In January, 2018, the clinical psychology division of the British Psychology Society published a very important paper. The document is titled The Power Threat Meaning Framework and is subtitled:
“Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis”.
The term functional psychiatric diagnosis does not imply that the “diagnoses” in question are useful or helpful, but is rather a reflection of the historical division of psychiatric “diagnoses” into those that are organic (i.e., stemming directly from brain damage or disease) and those that are functional (i.e. all the rest). This distinction was formally embedded in DSM-I (1952), but has been largely abandoned in psychiatry’s promotion of the hoax that all their “diagnoses” stem from brain malfunctions.
The authors of the report are:
Lucy Johnstone, Consultant Clinical Psychologist and Independent Trainer
Mary Boyle, Professor Emeritus of Clin Psychology, Univ of East London
Contributing authors/project group
John Cromby, Reader in Psychology, ULSB, University of Leicester
Jacqui Dillon, Survivor Activist and Chair, Hearing Voices Network, England
David Harper, Reader in Clinical Psychology, University of East London
Eleanor Longden, Postdoc Service User Research Mgr, Psychosis Research Unit, Greater Manchester Mental Health NHS Foundation Trust
Peter Kinderman, Professor of Clinical Psychology, Univ of Liverpool
David Pilgrim, Honorary Prof of Health and Social Policy, Univ of Liverpool
John Read, Professor of Clinical Psychology, University of East London
The Power Threat Meaning document consists of an introduction, eight chapters, an appendix, and 58 pages of references.
It is clear from the Introduction that the document has been long in the making:
“In 2013, the British Psychological Society’s Division of Clinical Psychology (DCP) issued a position statement entitled Classification of behaviour and experience in relation to functional psychiatric diagnosis: Time for a paradigm shift. The summary is:
The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model (DCP, 2013, p.1).”
And, of course, individual members of the BPS have been drawing attention to this need for decades.
The Introduction of the PTM Framework enumerates some of the limitations and inconsistencies of psychiatry’s disease model, and then:
“The philosophical position outlined in this document suggests a more sophisticated view of human beings and human emotional distress, within which we are active agents in our lives at the same time as facing many very real limits and barriers to the changes we can bring about. Those limitations may be material (money, food, transport) biological (physical disability) psychological (fear, anxiety, self-doubt) and/or social (gender expectations, isolation, discrimination.) More subtly but perhaps most damagingly, they may take the form of the meanings, beliefs, expectations, norms and values that we absorb, often unconsciously, from wider society.” (p 17)
CHAPTER 1: PROBLEMS OF PSYCHIATRIC DIAGNOSIS AND THE NEED FOR A DIFFERENT APPROACH
Many of us in the anti-psychiatry movement have drawn attention over the years to the problems and shortcomings of psychiatric “diagnoses”. One of the achievements of the Power Threat Meaning document is that the authors have not only drawn together the various threads in this debate, but have also managed to blend them into a coherent, cogent, and highly readable account.
“…the DSM presents itself as adopting a descriptive or atheoretical approach, as if its contents involved no underlying assumptions but were simply read off from nature. This is far from the case. We will be arguing in this document that what is needed is a completely different way of thinking about emotional distress and various forms of troubling and apparently unintelligible behaviour. Most of the document will be concerned with describing this way of thinking, the evidence which supports it and its implications for practice and service delivery.” (p 20)
“Most importantly, we have argued that it is the adoption of an inappropriate theoretical framework, designed for understanding bodies and not persons, which is largely responsible for the problems which have beset psychiatric diagnosis and the DSM since their beginnings, including a lack of fit between DSM categories and people’s actual problems and a failure to discover biological causes of ‘mental disorders’. Another effect of the DSM’s medicalised framework has been to marginalise the very large amount of research showing close links between social and personal adversity and mental distress. But above all, the DSM removes meaning and intelligibility from an increasingly wide range of human thoughts, feelings and actions, by treating them as ‘symptoms’ often fundamentally explicable in terms of genes and biology, using the theoretical frameworks of medicine. Yet as we have seen, there is no reliable evidence to justify this approach – as the DSM itself admits. Instead, there is abundant evidence – presented later in this document – that actions, thoughts and feelings said to be symptoms of ‘mental disorder’, including those said to be symptoms of ‘schizophrenia’ and other ‘psychoses’, are intelligible in terms of people’s contexts and life experiences. And, if we want to understand people’s problems and offer effective help then it is vital to take account of this relationship.” (p 32)
CHAPTER 2: PHILOSOPHICAL AND CONCEPTUAL PRINCIPLES OF ALTERNATIVES TO PSYCHIATRIC DIAGNOSIS
Having exposed the inappropriateness of psychiatric diagnoses as a framework for conceptualizing human distress, the authors turn their focus to the question of developing an alternative perspective.
