Letters

diagnosis debate – attack or thoughtful critique? FOR FULL LETTERS PAGES, DOWNLOAD PDF.

Distortions and maps of wonderland
Given the importance they attach to evidence, it is surprising that Essi Viding and Uta Frith (Letters, June) should use the words ‘attacking the DSM-5’, implying both aggression and lack of justification, for what is in fact a thoughtful, evidence-based statement by the Division of Clinical Psychology (DCP) on psychiatric classification.
In criticising the statement and subsequent ‘pronouncements in the media’, Viding and Frith present the current situation in mental health as one led by evidence, in which researchers and clinicians take due account of both environmental and biological factors in understanding ‘the symptoms that mark mental illness’. This is far from the case. For the last 30 or 40 years, research and practice in this area has been dominated by approaches which privilege genes and biology, depict emotional and behavioural problems as akin to physical illnesses, and systematically de-emphasise the potential causal role of people’s socialand personal contexts. This is in spite of a poor evidence base for all three of these stances. This situation itself has a social context, which may help explain both its persistence and the strength of feeling often evoked by attempts at change (Boyle, 2011; Cromby et al., 2013; Pilgrim, 2007).
And contrary to Viding and Frith’s claims, the DCP argument is not based on a ‘false dichotomy between genes and environment’. It does position itself for a reconceptualisation of the role of biology and against a model that sees mental, emotional and behavioural difficulties as symptomatic of biologically based illness. It also argues for due acknowledgement of the vast amount of evidence that many of these difficulties are meaningful responses to often extremely challenging life circumstances.
Finally, Viding and Frith imply that those who claim a causal link between child abuse and ‘schizophrenia’ are ‘not slowed down by a need for an evidence base, but instead irresponsibly make unsubstantiated and alarmist pronouncements’. This is completely unjustified. There is good evidence, some of it cited in the DCP statement, that the links between child abuse and psychosis are likely to be causal, and such claims are not made lightly. This evidence may be difficult for many to hear and unfortunately, Viding and Frith’s ad hominem response, rather than one engaging with the evidence, is not untypical.
I hope the DCP statement will encourage truly informed debate on these issues to the benefit of researchers, clinicians and, above all, service users themselves.
Professor Mary Boyle
University of East London


References
Boyle, M. (2011). Making the world go away, and how psychology and psychiatry benefit. In Rapley, M., Moncrieff, J. & Dillon, J. (Eds.) De-medicalising misery. London: Palgrave Macmillan.
Cromby, J., Harper, D. & Reavey, P. (2013). Psychology, mental health and distress. London: Palgrave Macmillan.
Pilgrim, D. (2007). The survival of psychiatric diagnosis. Social Science & Medicine, 65, 536–547.

We welcome contributions to the debate that has been raised by the DCP Position Statement on Classification. The statement is not about DSM specifically but about conceptual systems ‘based on a “disease” model’. This would include ICD. Nor do we see it as an ‘attack’ but as a thoughtful critique based on a two-year process of reviewing the evidence and consulting within all the DCP Faculties, where it has widespread support.
It is difficult to convey a complex argument through the media. We regret that some of the reporting has badged this as a psychiatry versus psychology battle. We have been working hard to counter this. The statement itself makes it absolutely clear that, to quote: ‘This position should not be read as a denial of the role of biology in mediating and enabling all forms of human experience, behaviour and distress… It recognises the complexity of the relationship between social, psychological and biological factors’ (p.2).
We are unhappy with responses that, quite wrongly, represent us as presenting ‘a false dichotomy between genes and environment’ and hope that all members of the Society will take the opportunity to correct such misinterpretations. Nevertheless, our position, supported by  a great deal of evidence, is that it is neither accurate nor helpful to conceptualise the experiences that may lead to a functional psychiatric diagnosis within a ‘disease’ model, in which biological causal factors such as genes or biochemistry are hypothesised to be the primary causal ones. We do not do this for other responses to life events – for example, bereavement – and by analogy, our argument is that the increasing amount of evidence for the causal role of all kinds of traumas and life circumstances in psychiatric breakdown makes it implausible to do so in many of these cases as well. The DCP is, in conjunction with the BPS Media Centre, monitoring the media coverage closely and working to correct any distortions of our message.
The point is well made that we need to explore the possibility of alternative clustering systems, and internationally there are a number of groups engaged in this task. The DCP has funded its own project to outline the principles of an approach that identifies common patterns of responses, both psychological and biological, to life events and social circumstances, and that might supplement and support the use of individual formulation.
Clearly, the existing classification system will be with us for some time. However, the DCP believes that it is vitally important to ‘achieve greater openness and transparency about the uses and limitations of the current system’ and ‘to open up dialogue with partner organisations, service users and carers, voluntary agencies and other professional bodies in order to find agreed ways forward’ (p.4).
Richard Pemberton
Chair, BPS Division of Clinical Psychology 

