Lucy Johnstone, a member of the British Psychological Association's Division of Psychology, is one of the lead authors of the Power, Threat and Meaning Framework. This new proposal, supported in the scientist's review, intends to serve as an alternative for the understanding of human suffering as opposed to the vision gathered in the traditional diagnostic classification systems, DSM and ICD.

 

In order to introduce us to the Power, Threat and Meaning Framework, Lucy Johnstone offers us the following interview.

From a global point of view, we are witnessing the crisis of the mental disorders classification/diagnose systems as well as a downturn of the biological models applied to mental health. How is this crisis/debate impacting Psychology in your country?

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LJ: You are right – we are seeing a crisis in the classification system as laid out in manuals such as DSM and ICD, and even the very senior psychiatrists who draw them up are admitting that the categories are unscientific. Millions of dollars are being poured into trying to develop more evidence-based versions of diagnosis, but in the meantime we are left with something completely unsatisfactory. Clinical psychologists in the UK have had a mixed reaction. Many are still supportive of diagnosis, and have built careers on treatments for ‘anxiety disorders’, ‘bipolar disorder’ and so on. But the Division of Clinical Psychology, which is a sub-division of the British Psychological Society, issued a formal statement in 2013 calling for the end of the diagnostic model of emotional distress. As far as I am aware, this is the first time any professional organization has taken such a position. Increasing numbers of psychologists in the UK are changing towards this way of thinking. UK clinical psychologists have also been in the forefront of developing interventions that are not based on diagnosis. As far as psychology more generally goes, the diagnostic models are still taught on nearly all school exam and undergraduate degrees with very little attempt to critique them.

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You have been one of the main authors of the Power Threat Meaning Framework which has been boosted by the limitations shown by the DMS and ICD classification systems. Could you briefly explain this proposal?

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LJ: We had the very ambitious aim of outlining a comprehensive alternative to the diagnostic model. In the UK we already have various approaches which do not depend on diagnosis, and we have included these as examples of good practice. However, we do not have a complete, evidence-based conceptual framework to replace the medical one, which can both support current non-diagnostic practice, and suggest new ways forward.

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Our starting point is that models designed to understand what goes wrong in people’s bodies are not suitable for making sense of emotional distress. The Framework summarises a great deal of evidence about the role of various kinds of power in people’s lives, such as poverty, discrimination and inequality, along with traumas such as abuse and violence, and how this links to distress or troubled behaviour. It illustrates the threats that misuses of power can pose and the ways we have learned as human beings to respond to threat. In mental health practice, these threat responses are usually called ‘symptoms’. The Framework shows 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.

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The Power Threat Meaning Framework can be used as a way of helping people to create more hopeful narratives or stories about their lives and the difficulties they may have faced or are still facing, instead of seeing themselves as ‘mentally ill’. It also shows why people without an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity.

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The Framework also has important implications for social policy and the wider role of equality and social justice.

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Could you tell us about the Power Threat Meaning Framework development process?

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LJ: This project was funded by the Division of Clinical Psychology although it is not official policy. I and Professor Mary Boyle were lead authors on this 5 year project, which was jointly produced by clinical psychologists and service users. We also had a consultancy group of service users and carers, a critical reader group to advise us on diversity issues, and contributions from a number of others. The core project group have all known each other for many years and shared the same rejection of diagnostic models. Nevertheless, it was a major and very challenging process to develop our alternative.

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This framework provisionally proposes seven general patterns destined to understand human suffering. Could you, please, briefly describe each one of these patterns?

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LJ: The General Patterns, which like the whole Framework are still in a process of development, are a replacement for medical patterns. We have described them as patterns of meaning-based responses to threat. We have shown that there are common ways in which people in a particular culture are likely to respond to the negative impact of power, such as feeling excluded, rejected, trapped, coerced or shamed. This does not just apply to peeople who are diagnosed with mental health problems but to all of us. It may be useful to draw on these patterns to help develop people’s personal stories. Because they are organised by meaning not by biology, they allow for the very different expressions and experiences of distress across cultures, and encourage us to respect these differences rather than translate them back into DSM or ICD categories.

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Which are the repercussions of using the Power Threat Meaning Framework? And what are the advantages of adopting such a model compared with the use of classification/diagnose systems?

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LJ: As we anticipated, there has been a mixed reaction to the PTM Framework. We have had quite a lot of hostility on social media, but the great majority of the responses have been positive. We are pleased that development and implementation of these ideas is already underway, both inside and outside services. There has also been international interest, from Denmark, Greece, New Zealand and Australia among other countries. The PTMF ideas can be taken forward in many different ways. Sometimes it may just be a matter of having a different conversation with someone – as we say in the UK: ‘Instead of asking What is wrong with you? ask What has happened to you?’ However, the PTM Framework also has much wider implications for the whole way we organise our services and indeed our societies. Obviously changes at that level would take much longer to appear.

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We hope that at least we have offered an alternative way of thinking about emotional distress. Nothing can change until we have a different understanding, and the fact that the project has been so widely welcomed suggests that many people are ready to take on this new perspective. At the very least, our approach offers a better way forward than the current one, which has no evidence to suport it and is often the start of lifelong stigma and dependence on psychiatric drugs. There is a great deal of research showing that the current model creates, rather than cures, disability. We have to do better than that.

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Is there anything you would like to add before finishing with this interview?

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LJ: Please do visit this link to find out more: https://www.bps.org.uk/news-and- policy/introducing-power-threat-meaning-framework.

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The 2 page Brief Summary is a good starting point. The Overview document is available in Spanish and it includes a Guided Discussion (Appendix 1) to help you think about these ideas in relation to your own life or someone you are supporting or working with.