“In developing alternatives to psychiatric diagnosis, in trying to understand and respond constructively to personal distress and troubling behaviour, we therefore need to move away from the assumptions underlying medicalised approaches and address four major questions:
- What different assumptions should we make, what different theoretical frameworks can we draw on, in understanding the behaviour and experience of persons within their social and relational environments, rather than the (mal)functioning of bodies?
- At the broadest level, what patterns have researchers described that might be helpful in understanding and alleviating emotional distress, unusual experiences and troubled or troubling behaviour from a non-diagnostic perspective?
- How might these broad trends and relationships be used to delineate narrower, provisional, general patterns which can inform our understanding of the particular difficulties of an individual, family or other group?
- What are the implications – therapeutic, social, ethical, legal – arising from adopting these non-diagnostic approaches and how might we address them?” (p 37)
The authors emphasize the fact that their approach is radically different from that taken by psychiatry.
“First, we question the idea of ‘mental disorders’ which have an independent and universal existence across time and culture. More specifically, we question that the experiences this term refers to are analogous to physical disease processes.
Second, we question the epistemological validity of defining these hypothesized ‘disorders’ by a process of revising and refining editions of diagnostic manuals such as the DSM and ICD, and of directing the majority of research endeavours towards biology.
Third, in relation to the ethics of diagnosis, we note the requirement for the procedures and information offered to patients to have a sound epistemological basis. This ethical scenario is the case in all forms of medical and psychiatric diagnosis, but psychiatry has an additional mandate to operate under conditions which are sometimes involuntary. Ethical considerations also apply to the potential harms caused by the imposition of psychiatric diagnoses (http://psychdiagnosis.weebly.com), and to the misuse or over-use of medical treatments and other interventions that a diagnosis may seem to justify (Whitaker, 2010) as well as its role in obscuring the importance of social factors as causes of distress.” (p 38-39)
The problems of applying a scientific methodology to human problems are discussed in detail, with particular regard to the routine marginalization of clients’ first-hand accounts as subjective, anecdotal, and untrustworthy.
“The implication of all of the above arguments is that human beings are active agents in their lives, both determined and determining beings, rather than objects acted upon by external forces. As human agents we both conform to the reality we encounter and seek to transform it. We do this through our capacity for meaning making, and for reflecting on and learning from our experiences. Social and cultural influences do not simply provide backgrounds and constraints; they are the conditions out of which meaning, agency, feeling and action arise (Cromby et al., 2013, Chapter 6). Alternative frameworks for distress must be built on these foundations.” (p 45)
The fact that psychiatric “diagnoses” are routinely used to obscure and divert attention from deep-rooted social and economic problems is addressed.
“…we have also suggested some principles and assumptions which should inform non-diagnostic approaches. We have shown that we need to go further than selecting a new model from existing alternatives. Instead, we need to re-visit a whole set of often unarticulated and unquestioned philosophical, theoretical, historical and cultural traditions and assumptions, supported by a range of personal, professional, economic, social and political interests. Moving away from what can be referred to in shorthand as the ‘DSM mindset’ is very difficult, since it is inextricably linked to deeply internalised aspects of the basic fabric of our thoughts, feelings, identities and worldviews. Such a move is also likely to reveal many social and ethical dilemmas which have been obscured by the current framework.” (p 74)
CHAPTER 3: MEANING AND NARRATIVE
It is a fairly obvious reality that we humans attach meaning to our experiences, and that these meanings can have a profound effect on how we respond to these experiences. Adversity, for instance, can be interpreted as: punishment for misdeeds; evidence that one is the victim of a conspiracy; evidence that life “sucks”; random events; etc.
