A major event takes place in London, UK today with the publication of the Power Threat Meaning Framework. The Framework is an ambitious attempt to outline a conceptual alternative to the diagnostic model of mental distress, unusual experiences, and troubled or troubling behaviour. The project has been funded by the Division of Clinical Psychology of the British Psychological Society over a five-year period. The project team (lead authors Mary Boyle and myself, Lucy Johnstone; contributing authors John Cromby, Jacqui Dillon, Dave Harper, Peter Kinderman, Eleanor Longden, David Pilgrim and John Read, with assistance from Kate Allsopp) consists of senior psychologists and prominent survivors, several of whom are bloggers on MIA. They have been supported by a group of over 30 additional professionals and service users as contributors and consultants.
Although the Framework does not represent official DCP or BPS policy, it builds on the Division of Clinical Psychology’s 2013 Position Statement “Classification of behaviour and experience in relation to functional psychiatric diagnoses” which called for “a paradigm shift . . . towards a conceptual system which is no longer based on a ‘disease’ model” and recommended work “in conjunction with service users, on developing a multi-factorial and contextual approach” to replace the current medical one. The Power Threat Meaning Framework synthesizes evidence about the causal roles of power, evolved threat responses, social discourses, and personal meanings and narratives. It is intended to provide the basis for an ongoing series of developments in clinical practice, service design and commissioning, training, research, service user/carer/survivor work, and public education. The project documents will be an evidence-based resource for restoring the link between distress and social injustice, and in doing so, supporting the construction of personal narratives and promoting social action.
The publication of Framework has been eagerly anticipated, and the 400 places for the launch sold out within two days. Other events are planned around the UK and further afield in due course. The launch marks the start of the second stage of the project, which is about translating its principles into practice. While use of the Framework, whether in personal or peer work or within voluntary or statutory services, is entirely optional, the team is encouraged by the interest already expressed.
The project documents will be available after the launch as free downloads from the BPS website. Appendix 1 of the Overview Document consists of a ‘guided discussion’ for one-to-one work in services or for peer support/self-help. Appendices 2-14 of the Overview Document give examples of existing non-diagnostic practice in various service and non-service settings. A two-page summary can be found here, and the full document (414 pages) is here.
Core principles of the PTM Framework
It applies not just to people who have been in contact with the mental health or criminal justice systems, but to all of us.
The Framework summarises and integrates a great deal of evidence about the role of various kinds of power in people’s lives; the kinds of threat that misuses of power pose to us; and the ways we have learned as human beings to respond to threat. In traditional mental health practice, these threat responses are sometimes called ‘symptoms’. The Framework also looks at how we make sense of these difficult experiences, and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt.
The main aspects of the Framework are summarised in these questions, which can apply to individuals, families or social groups:
- “What has happened to you?” (How is Power operating in your life?)
- “How did it affect you?” (What kind of Threats does this pose?)
- “What sense did you make of it?” (What is the Meaning of these situations and experiences to you?)
- “What did you have to do to survive?” (What kinds of Threat Response are you using?)
In addition, the two questions below help us to think about what skills and resources people might have, and how we might pull all these ideas and responses together into a personal narrative or story:
- “What are your strengths?” (What access to Power resources do you have?)
- “What is your story?” (How does all this fit together?)
Possible uses of the PTM Framework
The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they may have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. It highlights the links between wider social factors such as poverty, discrimination and inequality, along with adversities such as abuse and violence, and the resulting emotional distress or troubled behaviour. It also shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity.
The Framework describes the many different strategies people use, from automatic bodily reactions to deliberately-chosen ways of coping with overwhelming emotions, in order to survive and protect themselves and meet their core needs. It incorporates embodied aspects of power, threat response and meaning-making while avoiding simplistic statements about biological causality. Narratives drawing on the PTM Framework can be used to suggest a wide range of ways that may be helpful in moving forward. For some people this may be therapy or other standard interventions, including, if they help someone to cope, psychiatric drugs. For others, the main needs will be for practical help and resources, perhaps along with peer support, art, music, yoga, exercise, nutrition, community activism and so on. Underpinning all this, the Framework offers a new perspective on distress which takes us beyond the individual and shows that we are all part of a wider struggle for a fairer society.
One of the most important aspects of the Framework is the attempt to outline common or typical patterns in the ways people respond to the negative impacts of power — in other words, patterns of meaning-based responses to threat. This part of the Framework, like all of it, is still in a process of development. However, the evidence summarised in the Framework does suggest that there are common ways in which people in a particular culture are likely to respond to certain kinds of threat such as being excluded, rejected, trapped, coerced or shamed. It may be useful to draw on these patterns to help develop people’s personal stories. These general patterns can help to give people a message of acceptance and validation. The patterns can also assist us in designing services that meet people’s real needs, as well as suggesting ways of accessing support, benefits and so on that are not dependent on having a diagnosis.
In addition, the Framework offers a new way of thinking about culturally-specific understandings of distress without having to see them through a Western diagnostic lens. It encourages respect for the many creative and non-medical ways of supporting people around the world, and the varied forms of narrative and healing practices that are used across cultures.
Taking the PTM Framework further
It is important to note that Power Threat Meaning is an over-arching framework which is not intended to replace all the ways we currently think about and work with distress. Instead, the aim is to support and strengthen the many existing examples of pioneering work (such as trauma-informed and narrative practice), while also suggesting new ways forward.
The Framework has wider implications than therapeutic or clinical work. Chapter 8 of the main document suggests how it can offer constructive alternatives in the areas of service design and commissioning, professional training, the law, access to welfare and benefits, research, service user involvement and public information. Most of this is written with a UK context in mind, but the principles apply more widely. There are also important implications for social policy and the wider role of equality and social justice. It is a work in progress, offered as a resource for any individuals, groups or organisations interested in developing it further.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.