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Emerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service.People under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis.n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one’s life after trauma.Seventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions . There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% (Trauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy. While traumatic events are common in society, communities at the intersection of socioeconomic inequalities experience them at higher rates , 2. PeopHowever, encouraging findings from case series, feasibility studies and randomized controlled trials suggest that trauma-focused therapies that include memory processing are safe, acceptable, and efficacious for PTSD symptoms in psychosis –23. In lThis NICE guidance provides a helpful mandate for UK therapists to implement trauma therapies involving memory processing for psychosis. However, an implementation dilemma is that it is specific to PTSD and does not provide recommendations for how to intervene with the range of other, common trauma reactions people may experience, including trauma-related psychosis. We propose that the NICE recommended individual psychological intervention for distressing psychotic experiences, cognitive-behavioral therapy for psychosis (CBTp), can provide a helpful framework for clinicians in this regard. Whilst there is marked overlap between CBTp and tf-CBT , their key distinguishing feature is that the former addresses the sensory-perceptual experiences that drive hallucinations  and unusual beliefs, whereas the latter tends to emphasize the processing of intrusive episodic memories to ameliorate re-experiencing, the hallmark symptom of PTSD . CBTp addresses trauma consequences through collaborative development of an understanding of how trauma impacts sensory-perceptual experiences, appraisals, and their behavioral and emotional consequences, providing a validating and normalizing account which may reduce distress , 29. CogA further challenge in implementing therapy to address trauma in psychosis is whether, and how, to integrate tf-CBT and CBTp for people who have both re-experiencing and psychosis. Consecutive delivery of targeted therapies is a possibility and has been researched in a US context , 30. HowTo address the issue of how to support the range of trauma effects that may be experienced by people with psychosis, the therapy approach adopted by the PTSp clinic was formulation-based and problem-focused. This was assumed to be a potentially more acceptable approach than delivering diagnosis-based therapies consecutively and is in line with recommendations to integrate exposure within evidence-based therapies for complex populations , 34–36. n = 9)   of the fn = 9) . Therapyn = 9) . This auA mixed methods design was used, including a within-subjects repeated measures design to examine PTSD outcomes and qualitative semi-structured interviews conducted with a subgroup of participants to explore the therapy experience.The PTSp clinic was based in one of four geographical boroughs of the South London & Maudsley NHS Foundation Trust, which is culturally diverse and characterized by high levels of deprivation. The clinic’s remit was to provide specialist psychological assessment for people with psychosis who report being significantly affected by past traumatic events and, where indicated, trauma-focused therapy. The clinic had a small, part-time team, led by the first author who specializes in trauma therapies for psychosis , with input from a rotation of trainee clinical psychologists and assistant psychologists. All cases were seen by AH or a trainee clinical psychologist  under the supervision of AH. The audit was approved by the Psychosis Clinical Academic Group, South London & Maudsley NHS Foundation Trust (ref: PSYAUD 16/20).n = 6) consenting to be interviewed about their experience of therapy and giving informed consent for anonymized quotes to be used. This small sample size is acceptable given that this is the first audit of experiences of tf-CBTp in routine care, and therefore has strong “information power” with the interviewees uniquely place to give insights regarding implementation ] The TALE  was deveBoth measures assess PTSD symptom severity in relation to an identified past index (‘current worst’) traumatic event(s). The PCL-4  was initDemographic data and information on referrals, assessments, therapy, and serious adverse events (SAEs) were extracted from medical records by assistant psychologists, trainee clinical psychologists and the clinc lead and stored on the clinic database. In the tf-CBTp sample, SAEs could include deaths, suicide attempts, violent incidents (needing police involvement) and formal complaints about therapy. Any hospital admissions were also recorded.The semi-structured interview schedule was developed through reviewing previous studies of service-user experience of CBT for psychosis and in consultation with experienced therapists. The following topic areas were addressed: (1) the experience of starting therapy, (2) therapist qualities, (3) talking about past difficulties, stressful or traumatic events, (4) therapy endings and outcomes, (5) barriers to treatment, and (6) ideas for future service developments.Multidisciplinary community psychosis teams were informed of the clinic through leaflets and posters, and introductory talks given. However, due to resource constraints referrals were not regularly sought after the initial launch of the clinic. Following referral, service-users were contacted and offered an assessment with a clinical psychologist and/or trainee clinical psychologist to consider their needs and explore whether tf-CBTp might be suitable for them. During the assessment, the TALE and PCL were completed in an interview format as opposed to self-report. This was partly to reduce burden on the person, and partly to ensure that follow-up questions could be asked as required: for example, to assess whether reported problems  were associated with the person’s trauma history. The assessment took place over one or two sessions, including feedback and collaborative therapy planning. People meeting criteria for clinically significantly PTSD with re-experiencing were offered tf-CBTp, and the PCL was repeated at the end of therapy to evaluate change in PTSD symptoms. Therapy was provided by the clinical psychologist or trainee clinical psychologist who conducted the initial assessment, with no changes to the therapist once sessions had commenced. People who had completed tf-CBTp were contacted and invited to participate in an interview about their experience of receiving the therapy. Those that indicated an interest in participating were provided with an information sheet about the audit project, given the opportunity to ask questions, and provide informed consent to do the interview if they wished. All interviews were conducted by co-author SG, an MSc student with no prior relationship with the clinic staff or participants, or experience of the implementation of tf-CBTp. The interviews were semi-structured to facilitate exploration of people’s experience of tf-CBTp and were conducted either face to face (five interviews) or on the telephone (one interview).Clinic referrals and service user demographics are presented descriptively, and clinically significant change reported for PTSD severity on the PCL-4 and 5. Qualitative data from the individual interviews was transcribed and analyzed using thematic analysis following a critical realist framework , 55, whin = 34, 47.9%), care co-ordinators  and psychiatrists . The referrals consisted of 39 women (54.6%), with an overall sample mean age of 45.62 . Their ethnicity was: Black Caribbean , Black African , White British , White Other , Asian , South American  and Dual Heritage . Primary diagnosis was: schizophrenia , unspecified psychosis , schizoaffective disorder , bipolar with psychotic features , depression with psychotic features , PTSD with psychotic features , and personality disorder with psychosis . Following referral, 51 (71.8%) attended for an initial assessment and completed the TALE (or its precursors). Forty-six people (88.4%) reported an index trauma , followed by childhood sexual abuse , childhood physical abuse  and psychosis-related trauma . People reporting an index trauma were then assessed on