It is also clear that the meaning that an individual attaches to his/her life events is an area that is largely neglected by psychiatry.
“Social standards and expectations are obviously not new but in contrast with older, more overt forms of power, modern, less visible forms of power achieve their effects partly by establishing new forms of knowledge – often claiming scientific status – which in turn create new norms. People then engage in self-surveillance across a wide range of behaviours, personal characteristics, desires and achievements, routinely comparing themselves to these implicit norms, and identifying themselves as inadequate, deficient or pathological if they deviate from them. Such self-surveillance has huge consequences for psychological distress (see Chapter 4).” (p 81)
CHAPTER 4: THE SOCIAL CONTEXT
This section addresses the question:
“At the broadest level, what patterns have researchers described that might be helpful in understanding and alleviating emotional distress, unusual experiences and troubled or troubling behaviour from a non-diagnostic perspective?” (p 92)
In its efforts to promote its self-serving and spurious disease model, psychiatry routinely downplays, and even ignores, the role that circumstances and social context play in the development of emotional distress. In contrast, the PTM paper addresses this issue head-on.
“There is a great deal of evidence, which we will discuss in detail in following sections, that the circumstances of people’s lives play a major role in the development and maintenance of psychological, emotional and behavioural problems (further evidence is presented in the Appendix). Among the most important factors are: social class and poverty; income inequalities, unemployment; childhood neglect and sexual, physical and emotional abuse; sexual and domestic violence; belonging to subordinate social groups; war and other life-threatening events; bullying, harassment and discrimination and significant losses such as loss of a parent in childhood.” (p 92)
“Some of the strongest associations between social context and mental distress and troubling behaviour are in relation to factors which loosely describe social inequalities.” (p 94)
“The visibility or invisibility of power is also important in relation to the different experiences of privileged and more marginalised groups.” (p 96)
“Being in an aversive situation from which there seems no escape or possibility of change is a major cause of emotional distress, especially feelings of anxiety, hopelessness and depression (Brown et al., 1995; Kendler et al., 2003).” (p 122)
The negative effects of racism and discrimination are addressed.
“Racism and discrimination take many forms, some more visible than others. They include subtle putdowns, insults and dismissals (‘micro-aggressions’) as well as more overt racist insults, hostility and violence. Discrimination may also be deeply embedded in the procedures, policies, laws and employment practices of organisations and services (institutional racism) in a way which renders it more or less invisible except to those discriminated against. All of this is supported by the ideological context described earlier and there is consistent evidence that these various forms of racism and discrimination can have very negative effects on mental and physical health.” (p 134)
“Research across many countries suggests that feelings of shame and humiliation are integral to living in absolute or relative poverty…” (p 142)
“Bringing together our discussion here of social context, in Chapter 2 of ‘crossing cultures’, and in Chapter 3 of narrative and meaning, we can argue that it is the fundamentally social nature of humans and of the contexts and predicaments which ‘produce’ distress, as well as the social nature of its modes of expression and of judgements and evaluations of them, which also construct similarities and differences in patterns of distress within and across social groups and cultures. There are no ‘mental disorders’ which can be separated from all of this and diagnosed.” (P 150-151)
CHAPTER 5: THE ROLE OF BIOLOGY
Those of us in the anti-psychiatry movement are often falsely accused of neglecting, and even ignoring, the biological underpinnings of human activity. It’s not true, of course, but it makes a nice sound-bite for psychiatry’s adherents. The PTMF paper devotes an entire chapter to biological issues.