Professors Viding and Frith (Letters, June 2013) excoriate critics of DSM-5 who, they say, ‘are in danger of muddying mental health issues by ignoring… biology’. They write approvingly of Simon Wessely’s Observer article (12 May 2013) and endorse his claim that ‘a classification system is like a map. And just as any map is provisional, ready to be changed as the landscape changes, so is classification.’
Let me outline how history illustrates the value of this metaphor of mapping the mind.
In 1952, when the first Definitely Scientific Map (let’s call it ‘DSM-1’) was published, only 106 cartographic entities were in the atlas. A good index of the success of the cartographers of the mind is the phenomenal productivity of their subsequent explorations – new islands, continents, rivers, mountain ranges, swamps, and so on, were added, and although many old ones were thrown out they achieved an average rate of increase over the next 42 years of close to one every eight weeks: DSMap-4 (1994) showed 365 entities.
How had they achieved this fecundity? Untiring effort was the answer. Year in, year out their exploration vessels sailed the seven (7.34 ± 1.56) seas, proudly flying the Cartographers’ flag, a banner inscribed ‘BP’. (Crew members gave different answers when asked what the letters stood for: ‘Big Pharma’, said some, ‘Big-time Psychiatry,’ said others, but the groups worked together as one big happy family regardless).
It was not always smooth sailing. For example, when explorers sent descriptions of the landscape to the head office of the Cartographers of the Mind Association (CoMA) for official rulings, one might be told that a tenant was on Mount Skitzos while a second tenant in the same building was on the Isle of Catatonia, a third on Lake Normalia.But none of this impeded the enlightened help BP could provide to the inhabitants – the holds of the vessels of exploration were brimming with curative chemicals that were equally effective everywhere on the Map.
There were of course sceptics, people who thought, for example, that it might be more effective to build warm buildings in (bi?) polar regions instead of filling inhabitants with chemicals that made them complain less about the cold. As a gesture of goodwill (and to try to rid themselves of the distractions of repetitive complaints), exploration vessels started to carry small amounts of building material, pumps to drain swamps, and so on. CoMA itself even professed to subscribe to a Bio-Psycho-Social model of disorder: their banners accordingly now read ‘BPS’ not ‘BP’. (This new image has perhaps brought to light a little-researched version of the Stockholm syndrome, with scientists who are not members of the BP team taking up cudgels on the team’s behalf).
Sceptics even argued that the metaphor itself is flawed. Geographic cartographers, they say, draw representations of things we are reasonably sure exist independently ofthe maps drawn of them: mountains, islands, and so on, they disingenuously claim, are real. DS Maps of mental disorders, they say, are different. They are not representations of realities: the entities they purport to describe are constructions of the minds of Cartographers of the Mind. They are Maps of Wonderland.
Professor Justin Joffe
London N2