the PCL for PTSD symptoms, with 28 (54.9%) scoring above threshold for clinically significant post-traumatic stress [total score > = 44 (PCL 4) or 33 (PCL 5)]. Of these, 20 (39.2%) also met the threshold for re-experiencing, for which memory work was indicated, resulting in an offer of tf-CBTp. Four people (7.8%) declined the offer of tf-CBTp. People who reported post-traumatic stress reactions in the absence of re-experiencing, or who were below the clinically significant threshold , were offered CBTp to address problems such as trauma-related emotions and beliefs, avoidance, and hyperarousal. Of this group, 14 (27.4%) accepted this offer and 5 (9.8%) subsequently declined. There were 12 people (23.5%) for whom therapy was not indicated, mainly due to a lack of clinically significant trauma consequences , with a minority moving out of area  or being referred on to a non-psychosis service .Between 2014 and 2018, 71 people under the care of the borough’s psychosis community teams were referred for an initial assessment (see n = 16) was 50% female, with a mean age of 45.70 years, . Their ethnicity was: Black Caribbean , Black African , White British , Asian , White Other  and Dual Heritage . Primary diagnosis was: schizophrenia , unspecified psychosis , schizoaffective disorder , PTSD  and personality disorder with psychosis . The index traumas most reported were multiple childhood victimization  and child sexual abuse . Index traumas occurred prior to the onset of psychosis, with the exception of one person, who experienced an assault after their diagnosis. The mean number of sessions was 17.54 . Whilst adverse reactions occurred during therapy , often in response to memory processing, there were no SAEs or hospital admissions. Pre- and post- therapy PCL total and change scores are shown in n = 11) people and 37.5% (n = 6) no longer met the threshold for clinically significant PTSD. A deterioration in PTSD symptom severity was experienced by 18.3% (n = 3), which was clinically significant for 12.5% (n = 2). In both instances, PTSD symptom severity had improved during therapy although this was not sustained, with deterioration associated with an actual or threatened re-occurrence of their index trauma(s).The tf-CBTp group : “Tablets don’t cure abuse, neglect […]. With [Therapist] was the first time it was explored and talked through” . However, access to therapy likewise did not guarantee relief if practitioners were not sufficiently trauma-informed. For Lisa, this involved a previous therapist who minimized and disbelieved her account of childhood abuse, while Carl described earlier therapy that felt “empty”, “[not] constructive” and failed to provide specific trauma-focused techniques.In this regard the limitations of medication were also noted by some participants, including its inability to get to the “draining” (Ini), “hard” , “overwhelming” , “disturbing” (Jean) and “mental work” (Carl), in which positive gains could still come at a cost: “It hurt but it helped” (Lisa).Having withstood the wait to receive help, participants exhibited additional commitment and courage to engage with a process that at times could be extremely demanding. Receiving tf-CBTp could be “baby steps”) to avoid growing overwhelmed: “it took us slow progress but we done it […] we went out and faced my fears” (Jean).However, despite such challenges, a consistent theme amongst participants was a willingness to persist to overcome them. In part, this process could be facilitated somewhat naturally over time; for example, as comfort and familiarity with one’s therapist increased, as the process of disclosure and self-expression gradually grew easier, and/or as the rationale for different techniques began to clarify and make more sense. However, participants also described ways they had proactively adapted to a grueling process. Approaches used to make therapy as tolerable as possible included the use of in-session breaks, compartmentalizing session content from everyday life, planning and getting support for getting to and from therapy sessions and a gradual implementation of techniques and change strategies  while Don described his awareness of therapy not being an “overnight” solution, with long-term patience and determination also required. In turn, merely performing certain actions did not appear to be sufficient on their own, instead also requiring an intrinsic sense of commitment:In terms of the latter, dedication to therapy could also reflect an intuitive wisdom that healing in the aftermath of trauma was an arduous and ongoing process which could not occur immediately. For Carl, this included recognizing the value of incremental change . Salma provided the following account of how her aspirations for a caring ally were ultimately fulfiled:When relating their experiences of tf-CBTp, all participants referred to the varying ways in which their relationships with their therapists had been a source of guidance and solidarity. Therapists demonstrated numerous personal qualities which made it easier to engage with them, including such factors as empathy, courtesy, patience, kindness, perseverance, responsiveness to client experience, instilling a sense of trust, maturity and professionalism, being sympathetic, showing reassurance, a calming demeanor, a willingness to listen and understand, being non-judgmental, and knowing how to “I just had hope that this person would be kind, gentle, empathetic and would not pathologize things. And although I have a broken brain, I’m living in a broken world and not everything rests on my shoulders. Recovery is not just my responsibility. [My therapist turned out to be] calm, friendly, and the first thing I noticed about [her] was that she normalized things for me, she admitted that no one is free of making mistakes, she wasn’t demeaning, she listened, and she understood, and she didn’t say she knew things when she didn’t. I felt like she fought my corner and had my back. I did very much so feel heard by her.In addition to such interpersonal factors, participants also alluded to specific clinical approaches and strategies employed by their therapists that were valued as part of tf-CBtp delivery see .A willingness to be thorough and discuss issues in detailEncouraging overcoming the reservation to describe painful emotionEncouragement to proactively engage with recoveryExplaining therapeutic rationales in a way that made senseHelping to address feelings of shame and self-blameHelping to build confidence by practicing coping techniques in-sessionHelping to plan for challenging situations/encounters in advanceHelping to re-evaluate, explore and/or confront fearsHelping to recognize achievements and attributesNormalizing experiencesPersonalizing the treatment protocol to suit preferred pace and needsProviding in-person support during behavioral experimentsRespecting boundaries for disclosing distressing materialSupporting attempts to socialize and re-engage with enjoyable activitiesUsing relatable metaphors to make clinical concepts more understandableValidating client accounts of racism and homophobia within mental health services.She brought it into my world rather than in a model”) and, while also noting the power imbalance intrinsic to therapy (“It’s hard for your life to be open and theirs not”) further described how her therapist ultimately became a partner in the healing process:In this respect, the ability to engage with such work could gradually be bolstered by participants’ growing sense of comfort with their therapists. For example, Salma referred to how her therapist personalized their sessions .A concurrent feature of safety for many participants was finding ways to manage and mitigate negative emotions, either by utilizing pre-existing strategies or applying ones specifically taught during therapy. For Ini, one such helpful technique was learning breathing exercises which, while not a panacea, she discovered could be applied more holistically than previously realized: “it may not work automatically, the body’s not used to the process, but if I do it all the time it might eventually work” (Ini). Jean likewise stated that “I try my best, I get paranoid obviously, but when I get paranoid and the voices start I try different […] techniques.” As described by Don:Nevertheless, and despite such benefits, participants also noted that coping strategies were not always entirely effective for either preventing or