Tuesday, September 28, 2021

Comments by lcjohnstone

Showing 43 of 43 comments.

  • I agree with a lot of what Eiko says – as he knows – but I feel compelled to make my usual point. What on earth is a ‘mental disorder’? It’s as much of a ‘convenient fiction’ as any of the specific diagnoses. Sure, we need a systemic understanding, but that applies to all human experience. We will get nowhere if we are not able to drop, or at least question, or at very very very very least, avoiding assuming, that there is such a thing as a ‘mental disorder.’

  • Forgive me for my cynicism – I haven’t read the book, but anyone who is still trying to explain ‘psychiatric disorders’ is still firmly entrenched within the existing paradigm of pathology. There are many and varied forms of emotional suffering, but there is no such thing as a ‘psychiatric disorder.’ This sounds like an all-purpose theory of human experience – ie, it is the result of numerous factors interacting in complex ways. Common sense, really, but with limited explanatory value unless we can specify it more precisely than that. I am seeing increasingly complicated intellectual attempts to retain psychiatry as a legitimate discipline while absorbing enough of the critique to sound reasonable. This sounds like one of those.

  • Exactly, Steve and beokay. Defenders of psychiatry have got themselves into a winning position …. there is no possible way of disproving the hypothesis that someone, somewhere, sometime, will stumble across the holy grail of primary biological causal factors in what they persist in describing as ‘mental illness.’ But Aftab is playing a slightly different game here. He admits all the logical errors in the arguments about biomarkers BUT then uses this to create a position that we need to understand biomarkers in a much broader way, which will allow the hunt to continue. He has a similar strategy in relation to psychiatric diagnosis. No longer need we be stuck in the naive view that terms such as ‘diagnosis’ and ‘disorder’ denote medical conditions… they simply suggest that the person is SUFFERING in some way. Any ill-informed person who interprets these terms differently has simply not kept up with the sophisticated new philosophy of psychiatry. He doesn’t explain the existence of all those rather concrete manifestations of the failed ‘medical illness’ paradigm… you know, things like doctors, and nurses, and hospitals, and lots and lots of drugs (‘medications.’) Are these too based on a fundamental misunderstanding of current philosophical thinking, and if so, should we not be getting rid of them? Or does that not, in fact, follow? Very strange indeed.

  • Thanks for this summary and for pointing us towards this article. And also for mentioning the Power Threat Meaning Framework – which is a meta-framework, not a model as such, and as Ragnarok says, can thus be used to support a whole range of non-medical models, of which we have many. The idea that ‘we don’t have anything else’ is just nonsense. What about the many countries and cultures which have struggled by without the dubious benefits of the DSM for the whole of human history? – and where, according to the best research, recovery rates are better than anything Western medicine has produced? Don’t they count?

    Small point: ‘The PTMF is unique among psychiatric diagnostic systems…’ The PTMF is not a diagnostic system of any kind. In fact it is not a ‘system.’ It is a set of principles, and an imperfect, evolving attempt to get right away not just from medical models, but from their conceptual underpinnings – including the assumptions that can be summarised as positivism -which are so deeply embedded in Western thought. It therefore opposes any individualistic, pathology-based understanding, including psychological and psychotherapeutic ones.

  • Absolutely, Steve. But this is what their defences actually boil down to. They have nothing else. I made the same point in ‘A straight talking introduction to psychiatric diagnosis’:
    ‘British psychiatrist Simon Wessely said: “A classification system is like a map. And just as any map is provisional, ready to be changed as the landscape changes, so is classification.” But this depends on whether DSM and ICD do provide at least some guide to the territory. If they don’t, then we are, quite simply, using the wrong map. A map of Cornwall is of no help if you are driving round Scotland. You would be better off with no map at all than one which directs you down the wrong route.’

