The past 50 years has seen globalisation of psychiatric diagnostic (categorical) frameworks. Early versions were notoriously unreliable; when categories are unreliable they cannot be valid, meaning that they were at best useless and at worst harmful. This changed with development of the Diagnostic and Statistical Manual of the American Psychiatric Association version III (DSM III) and International Classification of Diseases version 9 (ICD9). DSM III in particular was an attempt to specify more reliable “operational definitions” of diagnoses, with considerable influence coming from the Spitzer and Endicott Research Diagnostic Criteria (Spitzer, Endicott & Robins, 1978) in the USA and the Present State Examination in the UK (Wing, Birley, Cooper, Graham & Isaacs, 1967). In these and later editions of diagnostic frameworks it had been clear that:
- The success of this strategy varied considerably across diagnoses;
- Some reliability and validity had been achieved and progress made (e.g. psychological understanding and treatment of anxiety disorders), although in other areas it has been both dismal and damaging (e.g. “Personality Disorders”);
- This strategy largely failed in biological psychiatry research, partly leading to the more recent advocacy of RDoC;
- Commercial, political and professional interests may have produced distortions.
What about the people who matter most? For service users, the outcomes of the almost universal adoption of diagnosis-led services and research varied from extremely helpful to catastrophic, and all points in between. Few would dispute that there are problems, but solutions have been elusive, which brings us to the specific rationale for the Power/Threat/Meaning Framework.
A position statement critiquing diagnostic frameworks entitled “Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a Paradigm Shift (PDF)” was adopted by the Division of Clinical Psychology of the British Psychological Society (DCP, BPS) in 2013. Regarded by many as professionally divisive, it had little impact on clinical practice, not least because it disregarded NHS requirements and pretty much ignored the opinion of many DCP members. So now we are introduced to the Power Threat Meaning Framework (PTMF) which “is the result of a project for work towards fulfilling that aim”; thus apparently laying claim to the heralded paradigm shift. Although the document (Johnstone and Boyle, 2018) prominently displays BPS and DCP logos, it is not an official position paper. It is the report of a five year project the DCP funded. We were surprised to learn that the DCP spent £15,000 on the PTMFramework launch, implicitly advocating for its adoption without any further review or discussion within the profession.
The introduction to the PTM Framework makes it clear that the document is meant to fuel the paradigm shift. Crucial to that is said to be the construction of non-diagnostic stories which will re-integrate reactions presently regarded as disorders back into the range of universal experience. So, the intention is to replace (rather than supplement) diagnoses with personal narratives primarily focused on power issues. Strangely, however, the framework also includes seven “provisional patterns” which have all the characteristics of diagnoses.
Is this the long awaited paradigm shift? If it is to be considered so, then it should be in the context that extraordinary claims require extraordinary evidence, something we consider here. We also note that the document claims to provide “innovative and important perspectives”. A major aim of this blog is to consider whether what is important is innovative and what is innovative is important.
The position paper is based on a narrative and selective review of the evidence in several areas crucial to mental health. Reviews were unfortunately not conducted systematically. The declared intention is to use the reviews to construct a “meta-framework”. The output is a large document (414 pages PDF) with a “shorter” summary version (138 pages PDF). None of these documents have been peer reviewed nor apparently subjected to any other external review even by the DCP. As the citation information makes clear, it is the position of two authors with some other “input” from others of a like mind.
The framework strongly advocates the use of narratives to better understand meaning, and following that principle, we have sought to extract the core narrative in the main document. We found it hard to follow, but seems to run thus:
- There are serious problems with diagnosis which is often found to be unreliable with limited or no validity
- Scientific positivism (particularly but not confined to diagnostic approaches) has failed in mental health and should be discarded/disregarded
- Narratives are the best way of accessing meaning
- Bad things happening, especially in childhood, have been shown to have serious negative psychological effects on the people who are involved
- Adversity and trauma are always the result of power imbalances and abuses
- There are no biomarkers of psychiatric diagnoses
- Mental health services need to be trauma-informed because trauma affects the brain in specific ways
- Given the above, the proposed solution is to adopt PTM Framework as an alternative
- There is one Foundational General Pattern and seven “provisional, probabilistic, evidenced General Patterns within the Foundational one”; these should be used as an alternative to diagnosis.
This is a problematic narrative. Some of these assertions are partly or wholly true (1, 3, 4, 6 and 7) whilst 2 is substantially incorrect in the view of many. Most importantly, 8 does not logically follow from the preceding narrative and both it and 9 are inventions not justified by the prior truisms, and lack empirical grounding. The narrative fails to meet the criteria for either inductive or deductive reasoning. Note that in saying this we do not disagree with those premises which are supported by evidence (1, 4, 5 and 6), just that the conclusion which they are asserted to support do not flow from them. Were this a piece of academic writing (which it apparently is), a reviewer would have to conclude that the hypothesis does not follow from the introduction. Crucially, there is literally no evidence for the proposed alternative; this is argument from a vacuum.