alleviating distress. Instead, they often required patience, practice, persistence, and a degree of experimentation: “[Therapy] doesn’t stop the feelings, it like puts them in a little corner […]. You can find distractions and ways of keeping it at bay, that the effects are not great like they were before. […] It doesn’t disappear, it can put its head up from time to time, but if you have got the tools to put it back in then it goes back in. So that’s what the psychology did […] they give you the tools to deal with the thing.It’s silly because when you mark yourself you can’t clear it […] I’ve just come through the pain and just accept[ed] it.” In turn, Salma reflected on how she no longer used social isolation to cope with paranoid feelings: “Rather than withdrawing, I learnt to challenge thinking and do reality checking with people.”In this respect, some participants also related the benefits of re-evaluating previous coping strategies. Carl, for example, described how he had stopped using alcohol as a way to manage emotion (something that occurred prior to receiving tf-CBTp) and that while he had previously employed self-injury to cope, this was no longer something he saw as helpful: “The third theme reflected the various struggles and constraints experienced throughout the process of engaging with tf-CBTp both in terms of its structure and content.the time would go really quick, so I had to hurry up and discuss what we had to discuss.” For her, the opportunity to “just have someone to hear what I’ve got to say” was valued, and while she ultimately felt she had “the time to say what I wanted”, also noted that “having more time to talk” would have been preferred via longer and/or more frequent sessions. Lisa, in turn, also summarized the inevitable confines of time-limited therapy: “I think for me to have gone through at least 20 years of being abused and suffering the consequences, I don’t think 18 months would be enough.”The first set of difficulties described by participants referred to therapy delivery; specifically, the inherent, organizational limitations of the services within which it was provided. For two participants, this was reflected by a sense of time pressure. Ini, for example, felt that an hour a week was insufficient: “I was scared ‘cause he being a man, I don’t trust men”), whereas Salma felt that therapists should ideally have a similar lived experience to their clients in terms of race and sexuality. For her, a lack of shared identity could inhibit the willingness to fully express her experiences:Although participants described positive therapeutic relationships, the potential problems of being unable to choose one’s own therapist due to insufficient resources was also noted. For Jean this involved an initial preference to work with women .Other issues included a preference for the benefits of combining individual therapy with group meetings and discomfort with the therapy venue  yet ultimately untenable due to the turmoil it created. In this case, the therapist’s responsiveness enabled the alliance to be preserved, yet also left Jean feeling bereft when she was discharged: “I felt as if I lost a good friend.” Despite some of the gains from tf-CBTp sessions, she ultimately noted that post-therapy her distress levels could still become overwhelming, with trauma continuing to trigger nightmares, voices, and incidents of self-harm.For this participant, some things remained too painful to discuss and required a shift in focus within the sessions to areas that were less emotionally threatening. When reflecting on her therapist’s initial encouragement to discuss such “[I] didn’t really want for these sessions to end, I got so used to them; routine, you know”) and concerns that talking about trauma could make her lose control (“some people start lashing out […] it could be the emotion comes out in different way […] [A]ll sorts of stuff could happen”). These reservations did not deter her from confiding in her therapist, yet the process was still “stressful” and “straining”:Some similar themes were also expressed by Ini, both in terms of loss at therapy’s conclusion , a reservation compounded by pervasive feelings of shame: “I felt embarrassed I didn’t want to be judged.” In the event of future therapy, she felt she would be more inclined to “say what I want to say get everything out”, stating that “therapy can’t be successful if you’ve still got a lot of baggage […] locked up inside of you.” However, when reflecting on the process, she also noted how such struggles were something therapists should be more proactive in encouraging clients to overcome; namely by reiterating the importance of expressing oneself freely and openly:An additional barrier for Lisa was a sense of cultural and ethnic alienation in the aftermath of trauma which was something she felt unable to articulate in-session  could also be a chance to gain new knowledge and perspectives on one’s suffering, although this was something that could take considerable time. For Salma, therapy initially “when you work on yourself and you get everything corrected, throw out all the negative; and when you got the facts there, you can only put it in when you got the facts, you know, and then you put it in the filing cabinet up in the top draw, put it in, shut it.…gives you an insight into why you feel like this” wherein the initial tumult of the sessions could gradually give way to a growing sense of clarity:Don similarly related how therapy “in the beginning it was a little bit like a tumble dryer; it was making sense, but not making sense, and then in the middle things began to, I could see a picture, and then from that on the picture become clearer. […] I could make sense of feelings I was having, why I felt like that, the things I was doing. Realizing that because of my condition it was just a natural reaction. But at the time I didn’t understand that.…probably one of the best, or the best, […] psychological therapies I’ve had.” Bearing witness to her own defenselessness at that age contradicted previous grooming by her abuser and, while provoking feelings of sadness, was “very helpful” and made her feel “like somebody cared, you know like I was […] not me, somebody else, and I just saw vulnerability.” In turn, other therapy components also provided opportunities for self-expression and to have another person bear witness to her experience.For Lisa, working with her inner child was “probably” would. Correspondingly, several descriptions were provided of ways in which tf-CBTp had the potential to help envisage more positive long-term outcomes, even if these could not be realized immediately. Lisa, for example, noted that she was “completely social[ly] withdrawn” at the start of therapy and that socializing was “a lot easier now” despite her continuing struggles: “I mean it feels maybe 5% willing to try to socialize, but before the day I met [therapist] it was literally 0.” Carl, who felt “pleased and triumphant,” at his progress and “that I’ve come a long way” similarly felt that future gains could take time: “I can’t learn something straight away because it don’t happen that way […] but I’m getting there and I’m working on that.” Don, in turn, noted that while he still struggled with feeling safe and would sometimes avoid leaving the house, engaging with therapy had helped to develop a growing sense of security for being in the world:Despite the challenges experienced during therapy, five participants said they would recommend it to other trauma survivors and one (Ini) stated she “I can go out, it built my confidence up. My fear, I see fear in a different way. And I see people in a different way. Because I thought all people are bad, they’re all demons, that’s what I thought; they were demons out there. They’re not good, their intentions are bad. This is one person and it’s not the whole world. Yeah, to learn that every time you go outside that something bad is not going to happen, cause that’s how I thought about it.was petrified” to discuss his trauma, yet reflected that such fears had since receded: “it’s all cleared up, it’s brand spanking new now, I can talk about it and it don’t affect me, it don’t send me in a twist, it don’t make me all over the place […] it’s gone it’s finished.”For other participants, therapy had provided opportunities to begin changing the way they related to their past experiences. Carl, for example, revealed that there had been a notable shift in the capacity of his memories to devastate him, as well as a certain sense of closure. Prior to therapy, he “I’m proof you come out the other end” of trauma, tf-CBTp had been “lifesaving” and a means of momentum toward recovery: “it was a pathway for me, so it was only going forward it wasn’t going back, so that’s what I needed and that’s what happened.” While reiterating that this process was a long-term endeavor, he also provided the following example of striving to move beyond the pain of the past:For Don, who felt that “you have to work from within yourself, you have to just be determined. If I’m just going to wither away in a corner then I’m giving into [perpetrator] […] So you’ve just got to be as strong as possible. Hope I think is just, hope is the word. Try and look forward not back. I’m still trying to get there I’m working on it. […] [E]very day brings its challenges but it’s just to try and do your best, if you feel today then okay don’t beat yourself up about it. Get back up again tomorrow and try, not give up I think is the thing, that’s it. It’s hard but in time you get there.