Publication of the Power Threat Meaning Framework

Lucy Johnstone, PsyD
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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.

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31 COMMENTS

  1. “what has happened to you, how did it affect you, what sense did you make of it, what did you have to do to survive ?”

    That is absolutely spot on and fine. But also what happened has affected the biology and that also needs to be addressed, obviously not with psychiatric drugs. Logic states that the mind/mental states can not exist without human biology and some of this biology is well understood. Also when you give people who are spellbound by drugs, (via GP/psychiatrists..the power) – I concentrate on benzodiazepine and migraine drugs – sound science and give them the information to read, it gives them a way out, they then begin to believe they can live without the drugs. What I have found with people who have been abused, is that they are stuck in that time frame and moment, emotionally/psychologically. Also found this in a stark way through my own abuse by psychiatry. It is terribly difficult to move on and develop. You come to understand why a grown man or woman is acting as a child and being totally failed because of the norms expected by society of adults and then enforced by psychiatry. This aspect is much more difficult to deal with, I wouldn’t pretend to have much of an answer other than time and talking with the right people.

    • I may be mistaken, but you seem pretty focused on finding a “biological solution” to trauma, essentially. I’m struggling mightily to find evidence that I “don’t get” what you’re saying, with little success.

      It is a reality that any mental/emotional state has a biochemical correlation; it does NOT follow that correlation is causation, or that problems with social and political geneses can/should be primarily addressed by tinkering with biology, as opposed to resolving the real life circumstances at the center of our “distress.”

      To point this out is not to discount the importance of good nutrition, brushing one’s teeth, etc., ESPECIALLY when withdrawing from neurotoxins, which may well deplete needed minerals, etc. that need replacement via supplements, diet and the like.

      • I went through 50 or so years of my life perfectly normal, had no interaction with psychiatry, didn’t even know what an SSRI was. I have never drunk alcohol to any great degree, maybe the odd glass of wine, never taken any street drugs what so ever, nor any prescribed drugs for years before I became ill. Yet I was – through no fault of my own- subject to sustained high level stress and became very ill in-terms of what I now know to be the equivalent of constant panic attacks. That is a correlation WITHOUT any psychiatry, I looked for the biological facts and found them very specifically in glutamate/gaba dysregulation and I later corrected my own problem. It did not involve talking. However the harm done to me thereafter by psychiatry is both psychological and physical. Akathisia is a physical manifestation of drug abuse, via a massive profit based ponzi type fraud, that uses the medical profession hierarchy. Being forced to take drugs that could have killed me – and almost did – is psychological power abuse and a crime.

      • Here is the 1976 study by Marie Asberg re serotonin

        https://www.ncbi.nlm.nih.gov/pubmed/1246632?dopt=Abstract

        “The finding suggests the existence of a biochemical subgroup of depressive disorder, characterized by a disturbance of serotonin turnover.”

        Note the word “SUGGESTS”

        I had a brief email correspondence with Marie, where she said there is much evidence for low serotonin and suicide. I replied saying there is much evidence for many other causes, including: low magnesium, up regulated zinc transporters and psychiatric drug induced akathisia. I did not get a reply. And that is what you find from psychiatrists… they hate to be challenged, no discussion allowed.

        My advice to anyone suffering significant anxiety is to listen to you lot so far and then study the biological chemistry of magnesium in the brain and all you can find on Glutamate/GABA, the receptors, what this system requires and what harms it. If a person does not have a psychological issue, that is where the problem is. Do not go near a GP or psychiatrist. Not only is the health system corrupted the method to hold people to account is also corrupted and therefore supporting the abuse. In the UK the CQC, PHSO, and GMC are more a kind of placebo facade.

        • My advice to anyone suffering significant anxiety is to listen to you lot so far and then study the biological chemistry of magnesium in the brain and all you can find on Glutamate/GABA, the receptors, what this system requires and what harms it.

          I on the other hand would — if I were friends with the person — help them explore the source of the anxiety and try to resolve it, or at least understand it.

          There are two subjects here — a) whether psychiatry should bite the dust, on which we both agree; and b) why people experience anxiety, which is a separate topic, about which I think you tend to overgeneralize from your personal experience.