Expert by experience commentary
I would not deny that some diagnoses are inherently problematic and actively unhelpful; so-called BPD/EUPD springs to mind. However, with my comorbid conditions (OCD and depression) both diagnoses have been useful in earmarking treatments which might work (in my case, medication, CBT and lifestyle changes). Moreover, since being diagnosed with OCD in my mid-thirties, it is clear to me that since I can remember I have had intrusive thoughts and odd worries, even before I was subjected to severe trauma through bullying at school. I would never deny that this prolonged trauma had an effect on my mental health but at the same time I believe there was more to it than purely social factors. I’d also never argue that we’ve solved the problem of psychiatric diagnosis; the DSM is, after all, not a static document. No decent mental health professional would say that the aetiology of mental health disorders is understood. We are in a reverse-therapeutic gap of sorts: we know what might work for certain conditions; but we don’t know the causes yet. And, just because biomarkers for psychiatric diagnoses have not yet been located, that does not mean they do not exist, or that we should stop looking for them.
It is also strange that both evidence-based medicine and outdated philosophies such as psychoanalysis and Foucauldian discourse are given the same weight in the Framework. Evidence-based medicine is just that: statistics have shown that it is effective for a high enough percentage of people to be useful. The same sorts of statistics can never be gathered for psychoanalysis.
In terms of narratives, I agree that they can be useful. Looking at what happened can be helpful, up to a point. Many of us, however, find it much easier to leave trauma in the past, and should not be encouraged to talk about it unless it is likely to be beneficial to do so. Much more helpful for me than psychoanalysis was CBT: not ‘what happened’ but ‘what shall we do about it’?
The notion that a utopian society would eradicate mental distress is extremely troubling. This attitude is deeply ableist and defeatist, and it also normalises severe illness. It would deny anyone experiencing mental distress a safety net. Had I been as unwell as I was in this situation, I would not have the right to be ill. And I was ill; my suffering was mental, physical and emotional.
It is, then, this flawed narrative that gives us the central assertion of the framework, which we understand to be that we should think about human distress as being determined entirely by power and its consequences. The core proposition is long and extremely complicated, so we have summarised it as best we could thus:
Psychological, emotional and behavioural problems occur because the operation of power poses threat to a person/persons, which is shaped by the meaning of the power induced threat, in turn producing learned threat responses which serve defensive psychological functions.
The implications are then spelled out, and surprisingly they clearly resemble a new set of diagnostic categories. These are labeled by the Authors as “response patterns”:
Seven Provisional General Patterns which emerge from within the Foundational Pattern. They are not one-to-one replacements for diagnostic clusters, but are based on broad regularities which cut across diagnostic groups, and which arise out of personal, social and cultural meanings.
Seven diagnostic clusters, of a type familiar from ICD and DSM, then. This impression is reinforced by their definition: “a pattern refers to associations that seem to occur above chance level”. This is reminiscent of the Maudsley-Newcastle diagnosis wars in the 1970s, in which the extent to which phenomena clustered or did not, and how if they did, was hotly and fruitlessly debated. The “patterns” in the framework appear to correspond to “syndromes”:
Within the General Patterns, it may sometimes be useful to consider sub-patterns relating to specific events or circumstances.
The seven “provisional patterns” are:
- Surviving rejection, entrapment, and invalidation
- Surviving disrupted attachments and adversities as a child/young person
- Surviving separation and identity confusion
- Surviving defeat, entrapment, disconnection and loss
- Surviving social exclusion, shame, and coercive power
- Surviving single threats.
It is said that the general patterns are not “one on one” replacements for psychiatric diagnoses, but this assertion is followed by the following extraordinary text:
Some of the General Patterns have rough correspondences to existing diagnostic categories – for example, the second one captures some people who attract the diagnosis ‘borderline personality disorder’, the fourth pattern does the same for some people who are diagnosed with ‘schizophrenia’, the fifth corresponds to some diagnoses of ‘depression’, and the sixth describes some people who end up in the criminal justice system with a diagnosis of ‘antisocial personality disorder’.
This is because psychiatric diagnoses do, to a very limited extent, reflect common psychosocial response patterns, albeit described in medical terms.
How surprising to see BPD referred to in this way in this document of all documents! The authors of this blog would like to see this diagnosis abandoned, not re-defined.
It is also indicated, again without evidence, that the patterns are based on the causes and “functions” of responses; that is, they are responses which meet social/psychological needs. The similarity with psychoanalytic “defence mechanisms” is striking. Trying to root psychological understanding of current distress in hypothetical causal factors and “function of responses” seems to us to be particularly problematic, something abandoned by most mental health professionals decades ago. Psychology and Psychiatry does not deal with causes because the evidence is simply not there.
Expert by experience commentary
It seems obvious to me that if we cannot say that the causes of mental distress are physical/biological, because there is no evidence, then neither can we say they are purely social/trauma based, because there is also no evidence. The authors of the Framework cannot rely on evidence only in cases where it suits them.