…In terms of reclaiming a sense of one’s own identify beyond trauma, Salma also described the process of looking toward a more positive future:It has made a huge difference in my life. I feel more at peace and have less negative voices. I feel for the first time I am taking control of my life. Not my past, not my voices, it’s me. […] If I hadn’t had therapy I would have committed suicide, that’s my belief. It has made life not only worth living I can see its beauty that I didn’t see before.To the best of our knowledge, this audit is the first mixed methods evaluation of a trauma therapy care pathway for users of NHS community psychosis teams. Overall, the findings demonstrate that implementation of tf-CBTp is feasible and safe, with promising indications of effectiveness. Despite limited recruitment resources, there was a consistent rate of referrals and uptake of assessments was excellent for this population, with nearly three quarters attending. Tf-CBTp (which addresses both “reexperiencing” characteristic of PTSD and distressing psychosis) was indicated for 39.2% of referrals. A similar proportion of referrals were experiencing traumatic stress reactions that did not involve significant re-experiencing and were instead offered CBTp to address trauma-related beliefs, experiences, emotions, and coping strategies. Only a minority had no significant effects of trauma at assessment (15.4%) which may have been due to their absence, or people being unwilling or unable to disclose them. However, amongst the latter group, being provided with an opportunity to discuss trauma consequences may have increased the likelihood of sharing in the future, when they felt ready and able to do so. Taken together, the findings suggests that a specialist PTSp care pathway can support the recognition of people with psychosis who are significantly affected by past trauma, and that comprehensive assessment of the phenomenology of post-traumatic stress can assist appropriate access to evidence-based therapies. As highlighted by the qualitative interviews, people reported that access to trauma-focused therapy required perseverance, sometimes with considerable delays. Whilst Chadwick and Billings  found thThe majority (80%) of people who were offered tf-CBTp completed therapy, suggesting that the approach was viewed as appropriate for their problems. Clinically significant changes in PTSD symptom severity were found for two thirds of people, with just over a third no longer meeting criteria for PTSD. This was supported by the thematic analysis, with participants reflecting on how the therapy supported expression and understanding, alongside providing possibilities for a more peaceful future relative to the pain of the past. This indicates that routine care provision of tf-CBTp can deliver the beneficial effects found in research, although it is noted that the effects were more modest than those found in an RCT of EMDR or PE for PTSD in people with a lifetime diagnosis of psychosis . This isAlthough most of the sample experienced benefits, the focus on painful traumatic experiences and their effects meant therapy was often emotionally challenging and burdensome. Whilst there were no SAEs in the audit sample, adverse reactions were anecdotally noted as common, often in response to memory processing. This finding is consistent with other studies investigating the frequency of exacerbation. For example, Burger et al.  found thWhilst positive effects were found in the therapy subgroup, it is important to recognize tf-CBTp is not a panacea. The majority still had clinically significant PTSD symptoms at the end of therapy, and the interviews likewise reflected the enduring effects of trauma and ongoing need for support. This included struggling with the time-limited nature of the work, mostly as a result of organizational and resource constraints. The mean length of therapy was 17 sessions, although there was a significant range, with some people being seen by the clinic lead for a longer duration when indicated. Whilst the case with the greatest gains was only seen for 12 sessions, this was largely attributable to the person reevaluating their memories of past trauma as a construction of their anxieties about interpersonal relationships, as opposed to being a result of experienced abuse. Therapy duration for most cases was limited by the clinic’s trainee clinical psychologists being on placement for six months. NICE recommend a minimum of 16 sessions over six months or longer for psychosis, whereas therapy lasting 12 months plus boosters is recommended for complex PTSD where there are multiple or chronic traumas , 60. TheA lack of workforce diversity was another systemic factor relevant to the experience of tf-CBTp. Encouragingly, the ethnic diversity of referrals and the tf-CBTp subgroup were representative of the local community, in contrast to previous findings indicating that Black people may be less likely to receive CBTp compared to their White counterparts . HoweverLimitations of this audit study should be noted. First, data collection was constrained by resources  and impacted by the pragmatics of delivering therapy in routine care . In turn, pre- and post-therapy assessments of other trauma consequences and psychosis would have been beneficial as this was only done for PTSD symptom severity. Further, robust conclusions cannot be drawn about therapy effects on psychosis, as whilst some interviewees commented on these experiences they were not explored routinely. Standardized questionnaires of complex PTSD (cPTSD) were also unavailable at the time of data collection  althougSecond, while limiting the sample to those willing and able to be referred was appropriate given therapy should only be considered in this context , this diIn conclusion, we hope that this audit study will provide encouragement to clinicians to implement trauma therapies for psychosis in their local services, in line with the NHS Long-Term Plan . As highThe raw data supporting the conclusions of the article will be made available by the authors upon reasonable request.The studies involving human participants were reviewed and approved by Psychosis Clinical Academic Group, South London & Maudsley NHS Foundation Trust (ref: PSYAUD 16/20). The participants provided their written informed consent to participate in the interview study.AH led on the study design, delivered or supervised therapy cases, participated in the acquisition, analysis and interpretation of the data, took the lead for drafting and revising the manuscript, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. SG contributed to the development of the topic guide, led the qualitative interview data collection, made substantial contributions to drafting and revising, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. JD contributed to data collection and cleaning of the quantitative data, made substantial contributions to drafting and revising, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. EL led the thematic analysis and write-up of qualitative interviews, made substantial contributions to drafting and revising, gave final approval of the version to be published, and agreed to be accountable for all aspects of the work. All authors contributed to the article and approved the submitted version.