“We argue, however, that there is a meaningful and important difference between forms of distress and troubling behaviour that are enabled and influenced by our biology – as all human experience is – as opposed to those cases where there is evidence for a primary causal role for biological pathology or impairment in the major aspects of the difficulties. This would include diagnoses such as the dementias, Korsakoff’s syndrome, Huntington’s disease, syphilis, urinary tract infections in older adults, and so on. But, as we noted in Chapter 1, in relation to the great majority of psychiatric diagnoses including those experiences and behaviours labelled as schizophrenia, bipolar disorder, depression or depressive disorder, anxiety disorder, personality disorders and eating disorders, there are no consistent associations with any biological pathology or impairment, and no biomarkers have been identified.
There are nevertheless hundreds of studies claiming to have discovered relationships between these functional diagnoses and one or other aberrant biological feature. For example, and with respect to the diagnosis of ‘schizophrenia’ alone, in recent decades these claims have focused upon anatomical features such as enlarged ventricles, cerebral asymmetry, temporal lobe abnormalities, thickened corpus callosum, thinner corpus callosum, abnormalities of the basal ganglia and cerebellum, and reduced overall brain volume. At the same time, relationships have also been claimed between schizophrenia diagnoses and abnormalities of, or differential functioning within, neurotransmitter systems and pathways for dopamine, glutamate, serotonin, acetylcholine, gamma-butyric acid, prostaglandin and neuropeptides (Cromby et al., 2013). Nevertheless, in all of this research there is no pattern of well-designed studies with large samples and adequate controls, replicated successfully by other groups and not significantly contradicted by other findings, and which consistently demonstrates associations between any of these features and the diverse experiences associated with a ‘schizophrenia’ diagnosis. In any case, even if such a pattern were to emerge we would still need to remain wary of assuming that correlation means causation.” (p 153)
CHAPTER 6: DESCRIBING PATTERNS WITHIN A POWER THREAT MEANING FRAMEWORK
In this chapter, the authors describe how the general principles developed earlier in the paper can be used to help understand the particular difficulties of an individual, family, or other group.
“Humans are fundamentally social beings whose experiences of distress and troubled or troubling behaviour are inseparable from their material, social, environmental, socioeconomic, and cultural contexts. There is no separate ‘disorder’ to be explained, with context as an additional influence.” (p 182-183)
“The evidence cited in this document supports the contention that humans are social beings whose core needs include:
- To experience a sense of justice and fairness within their wider community;
- To have a sense of security and belonging in a family and social group;
- To be safe, valued, accepted and loved in their earliest relationships with caregivers;
- To meet basic physical and material needs for themselves and their dependants;
- To form intimate relationships and partnerships;
- To feel valued and effective within family and social roles;
- To experience and manage a range of emotions;
- To be able to contribute, achieve and meet goals;
- To be able to exercise agency and control in their lives;
- To have a sense of hope, belief, meaning and purpose in their lives
…all of which will provide the conditions for them to be able to offer their children…
- Secure and loving early relationships as a basis for optimum physical, emotional and social development and the capacity to meet their own core needs.
Anything that prevents these core needs being met may be experienced as a threat to emotional, physical, relational and/or social safety and survival.” (p 189-190)
“The identity of ‘mentally ill’ has mixed consequences. It may represent relief from guilt and uncertainty, and hope for expert guidance and effective intervention. At the same time, the ‘sick role’ identity has been theorised as facilitating passivity and a reduced sense of responsibility for one’s recovery. Diagnosis has been shown, overall, to incline the person diagnosed to have less optimism about recovery, make less effort to recover, and be more likely to use alcohol to cope, as well as to have lower perceived control over their difficulties and undermining the effects of therapy. Conversely, rejecting one’s diagnosis has been linked to better outcomes. However, this may lead to conflict with professionals, and the need to access services and benefits rules out this option for most people.” (p 221)
CHAPTER 7: SERVICE USER CONSULTATION AND FEEDBACK
In developing the PTM paper, the authors consulted with a group of eight service-users/survivors and carers. Most of the consultants had been assigned more than one “diagnosis”, including:
“‘borderline personality disorder’, ‘PTSD’, ‘bipolar disorder’, ‘bipolar disorder-2’, drug induced psychosis, ‘depression’, ‘schizophrenia’, anxiety, and at risk mental state/sub-threshold ‘psychosis’.” (p 255)
The consultants were a heterogeneous group with “a range of perspectives”. In general, their responses to the PTM framework were positive, and sometimes tinged with regret that such a perspective had not been available to them during their contacts with the mental health system.