The initial conclusions of PTMFramework are uncontroversial and it is of course helpful to remind services of their importance:
- Start with service users by helping them to tell their story
- Move away from hard line diagnostic practice
- Involve service users and survivors more in developments
However, these do not flow from the framework itself but are all highly appropriate values for mental health services and professionals and many mental health services already do this. Rather harder are the broader political conclusions which are:
- Tackle and eliminate oppressive austerity
- Tackle and eliminate all forms of discrimination and power abuse
- Tackle and eliminate child abuse and neglect
- Emphasise prevention in mental health policy.
Few would disagree with these, but again they neither flow from the Framework nor lead to it.
The main strength of the PTM Framework is the way it brings the issue of power in mental health into sharp focus. This is an important and often neglected issue which deserves serious treatment in itself. However, issues of power are mainly an assumption for the framework, rather than the substance of a comprehensive psychological and sociological analysis; we consider this to be an unfortunate lost opportunity.
Expert by experience commentary
It is refreshing to see ‘power’ placed at the forefront of this so-called paradigm shift – I’ve been subject to the sorts of imbalances of power that are inextricably bound with mental health difficulties. So, reading the PTM Framework, I expected to find robust plans for empowering service users: but instead what I came across was obfuscatory language designed to repel even those of us educated to PhD level; a description of an extremely opaque consultation with service users; and references to obscure and inaccessible philosophies; most notably that of Foucault. This is not the way to empower a broad range of service users: one is put off almost immediately at the thought of reading even the shorter 138-page summary. One must ask, then, where the power actually lies within the PTM Framework.
Limitations are legion. The documents are very hard indeed to read. After considerable effort it is clear that the narrative is seriously flawed. This is unfortunate given the importance afforded to narrative by the authors. Overall, the documents are meant to comprise reviews pointing to particular conclusions and recommendations. The reviewing varies greatly in quality, but it is never systematic and often very ideologically driven. There is a muddle in terms of the extent to which “positivism” (i.e. research-led) constructs are rejected or adopted; in several places the authors seek to draw on research findings in what seems to us to be misleading ways. There is another major lost opportunity in the way the crucial Service User chapter was developed and presented. It has some of the methodological trappings of qualitative research and it comes as a surprise that this is not done; it is not made clear, but seems that that whole section is the authors’ take on unspecified interviews.
Expert by experience commentary
The service user consultation is opaque in terms of selection process; we are told that:
Consultants were recruited through informal service user and professional networks, aiming for diversity in terms of gender, age, ethnicity, and socioeconomic status. One person was known to a project member through their campaigning work but most of the others had not been exposed to critical perspectives in any detail. This meant that although we did not have advance knowledge about their views on psychiatric diagnosis, we were able to recruit people with a range of perspectives. For the most part, potential consultants were contacted by someone who already knew them and asked if they were interested in participating…
A group of eight participants over five years is far too low a number to gain any meaningful quantitative statistics on the Framework. The impression given is that service user participation was deliberately kept to a bare minimum in order to tell the desired narrative of the authors. Somewhat ironically, the balance of power within the consultation process is also unclear. How was information presented to the participants in order to make meaningful and informed decisions on the Framework? No information is given about HOW the service users views were included; interviews are mentioned, but without detail.
Implications for practice
This blog began by examining the assertion that the Framework was intended to provide, in the words of the authors, “innovative and important perspectives” and whether the announced need for a “paradigm shift” has been met. We sadly must conclude that what is important is not innovative and what is innovative is not important.
“Paradigm shifts” occur when scientists encounter anomalies that cannot be explained by the previously held theoretical positions which had dominated the research. The scientific discipline descends into a state of crisis which leads to the trying out of new ideas. The PTM Framework is not a paradigm shift by any stretch of the imagination.
Sadly, then, there are no new implications for practice. The principal recommendations for practice are to highlight the need to deal with adversity (mainly through political change), to acknowledge the importance of trauma, seek parity of esteem between physical and mental health, to reduce stigma in mental health and to reduce the use of coercion. There is no evidence that a shift from diagnosis to the use of Seven Provisional Patterns would achieve any of these entirely desirable aims any more than it would achieve world peace.
Summary and conclusion
The Framework is hard to understand; the core statement was run through a readability analysis (readabilityformulas.com) and registered as having a Flesch Reading ease score of -9.9 which the site categorised as “Impossible to comprehend”. It is clearly highly inaccessible to those it is supposedly aimed at. We were urged by one of the authors to read the entire document before commenting, something we have done. The way it is expressed de facto serves to conceal the underlying narrative, something we presume is unintentional. Nevertheless, the effect is to obscure the meaning, which is an ironic and paradoxical outcome. Spread over more than 400 pages, we consider that the logic claimed to underpin the Framework is not valid. There is quite literally no evidence for the validity of the framework itself, or for the seven provisional patterns proposed as an alternative to psychiatric diagnostic categories. The authors assert that the gathering and synthesis of evidence (positivism) which lies at the heart of psychiatry and psychology should in any case be rejected. We regard the rejection of positivism as the ultimate baby and bathwater situation. Those who seek help from mental health professionals typically need evidence for effectiveness so that they can choose how best to engage with the range of help offered.