          I was – through no fault of my own- subject to sustained high level stress and became very ill in-terms of what I now know to be the equivalent of constant panic attacks

          “Ill,” or very anxious? You seem to conflate the two. In any event, unless the “high-level stress” was caused solely by magnesium depletion and not any real-life situation, why would the solution be primarily “biological” rather than dealing with the objective source of the anxiety?

  2. Expresses many things people are argued for over decades so not entirely new.
    Very poor involvement of people with first hand experience of psych services, only 8 named, when this is supposed to be an entire diagnostic alternative for all. A 5 year project should have talked with a lot more than that and with people who have diverse experience and circumstances.
    The social justice refs verges on insulting (although the full doc is not out yet), because this appears to be solely in relation to diagnosis and social justice constitutes a lot more than that. Sadly no social justice groups were consulted alongside no service user/survivor/patient groups.
    How far this permeates beyond a very narrow clique of psychologists and a couple of international recovery speakers seeking to seize power from psychiatry remains to be seen. It might encourage some psychologists to refuse diagnosis where that is bureacratically required.
    It’s pretty much impossible to implement an entirely new system without involving government departments of health and welfare which the project hasn’t done.
    Currently we have a very neoliberal government who would simply use it to cut back and marginalise further. We would need regime change to see the best parts of this implemented.
    This is a guideline for people with experience of early attachment/trauma issues especially abuse. I think if it were promoted as such then it would be more accurate. This is not however a replacement for ICD and DSM.
    I’m no lover of diagnosis and would happily see the fall of Personality Disorder especially, as for the rest, the timing given our political situation is not great. The focus for social justice groups is keeping people alive as 43% of claimants are attempting suicide because of the processes, sometimes experienced as even more threatening than psychiatric services.
    I dislike the implication that there are one group of people who have experienced trauma of specific kinds and there’s another who are sitting in sick role. Psychologisation is no smarter than psychiatrisation

  3. Their solution to the welfare issue is Universal Basic Income which is interesting given a couple of project members have stated they know little about it so evidence seems to not matter there. Can see that it’s useful for in psychologists levering out diagnosis, there’s just the issue of the people who have to live on it. Typically UBI is proposed by those with more privilege for others.

  4. The author refers to a paradigm shift . . . towards a conceptual system which is no longer based on a ‘disease’ model. Yet this project is funded by “clinical” psychologists, which implies medicine/disease/treatment. And if we’re talking about “misuse of power” why is capitalism not mentioned once? These are the sorts of things the “human services” expect us to gloss over.

    • This is an excellent point. The entire economic system we operate in is organized around oppressive principles and assumptions, and unless that’s fair game for discussion, we end up colluding with that system, no matter how helpful our individual interventions might be.

      • All these approaches take “the system” as a given, either openly or implicitly, hence the cycle of oppression continues.

        There’s more though — invariably statements such as the above are met with an unnecessary “defense” of the character or integrity of the person whose statements are being analyzed or criticized (which had never been questioned), and the thread gets diverted to a debate about whether the author is a “good” or “bad” person. Exit discussion topic.

      • Oldhead: “And if we’re talking about “misuse of power” why is capitalism not mentioned once? These are the sorts of things the “human services” expect us to gloss over.”

        Indeed – for example on page 11 this appears:

        “The PTM Framework is also relevant to problematic forms of behaviour including some of those seen in the fields of addictions and criminal justice.”

        Problematic for whom, and why are the obvious questions that need addressing and are glossed over – generally the poorest sectors of the population whose liberties are curtailed in these fields – and almost certainly inextricable from the capitalist power nexus – as we have seen recently, where decriminalisation occurs things change on the ground……..

    • I think “clinical psychologists” don’t necessarily come with a “medicine/disease/treatment” framework. People like Lucy Johnstone and Peter Kinderman, who contributed to this approach, don’t operate from this framework. Of course, they do work in a system in which they work with people who are seeking help for psychological problems, and get paid for doing so, but it’s possible to do this work in my view without operating from oppressive principles and assumptions. It can be difficult because of the rules of the system, but it is possible.