  • Thanks everyone for your comments. The whole thing was a very strange experience. Dr Aftab did not tell me he was going to invite additional comments – no other interviewee has had extra contributions inserted at the end – and I am at a loss to know how I misrepresented their views (although they certainly misrepresented mine.) The wider reaction on Twitter was extraordinary. I was called everything from arrogant, vicious, reductionist, dangerous, flaky, misguided, hostile and bullying to ‘morally depraved’…..and all of those comments were from professionals. None of those who disagreed with the views I put forward (as they have a right to do) actually engaged with the arguments. I think this says a lot about the fragile foundations of psychiatry…. Robin Murray is regarded in the UK as an open-minded critic of many aspects of his profession, probably much more so than his US counterparts, but it appears that there is an line of criticism that you must not cross. You can go so far and no further. I’m pleased people liked the content, but the process was even more interesting….

  • Thanks everyone for your comments. I agree with you, O.O. Even though psychiatry is not offering appropriate help, it is sometimes the only avenue open to people. It’s useful to be reminded that having an advocate can help to protect from abuses.

  • Excellent blog, Miranda. It’s a fascinating dissection of the contradictions of the ‘mental illness’ discourse. My blog, due tomorrow, makes similar points but from a UK perspective. Unfortunately we seem to be experiencing a pandemic of medical model thinking….. there’s no crisis which can’t be used to feed the psychiatric and psychological empire…

  • This is a very interesting article – and by a strange coincidence I wrote a rather similar one about the fascinating story of the Genain quads in 1996. You may be able to access it here: https://drive.google.com/file/d/1cJgrD8B5QMOdglSPMTOW1pUSLgrXEWKR/view

    I was led to explore their story by reading all the accounts in standard psychology textbooks (I am a clinical psychologist) describing them as strong evidence for genetic factors in ‘schizophrenia’, when in fact – as I discovered, and as you have demonstrated – they are evidence for exactly the opposite conclusion. More specifically, as I have tried to show, the degree of abuse they experienced (which was slightly different for each quad) correlated exactly with the degree of damage they showed in their later lives.

    An extraordinary fragment of psychiatric history, and well worth revisiting – thank you. Lucy Johnstone

  • This scenario is nonsense, and more or less the exact opposite of what the PTMF advocates for. It is not a manual. It is not particularly aimed at therapists. It argues strongly that problems are not located within the individual or their ‘character’, and that real life solutions are what is needed. Further more, it questions the whole idea of therapy, mental health services, and the rest of the current system. I won’t be responding further.

  • I should probably ignore this comment, and the many others like it, but I do find it frustrating when people who apparently have not read the PTMF make blanket statements about what it says, which are actually the opposite of its arguments, and then state that it should be arguing for X,Y and Z instead, which in fact it already does.

    The PTMF does not support any kind of psychiatric diagnosis, or variation on the diagnostic system, whatsoever. It is not about psychotherapy except in a very indirect sense. It is about all of us, whether labelled as ‘mentally ill’ (a grouping which it does not accept) or not. It promotes non-professional support and help and activism as much as, or more than, professional interventions. It is centrally concerned with issues of social and civil rights. It argues that we need a fundamental re-think of our welfare systems, including, possibly, UBI – and it includes a detailed discussion of the pros and cons of UBI and other alternatives.

    I am not sure what document PacificOcean has been reading, but it is not the PTMF. The PTMF is an imperfect, evolving project, which may not be to your taste, but it bears no resemblance to the version that is assumed by several MIA commentators.

  • I think we have had this conversation before, Oldhead… you do not have to like the PTMF, but its strongest message is that distress is NOT simply a personal matter; that we must make the links between personal distress and social injustice/inquality; and that the main changes must happen at that macro level, collectively and politically, and mostly outside the MH system. Not quite sure how you managed to read it differently…?

  • Thanks for this article, Paula. I think you make important points, and I am glad that you and Bob have opened up this topic.
    My own view is that the only consistent and scientific approach is to indicate the problematic nature of these categories whenever they are used. This is sometimes a little clumsy – but challenging our language is the first and necessary step in challenging our (and others’) thinking. Uncritical use of diagnostic and related terms (‘symptom’, ‘treatment’, ‘prognosis’ etc) limits our critiques and implicitly reinforces the status quo.
    There is a precedent that might be useful. A few years ago the UK Division of Clinical Psychology published language guidelines that, in theory, apply to all its publications. They suggest various ways of avoiding the trap of assuming the validity of unscientific constructs. The editor of Clinical Psychology Forum supports and upholds this policy. It caused a ludicrous fuss on social media when it was first published – which is interesting in itself, of course, and shows how changing our language is intimately tied up with changing power structures – but has not been particularly problematic to implement. The link is here:https://www1.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/Guidelines%20on%20Language%20web.pdf