Eighteenth-century naval ships were impressive infrastructures, but subjected to extraordinary strain. To assist with their “voyage repairs,” the Royal Navy gradually established numerous overseas bases, displaying the power, reach, and ruthless logistical efficiency of the British state. This article, however, is concerned with what happened where no such bases (yet) existed, in parts of the world falling in between areas of direct British administration, control, or influence. The specific restrictions imposed by technology and infrastructures have been studied by historians interested in naval strategy, but they can also help to reframe national narratives of power or observe the transnational interactions surrounding access to knowledge and resources. This paper discusses the material, cultural, and diplomatic constraints that could appear when vessels, and especially “discovery ships,” sailed in strange waters or sought technical assistance in allied ports. I argue that the “mortification” of some commanders at their vessels’ unfitness for service was an important – and often neglected – element on the palette of emotions undergone by voyagers, capturing their strong sense of ultimate material powerlessness. Such frustration even became embedded in imperial cartography, as shown by the case study of Matthew Flinders. This perspective highlights the limits of naval technology, complicating imperialistic “success stories” and better reintegrating the navy into the history of maritime travel and transportation, from which it is often singled out. Raw construction materials were frequently imported through a delicate supply network.29 Moreover, British metropolitan shipyards were then developing industrial procedures that, some have controversially argued, anticipated the civilian sector by several decades.30 The products of such advanced processes could not always be easily replicated in subsidiary facilities. As a result, even in some British bases – let alone away from them – “shortage of stores was the norm, rather than the exception.”31All navy ships carried a carpenter, a sailmaker, a boatswain (who took care of the rigging as well as discipline), a caulker, a ropemaker, and various teams working under their orders – “carpenter’s crew,” “sailmaker’s crew,” and so forth.32 Lisbon was fundamental as a repair, refuge, and resupply base for the British fleet throughout the century, but it was abruptly closed if the Portuguese government chose neutrality.33 Even where goodwill was not lacking, resources might be. Between 1798 and 1802, the British and Russian fleets were indispensable to the defense of the Kingdoms of Naples and Sicily; as a result, once his arsenals were depleted, the Neapolitan King went as far as supplying the allies with spare parts scavenged from his own warships. These pieces, however, were insufficient and rotten.34 In short, even in Europe, reliance on other countries was an intrinsically precarious and uncertain way to operate, and the urgency of repairs could mean depending on “weaker” allies. The material details of these encounters are key to integrating technological naval history into cultural, diplomatic, and transnational history.Reliance on the port facilities of allied or neutral powers was also not straightforward. Although eighteenth-century European warships were a common transnational technology, political reasons might prevent mutual support. For example, the Order of St John of Jerusalem, which ruled Malta until 1799, strived for neutrality and non-assistance toward Christian powers at war with each other: from 1768, foreign warships allowed in the harbor of Valletta were capped at four.If geographical and technological displacement caused problems to any naval vessel, this was especially true of “discovery ships,” whether warships by build or repurposed merchantmen. Nearly all exploration voyages sponsored by the Royal Navy in the second half of the eighteenth century met with considerable infrastructural issues, forcing the commanders to rely on their crews’ carpentering and manufacturing skills, or on the assistance of authorities in remote settlements of other European powers.35 During his journey in HMS Dolphin, in 1764, Commodore John Byron had to stop at Rio de Janeiro for substantial refits. He hired six Portuguese caulkers, and the officer who later published an account of the expedition was fairly disparaging of their industry and of their country’s resources, but not of their workmanship: “one of our English caulkers would do as much in one day,” he wrote, “as they could in three; but though they are slow and inactive, they perform their work very completely, or else their vessels could not run so many voyages in a shattered condition as they frequently do.” Thousands of miles from the nearest British base, Byron had to make do with what was available, and in fact the episode turned into an opportunity for a technological cultural encounter: the account observed that these men could fix even large seams, making them “as hard as the plank itself, and yet they use not any moisture, as our English caulkers do, except what little proceeds from the constant application of the iron to their mouths.”36 Technological observation and “dissemination” are only profitably studied at this sort of micro-level.37After his expedition in the north-western Pacific, Captain George Vancouver extolled the “friendly and hospitable reception” of the Spanish in California: this included free supplies and, when his own armorer ran away, in January 1793, the very generous loan of the only trained smith in the Monterrey establishment, which solved an otherwise significant material problem. As Vancouver wrote, an armorer “was an artificer of too much importance, to persons in our situation, to be hastily declined.”38 Byron warned “future navigators, particularly those of our own nation,” that the Portuguese at Rio habitually “enticed” or tricked seamen away from the ships that stopped there to refit and resupply; the Portuguese pilot he hired also proved unreliable, and almost wrecked the Dolphin.39 The most trouble with foreign port authorities was perhaps had by Philip Carteret, as commander of HMS Swallow. When he arrived in Celebes in 1767, his ship and his men on their last legs, the Dutch East India Company received him with extreme suspicion and fears of commercial “intrusion,” refused him help at Macassar, and sent him over to Bonthain; the result was that he was easily dragged into local intrigues and convinced of an existing plot to seize his vessel.40 Later, in Batavia, after some diplomatic sparring about the previous incident, and complaints against Carteret’s “arrogance,” Dutch carpenters repaired his ship. The Swallow was in such bad state that they would have condemned it as unseaworthy, had he not rejected their opinion and taken full responsibility.41In any case, as Dániel Margócsy and Mary Brazelton discuss in the Introduction to this special issue, the relocation of technologies of transportation can result in “conversations” and knowledge exchange between locals and newcomers, but also in “control” issues.Providence remarked in his account that the ship “was singly sheathed with copper,” but he reckoned “it would be proper, that all ships employed in distant voyages should be sheathed with wood, and coppered over the sheathing.”42 Without adequate coppering, the hulls of vessels fell prey to the inexorable shipworm teredo navalis, which proliferated in tropical latitudes.43 For one whole year, the Providence made 2–4 inches of water per hour. The leak was eventually repaired only in April 1796, when the ship’s carpenters were able to build a wharf in Nootka and heave down the vessel.44 The Vancouver expedition of 1791–5 was in all respects very well equipped, and the Discovery was an excellent ship, but