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Introduction to the PTMF

The Power Threat Meaning Framework was developed, over the course of five years, to serve as an alternative to more traditional models based on psychiatric diagnosis.

A group of senior psychologists (Lucy Johnstone, Mary Boyle, John Cromby, David Harper, Peter Kinderman, David Pilgrim and John Read) and high profile service user campaigners (Jacqui Dillon and Eleanor Longden) spent five years developing the Power Threat Meaning Framework as an alternative to more traditional models based on psychiatric diagnosis.

They were supported by researcher Kate Allsopp, along with a consultancy group of service users, carers, and others who supplied examples of good practice not based on diagnosis.

The Framework applies not just to people who have been in contact with the mental health or criminal justice systems, but to all of us.

It 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 misuse of power pose to us and the ways we have learnt to respond to those threats.

Dr Lucy Johnstone, one of the lead authors of the Power Threat Meaning Framework, said:

"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 have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’.

It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress or troubled behaviour, whether it is confusion, fear, despair or troubled or troubling 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. “

In traditional mental health practice, threat responses are sometimes called ‘symptoms’.

The Framework instead looks at how we make sense of these experiences and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt.

The approach of the Framework is summarised in four questions that can apply to individuals, families or social groups:

  1. What has happened to you? (How is power operating in your life?)
  2. How did it affect you? (What kind of threats does this pose?)
  3. What sense did you make of it? (What is the meaning of these situations and experiences to you?)
  4. What did you have to do to survive? (What kinds of threat response are you using?)

Two further questions help us think about what skills and resources people might have and how they might pull all these ideas and responses together into a personal narrative or story:

  1. What are your strengths? (What access to Power resources do you have?)
  2. What is your story? (How does all this fit together?)

The Framework is an attempt to outline a conceptual alternative to the diagnostic model. It is not a single model or approach.

It 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 the misuse of power pose to us and the ways we have learnt to respond to those threats.

Because these processes can affect any of us, the Framework can apply to anyone, whether or not they have been in contact with mental health or criminal justice services.

The PTMF is a broad, overarching perspective that includes many aspects of current theory and practice, and provides a basis for further developments.

It is not meant to replace all current ways of working. It is intended to support and enrich existing non-diagnostic approaches, respecting different cultural traditions, and also suggest new ways forward.

The publications - both Overview and Main versions - are fairly detailed and dense. This is because the basic principles of the Framework, the ways in which it is different from diagnostic approaches, and the evidence supporting it, need to be spelled out fully.

For a brief introduction to the PTMF, the BPS PTMF website has the following resources: the 2 page summary; interviews; videos; the Guided Discussion which may help you to get an idea about how the PTMF ideas might be relevant to you or someone you are supporting or working with. .

The development of the Framework was funded as a project by the British Psychological Society’s Division of Clinical Psychology.

The Division of Clinical Psychology represents clinical psychologists within the BPS and in the outside world.

It has administrative support within the BPS and has an elected Executive working on a very part time basis.

It does not provide clinical services and does not have resources to help people with personal clinical issues.

The Framework was funded as a project by the British Psychological Society’s Division of Clinical Psychology.

However, it is not an official DCP or BPS position or model.

It is not a set of Guidelines (suggestions for good practice) or Standards (codes of practice which are mandatory for psychologists).

Like many documents published by the BPS every year, it is a scholarly work intended to promote discussion and debate, and thus in the long term to contribute to evolving best practicee.

The project members were a group of senior psychologists (lead authors Lucy Johnstone and Mary Boyle, with John Cromby, David Harper, Peter Kinderman, David Pilgrim and John Read) and service user campaigners (Jacqui Dillon and Eleanor Longden).

They were supported by researcher Kate Allsopp, by a consultancy group of service users/carers, by a Critical Reader group with a particular remit to advise on diversity issues, and by a number of other people who contributed sections of the document and/or supplied examples of good practice that is not based on diagnosis.

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 the misuse of power pose to us and the ways we have learnt to respond to those threats.

Because these processes can affect any of us, the Framework can apply to anyone, whether or not they have been in contact with mental health or criminal justice services.

In traditional mental health practice, threat responses are sometimes called ‘symptoms’. The Framework looks instead 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 approach of the Framework is summarised in four questions that can apply to individuals, families or social groups.

The questions suggest broad areas for discussion, and can be re-worded or adapted for particular settings or personal preferences. They are:

  • 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?)

Two further questions help us think about what skills and resources people might have and how they 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?)

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 have faced or are still facing, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’.

It highlights and clarifies the links between wider social factors such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and the resulting emotional distress, confusion, fear, despair or troubled/troubling 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.

As well as having implications for therapeutic or clinical work, the Framework suggests constructive alternatives in the areas of service design and commissioning, professional training, research, service user involvement, peer support and public information.