The Framework relies on empirically unsupported claims regarding the “cause and function” of psychological distress. This is something which has eluded the field for its entire existence. All is not lost, however. Progress in psychological interventions at every level has been made by efforts to understand why, for some people, distress becomes particularly severe and particularly persistent to the point that they need help and support to deal with it. The range of effective psychological treatments we have are all based on such an understanding and this has been the emphasis of the applied science of clinical psychology and increasingly in psychiatry over the last four decades. There are real and exciting possibilities of understanding causes and therefore developing primary and secondary prevention interventions. These are almost entirely complementary to the demonstrably effective strategy of helping people to deal with factors which maintain their problem in ways which empower them to be able to bring about changes towards their preferred goals. By contrast, the PTM Framework has opted to take a quite different path, set out by a hybrid social constructionist, anti-psychiatry, anti-science and political agenda. The PTM Framework is more manifesto than scholarly document. What is needed is evidence such as that in the excellent recent paper by Perkins et al (2018). These are complex matters not best dealt with by polemics.
Johnstone L, Boyle M, with Cromby J, Dillon J, Harper D, Kinderman P, Longden E, Pilgrim D, Read J. (2018) The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis (PDF). Leicester: British Psychological Society.
Perkins, A, Ridler, J, Browes, D, Peryer, G, Notley, C, and Hackmann C (2018) Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings. The Lancet Psychiatry https://doi.org/10.1016/S2215-0366(18)30095-6
Spitzer RL, Endicott J, Robins E. (1978) Research Diagnostic Criteria: Rationale and Reliability. Arch Gen Psychiatry.1978;35(6):773–782. doi:10.1001/archpsyc.1978.01770300115013
Wing, J. K., Birley, J. L., Cooper, J. E., Graham, P., & Isaacs, A. D. (1967). Reliability of a procedure for measuring and classifying “present psychiatric state”. The British Journal of Psychiatry, 113(498), 499-515.
- Photo by sean Kong on Unsplash
- By Bering Land Bridge National Preserve (Winding Rivers of BELA) [CC BY 2.0], via Wikimedia Commons
- Nick Webb CC BY 2.0
- Believe by Nick Youngson CC BY-SA 3.0 ImageCreator
- By Erroman [CC BY-SA 4.0], from Wikimedia Commons
- Simon Matzinger CC BY 2.0
It’s probablly a first when reading such a detailed critique but I couldn’t agree more with everything that is written here. Those who can logically deconstruct whilst avoiding the illogical pitfalls are not in enough supply. I wonder does the profession need to Improve/change approach to rigour in training to combat these sort of things that could possibly bring the profession into disrepute.
Gulp! I’m now a trainer. Doing my best, will continue to do so.
Thanks for the comment
I have already commented on Twitter – I think it’s a great account and critique. I do have one issue though. I think the authors are a bit over-optimistic in their praise of how the Framework deals with issues of power.
What is very disappointing, in my view, is that the Framework doesn’t take stock of its own power, let alone the power of the individual ‘Framework clinician’. I reject the notion that the PTMF will only result in empowerment (and world peace too), I also reject the notion that clinicians using the Framework will somehow be giving up the power to define reality they have.
In my view, the proposal would be much more credible, if it shone some power-light on itself. It is utterly disingenuous to set up the opposition between dominant-powerful discourses of psychopathology and the Framework. Just because a particular story is not dominant, it doesn’t mean it’s not powerful.
You are right, of course, but we were working very hard to avoid commenting too much on the process and anything which might be construed as “ad hominem”, focussing on the logic and content. I am of the opinion that highlighting Power issues is helpful in general but entirely get what you are saying here.
Dariusz, I think your critique is much more focused and important than anything in the above article. Substituting a new “framework” for the old and failing one does not change how individuals treat those in their care. I do find (and research supports) that the process of “diagnosis” does, in and of itself, make it easier for people to distance themselves from “the mentally ill” and that much of the “stigma” so often talked about is in fact caused by the mental health professionals themselves adopting a superior and condescending attitude towards the “diagnosed.” I think the PTM framework attempts to address this, but fails to get to the core of it, which is, exactly as you say, the inevitable power differential between the clinician and the client. Figuring out how THAT dynamic can be resolved is, in my mind, what separates a mediocre from an effective therapist.
I and other family members who struggle variously with anxiety, depression, and eating disorders, have found diagnostic labels to be empowering and normalizing, rather than as you describe.
What’s important, whatever the so called ‘diagnosis’ is that those who work with people who are challenged by mental health issues, are capable of expression empathy and compassion, and have integrity. What is lacking are these qualities, and without them no amount of re-defining the way people are ‘diagnosed’ will make the slightest bit of difference.
