are stunning examples of what can be achieved. The work of Bruce Alexander (2010) in establishing and investigating Rat Park is a striking example of the way in which psychological science can challenge the status quo and point to more optimistic but also more confronting horizons. Alexander’s work challenged the notion that addiction was an illness or a disease and, instead, proposed that problems of addiction had social and psychological foundations which implied entirely different efforts to address the problem. Again, Alexander’s work has been criticised on methodological grounds, however, the fundamental message of addiction not being solely a feature of an individual’s biochemistry but being heavily influenced by the life circumstances of the individual is an important message.

As a devotee, I’ve learned that psychological science can be considered to be a process of discovering what is right or what is most right at the current time based on the best available evidence. I’ve also discovered that ‘right’ is a relative concept and rarely has universally accepted standards. Engaging wholeheartedly in psychological science suggests one should be able to tolerate uncertainty and ambiguity. It also implies that one should be able to think critically and stand apart from common views or popular beliefs. Divergent ideas are frequently expressed and tolerated. Sometimes, though, erroneous ideas can become entrenched.

As previously discussed, the notion of a certain number of sessions for particular disorders is one of these beliefs. Another is the attitude that randomised controlled trials (RCTs) represent a gold standard of research. This view persists and influences the way in which research questions and hypotheses are expressed despite firm opinions to the contrary. Jadad and Enkin (2007), for example, “believe that the still present tendency to place RCTs at the top of the evidence hierarchy is fundamentally wrong. Indeed, we consider the very concept of a hierarchy of evidence to be misguided and superficial. There is no ‘best evidence’, except in reference to particular types of problem, in particular contexts” (p. 106).

Despite its imperfections, psychological science has the potential to transform social living and to produce solutions to some of our most vexing intra- and interpersonal problems. Psychological science provides the opportunity to identify problems, pose important questions, and pursue systematic methods of finding answers to those questions. Being a member of the APS has provided me with a psychological science community where I can work with others in promoting the benefits of psychological science for society.

Fostering psychological science opportunities

In my role as Director on the Board of the APS I have the privilege of co-chairing the Division of Psychological Research, Education, and Training (DPRET). This role has afforded me the opportunity of spending time in the company of some of the greatest minds in the country. The APS is indeed fortunate to have within its ranks, national and international experts, across a wide range of areas of psychological science.

There are tremendous initiatives in Australia at the moment which DPRET is keen to support and engage with in the interests of furthering psychological science. Some DPRET members, for example, are key contributors to the Australian Brain Alliance which is a large consortium of highly talented researchers working together to 'crack the code' of the brain. It is encouraging and appropriate that psychology is firmly entrenched in these investigations. Unlike me, the ABA is acutely aware of the importance of political support and is making strong representations to the Federal Government to ensure the sustainability, dissemination, and impact of their work. The Million Minds Mission is another exciting Federal Government initiative which is firmly on the APS’s radar.

DPRET is very keen that psychological science is seen as a game that the whole APS family can play. Not everyone has to engage in research but, as psychologists, psychological science is the backbone of what we do. The fact that, in psychology, there is a tight link between the science and the practice, puts our profession in an unparalleled position. The APS can, should, and does, promote the work of DPRET members but, in return, DPRET members can provide valuable information to other APS member groups through their various programs of research.

In many ways, psychological science is not so different from other fields of science. In terms of the important methods and processes, for example, there is overlap with other areas of scientific endeavour. The content matter of psychological science, however, is what gives psychological researchers an unprecedented opportunity to contribute in all areas of human activity. Moreover, with an advanced understanding of the biopsychosocial model, psychological researchers have the ability to provide an integrative perspective to help us understand the ways in which findings from areas such as neuroscience and epigenetics might translate into psychological and social functioning. The power of psychological science to provide important new knowledge enabling people to thrive in their different social contexts should not be underestimated. The APS in general, and DPRET in particular, are making strong efforts to communicate this message and also to demonstrate it in explicit ways. There is still a lot of work to do. Psychology is a long way back from the front of people’s minds when national policies or important initiatives are being discussed. DPRET, however, are doing what they can to change that situation so that many more Australians are aware of the knowledge and expertise they could be harnessing for their benefit.

The author can be contacted at [email protected]