There are also important implications for social policy and the wider role of equality and social justice.

The Framework is a set of ideas, which the authors are offering as a conceptual resource. People may or may not wish to explore them further, and that decision will be up to them.

However, a range of individuals, organisations, training bodies, researchers and practitioners have expressed interest in taking on board some of its ideas and principles and starting to use, teach or research them, or in other ways begin to translate them into practice. 

This can, of course, include individuals or groups of service users. We would expect, in keeping with the principles of the Framework itself, that any such plans would fully involve all relevant stakeholders.

The project team will be interested to hear about such developments, although realistically the level of direct support they can offer will be limited.

To the best of our knowledge, this is the first attempt to outline a major new conceptual framework that is co-produced with service users/survivors, both as members of the core team and as consultants to the project.

A number of other contributors in the larger project group also had service user experience (but did not choose to state this in every case).

The SUs came from a range of personal and work backgrounds, from experienced activists to people with no public profile. They collectively represented a range of class, gender and ethnic backgrounds and diagnostic attributions.

The project itself draws extensively on service user/survivor testimony and literature as part of its challenge to traditional notions of what counts as ‘evidence’.

The PTMF Committee, set up in 2019, consists of professionals and Experts by Experience who are jointly working to develop resources for specific groups, training materials and so on, and to offer training sessions on the PTMF.

Interest in the PTMF has been expressed by a number of services and organisations, and we would expect, in keeping with the principles of the PTMF itself, that any plans they draw up would fully involve all relevant stakeholders, including service users.

There are no implications for anyone who has, or who needs for various purposes to have, a particular diagnosis.

The Framework summarises the large and widely-available literature on critiques of diagnostic theory and practice but purposely does not address specific diagnoses (except in some cases to exclude them from the main discussion – see ‘Scope of the PTM Framework’, pp. 11-12 in the Overview).

Given the acknowledged problems with the current classification systems, the Framework takes the position that professionals should be open about these debates, rather than presenting diagnoses to service users as undisputed facts.

This more nuanced position may be helpful for people who prefer non-diagnostic understandings of their difficulties but whose views and choices are largely unrepresented within current service provision.

There are no implications for these areas. Clinical psychologists and other professionals will continue to support clients/service users to access their entitlements as before, if necessary by using diagnostic terms.

The PTMF makes this clear:

"In the short and medium term, psychiatric diagnoses will still be required for people to access services, benefits and so on. These rights must be protected."(Johnstone & Boyle 2018, Main document, p.18). 

However, while this is acceptable to some, other service users are unhappy about the need to take on a diagnostic label in order to obtain essential resources or services. Chapter 8 of the Main document outlines the pros and cons of a range of welfare system alternatives, starting with creative use of the existing system and leading up to more radical ideas such as universal basic income. None of these ideas is presented as a recommendation or easy solution, and all are recognised as having limitations as well as advantages. 

The PTMF recognises the argument that dropping diagnostic categories could be used to promote a neoliberal agenda of withdrawing support; but it is also true that diagnostic labels have not prevented the current dire situation in which welfare recipients have been driven to destitution and even suicide. For all these reasons, the PTMF aims to start an important and necessary discussion about ways in which the benefits system might start to move away from diagnostic assumptions.

This is a tricky question given that a lot of alarm has been stirred up by deliberate use of the misleading terms ‘implemented’ and ‘rolled out’.

The Framework is a set of ideas intended to promote discussion, not a plan for services or for anything else.

Unlike the diagnostic system, it is an optional conceptual resource, which no one has to read, agree with or use, and neither the DCP/BPS nor the authors have the power, or wish, to impose it on any person, service or system.

Since the launch a range of individuals, peer groups, organisations, training bodies, researchers and practitioners have expressed an interest in taking on board some of its ideas and principles.

This might include anything from minor modifications to existing practice, up to more ambitious plans to integrate the ideas into particular settings.

We would expect, in keeping with the principles of the PTMF itself, that any such plans would fully involve all relevant stakeholders.

The PTMF committee which reports to the DCP Executive has been set up to collate these developments and put people in touch with each other via the main website.

This will allow evaluation and further development of the PTMF.

As described above, the Framework is a set of optional ideas, not official recommendations or standards for clinical psychologists or other professionals.

Clinical psychologists will remain accountable to HCPC standards, as before.

Any plans for further DCP-funded projects related to the Framework would be subject to the same processes of funding application, evaluation and ongoing monitoring as the original project.

This kind of question is very likely to come up. You can point towards relevant examples from the website under ‘Good Practice Examples’ or from Clinical Psychology Forum January 2019.

Chapter 8 of the Main document makes suggestions in the areas of public health policy, mental health policy, service design, principles and outcomes, access to benefits, therapeutic interventions, the legal system, research, and use of language.