  • Great article. When I visited NZ with the Power Threat Meaning Framework, I was privileged to have the chance to present it alongside Maori speakers and attenders. It was one of our hopes that the PTMF, in contrast to diagnostic models, conveys a sense of respect for indigenous understandings and healing, and it was very gratifying to find that the attenders saw compatibilities and commonalities between the PTMF and traditional Maori perspectives. I was left with many reflections about what we (as in Westerners) have to learn from older traditions. The blog is here:


  • Thanks for these comments. The article Zenobia describes can be accessed here, along with others on some of the ways the PTMF is being used: https://shop.bps.org.uk/publications/clinical-psychology-forum-no-313-january-2018.html

    There are also 2 blogs on introducing the PTMF in New Zealand and Australia here:

  • I haven’t read this article, but I own up to being irritated by its content judging by Zenobia’s (excellent) summary. What is the matter with philosophers who write about ‘mental health’??? They above all should be careful with their language and wary of unquestioned assumptions, but as several people have said, their uncritical starting point is that there is such a thing as a ‘psychiatric DISORDER’, complete with ‘symptoms’ – begging about 100 questions and setting us up for a kind of ‘how many angels can dance on a pinhead’ chase. I am continually dismayed by how deeply these assumptions have infiltrated the minds of philosophers as well as service providers/users. I suggest the authors start with the question ‘How do we understand the emotional distress and suffering that is labelled as psychiatric disorder?’ and take it from there…. There is plenty to draw on!

  • People are 100% entitled to their views, and I understand the suspicion about any new perspective … but I do wonder if you have read the Framework, Frank? You say: ‘With the PTM framework you are expecting “user/consumers” to buy whatever it is you’re selling. Liberate people from the mental patient role, and you no longer have “user/consumers” contending over what sort of fraud it is they are willing to buy (i.e. the bio-medical fraud versus the power-threat-meaning fraud).’ The Framework was not produced by professionals and then aimed at ‘user/consumers’ since it does not recognise such a distinction in terms of distress/extreme states/unusual experiences. The Framework was co-produced with survivors from the first meeting. It is about how we all, however we are categorised, struggle with the impact of power and with the emotional suffering arising from it. It is imperfect and incomplete but it is not as you seem to be assuming.

    Ditto Oldhead’s comment: ‘When people make the connection that we feel this shit because we are being oppressed by concrete, identifiable forces we can then learn the value of defeating those forces — something the “framework” glosses over — and changing the objective situation for us all. THAT is the only thing that will ever get us finally venturing out of our individual little prison cells and collectively experiencing humanity — and life — as worthwhile and joyous.’ I totally agree. And this is what we have tried to convey – albeit imperfectly – in the Framework. If this message really isn’t coming across at all – which I find surprising – we would welcome thoughts on how to make it even more explicit.

  • Thanks, Wayne. If anyone is in doubt that the Framework does offer at least some challenge to the status quo, then follow the hashtag #PTMFramework on Twitter and you will see a whole series of brutal and very personal attacks, often from professionals using their own names…. so far we have been accused of being Marxists, ‘alt right’, (not sure how those two go together), Scientologists (of course!), of collectively bullying, silencing and ‘vilifying’ anyone who criticises the Framework, and/or of setting up ‘sock puppet’ accounts to do so, and/or of writing to people’s employees to silence them with false complaints; of deliberately obstructing the Division of Clinical Psychology consultation process (which was long and detailed); and worst, that the professionals in the project group have forced the survivor contributors to act as ‘trauma porn stars’ and trade their personal stories in order to ‘pay our mortgages.’ Bizarre analogies have been drawn with Mao, Stalin and Hitler (yes, seriously….) Senior professionals have described me and Mary Boyle, the lead authors, in grossly misogynist terms such as ‘queens and their courtiers’, ‘women of a certain age’ and ’empresses with no clothes’, while circulating sexist cartoons. Entire critical blogs have been written based on statements that do not actually appear in the documents. Allen Frances himself alluded to the Framework in the phrase ‘worse than mental masturbation.’ It is also, of course, ‘entirely without evidence’, ‘anti-psychiatry’, ‘anti-science’ and nothing more than a ‘polemic’ or ‘manifesto.’ Luckily the Framework gives us a handy way of analysing this …. we are clearly posing a threat to ideological power, which is a major theme in the Framework. Along with this we have also had some very welcome, relevant and constructive feedback – which is exactly what we want to receive, since we see the publications as very much as a first step in need of further development. I hope I have persuaded you that you need to read this appalling document for yourselves! See my comment to Sarah above which has links to the relevant documents and resources.