The American critic H.L. Mencken once remarked, ‘For every subtle and complicated question, there is a perfectly simple and straightforward answer, which is wrong’. The question of how to respond to psychological distress is subtle and complicated. The answer that has dominated recent Western thinking, namely
that there exist mental illnesses and that these are illnesses like any other, has the virtue of being simple and straightforward. But it may also be wrong – or at least, partial, misleading and, in some cases, actively unhelpful.
The DCP’s recent statement is to be commended for not trying to replace one ‘simple, straightforward and wrong’ answer with another. The document acknowledges the subtle and complicated nature of the issues. Contrary to what some commentators have suggested, it does not pit clinical psychology against psychiatry or deny the role of biology – indeed, it states explicitly that what is required is ‘multi-factorial and contextual approach, which incorporates social, psychological and biological factors’. It highlights problems with the current system of classification, but does not object to classification per se. It offers no off-the-shelf alternative, calling instead for wide-ranging dialogue to develop new approaches. Even the document’s most striking suggestion, a move away from the system of diagnosis described by the DSM-5, is hardly radical. Similar arguments have recently been made by influential and mainstream groups such as Mental Health Europe (see tinyurl.com/bqdgos9) and the US National Institute for Mental Health (see tinyurl.com/cl5ekbc).
That such a measured and non-polemical statement should provoke howls of outrage perhaps tells us something about the tenuous foundations of the medical model. If proponents had the confidence of their convictions they would have nothing to fear from – indeed would welcome – critical interrogation. By contrast, those who raise problems with diagnosis, or with the concept of mental illness as such, are accused of ‘anti psychiatry prejudice’ and of having no interest in relieving suffering (see tinyurl.com/no88tpb). Most baffling of all is the response that criticising diagnosis is somehow anti-scientific – particularly absurd when, as the DCP statement makes clear, many of the difficulties of the DSM arise from a failure to follow the scientific method.
Although the DCP statement makes no new arguments, it performs a valuable service by bringing vital critiques of the medical model of mental illness to wider public attention. Personally, I am proud to see the BPS finding its voice and raising subtle and complex questions.
Dr Sam Thompson
Institute for Psychology, Health and Society
University of Liverpool

Methodological shortcomings of biological research 

I read with interest Essi Viding and Uta Frith’s response to the DCP’s recent statement concerning DSM-5. They write that the DCP representatives are ‘in danger of muddying mental health issues by ignoring the biology’ and that ‘their present stance will fail to deliver help for those who suffer from mental health problems’. I thought this was a curious response, given the outright failure of behaviour genetics research over several decades to benefit service users in any way whatsoever. This failure to deliver anything of use to those on the sharp end should not be considered surprising given that the case for a genetic basis for the behaviours and experiences which are categorised as serious mental illness has been vastly over-stated.
A recurrent feature in this work has been the poor reliability of diagnostic categories, absence of biological markers and an automatic interpretation that data from twin and family studies favour a genetic interpretation when in actuality the greater genetic similarity of MZ twins compared to DZ twins is confounded by their greater shared environment. It is simply not the case that the equal environments assumption can be so blithely ignored or that the use of structural equation modelling as a research tool can circumvent the problems. It is well known – or at least ought to be – that in any multivariate model where there are two potential predictors of an outcome of interest and these are strongly related (as is the case for genetic similarity and degree of shared environment in twin studies) the one which is measured with greater precision will seem to be the more strongly related with the outcome than is actually the case (Davy Smith & Phillips, 1996; Phillips & Davy Smith, 1991).
Twin studies incorrectly interpreted have led researchers to expect huge genetic effects that have simply not materialised in molecular genetics research. The recent ‘breakthroughs’ proposing a common genetic pathways in five psychiatric disorders for example (Cross-Disorder Group of the Psychiatric Genomics Consortium, 2013) is but one example. The authors were only able to explain between 1 and 2 per cent of the variance in any of the target disorders (ADHD, ASD, bipolar disorder, major depressive disorder, and schizophrenia) with the expressed possibility that their results could have been inflated by diagnostic overlap. Given the sample size they used (over 30,000) the findings may have no clinical significance whatsoever.
Their preference for biological theorising made clear, Viding and Frith, with a rhetorical wave of the hand, then refer to ‘unsubstantiated and alarmist pronouncements about child abuse causing schizophrenia’. That child sexual abuse is a risk factor for almost all forms of ‘psychopathology’ (including schizophrenia) is not unsubstantiated but is in fact well attested by a large body of research (e.g. Roberts et al., 2004). Viding and Frith are of course correct to point out that current interventions (both medical and psychological) are far from effective, but that situation is not likely to improve until the poor track record and methodological shortcomings of biological research in mental health is acknowledged.
Ron Roberts
Kingston University