General answer: The PTMF is a set of principles, not specific recommendations about how to proceed in particular circumstances. The intention is for people to try out translating these principles into practice in their own settings, where they are the experts, and for this to feed back into the further development of the PTMF.

This is a priority for feedback and development. The PTMF documents benefited from a critical reader group with a particular remit to advise on diversity. The Main document includes extensive consideration of diversity issues, including gender, class, ‘race’, culture and ethnicity (Chapters 2, 3 and 4 of the main document.) The current PTMF committee, with the remit of collating resources and research related to the PTMF, is working towards representation of people from a diverse range of ethnicities and cultural contexts.

The General Patterns provisionally outlined in the PTMF are applicable mainly within Western or Westernised contexts. This follows from the argument that patterns of distress are fundamentally shaped by meanings at personal, social and cultural levels, and thus there can never be a universal lexicon. While the total group of authors and contributors was drawn from a range of backgrounds and ethnicities, it is a majority white group, living in a society dominated by Western cultural values. Since expressions of distress necessarily reflect their particular cultural context, the General Patterns in this version of the PTMF will inevitably do so too. It would not have been appropriate to do or to claim otherwise. 

In contrast to the Global Mental Health Movement, which is exporting the diagnostic model across the world, the PTMF argues for respect for the many culturally-specific ways of expressing and healing distress both within and beyond the UK . The PTMF also argues that its very basic principles, to do with core human needs, evolved biologically-based responses and capacity for meaning-making, are universally applicable, and thus provide an opportunity for shared communication and understandings across cultures. 

We want future applications of the PTMF to give more space to Black psychologies and other perspectives that are present, but marginalized, within White-dominated societies. We have developed a set of core principles for those disseminating, or offering training in, the PTMF. This includes:

In line with the PTMF principles, training events should include the experiences of people and groups who are most likely to be affected by abuses of power for reasons of race, ethnicity, gender, culture, class, sexuality, culture, age, disability and/or 'mental health' status. Events should be delivered in a way that acknowledges the positions of the trainers themselves, and the ways they, or the professional group they are members of, have benefited or are benefiting from access to power. The website has recommended reading for trainers to familiarise themselves with the relevant evidence in these areas, and the section on Diversity, Inclusion and Antiracism  has additional reading and resources. We also recommend that trainers include discussion and exercises that help to highlight these varied experiences of power.

The PTMF does not consider autism as a specific diagnosis, and nor does it consider any other specific diagnosis in detail. It points readers towards the relevant debates about autism, which is a complex field including presentations that may be best understood as neurodevelopmental disorders.

With such a wide range of difficulties captured under the label of ‘autism spectrum disorders’ (which since DSM 5 includes Asperger’s) it is impossible to make general statements about validity or causation.

The PTMF does, however, suggest that it is worth reflecting on the reasons for the steep rise in the diagnosis of ‘autism spectrum disorders’.

The PTMF principles suggest that at least in some cases, this may be driven by factors beyond the person – for example, growing societal intolerance for individual difference.

(NB For more ideas on addressing this question, see paper by Flynn and Polak,  ‘Incorporating the Power Threat Meaning Framework into an autism and learning disability team’ in the Clinical Psychology Forum special issue)>

The PTMF is not about professional wars or rivalry. It is about putting forward a new set of ideas, which challenge mainstream practice across the board, including some traditions in  psychology. Members of all professions, including psychiatry, share our desire for a better way forward, and their work is cited in the documents. The team has been invited to do presentations to a range of professional audiences, including psychiatrists, and we welcome their interest and involvement.

The PTMF strongly supports personal choice of language to describe your difficulties, including, if that is your preference, diagnostic terms.

However, it also argues that professionals have a duty not to present or impose terminology that is acknowledged to lack validity as if it were fact.

People have a right to make a fully informed choice about their language preferences, and this is very rarely offered in or outside services – in fact, non-diagnostic understandings may be actively opposed in services. Relevant quotes:

‘We support individuals’ right to make their own choice of terminology’ (Johnstone and Boyle, Overview, 2018 p.85). 

‘…it can no longer be considered professionally, scientifically or ethically justifiable to present psychiatric diagnoses as if they were valid statements about people and their difficulties’ (Johnstone & Boyle, 2018 Overview, p.85).

The latter statement allows for sensitive, open negotiation about the appropriate terminology for securing benefits/services etc, without assuming the ‘truth’ of the label.

The PTMF draws on trauma-informed theory and practice among other areas.

The PTMF shows that experiences of trauma and adversity are on a continuum.

Even in the absence of obvious traumatic events, people can be affected by the cumulative impact of adversities, including contexts such as poverty and discrimination.

However, the PTMF also argues that everyday, ‘normal’ aspects of our lives, can lead to distress even when someone has not experienced more obvious forms of ‘trauma’.