even in the initial passage from Spithead to Falmouth the Chatham, the armed tender accompanying it, “proved so very crank, as, in some instances, to occasion considerable alarm”: its “crank situation and bad sailing” caused delays and inconveniences throughout, making it lag behind the Discovery.45In many cases, exploration vessels developed faults as a result of ongoing and exceptional strain. However, the issues were often there from the start. Captain William Robert Broughton of HMS Swallow during its 1766–9 voyage. The officer complained that it was “an old Vessel . . . and one of the worst, if not the very worst of her kind; in his majesty’s Navy, and was in every respect, but indifferently fitted out.” Even before departure he knew that it was not ready and lacked essentials like a forge: it “was only supply’d with the common, but scanty necessaries, in the manner a Vessell of that kind might be, if bound on an Ordinary voyage, such as to the Mediterranean, & where in case of need, she could be assisted.” As he pointed out, this was inconceivable for “a voyage of discoveries, in the most distant, and dangerous part of the world; where no other helps could be procured, but those we should carry with us.” The situation of the Swallow made “common Navigations in Europe, where every Port is open to repair our damage”  look comparatively safe. However, his requests for improvements had been refused by the Admiralty. Carteret may be a biased commentator, but the conditions of the Swallow did mean that the expedition repeatedly teetered on the brink of disaster, and to the end he bemoaned the fact that “such an old Vessell, that was known to have been a bad tool of a ship . . . should be purposely picked for such distant Service, out of all the numerous navy of Great Britain, since there were so many better Ships, lying unemployed, & for want of use, rotting in the harbours of England.”46 Exploration vessels were not “neutral” means of transportation, to be taken for granted: they were “tools,” and indeed the most indispensable tool of all. Carteret also alerts us to the contradiction between naval and national might and broken ships, to which we shall return. Much of his rightful indignation was watered down in John Hawkesworth’s Admiralty-sponsored edition of his journal.47 This was an attempt to conceal the fact that, oftentimes, explorers were not simply fighting the mighty natural elements and the perils of the unknown, as the heroic narrative goes, but their own incompetently and negligently equipped vessels.Most notorious of all is the case of Carteret’s HMS Dolphin and the Tamar when he “had the mortification to find the Tamar a very heavy sailer.”48 Samuel Wallis set off in August 1766 with the Dolphin, Swallow, and Prince Frederick, but he “had soon the mortification to find that the Swallow was a very bad sailer.”49 In August 1776, again scarcely a month after departure, Cook had “the mortification to find our ship [HMS Resolution] exceedingly leaky in all her upper works. The hot and sultry weather . . . had opened her seams, which had been badly caulked at first, so wide, that they admitted the rain water through as it fell”: all the crew’s quarters were drenched and made uninhabitable, and the sails “damaged.”50 Vancouver had much frustration with masts. In June 1794 he “had the mortification to understand, that just as the carpenters employed on the bowsprit were about leaving off work, they had found it rotten nearly in the middle”; in March the following year, he “had the mortification to learn, that there was not a spar, either at Valparaiso, or in the country within our reach, of a size sufficient to be converted into a [main]mast, for the purpose of replacing our disabled one on board the Discovery”; and further “mortification” was caused by discovering that his mainmast was more damaged than he had reckoned, by understanding that the heel of the mast was rotten, even if not sprung like the head, and finally, once the mast was fixed, by the revelation that the mainyard was also largely rotten, and “intirely unfit for service.”51 “This was a mortification I did not expect to have met with,” he mourned,52and as there was no possibility of procuring at this place a spar of sufficient size to replace it, the only means we had of repairing the defect was by making a temporary yard out of a spare maintopmast, with the addition of the yard arms of the yard which was decayed, and which I was extremely sorry to observe were by no means in a perfectly sound condition.Regardless of anybody’s direct culpability, one common sentiment, almost a trope, recurs throughout voyage accounts, capturing the feelings of commanding officers upon discovering that their ships were defective or damaged. In July 1764, Byron had barely set sail with the 53This “additional disaster” put an early end to his expedition: “the regret” he “felt in being thus compelled to abandon the examination of this almost unknown, yet interesting part of the coast, is not to be described”; but continuing would have been too dangerous.Of course, published accounts are written for an audience, and the subtle public rhetoric of blame and self-defense needs to be taken into account. However, the language of mortification seems to capture an important element on the palette of emotions undergone by voyagers, and in particular their strong sense of ultimate material powerlessness.These feelings are routinely obscured in narratives that only emphasize the overcoming of obstacles and “success story” of naval enterprise in the late eighteenth century. This is illustrated particularly well by one of the most celebrated British expeditions of the time, if we examine it from the point of view of naval technology. Because of its national and imperial significance and mythologization, Matthew Flinders’s mission to chart the Australian coastline is the perfect case study to explore how failing infrastructure can undermine both power dynamics and power narratives.Investigator along the coasts of “New Holland” , where “His Majesty’s colony of New South Wales” was located, producing detailed charts ; friends and shipmates featured, together with labels like “Point Dover” for a white cliff.71 He also preferred “Terra Australis,” or “Australia,” as general name for the continent, because it prevented “New South Wales” from becoming part of “New Holland.”72 Labeling and measuring a territory, and positioning it in relation to Greenwich, are plain forms of appropriation.73 However, paying more attention to the specific technological features embedded in Flinders’s charts reveals a stark counter-narrative.At first sight, these charts, commissioned by the British Admiralty, are themselves an embodiment of the national imperialistic myth. Eighteenth-century maritime science oscillated between cosmopolitan international collaboration and, by 1800, growing nationalisms.Investigator’s track, with relative dates.74 His charts are dynamic, expressing movement next to fixed geographical features, “wayfinding” next to “map-making.”75 Choosing to record an individual journey, beside universal and supposedly unchanging features, is in itself an epistemological declaration, a scientist’s way of turning a chart into a falsifiable, provisional, case-specific theory, rather than an impartial statement. Tracks on eighteenth-century charts act as the concrete manifestation of the ship’s role as a surveying instrument.76Like many contemporary explorers and cartographers, Flinders meticulously marked the Investigator covered 395 nautical miles, hence doing an average of 5.49 knots , coming from one of the best angles – the vessel is “on broad reach,” in technical terms.79 The sloop was then rather far from the coast, it had ceased to take any measurements which would have slowed its pace, and in fact Flinders was