References

Cross-Disorder Group of the Psychiatric Genomics Consortium (2013). Identification of risk loci with shared effects on five major psychiatric disorders: A genome-wide analysis. Lancet, 381, 1371–1379.
Davey Smith, G. & Phillips, A.N. (1996). Inflation in epidemiology: ‘The proof and measurement of association between two things’ revisited. British Medical Journal, 312, 1659–1661.
Phillips, A.N. & Davey Smith, G. (1991). How independent are ‘independent’ effects? Relative risk estimation when correlated exposures are measured imprecisely. Journal of Clinical Epidemiology, 44(11), 1223–1231.
Roberts, R., O’Connor, T.G., Dunn, J. et al. (2004). The effects of child sexual abuse in later family life: Mental health, parenting and adjustment of offspring. Child Abuse & Neglect, 28(5), 525–545.

Stepping from the shadow

We are writing to commend the immediate and comprehensive use of the DCP statement on formulation to all of our colleagues. It has appeared at the very time when the shortcomings of psychiatric diagnosis have been exposed in the critical international response to the publication of DSM-5 by the American Psychiatric Association. Our current context then provides the profession of clinical psychology with a unique historical opportunity to adopt a clear position of scientific humanism.
DSM and other forms of psychiatric nosology are incompatible with a psychological approach to helping people with their problems, which should be both humane and scientific. Our approach to helping others should be based on identifying specific problems (defined by clients themselves but, for obvious practical purposes reflecting a common lexicon) and working with them to develop individual and context-bound formulations. These would include the unique events in a person’s life past and present, the meanings they invest in, or attribute to, those events and strengths to build upon that he or she has exhibited to date in coping with challenges in their life.
David Pilgrim
Professor of Health and Social Policy

Peter Kinderman
Professor of Clinical Psychology
Richard Bentall
Professor of Clinical Psychology
University of Liverpool

As 210 clinical psychologists and mental health professionals, we support the DCP’s call for a paradigm shift in how we think about mental distress and the need to move away from psychiatric diagnosis. We are pleased by the media coverage and the debate this has stimulated in the wider public.
It is essential that diverse voices are heard and that rather than considering individuals as receptacles of disorders, deficits and distortions, we make sense of distress in more helpful and evidence-based ways. We need to focus far more on people’s lives, experiences and social contexts and to consider how people embody and are shaped by the world around them.
We note that organisations such as the Hearing Voices Network and Mental Health Europe, which represent the service-user perspective, have recently challenged the diagnostic and professional expert-driven status quo, and we believe that clinical psychology needs to support and work with these groups. We need to step out from the shadow of biological reductionism and consider the multifaceted nature of what it is to be human and to be part of the world around us. We wish to support the DCP and the growing number of service users, carers, professionals and organisations who are questioning the dominant paradigm.
This is a very important step for the profession and one that is long overdue.
Dr Mel Wiseman
Wellingborough
 