For example, this may include perceived failure to live up to social norms and expectations about the way we should look, behave and conduct our relationships, or messages about the kinds of aspirations and values we should have.

This is a strength of the PTMF, and is one of the reasons it applies to all of us, not just those with histories of trauma and deprivation, and not just those who have had contact with services.

Not everyone wishes to tell a ‘story’, and there is no PTMF requirement on anyone to do so. Formulations or narratives may not be an appropriate starting point if someone is in acute distress, and may take many months to evolve. Specifically, a personal story is not suitable for purposes such as claiming benefits (Chapter 8 of the Main document discusses non-diagnostic alternatives such as problem-description or needs-based assessment.) 

However, the PTMF sees a crucial difference between a system based on diagnosis, with its underlying assumptions of medical type illnesses, and one based on the assumption that people’s experiences and expressions of distress arise out of reasons, functions and meanings, all of which are deeply rooted in their relational and social environments. This shift has implications for every aspect of a person’s intervention or support, even without the construction of an individual, family or group narrative.

The PTMF draws on an extensive range of theory, research and evidence across disciplines (see the Main document.) This includes research based on positivist traditions and assumptions along with forms of evidence which have traditionally been marginalised, such as historical analyses and survivor and other personal accounts. It is this evidence that offers strong support for the overall Framework itself and for the core PTMF questions. 

The PTMF argues that all research traditions have valuable contributions to make, and gives equal weight to qualitative and quantitative research. (Quote from Forum article by the authors: ‘We point to the value of some positivist-based research and draw on it in our analysis, but without necessarily accepting unspoken assumptions about diagnostic categories…and so on.’) However, it takes the position that emotional distress itself cannot be satisfactorily understood using theoretical frameworks and metaphors derived from medical sciences. The PTMF also critiques assumptions about what counts as evidence, the possibility of separating facts from values, and so on. 

The specifics of the PTMF are all open to development and evaluation. This might include, for example, more detailed study of the ways in which we are impacted by power, of the experience of threat, the meanings people attribute to their experiences, the contexts in which particular threat responses are adopted and the functions these responses can serve. It would also include evaluation of the effectiveness or otherwise of particular ways of translating the PTMF into practice, further elaboration of the Patterns, and so on. This is the second stage of the project, post-launch, and is supported by the PTMF Committee, which is collating examples of evaluation and research into aspects of the Framework.

The PTMF discusses the operation of power in relation to psychology and psychiatry, particularly in Chapters 2, 3 and 8 of the Main publication. Power as it applies to the profession of clinical psychology is critiqued at many points, for example through consideration of practices such as formulation and the national roll-out of some psychological therapies. Those of the authors who have a psychology background agree that additional examination of their own position would be useful, and will be addressing this in more detail in future editions.

This issue is discussed on pp 304 -306 of the Main document. The PTMF is not ‘anti-drug’ and recognises that psychiatric drugs may be helpful in situations  such as acute distress. It is pro-informed choice, and believes that many people are not given accurate information about the mode of action of drugs, and the limitations or in some cases harms that may accompany the benefits. It argues that instead of a ‘disease-centred’ model, based on misleading statements about rectifying chemical imbalances and so on, a more limited and appropriate role for psychiatric drugs would result from a ‘drug-centred’ model, in which the drugs are seen as having a range of non-specific psychoactive effects. In some circumstances and for some people, this may be helpful in relieving distress, but this is not the same as ‘treating an illness.’ In other words, psychiatric drugs should be described, explained and used within a non-diagnostic model.

The General Patterns may superficially look like a variation on diagnostic clusters, and perhaps our familiarity with the latter may make it hard to see how different they are, in the following important respects: 

They are NOT – as diagnostic patterns aspire to be - discrete, universal causal pathways which are a precise fit for a given individual, and which are stable across time and cultures.

They ARE – fundamentally shaped by meaning which varies across time and cultural contexts; Not what people HAVE but what they DO; Contingent, provisional, overlapping (because they are based on a different understanding of causality that is mediated by meaning); Evolving over time and across cultures; In need of further development and validation. 

However, we recognise the danger that they will be re-cast as a version of diagnostic patterns, partly because that is the default mode of thinking, and partly because of the inevitable process of assimilation – beware!

Please see pp 213 -217 of Main document, and Lucy’s article on the General Patterns in J of Constructivist Psychology.

The PTMF attempts to describe what an alternative – in the sense of a system replacing the diagnostic one – would look like. Whether and how it is implemented, as a complete ‘alternative’ in this sense, or perhaps more realistically in the short-term as an option running alongside the diagnostic one, is not a decision for the PTMF authors or the DCP/BPS, but a position to be reached within particular settings in discussion with relevant stakeholders. Some practice (eg examples in the PTMF Overview Appendices) is consistent with the PTMF already, and the aim is to offer these approaches additional support.

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