“Meaning to what was going on was given by medics to my detriment and [any resistance] resulted in being labelled as a troublemaker. As a direct consequence I started to not trust people…’” (p 257)
“…absolutely everything I had to say, including that the drugs were making things worse, [staff] made me, and more specifically my brain, the problem, rather than my traumatic experiences…” (p 258)
“…another…spoke of the difference a PTM Framework like this could have made to the trajectory their life took, and another…of their sense of grief that had a PTM Framework like this been available at the time, they might not have lost so many years of their life to mental health problems.” (p 259)
CHAPTER 8: WAYS FORWARD
The authors are fully aware of the difficulties that lie ahead.
“Such a major shift in policy, practice and thinking will take many years to develop and to embed fully, and we make no claim to be providing a complete answer.” (p 262)
“Regrettably, economic inequality and associated levels of discrimination and disadvantage in the UK show no sign of reducing.” (p 266)
“Some public health reports have made explicit links between distress and inequality, austerity and social injustice, although this message has not always been taken on board in terms of national economic policy.” (p 268)
“Another common feature is the need for action and intervention at a whole community level in order to address these multiple causal factors.” (p 269)
“…calls for better access to MH services fail to acknowledge the extent to which diagnostically-driven practice can reinforce and actively obscure the disconnect between social contexts and distress, downplay the need for care that acknowledges the impact of adversities, and may be disabling and re-traumatising in its own right. There is little detailed consideration of the ways in which inequalities of power and privilege arising from subordinate or devalued identities profoundly influence both the nature of adversities and people’s responses to them.” (p 270-271)
“In conclusion, there is general acceptance within current UK mental health policy that social adversities are both cause and consequence of mental distress, and that intervention needs to take place at a societal as well as individual level, even if the details are sketchy and fall short of challenging the governmental policies that underpin inequality and injustice. At the same time, these progressive ideas are, if these documents are taken as typical, undermined by unquestioned assumptions of medicalisation. Social factors are ‘related’ to mental health problems rather than being at their root. Emotional distress is conceived as ‘illness’ to be ‘treated’ rather than intelligible response to life circumstances. The prevention of adversities is less of a priority than the need to increase access to ‘treatment’. More mental health services are promised, but the appropriateness of the diagnostic model on which they are based is not open to question or dispute.” (p 272)
“However, the issues relating to the development and implementation of alternatives to diagnostic thinking and medicalisation will not be resolved without the driving force of those who have been ascribed a psychiatric diagnosis. This needs to be backed up by a sea-change in messages to the general public about alternatives to the narrative of medicalisation. We hope that our PTM Framework will be a contribution to these aims.” (p 317)
APPENDIX: EVIDENCE TO SUPPORT THE GENERAL PATTERNS
Evidence for the various positions and perspectives is provided in the general narrative, but is also summarized in this chapter for ease of reference and convenience.
SIGNIFICANCE OF THE PTM FRAMEWORK
The PTM Framework document constitutes a critically important contribution to the anti-psychiatry debate, and to the development of valid, person-centered and context-focused perspectives. In marked contrast to psychiatry’s simplistic and spurious “diagnostic” system, the PTM paper examines the various questions and issues in a manner commensurate with the inherent complexity of the subject matter. The paper runs to 411 pages, which includes 58 pages of references for readers who wish to examine the evidence or to pursue issues in greater detail.
In a post of this nature it is not possible for me to convey more than the barest flavor of the paper, and I strongly encourage readers to study the document for themselves.
There is a short version (139 pages) of the PTM Framework available, for readers who are pressed for time.