with: Dr Aayesha Mulla, Clinical Psychologist; Aiden Kelly, Trainee Clinical Psychologist; Dr Alexis Berry, Clinical Psychologist; Alice Liddle, Trainee Clinical Psychologist; Alice Reid-Williams, Assistant Psychologist; Dr Alison Lauder, Clinical Psychologist; Allyson Edmunds, Counsellor in the NHS; Alyson Williams, Psychotherapist in Primary Care; Dr Andrew Newmnan, Clinical Psychologist; Dr Andrew Vidgen, Consultant Clinical Psychologist; Dr Angela Byrne, Clinical Psychologist; Dr Anna Lagerdahl, Clinical Psychologist; Annie Mitchell, Clinical Director Doctorate in Clinical Psychology, University of Plymouth; Anna Perrin, Clinical Psychologist; Dr Anna Pollock, Clinical Psychologist; Dr Annabel Ivins, Clinical Psychologist; Annabel Denney, Trainee Clinical Psychologist; Anne Cook, Principal Lecturer Canterbury Christchurch University; Dr Anwen Pugh, Clinical Psychologist; Prof Arlene Vetere, Deputy Director PsychD University of Surrey; Arupita Roy, Clinical Psychologist; Dr Bea Verastegui, Clinical Psychologist; Dr. Beth Greenhill, Senior Clinical Tutor, University of Liverpool; Bob Diamond, Clinical Psychologist/Academic Tutor Trent Clinical Doctorate; Bronwen Davies, Trainee Clinical Psychologist; Cailzie Dunn, Clinical Psychologist; Dr Caroline Morgan, Clinical Psychologist; Caroline Rake, Consultant Clinical Psychologist; Dr Catherine Taylor, Clinical Psychologist; Celia Heneage, Clinical Psychologist; Dr Cerith Waters, Clinical Psychologist; Dr Cathryn Young, Clinical Psychologist; Cheryl Bullion, Trainee Clinical Psychologist; Dr Chris Pitts, Clinical Psychologist; Christian Williams, Trainee Clinical Psychologist; Christina Rowe, Trainee Clinical Psychologist; Dr Clare Marriott, Clinical Psychologist; Dr Colleen Nasir, Clinical Psychologist; Dr Damian Gardner, Consultant Clinical Psychologist; Dr Danny Taggart, Lecturer in Clinical Psychology University of Essex; Dr Darren Baker, Clinical Psychologist; Dr David Harper, Reader in Clinical Psychology, University of East London; Dr David Ward, Clinical Psychologist; Prof David Winter, Prof. Clinical Psychology University of Hertfordshire; Dr Elanor Grant, Clinical Psychologist; Dr Elanor Maybury, Clinical Psychologist; Dr Eleanor Shoultz, Clinical Psychologist; Dr Ellie Taylor, Clinical Psychologist; Dr Emmie Williamson, Clinical Psychologist; Dr Evangelia Karydi, Counselling Psychologist; Fabio Tartarini, Psychologist MBPS; Dr Freddy Jackson Brown, Clinical Psychologist; Dr Farhana Patel, Clinical Psycologist; Fiona Williams, Psychological Therapist; Gabrielle Farran, Trainee Clinical Psychologist; Gareth Morgen, Clinical Psychologist; Dr Garry Brownbridge, Consultant Clinical Psychologist; Gemma Cody, Trainee Clinical Psycholoigst; Dr Gemma Dexter, Clinical Psychologist; Gemma Smith, Assistant Psychologist; Gilli Watson, Associate Professor Doctorate of Clinical Psychology, University of Plymouth; Dr Gillian Bowden, Consultant Clinical Psychologist; Dr Hanne Fisher, Clinical Psychologist; Hazel Barker, Trainee Clinical Psychologist; Hazel Mills, Clinical Psychologist; Dr Helen Combes, Clinical Psychologist; Dr Helen Millar, Clinical Psychologist; Dr Helen Mitchell, Clinical Psychologist; Dr Helen Westbury, Clinical Psychologist; Hilary Priestman, Clinical