  • Thanks for this, Sarah. You’ve done an excellent summary of the messages of the PTM Framework. The only thing I would add is that it was developed and funded by the Division of Clinical Psychology, which is a sub-division of the British Psychological Society (the latter represents all brands of psychologists in the UK); and, importantly, it is not official DCP or BPS policy. Rather, it is one of a range of publications issued each year, most of which are discussion documents of some kind or another.
    One of the advantages of having this organisational support is that the Framework can be offered as a free intellectual resource to anyone, rather than being sold as a book or paywalled in a journal. This is in keeping with our aims of breaking down professional/service user barriers and counteracting ‘epistemic injustice’ – that is, being deprived of the knowledge to make sense of your own experiences due to unequal power relations (think of almost everyone who ends up in services and is wrongly told that their diagnoses are facts.)
    Unfortunately I have missed some of the sessions but I will try and join some of the others. We have been in touch by email – in due course I’d love to have some kind of feedback about how it all went, and ideas people may have had for developing/adapting the Framework further. In the meantime, because the main documents are pretty lengthy and complex, here are some easier ways in (in addition to your workshops): Interviews with authors and attenders at the launch: https://vimeo.com/264387393 Videos of the main talks at the launch: https://vimeo.com/267401691 Link to FAQs, a 2 page summary, and a suggested ‘Guided Discussion’ for reflecting on the ideas in relation to your own life or someone you are working with: https://www.bps.org.uk/news-and-policy/introducing-power-threat-meaning-framework Interview with me elsewhere on the MIA site: https://www.madinamerica.com/2018/03/dr-lucy-johnstone-power-threat-meaning-framework/ You can order your own copy of the shorter Overview document by emailing [email protected]. We welcome thoughts and feedback.

  • And so do I, Phil Hickey…not only psychiatric diagnosis but the whole conceptual edifice on which it is built has to go. That is what the Framework argues. It also makes clear links between distress and social injustice in the form of capitalism, neo-liberalism and all the ideological messages that accompany and support them. How successfully it does this is up to others to judge. However, we are encouraged by reports not just from professionals but from service users, peer support groups and so on that people are finding it a helpful way of getting beyond diagnostic assumptions.