Couldn’t agree more
Thanks Irene and Paul for the digested read.
Not quite sure I can bring myself to read the full document.
Don’t worry Fergus. Around the launch I was very firmly told by Lucy that it was not appropriate to comment without reading the full 414 page document. However, the authors say that they are now working on a two page version, so maybe you won’t need to read it all. Also, I did manage to summarise the core concept in a single tweet, so thats probably fair enough.
Isn’t it weird they say you can’t comment without reading the whole thing when the critical crowd haven’t seemed to have read the manual of DSM or ICD which states not necessarily bio cause or disease or that clinical phenomenon categorised may not exist as a discrete category
Suggests they feel they are too powerful to follow their own advice !
Thank you Paul for digesting something that most CPs will not read. It’s alarming – not that a new framework is being proposed, that is par for the course in psychology – but that it seems to be promoted as a position of the profession as a whole. Especially if it is based on a position it’s authors have taken while rejecting the usual standards of scholarship. One question is raises for me is, does a rejection of positivist scientific method obviate the need for evidence? I think not, so what is the evidence this approach is more helpful? If it can be shown to help more people, or help people more effectively, bring it on. But it if can’t, why should we give it the time of day?
Yes, but its odd, isn’t it, that for some points evidence is adduced in the framework where it supports the position being espoused. We worked very hard indeed to try to identify the logic of the piece, and it seems like we may have succeeded. However, there are as we try to indicate some good points made in the document, but these are not in any sense innovative, and the attempt at innovation is very much out of the blue rather than logically derived. As we say, it appear to come from some combination of social constructivism and the teachings of David Smail.
Nothing wrong with the the teaching of David Smail! Offered something strikingly helpful in this world of commodification of psychological distress!
> But it if can’t, why should we give it the time of day?
Some thoughts on this.
There are different ways to gain confidence in an idea than scientific experiment. You can see if a theory is small, consistent, condenses a range of ideas, and consistent with observed evidence.
Then given this model, you can construct predictions and test them. Any new intervention will, by definigion, not be tested, but there are ways in which you can assess how sound and compelling it is to assess whether it should be tested.
Thanks for this blog.
I’m really confused about what you say here though:
‘It is also indicated, again without evidence, that the patterns are based on the causes and “functions” of responses; that is, they are responses which meet social/psychological needs. The similarity with psychoanalytic “defence mechanisms” is striking. Trying to root psychological understanding of current distress in hypothetical causal factors and “function of responses” seems to us to be particularly problematic, something abandoned by most mental health professionals decades ago. Psychology and Psychiatry does not deal with causes because the evidence is simply not there.’
To me, exploring the function of behaviour is precisely what functional analysis of behaviour is about, and this is an important part of CBT. It is also an important part of formulation. So I really don’t understand your comment here.
Thanks Penny. Different use fo the word “functional”. I really don’t think the authors of PTMF would be amused by the idea that they were taking a radical behaviourist perspective! Hope the helps the confusion.
In what way is it a different use of the word functional? And why would the PTMF authors not be amused by this?
Thanks Penny. This is pretty fundamental. Functional analysis has a specific meaning, and typically is validated by extablishing experimental control. For FA 101 see this:
By contrast, see how function is considered in psychoanalysis 101 here:https://en.wikipedia.org/wiki/Psychoanalysis
Hope that helps
Leaving aside the academic reputation of the two authors of PTMF the document itself makes it clear that they are not adherents to radical behaviourism and Skinnerian approaches, more Smail. However, thinking about it, they may well find the comparison amusing!
Yes I’m aware what functional analysis is – I trained with the Institute for Applied Behavioural Analysis before I did clinical psychology training. I’m definitely not the first person to see how these two positions can fit together: it was said of Bowlby: ‘Oh Bowlby, yes, he started off as an analyst, but didn’t he really become some sort of behaviourist?’ Also, it has been recognised that Skinner’s radical behaviourism considers ‘four kinds of variable which determine any behaviour: genetic endowment, physiological conditions, past learning history and the current environment.’ David Smail referred to radical environmentalism and also said that whilst he didn’t mourn the demise of behaviourism, it did have a point, which was that the inner workings of ourselves, our thinking, whilst being the very thing that makes us human, and very important to our experience of the world, in itself had no power. Maybe the authors would find it amusing, I don’t know. I find it more interesting than amusing – think it would be a good topic for something like In Our Time, with Melvyn Bragg.
[…] Some of the criticisms of the PTMF are articulately laid out here. What I want to do in this blog is lay out a basic version of what the PTMF promotes, why it’s […]
Great job Paul and Irene. The effort that you’ve made to present the premises of their argument is very much appreciated. For mine, the most concerning thing about this is that the new framework appears to have BPS endorsement without peer review and extensive discussion. Vigorous peer review, and several redrafts, could have produced an interesting manuscript. Instead, an intellectual mess has emerged.