making all the sail he could to return to Port Jackson as fast as possible, and avoid further casualties among his severely sick crew.80 Therefore, we can consider this measurement an accurate gauge of the capabilities of the Investigator: it was, by then, making water at the rate of five inches an hour, and would have sunk if the wind had come from either the larboard side or the larboard or starboard quarters, pushing below the waterline the most rotten parts of its hulk.81 Similar calculations could of course be performed throughout the Atlas, and cast some more light on the British Admiralty’s priorities, resources, and commitment to scientific exploration: Britain possessed the largest fleet on the globe (285 vessels in 1800), and yet – familiar refrain – “no better ship could be spared.”82 The truth is that the Investigator had started leaking, to Flinders’s “mortification,” as soon as it left England.83 Through the slow, limping black track of the sloop, the deficiencies of his patrons are thus engraved into the chart, which consequently tells, next to the grand narrative of British power impressing commuters at Euston, a more subversive story subtly undermining it.Indeed, this narrative, temporal aspect of the charts makes the ship itself visible and contains a story hidden to a superficial glance. The graphic record allows us to calculate the speed of navigation, seldom reported in Flinders’s published journals. For instance, between May 24 and 27, 1803, just before its arrival in Port Jackson, the 49 knots .77 This 84 the very technology that permitted naval operations in distant seas could, when it ceased to function, become the weakest link in the chain.The eighteenth-century British Navy was unquestionably a successful tool of global power. However, any flat narrative of its achievements, now firmly embedded in national mythology, obscures the limitations of such power. Many of these limitations stemmed directly from the “paradoxical” quality of infrastructures:Navy ships would be away from British shores for years at a time, regardless of their build or the availability of local resources. Especially when away from British bases, men-of-war were forced to rely on the often precarious, whimsical, or limited help of foreign ports. Royal Navy vessels were not and could not be fully self-sufficient or self-reliant, because complex technologies and infrastructures rarely are. This fact is strikingly embedded in some of the most celebrated feats of naval expansion, hidden beneath the layers of human heroism that have been emphasized instead.The points where British naval power found itself overstretched, and figuratively and literally “out of its comfort zone,” afford examples of bravery and resourcefulness to those who set out to build national pantheons, important considerations to the naval strategist, but also a different type of insight. On the backdrop of glorious victories and worldwide domination, material fragility, displacement, inadequacy, and dependence also featured, and they help us to tell an alternative, or rather complementary, history of the eighteenth-century British Navy. The interplay between travel distance and the relative brittleness of naval technology can be profitably studied by historians interested in technological transfer, cultural interactions, and transnational contacts. The material difficulties of the sailing navy thus allow us to reintegrate it into maritime history and the history of global travel and transportation, from which it is often implicitly singled out.


I establish that ADHD, along with the evolving biomedical model for psychiatry, was accepted in the third edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual (DSM-III) as the result of bias and compromise between theorists' of different persuasions. Although initial ideas are expected to be subjective, they also need to demonstrate plausibility prior to empirical investigation. Research from the disciplines of biological psychiatry and cognitive psychology influenced the creation of ADHD, so I critically examine specific ideas that underpinned these disciplines at that time. I find these to be implausible and not congruent with current scientific knowledge, this extends to more recent theory. I conclude there is little good reason to consider DSM-III's concept of ADHD as empirically confirmed, nor do I find good reason to expect such confirmation will be forthcoming.Prior to the establishment and promotion of ADHD as a psychiatric disorder, the labels “minimal brain dysfunction” (MBD), “hyperactivity” (HA), and “learning disability” (LD) were diagnostic terms for children with hard-to-manage behaviors. At the time, these labels and the treatment interventions, especially the heavy reliance on stimulant medications, were subject to criticism. Nearly half a century later, these criticisms apply equally to ADHD, suggesting a disturbing lack of progress in this area of child psychiatry. Therefore, the aim of this article is to examine the scientific integrity of ADHD, to establish why this is the case. I use a philosophy of science framework to track the  Attention-deficit/ hyperactivity disorder (ADHD) was originally called attention deficit disorder (ADD) when it first appeared in DSM-III . InapproEric Taylor, Emeritus Professor of Child and Adolescent Psychiatry at King's College London, described how different views of the disorder caused division between psychiatrists and between other professionals, such as social workers and educators . Taylor Such controversy and division is not new to psychiatry. Roger D Freeman, Professor of Psychiatry at the University of British Columbia, opened a lengthy article with the statement:There is only one phrase for the state of the art and practice in the field of minimal brain dysfunction (MBD), hyperactivity (HA), and learning disability (LD) in children: a mess. There is no more polite term which would be realistic. The area is characterized by rarely challenged myths, ill-defined boundaries, and a strangely seductive attractiveness. These categories and their management, because of massive support from frustrated parents, professionals, government, and the drug and remedial-education industries, constitute an epidemic of alarming proportions—-but is the problem the disease or its treatment? Freeman concluded that there was no “epidemic” to justify the widespread use of stimulant drugs; rather, he considered this period in psychiatry to be “an unfortunate episode in the history of progressive medicalization of deviant or troublesome behavior” (p. 22). He outlined five reasons for his conclusions.First, Freeman  argued tFreeman  commenteFreeman  doubted Bayer and Spitzer  argued tAs noted above , ADHD ocNevertheless, by associating Freeman's  historicIn essence, the aim of this article is to hold psychiatry to account in a manner consistent with the philosophy of science . Traditidistinction between “context of discovery” and “context of justification” (DJ or “context distinction”)” (p 151). Kordig (Aufrecht  explaineion”)” p 1. KordigLogical empiricists distinguish discovery from justification. Discovery concerns the origin, creation, genesis, and invention of scientific hypotheses. Justification concerns their evaluation, test, defense, success, truth, and confirmation. … Discovery is subjective. Justification is objective. It is also normative. It determines what ought to be accepted. It evaluates scientific theories and hypothesis. Discovery concerns their origins. It may deal with the initial selection of facts for study. Justification asks whether the facts—-however selected—-constitute objective evidence for the hypotheses (p. 110).initial thinking, plausibility, and acceptability.Nevertheless, these distinctions attract controversy, because some scholars maintain that the two contexts are