  • No one has to read the Power Threat Meaning Framework or to agree with it if they do. It is certainly not perfect and we welcome feedback. However, several of the comments have fundamentally misunderstood its content and purposes. I will briefly correct some of these assumptions.
    1. The Framework is not an ‘alternative’ in the sense of a new or replacement version of diagnostic categories. Its starting point is that we need to completely abandon diagnosis and the whole biomedical model it supports, along with all the subsequent consequences and assumptions, and to develop a new perspective by unpicking the philosophical roots of the current system. These are deeply embedded in rationalism, positivism, and Western worldviews encompassing, but not limited to, the separation of mind from body, individual from social group, and humans from the natural world.
    2. The Framework was co-produced with the survivors in the core project team from the very start. In addition we benefited from input from a service user/carer consultancy group. It draws extensively on survivor literature and experience, and values these forms of evidence just as highly as the more traditional kinds.
    3. The Framework thoroughly supports oldhead’s suggestion that ‘depression’ (although it avoids this kind of diagnostic language) or any other form of emotional suffering, is one of the end results of damaging socioeconomic systems and social values. One of its main stated purposes is to restore the link between personal distress and social injustice. The Framework attempts to do this by placing a very strong emphasis on the aspects of power usually absent from analyses of distress – particularly ideological power, or power over language and meanings. It thus places its strongest emphasis on the need for social action.
    4. The Framework is not fundamentally about psychologists, or any other professional group, coming up with a new system for those said to need their services, for the simple reason that it does not recognise a distinction between ‘mad’ and ‘sane’, ‘normal’ and ‘abnormal’, those who are in need of intervention and those who are not. Emotional suffering is universal, and we are all subject to the impact of Similarly it places a very strong emphasis on people’s ability to create their own narratives and sources of healing outside services, once freed from the dominant medical assumptions that are imposed on them. For these reasons, we intend the Framework to be a publicly available knowledge resource, and have thus chosen to make it free online, rather than in book or paywalled journal article form. It is a fairly dense read, but accessible versions are available on the website (eg a 2 page summary and a ‘Guided Discussion’) and more are due to be developed.
    5. The Framework is a set of ideas, not a policy document or a plan for services. It is an entirely optional perspective. However, we hope that others may be interested in taking on its ideas and developing it in their own ways, whether in services, peer groups, training, or for personal use. So far the response has been very encouraging.
    As I say, we welcome feedback…ideally based on first finding out what we have actually said!

  • Thank you for this clear and concise summary, Phil.
    This link gives access to both the online versions of project documents, plus slides from the launch, an accessible 2 page summary, and the Guided Discussion for starting to think about these ideas in relation to your own or someone else’s life.

    This is a link to interviews with the authors and attenders at the launch:

    This an interview I did on the project for MIA:

    UK residents can order a hard copy of the shorter Overview document from the British Psychological Society – you do not have to be a BPS member. Email [email protected]

    The video of the main talks from the day will be out very shortly.

  • This is a fantastic summary, Sarah. I do not have a background in medicine/neuroscience/physiology, so I am not qualified to comment in detail, but it makes perfect sense of the phenomena I have observed in many clients who have been diagnosed as ‘bipolar.’ From a psychological perspective, mood swings do sometimes seem to be driven by the need to escape from overwhelming unprocessed emotional memories of grief, pain and powerlessness, into a state of feeling confident, powerful and outwards-directed, and I have found that working with the underlying emotions and memories can reduce the need to escape into ‘mania.’ I think this is compatible with your model. Your synthesis is also a very useful expansion of the biological mediating factors that we have discussed in the Power Threat Meaning Framework.

  • This is one of your best blogs, Phil, out of a very strong field.
    I sometimes put it like this: All human experience has biological correlates – but not all human suffering is best described as a disease process. The ‘grief’ analogy can be useful. Someone whose partner has just died might well be highly agitated, anxious, distressed, weepy, unable to concentrate or sleep, perhaps seeing or hearing the dead person – in other words, meeting the criteria for a range of ‘mental illnesses’ – but most sensible people don’t call this a ‘mental illness’, because we know there is a causal link to a very traumatic event. If we were sophisticated enough to make this kind of link in every case (with obvious exceptions like dementia), it would be equally apparent that the ‘diagnosis’ is completely redundant. There is a mountain of research encouraging us to do this, and none at all supporting the current paradigm, as you have so powerfully demonstrated. The current case for psychiatry is resting entirely on a series of tautologies and logical errors. Lucy Johnstone

  • I’m so pleased to hear about this. From the other side of the Atlantic I have had a similar feeling that we may be at a tipping point. I and some new allies – both professional and survivor – are setting up a series of talks in cities in the UK. We’ve had a pilot run in Birmingham, which was very positively received and attracted a very varied audience, and will be in Bristol on March 3rd, and Edinburgh on March 10th. There are more to come! Everyone is welcome.
    It is so important to feel that our efforts are paying off, when sometimes things seem so hopeless. Let’s celebrate our successes. Lucy Johnstone