As a psychiatrist who believes that there is much overmedication, especially of depression by GPs, but ‘abandoning diagnosis’ is flawed, I am working on my own critique of the PTMF after a 3 year sabbatical broadly in ‘Medical Humanities’.
Salkovkis and Sutcliffe make many good points, but there are perhaps two (linked) ones that I expected from their previous tweets and did not find. The first is about trauma and abuse: the PTMF claims to be ‘trauma-informed’, yet it rejects the diagnoses of PTSD and borderline personality disorder.
The second point is about ‘allocation of resources’ and is linked to the first as follows: PTSD & BPD appear to be replaced by a ‘trauma-informed’ quasi-diagnosis of a validity and severity which is determined by the nature and degree of trauma and abuse (the causes).
But because ‘the specialised language of science
and medicine’ is itself oppressive, this quasi-diagnosis can only be conferred and ranked by the PTMF’s own experts, who have both vanquished ‘positivism’ (note the absence of the more easily understood ‘scientism’) and become mysteriously attuned to the relevant ‘lived experience’.
If the PTMF experts get to control resources, they will reduce them for people with mental health problems who are unable or unwilling to foreground ‘trauma and abuse’.
I simplify and exaggerate, of course. But one last point. The PTMF authors also repeatedly claim to be ‘anti-neoliberal’ and ‘anti-capitalist’. In fact, however, calls to reduce diagnosis are very much in keeping with the state-shrinking aspect of ‘neoliberalism’.
I suggest that in seeking to reduce mental health diagnosis overall, and distracting from that aim by making a great show of opposing traditional psychiatry, the PTMF authors are reprising the left-right antipsychiatric alliance of the 1980s which failed to adequately fund ‘care in the community’ after the closure of the asylums.
I am a bit less gloomy after discovering what the quasi-diagnosis is, after going through the 400+ pages more carefully and reading more of the PTMF-promoters work.
Quoting from my comment at MIA (https://www.madinamerica.com/2018/05/may-power-threat-meaning/#comment-131373) from a few days ago: ‘…an alternative is being smuggled in.
Going through the main document finding words such as ‘trauma’ helps identify what that is. ‘Trauma-informed’ is key even though ordinary ‘PTSD’, as a DSM no-no, is rejected. However, great stress is placed (p.201) upon ‘a new category of Complex Post-Traumatic Stress Disorder (Complex Trauma for short)’.
‘Our argument is that the great majority of the experiences that are described as ‘symptoms’ of ‘functional psychiatric disorders’ (and many other problems, including some examples of criminal behaviour) can be understood in this way, but with no assumption of ‘mental disorder’’
So, ‘Complex Trauma’ is NOT a diagnosis. Anyone who disagrees will be blocked on Twitter, as two UK psychiatrists have been by Lucy Johnstone. I don’t think other UK psychologists, never mind service users or psychiatrists, will be completely convinced.
Reality check here for US (and maybe UK) readers: PTMF is not official BPS policy, but it appears to have come across as such. From the last 2 months I estimate that 0.3% of tweets by the BPS have referred to it: from the BPS Clinical Psychology Division, 1.5%.’
I still think my comments about the quasi-diagnosis (‘complex trauma’) are reasonable.
The tone of this is so arrogant and dismissive that for me it completely clouds any of the actual arguments being made.
[…] Power Threat Meaning Framework: innovative and important? #PTMFramework […]
I have a particular problem with the use of obfuscatory language which, it seems to me, is always calculated to divert attention from the fact that the Emperor is in fact, naked.
Are the authors really asserting that the question “what happened?” is incompatible with “What are we going to do about it?” Or that trauma-focused therapy always has to involve re-experiencing past trauma or spending time exploring historical events? As a therapist myself who has done trauma work with many clients over the years, I find this assertion puzzling. A good therapist uses whatever approach works for the client. Some are very interested in delving into the past and discovering the reasoning or fears behind their current coping measures. Some want to focus on establishing immediate control of their environment. And some move back easily between one and the other. We should do what meets our clients’ needs, which I think is a lot of what the PTM framework is suggesting.
I also find it kind of ironic to expect “extraordinary evidence” that the PTM is valid in light of the laughable “evidence” on which the DSM is based, most of which is focused on “reliability” and almost none on “validity.” When the NIMH itself states that your diagnostic categories are nonsense, it’s time to adopt some humility.
Finally, if the PTM framework is flawed (and of course, it certainly is open to criticism on a number of fronts), what is your suggestion? Stick with the sketchy DSM? Your comments seem to allow some criticism of the DSM, and yet in the end, the entire article sounds like an attempt to defend it.