          • If a person who is struggling psychologically seeks the help of a credentialed psychologist, and visits that psychologist at his or her office, is this an inherently medical paradigm? Does calling the office a “clinic” make it so? Perhaps the answer depends on what we mean by medical paradigm. If by medical paradigm we’re simply referring to a person seeing a credentialed member of a helping profession in a professional setting and paying that professional for services, then sure, clinical psychology is part of a medical paradigm along with every other profession associated with the healthcare system. But to me, there is a critical difference between this general medical paradigm and the biomedical paradigm of psychological struggles, in which they are diagnosed with a DSM label, framed as mental illnesses, assumed to be the products of biological dysfunction, and treated with psychiatric drugs. The authors referenced in this blog post reject this biomedical paradigm. But yes, they are part of the general medical paradigm described above. If you reject the notion that it is acceptable for people who experience psychological struggles to voluntarily seek help from a credentialed professional like a clinical psychologist who is paid for services rendered, I’d be interested in learning why.

          • Does credentialing actually provide any assurance that the practitioner is competent or ethical? Studies seem to indicate that para-professionals or untrained peer counselors do at least as well as professionals with advanced degrees. What does licensure provide, other than job protection for those so licensed?

          • Steve, you’ve changed the subject. This is an interesting topic though and I imagine we have similar perspectives on it. For my benefit, I’d be interested in seeing the studies you noted that show similar or better outcomes with para-professionals or untrained peer counsellors compared to professionals.

          • I think the semantic/self-empowerment implications of “treatment” or “clinical” anything vs. something generic like “counseling” should be apparent.

      • ‘”Clinical psychologists’ don’t necessarily come with a ‘medicine/disease/treatment’ framework.”

        Those who work at the community centers do, Brett. It’s uphold the status quo and keep mainstream psychiatrists happy or lose your job.

        If I ever see a counselor again it will be in a private practice. Not a Mental Illness assembly line at the Pharma-Psychiatry Factory.

  5. I haven’t had time to really review this in detail, but one quick comment: A lot of the basic questions suggested seem really good, but one I don’t care for. That is, “What did you have to do to survive?” This question seems to presume that the person had to do everything they did in order to survive, when in fact much of what we do in our attempts to survive may be unnecessary or even counterproductive – but still perfectly understandable given the threat we faced and what we felt at the time.

    So I’d replace that with a different question, “What did you do in your attempts to survive, and what impact did that have?” This can bring out both stories of responses that were really helpful, and ones that had other kinds of results. Some of the latter can be harder to talk about – it’s stuff we did that didn’t help our situation – but when we see it in the context of the story and the threat and what we were capable of at the time, it makes sense that we did it and also that we can act differently now.

    • I like this. I have also approached it from the other direction – “What were you hoping to accomplish when you did this – what was your goal?” Or “What need were you trying to meet with this behavior?” Not always an easy question to answer, but I found it digs down very quickly to the key issues that are hanging the person up. Whether or not it worked, or continues to work, I come from the point of view that all behavior is intended to meet a need, to accomplish something, and once we find the goal, we can talk about other options that might meet the same need at a lower cost.

  6. Don’t want to reform or otherwise perpetuate any aspect of Psychiatry or Psychotherapy. Want to eradicate it, and get Crimes Against Humanity convictions on as many of its practitioners as possible.

    It starts with getting patients to start standing up for themselves, and especially the children.

  7. I received several years of outstanding counseling from a Licensed Professional Counselor who was extremely knowledgeable about psychiatric abuse and how it had affected my family. I miss my counselor! He is stupendous! Embarrassingly, I can no longer afford the expense of seeing him.

    I don’t know about others who hope to benefit personally from this framework. To me it sounds wonderful. However, this type of approach would require a lot of work. In my previous two years of counseling I barely touched the surface. It would take time for me to become conscious of the many ways that I responded to threats in the past. It could go all the way back to my childhood and have relevance to my marriage, home-life, parenting style, career, social life, etc. My MO may also be tangled up in my impulsive/compulsive behavior and other bad habits I have acquired along life’s way. Talking about such things elicits shame and embarrassment, and it takes time to build trust. Most private insurance require that a LPC’s and other practitioners diagnose a client using the DSM and come up with a treatment plan in order to be compensated. There is a sense of ‘hurry hurry, hurry’ when dealing with the medical industrial complex in the US.

    In the UK, this model may have a chance to see the light of day. It might win some research grants and have a chance to be implemented in a more ‘outcomes’ based socialist medical system. In the U.S. even if this model were very worthy and had a large evidence base, its proponents would face a steep uphill battle to gain the attention of the guilds and the media and a huge lobbying effort to force insurance companies and government programs to provide access. If it sounds too good to be true, it is.

    Also, in this model, there is a sense of providers biting the hand that feeds them.