Psychologist; Isabel Clarke, Chair of  Psychosis and Complex Mental health Faculty; Jade Ark, Trainee Clinical Psychologist; Dr Jane Spurr, Clinical Psychologist; Dr James Bourne, Clinical Psychologist; Dr James Brennan, Consultant Clinical Psychologist; James Rathbone, Trainee Clinical Psychologist; James Peddie, Trainee Clinical Psychologist; Janet Shelmerdine, Consultant Clinical Psychologist; Dr Janine Soffe-Caswell, Clinical Psychologist; Dr Jasmine Chin, Clinical Psychologist; Dr Jay Watts, Clinical Psychologist; Jennie Boland, Clinical Psychologist; Dr Jenny Maslin, Clinical Psychologist; Dr Jennifer Moses, South Wales Doctorate in Clinical Psychology Cardiff University; Jenny Stuart, Trainee Clinical Psychologist; Dr Jenny Svanberg, Consultant Clinical Psychologist; Dr Jo Brown, Clinical Psychologist; Jo Timms, Clinical Psychologist; Johanna Goll, Trainee Clinical Psychologist; John Cartmell, Trainee Clinical Psychologist; John Cromby, Loughborough University; Dr Jon Crossley, Clinical Psychologist; Dr John McGowan, Academic Director Applied Psychology Canterbury Christchurch University; Kara Bagnall, Trainee Clinical Psychologist; Katie Snow, Trainee Clinical Psychologist; Dr Kath Roberts, Clinical Psychologist; Dr Katherine Huke, Clinical Psychologist; Dr Katherine Johnson, Principal Lecturer in Psychology, University of Brighton; Katherine Miller, Assistant Psychologist; Katherine Regan, Trainee Clinical Psychologist; Dr Kate Danvers, Chartered Psychologist; Kate Gauci, Consultant Clinical Psychologist; Kate Ward, Trainee Clinical Psychologist; Dr Kathy Fordham, Clinical Psychologist; Dr Katie Williams, Clinical Psychologist; Dr Katrina Jones, Clinical Psychologist; Dr Kirsty Smedley. Consultant Clinical Psychologist; Dr Laara Jupp, Clinical Psychologist; Dr. Laura Golding, Academic Director D.Clin.Psychol. Programme The University of Liverpool; Dr Laura Hickman, Clinical Psychologist; Laura O'Halloran, Trainee Clinical Psychologist; Dr. Leanne Nicholls, Clinical Psychologist; Lesley Hitchman, Consultant Clinical Psychologist; Lin Harrison, Senior Psychotherapist; Lisa Fensom, Clinical Psychologist; Lisa Cant, Clinical Psychologist; Dr Lisa Thorne, Clinical and Community Psychologist; Lizette Nolte, Clinical Lecturer/Clinical Psychologist University of Hertfordshire; Dr Lucie James, Clinical Psychologist; Lucie Nalletamby, Trainee Clinical Psychologist; Lucy Hepworth, Art Psychotherapist; Dr Lucy Parkin, Clinical Psychologist; Dr Lucy Weaving, Highly Specialist Clinical Psychologist; Mandy Walsh, Psychotherapist; Dr Maria Castro, Senior Lecturer, Doctorate In Clinical Psychology University of East London; Dr Marian Liebmann, Art Psychotherapist; Dr Maggie Cormack, Clinical Psychologist; Margaret Oke, Consultant Clinical Psychologist; Dr Mark Wylie, Clinical Psychologist; Dr Martin Rimmer, Clinical Psychologist; Dr Mary Griggs, Clinical Psychologist; Dr Matilda West, Clinical Psychologist; Matt Bristow, Trainee Clinical Psychologist; Matt Spencer, Trainee Clinical Psychologist; Dr Matthew Faull, Clinical Psychologist; Dr Mel Wiseman, Clinical Psychologist; Dr Melanie Jewell, Counselling Psychologist; Michele Roitt, Clinical Psychologist and Psychoanalyst; Dr Michelle Desmier, Clinical Psychologist; Dr Miltos