Thanks. Mostly I would reiterate what is in the post. We advocate for hearing personal narratives including but not confined to the experience of being subject to abuse of power and trauma. We disagree with the reification of diagnosis but consider collaborative problem definition an important first step towards reaching a shared understanding and preliminary formulation. Anyone who wishes to exert power on the scale of this framework (essentially, to determine the form and substance of all MH services) should in our view be prepared to back up their extraordinary claims with extraordinary evidence in order to differentiate their framework from the wide range of passing fads which claim to have the answer to the complexities of MH
[…] Power Threat Meaning Framework: innovative and important? #PTMFramework […]
Just re-read your blog following a presentation and discussion of the PTM framework in our psychology department. Whilst I dont agree with all you say, perhaps not surprising given our different approaches to therapy, I most certainly very much welcome the robust and thorough criticism that you make. This document worries me: I fear it is, paradoxically,inherently dis-empowering of the people we try to help; and it represents a destructive political battle against colleagues and approaches that we should be forming alliances with for the benefit of the patients we serve.
Thank you for your (significant!) effort in writing this.
Thanks Charles. Clearly I’m coming from my own perspective BUT I consider that most of these issues are pan theoretical My biggest concern is the fact that the authors IMO have failed in what I would consider their duty to their sponsors (the DCP) to engage with this blog (effort fully contributed produced) in any way and the DCP itself disregarding concerns such as this one. The fact that they set up an implementation group in this context is extraordinary in my view. Thanks for commenting. Best wishes Paul
Paul, I agree with Charles but also feel Lucy and colleagues may have to take such a stance sadly because your own Society cannot move from each end of the spectrum. We are practitioner s ( whatever modality ) that espouse great achievements in helping clients manage, challenge and even change beliefs to resolve their inner and out battles. Yet the whole of BPS and RCPsych for that matter still struggle. And to entrench each end of the spectrum deeper against each camp you use academia as a tool in the belief that the most academic will come out winners.
Perhaps TPM should sit more in the well-being arena where people can introspect without diagnosis and seek resolution. ( without diagnosis )
This is an indictment on the lack of narrative within the BPS as these two paradigms( or whatever academics what to use ) could form a synthesis.
Thanks Alan. I’m afraid I’m not entirely clear about what you are saying?
As far as I’m concerned the blog is about what is actually a synthesis being ignored by the PTMF, but I may have misunderstood you there!
I think Power Threat Meaning Network helps a person, who suffers from voices, or self-harming behaviour, to avoid role of “a patient” with stigmatising and pessimistic diagnoses of schizophrenia or personality disorder.
Apart from that, current medical model overmedicalise normal human emotions, like sadness. The outcome in the UK is a disaster and disgrace – 7 millions with antidepressants-induced “chronic depression”.
“So, the intention is to replace (rather than supplement) diagnoses with personal narratives primarily focused on power issues.”
I have read the document. I absolutely did not have that impression when reading it. Could you quote the passage that fuels this inference in your mind?
“If it is to be considered so, then it should be in the context that extraordinary claims require extraordinary evidence, something we consider here.”
Yeah. Well, no.
If you want to validate a diagnostic construct, at least, as a first step, you have to lay it down! Now, there may well be a lack of evidence. That’s very possible. But the goal of a tentative diagnostic construct is first and foremost to provide a framework through which you can categorize clinical data. And then, and only then, do the relevant statistical work to see if the construct makes sense.
That’s exactly the way science works…
“By contrast, the PTM Framework has opted to take a quite different path, set out by a hybrid social constructionist, anti-psychiatry, anti-science and political agenda.”
As if laying down a framework was a Sin against Science. All that is FUD. And Big Words.
You’re digging a conspiracist rabbit hole. Seriously.
Constructing random theoretical scaffolding and claiming to test it through quasi-hypotheses that are de facto resistant to falsification is in fact anathema to any useful definition of science.
“Constructing random theoretical scaffolding and claiming to test it through quasi-hypotheses that are de facto resistant to falsification is in fact anathema to any useful definition of science.”
Hum. No. I do not see how you can support your claim that it is a “random theoretical scaffolding”. I do not see what are “quasi-hypotheses” that are “de facto resistant to falsification”.
Please support your statements by an analysis of the PTM framework. For now, all I see are unsupported claims. And FUD.
Again: you have to propose a (not so) “random” theoretical scaffolding to start doing basic work. Like inter-rater reliability analysis of various diagnostic categories.
Not even accepting that a framework be set in place is precisely a way to get such an analysis of inter-rater reliability of diagnostic constructs to never be realized.
That’s precisely what obscurantism is about. No need to shout “Science!” when you’re endorsing obscurantism.
Please prove me wrong. And don’t tell me I haven’t read Popper. Please: be serious.
I’m a psychologist and met Lucy Johnstone when attending one of her PTM workshops in Australia. She was genuine, insightful, and her challenging of traditional psychology is overdue. While the PTM model was being rolled out, I was completing my own series of books, The Reactive Alien, which are very aligned with PTM. After Lucy’s workshop, I was inspired to synthesise the trilogy into a more accessible volume – Reactivity: An Evolutionary Solution to a Biogeographical Dilemma (available at Amazon.com) – which I believe fills in many of the gaps that PTM is itself being challenged over.