  • It’s encouraging to read this article, which describes something similar to the widespread practice of team formulation in the UK. In this, a team is facilitated to come to a shared understanding, hypothesis or ‘best guess’ about the psychosocial reasons for someone’s difficulties. I’ve written about the approach in my posts on this site. Some examples of recent practice are described in this edition of Clinical Psychology Forum (the monthly magazine of the UK’s Division of Clinical Psychology, Nov 2015.) I’m not sure if this link will work, but otherwise, visit http://www.bpsshop.org.uk Lucy Johnstone


  • I was there too! There was a very powerful set of presentations, and it was an important and encouraging event which, I hope, reached the ears of people who have power to bring about some real change. I understand that a video will be available via the Council for Evidence-based Psychiatry at some point. In the meantime, you can get a flavour from my live tweeting at @ClinpsychLucy. Lucy Johnstone

  • Thanks, Jay, for this excellent summary. This is a slide I often use in presentations:

    Recovery themes

    Connectedness (including support from others and feeling part of the community); hope and optimism about the future (including belief that recovery is possible); identity (including overcoming stigma); finding meaning in life (including the experience of ‘mental illness’); and empowerment (including taking personal responsibility, focusing on strengths, and taking control of one’s life) (Leamy et al 2011)

    I then point out that the recovery themes are more or less the exact opposite of the messages conveyed by psychiatric diagnosis. So – it is legitimate to ask what people are meant to be recovering FROM – the ‘illness’, or the diagnosis (and associated ‘treatment.’) What an irony. First we mess you up (let me hasten to add, often with good intentions…) and then we turn round and tell you it’s now your job to ‘recover’ from what we’ve done. Lucy Johnstone

  • Great blog as usual. I only have one comment to make. Allen’s rhetoric relies on a misuse of language; ie begging the question by referring to people as ‘severely mentally ill.’ But this is exactly the issue under debate. Are they, in any scientific or evidence-based sense, suffering from medical ‘illnesses’? Replace that term with ‘severely traumatised and socially marginalised’ and it immediately seems less obvious that they should be medicated for life. I also think use of the term ‘antipsychotic’ plays into this misleading picture. As we know, the drugs do not rectify biological dysfunctions that cause ‘psychosis’, whatever that is. Clarity of language is the first step towards changing minds and changing practice. Keep up the good work! Lucy Johnstone

  • Interesting article. There are a lot of this type around at the moment, testifying to the failure of the biomedical model to find any causal pathways at all. However, I do have doubts about these attempts to find, in their words, ‘distinct pathways from specific forms of child abuse to particular psychotic symptoms.’ First: the pathologising, pseudo-medical language, which posits the existence of entities such as ‘psychosis’ which are just as questionable as ‘schizophrenia’ – and which in fact raise even bigger questions of reliability and validity, given their woolly, open-ended nature. These mysterious entities then operate as a kind of intermediary between the event (eg abuse) and the outcome (eg terror, confusion) with the risk of becoming the main focus of ‘treatment’ via meds etc.. Alternatively, as I suggested in ‘Demedicalising Misery’ eds Rapley, Moncrieff and Dillon 2011, we might be brave enough to recognise that ‘There is the abuse, and there are the responses to the abuse. There is no additional “psychosis” that needs explaining.’ Secondly, this kind of research quickly runs into the ‘Everything causes everything, everyone has experienced everything, and everyone suffers from everything’ problems. CA is a risk factor for every psychiatric diagnosis, and conversely, about 20 other factors have also been identified as risks in ‘psychosis’. MH service users who have experienced single adversities are very rare. And the vast majority of people present with a whole range of ‘symptoms’, not just ones that might be designated ‘psychotic.’ Moreover, and not mentioned in any of this research, people may then be subjected to a whole range of re-traumatising ‘treatments’ which exacerbate the original trauma(s). In other words, the picture is way, way more complicated than the researchers seem to hope, not least because of the over riding importance of the construction of meaning in shaping the impacts of any event. How does that fit into the causal picture?

    In summary, I think this is an attempt to squeeze the complexity of human experience and human suffering into a primarily positivist, natural science model of causality, and ultimately it just won’t work. We need to get further away from our basic assumptions. Having said that, I would like to see subsequent articles building on the implication that actually, life events and attachments are all we need in order to explain what we call ‘psychosis.’ That really might take us somewhere new.