Hadjiosif, University of East London; Dr Mike Rennoldson, Academic Tutor Trent DClinPsy University of Nottingham; Dr Mike Ridley-Dash, Clinical Psychologist; Dr Miranda Roberts, Clinical Psychologist; Dr. Monika Tuite, Clinical Psychologist; Dr Morwenna Roberts, Clinical Psychologist; Dr Nancy Vanderpuye, Clinical Psychologist; Dr Naomi Swift, Clinical Psychologist; Natalie Barazzone, Trainee Clinical Psychologist; Dr Nenna Ndukwe, Clinical Psychologist; Dr Nick Horn, Clinical Psychologist; Nicky Bundy, Assistant Psychologist; Dr Nicola Clisby, Clinical Psychologist; Nicola Motton, Trainee Clinical Psychologist; Dr Olivia Donnelly, Clinical Psychologist; Olivia Fakoussa, Trainee Clinical Psychologist; Dr P.O. Svanberg OBE, Consultant Clinical Psychologist; Paul Hollingworth, Trainee Clinical Psychologist; Paul Moloney, Counselling Psychologist; Dr Penny Leroux, Clinical Psychologist; Dr Penny Priest, Clinical Psychologist; Peter Elliott, Programme Director in Clinical Psychology University of Southampton; Dr Phil Anscombe, Clinical Psychologist; Philip Byrne, Trainee Clinical Psychologist; Dr Philip Houghton, Clinical Psychologist; Dr Rachel Potter, Clinical Psychologist; Rebecca Mills, Trainee Clinical Psychologist; Dr Rebecca Murphy, Clinical Psychologist; Prof Reg Morris, Programme Director South Wales Programme Clinical Psychology; Dr Rona Aldridge, Clinical Psychologist; Dr Rosemary Ingleton, Clinical Psychologist; Prof. Rudi Dallos, Research Director DClinPsy, University of Plymouth; Dr Sadie Thomas-Unsworth, Clinical Psychologist; Sally Pugh, Trainee Clinical Psychologist; Sally Zlotowitz, Clinical Psychologist; Sara Jenkins, Consultant Clinical Psychologist; Dr Sarah Baldry, Senior Lecturer in Clinical Psychology, University of Plymouth; Dr Sarah Bradley, Clinical Psychologist; Dr Sarah Davidson, Deputy Clinical Director ClinPsyD UEL; Dr Sarah Keenan, Clinical Psychologist; Dr Sarah Lack, Clinical Psychologist; Sarah Masson, Trainee Clinical Psychologist; Sarah Perkins, Occupational Therapist Outreach Practitioner; Dr Sarah Wallis, Clinical Psychologist; Dr Sarah Zohhadi, Clinical Psychologist; Dr Sasha Lillie, Clinical Psychologist; Dr Shane Matthews, Clinical Psychologist; Dr Simon Downer, Psychiatrist; Simon Mudie, Service User and Carer Representative; Dr Simon Platts, Clinical Psychologist; Dr Stella Christofides, Clinical Psychologist; Steph Wilson, Trainee Clinical Psychologist; Dr Steve Melluish, Clinical Psychologist; Prof. Steve Onyett, Associate Professor University of Exeter; Dr Stu Brooke, Clinical Psychologist; Sue Breton, Consultant Clinical Psychologist; Dr Sue Knowles, Clinical Psychologist; Susan Cox, Clinical Psychology Admin Support; Dr Susan Elliott, Clinical Psychologist; Dr Suzanne Elliott, Clinical Psychologist; Dr Tamzin Haile, Clinical Psychologist; Tessa Hughes, Trainee Clinical Psychologist; Dr Theresa White, Clinical Psychologist; Toni Hoefkens, Consultant Clinical Psychologist; Dr Vannessa Tobin, Clinical Psychologist; Victoria Smalley, Clinical Psychologist; Dr Vik Nair, Clinical Psychologist; Dr Virginia Lumsden, Clinical Psychologist; Wendy Solomans, Clinical Psychologist; Dr Yvonne Waft, Clinical Psychologist; Dr Heledd Davies


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