@Steve Meade: OK. You have some affinity with the PTM framework. That’s fine. We’re free to have opinions.
“By contrast, the PTM Framework has opted to take a quite different path, set out by a hybrid social constructionist, anti-psychiatry, anti-science and political agenda.”
Don’t you think it is your job as a psychologist, and hence a scientist if I’m not mistaken, to assess whether the author is right?… or wrong here? Because if he is wrong, it would be nice that you’d step up a defense of the PTM framework on a rational (if not rationalistic) stance against these “deep” and “serious” accusations…
Be brave. Please.
An interesting polemic, you’ll forgive me if I pay as much attention to balance here on The National Elf: “No Bias. No Spin.”
Firstly, it was generous that your smallest paragraph acknowlegded the impress of power before immediately reprimanding the authors for not engaging in detailed sociological analysis; I admit I struggled to follow your logic given criticisms levelled as its supposed unintelligibiity, verbosity and scary language which you feel might scare off the passionate professionals and highly resourceful service users who characterise this field. (The readibility score is graduate level, samplng just a few random pages will regularly give scores in the plus 30s…)
I was also glad you were able to stay true to your espoused values of co-writing this piece with a single service user who was treated at the clinic you have managed: a purposive sample of more than one participant could really help.
Twitter tells me that you recently apologised on the behalf of your profession at the RCPsychiatrist conference for the PTM framework. Given that your choice audience are psychiatrists where less than 1% believe mental health problems are primarily social compared to 46% in biological causes (Kingdon et al, 2004) you must have found other presentations so boring given that in your view causes are of little relevance or interest to most professionals or service users?
I wonder how a more plurastic approach to clinical psychology which priveleges a recognition of the social inequality would affect your professional and personal interests. Its a shame that the national elf service has no space for declarations of interest rather than this article, a defamation of uninterest.
So glad you pointed out the “No Bias. No Spin.” tagline here James. I find my experience of how conceptually distanced removed from the reality of people in distress many Psychiatrists and Psychologists are, especially considering all they purport to be, Professors, Dr.’s, Directors, etc etc… all this but can be so wrong, how can it be?! :-( I guess it’s nothing new :-(
I attended a Mental Elf event, and when the bizarre expectation of psychiatrists to expect survivors of the psychiatrists (to put it mildly) many misdemeanours to listen to their ‘well-intentioned’, generous goings-on with respect blew up in their face, they appeared like rabbits in the head lights.
It seemed they had no ability to hear or understand what was being communicated. As if there was a massive lens between them and the people in-front of them – which I guess there was – ‘that person is mad so there can’t be any truth or relevance to there emotion’ tinted-spectacles. The psychiatrists and psychologists on this particular panel demonstrated no ability to relate, listen or reflect. Little capacity for insight or self awareness was shown.
I assume they feel attacked and misunderstood and they get caught up in and believe their own hype.
I guess because it is in their interests, personal, professional.. and in the interest of their entire identities, in order to be able to sleep at night, to feel assured that more humane considerations such as the PTMF are un-sound.
As a survivor of the mental health system and so much of the violence it commits, and now someone working in it, I’m throughly saddened to see the inane and tragic, albeit deluded conviction of this article, as it reminds me of the sheer (willing?) blind-sighted dangerousness of the author, those alike to him, and the power they wield.
Shame on you Paul.
I’m sure that I’d fail on the Flesch readability test, but I know this article depressed me, whereas the PTMF filled me with hope.
As someone who has been psychotic, depressed, anxious, suicidal etc etc, I know who I would rather be in the care of in a period of distress, or troubled and troubling behaviour, and it is not Paul Salkovskis (who I hope will one day learn an awful lot both about himself, albeit with much serious and challenging self-reflection, and how to be with people, from reading, understanding and appreciating the oft-aluded to David Smail), but Johnstone, Boyle, Cromby, Dillon, Harper, Kinderman, Longden and Read, or those who have the self-humility, time and lovingness to draw strength and solidarity from their views.
Soz, should read:
I find my experience of how conceptually distanced removed from the reality of people in distress many Psychiatrists and Psychologists are EXTREMELY DISTURBING and SADDENING, especially considering all they purport to be,
Hi Survivor B,
Please can I ask which “Mental Elf event” it was that you attended?
> The authors assert that the gathering and synthesis of evidence (positivism) which lies at the heart of psychiatry and psychology should in any case be rejected
Okay, so that’s complicated. Though the authors claim to be attacking positivism I’m not sure that’s what they are really doing, rather than they are attacking the ideas that are used to reason about mental health. The claim is that the constructs are wrong.
This idea comes up in other fields. The idea that you can see someone doing something that works, take the idea somewhere else and find that it is completely non-functional because of dozens of other factors, or you didn’t understand the intervention in the first place etc etc etc or you are actually measuring something unrelated.
The question is what you *do* when you know that the factors and concepts that you are using to understand something don’t work, and whether you can jump into defining new concepts.