not clearly distinguishable , 16. Korhit upon, think up, imagine, and make conjectures. As the process of discovery is subjective, neither logic nor good reasons are essential to initial thinking. However, initial thinking is prior to, and psychologically distinct from, plausibility and acceptability. Plausibility may be expressed in various ways, but Kordig determined that a hypothesis needs to be plausible “before its test” (p. 115). Furthermore, Kordig warned that there is no guarantee that plausible lines of research will survive further testing.Kordig  describeprior to empirical test they also support plausibility…” such good reasons need not, and usually do not, change when scientific theories change (p. 115–116). Good reasons help define regulative standards of excellence.Kordig  uses theThese regulative standards of excellence are consistent with my understanding of scientific integrity. Additionally, Kordig's  distinctI divide this evaluation into three components, to reflect Kordig's  distinctI then discuss this background in relation to the creation of ADHD. I detail the influence of Paul Wender, a prominent child psychiatrist and proponent of the diagnostic label of MBD. I link Wender's interest in attentional difficulties to research by cognitive psychologists.As already stated, it is the plausibility of initial ideas that helps determine the likelihood of future empirical confirmation , hence sDespite this, ADHD continues to be diagnosed and treated as a psychiatric disorder, so the next section outlines the period following DSM-III, to ascertain reasons for this ongoing acceptance. One major contribution to more recent discourse came from the work of a lead expert, the cognitive psychologist Russell Barkley . My critI then bring my discussion back to the concerns expressed decades ago by Freeman , where IPrior to the publication of DSM-III , psychiaAt the same time, historical accounts identified the 1970s as a time of crisis for psychiatry , 19. TheThere was, however, a more practical force at play, that of resource dollars. Insurance companies were disgruntled with the unregulated nature of clinician payments, and they questioned whether the then dominant psychosocial model demonstrated quantifiable effectiveness . FederalDissatisfaction with psychiatry was also building from within the profession, especially among a group who considered the field's future lay within a biological framework . The sucFinally, two specific events occurred to provide the catalyst for change . The firSpitzer was influenced by what came to be known as the Feighner criteria , 18, 20.As chair of the task force, Spitzer was able to select committee members whose ideas were compatible with his own. Half of these members were in some way affiliated with Washington University . AccordiBayer and Spitzer  explaineFreeman's  descriptMinimal Brain Dysfunction in Children. According to Rafalovich, Wender wanted to unify a surfeit of different terms such as, minimal brain damage, minimal cerebral palsy, minimal cerebral dysfunction, maturational lag, and post-encephalitic disorder into the single clinical entity of MBD. Furthermore, Wender was opposed to the psychodynamic community's approach to childhood problems, because he saw them as only offering “band aid” solutions to complex problems .From this explanation, especially the phrases “this disorder” and “these diagnoses”, it would appear that the prior terms listed above are either the same, or closely related to ADD.with hyperactivity and attention deficit disorder without hyperactivity” (p. 363). ADD with hyperactivity replaced DSM-II's .According to Taylor , the newBiological psychiatrists' solution to such criticisms was to find a definition based on “psychological changes rather than unknowable neurological ones” .Thus, it would appear that the idea of attention deficits solved several problems for the psychiatrists tasked with DSM-III classification. It provided a label that did not overtly implicate organic etiology, thus reducing the controversy of previous labels, there were tools already in place for future research, and according to Taylor . ADD wasBut these behaviors are also exceedingly common, as evidenced by data obtained from an epidemiological study conducted by Werry and Quay . In UrbaThis point was made by Wilson  when he To summarize as per Kordig's  distinctthere is no such thing as a psychiatry that is too biological. I say this even though I believe that we still know all too little about the physiology of the brain in most psychiatric conditions” .In my account of the origins of ADHD, I described the link between psychiatry and cognitive psychology, including how Wender “regarded attention deficits as the key to understanding MBD” .The brain does not function in the precise manner of a machine. Nor is it “programmed” by the human genome and developed by “appropriately” arranged nucleotides as per Guze's  descriptOne of the main organizing principles … is that each brain has uniquely marked in it the consequences of a developmental history and an experiential history. The individual variability that ensues is not just noise or error … it is an essential element governing the ability of the brain to match unforeseeable patterns that might arise in the future of a behaving animal. No machine we are familiar with incorporates such individual diversity as a central feature of its design .Similarly, Fuster  explaineEdelman  considerFuster  also bemspecific cognitive functions, are represented in associative areas. Thus some neuroscientists have been led to believe that there are cortical modules or “centers” for perception, memory, language, attention, and executive control, among other cognitive functions. And thus a more or less academically condoned “neophrenology” has emerged (p. 125–6).However, by theoretically extrapolating the evidence from primary areas to upper associative areas, and by over-interpreting some behavioral results of cortical lesions, it has been incorrectly assumed that not only complex sensory features or movements, but also Another noteworthy criticism came from within cognitive psychology during the era that Wender turned his attention to this discipline. Ulric Neisser, whose contribution to this school of thought was considerable , expressAltogether it is apparent that the mid-20th century ideas about genetics and the brain that underpinned the creation of ADHD are not congruent with current knowledge. Guze's vision is suggestive of genetic determinism ; Wender'Thus, far I have provided the historical context prior to DSM-III, including the reasons for psychiatry's move to a biomedical model, and the thinking underpinning this change. I have evaluated specific theoretical constructs and found them unsupported by current understanding and knowledge. All of this belongs to what Taylor  describeDisorders usually first diagnosed in infancy, childhood and adolescence. The latest edition, DSM-5 , shows the large amount of intellectual property he owns as an outcome of his standing as an expert.The second, third and fifth points raised by Freeman , those oFreeman's  hard-to-As to Freeman's  fourth pIn conclusion, the use of Kordig's  distinctThe author confirms being the sole contributor of this work and has approved it for publication.


The original article has been corrected.The article “Transposon dynamics and the epigenetic switch hypothesis”, written by “Stefan Linquist. Brady Fullerton”, was originally published Online First without Open Access. After publication in volume 42, issue 3–4, page 137–154 the author decided to opt for Open Choice and to make the article an Open Access publication. Therefore, the copyright of the article has been changed to © The Author(s) 2022 and the article is forthwith distributed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit