The “Power Threat Meaning Framework” – a new paradigm for mental health?

6 June 2019

Photograph: Renée Bleau

Psychologists and service users have worked to provide a discussion framework document as an alternative to the current diagnostic system

At the Glasgow Sloth, it’s our mission to take our time reporting the news.

So, here I am writing up a story that I started researching in November last year. It’s a story about mental health. It’s a story which may change how we think about mental health.

On 2 November 2018, the new “Power Threat Meaning Framework” document was introduced at a launch event took place in Glasgow at a British Psychological Society (BPS) meeting. The document was published by the BPS Division of Clinical Psychology.

The event was reported initially in an article in The Herald by Stephen Naysmith with an opening quote by one of the PTMF document lead authors, Dr Lucy Johnstone: “There is no such thing as depression.” This bold claim drew a lot of fire from readers.

In response to the article, Johnstone herself left a reply in the comments section: “Just to clarify: I have not said, and would never say, that ‘there is no such thing as depression.’”

Naysmith responded subsequently in the comments’ section of article: “Just to be clear, I do stand by the quotes, and am happy to discuss further […] I don’t have a dog in this fight. I’ve not experienced any of the conditions discussed, I’m not a social worker, psychiatrist or psychologist. I report what people say, if it is interesting, even if it is controversial. If the ideas people raise with me later create controversy or even anger, I don’t think this is a reason to back away from raising them. I believe I’ve covered this difficult topic as accurately as I can.”

I had been told by Johnstone that Naysmith was writing an article for the Herald but that she had not yet seen it. I don’t know if the misunderstanding was cleared up between the lead author of the radical reconceptualising document and the journalist reporting on the event that he attended where the document was introduced. In my view, both are to be commended, for different reasons. Johnstone for her perseverance in presenting the new, radical framework. Naysmith for reporting on its content, as accurately as he said he could.

Johnstone has suffered personally. As lead co-author, she considers this to be because she is the most prolific Twitter user of the project group, who have worked together to produce the document, which is available in long form, and an abbreviated version. Arguably, anything that challenges the status quo can be met with resistance. However, in this brave new world of 24/7 social media, it can be a new kind of tough going when the criticism is so personal and so targeted.

Johnstone said: “I have been subject to a lot of personal attack […] There have been a lot of vicious, brutal and often very sexist attacks often by professionals tweeting under their own name which is particularly shocking […] Some psychiatrists, some psychologists, some nurses, some service users who don’t like it – and of course it is absolutely up to them whether they read it, don’t read it, like it or dislike it. This is optional – this is not imposed on anyone in the same way diagnosis is imposed on anyone.”

Despite these attacks, Johnstone is committed to the project, which began following the publication of a position statement in 2013 by the BPS Division of Clinical Psychology. As is highlighted in the introduction to the PTMF abbreviated document, the statement was “issued in the context of widespread acknowledgement that the current classification systems such as DSM or ICD are fundamentally flawed.”

Johnstone explains the radical work: “What a group of us has been developing over the last five years is a completely different understanding of an approach towards mental distress. The things we usually call things like clinical depression, or bipolar disorder, or psychosis, or schizophrenia. The current approach does not work; it on the whole does not make people better or help them recover.  We think we need a fundamentally different way of understanding distress, which is about looking at it in the context of people’s lives and relationships.”

Skype interview with Dr Lucy Johnstone: @ClinPsychLucy. Video: Renée Bleau

When referring to the current approach, what she means is: mental health professionals’ use of the DSM V as the “standard” method of diagnosing individuals who go for help with thoughts and behaviours that are causing them distress.

The DSM V is referred to as the “bible” of mental illness by the Guardian in the launch article of their new series on the Global Mental Health challenge.

According to Johnstone and her colleagues, this is exactly the approach they say is not working, so far from being a bible, in her view.

Johnstone explains: “Instead of giving people diagnostic labels which are not actually based on science and not actually based on evidence, what we are saying is that maybe you need to sit down with someone and understand their story, their narrative.”

“Psychologists call it a formulation. What is [it] that has gone on in your life that has brought you to this point? How did you make sense of it?”

I contacted Richard Pemberton, who was Chair of the BPS Division of Clinical Psychology in 2018, when the PTMF was first published, to ask his view of the impact of the publication of the new framework document.

Pemberton said: “It’s had quite a powerful impact. It’s stirred up a lot of controversy and attracted a lot of support but has also upset a number of people. It’s upset a small number of psychologists and psychiatrists but most concerning, some service user groups, people with lived experience of mental health problems have been upset by it.

“We are working to learn some important lessons from this and we are working hard to take on board the concerns that service users have expressed.”

I asked him what he thought our famous Glasgow psychiatrist, RD Laing, renowned author of Sanity, Madness and the Family and The Divided Self would have made of the new paradigm being proposed. Pemberton speculated: “The thread that does link them is finding meaning in acute distress, disturbance or what we call madness.

“The PTMF is hugely to be welcomed and it’s sad that we’ve had about the past 30 or 40 years with people’s very interesting and sometimes crazy thoughts, as being thought of as just noise really.”

Skype interview with Richard Pemberton: @socratext. Video credit: Renée Bleau 

We are now seeing mental health being discussed openly in a way like never before, and mental health issues on the increase. The current response in Scotland has been a substantial rise in prescribing rates of antidepressants in the last 10 years, according to data from ISD Scotland.

Infographic: Renée Bleau

But can antidepressants really help?  What we need is a way to help people succeed, not be saddled with a diagnosis which potentially ends up holding them back.

What do I mean? What do I have in mind? With permission, I am quoting a tweet from journalist Holly McCormack. She exemplifies the kind of distress that comes from having mental health concerns. This is what she said last night.

McCormack, who was commended at the recent Scottish Students Journalism Awards 2019 last week, says she feels like “nothing and nobody and it is hard.” If our current mental health services don’t provide the support that she needs to thrive, then indeed maybe it is time for a new paradigm, with a new way of thinking about mental health and how to help people psychologically.

Of course, the new PTMF paradigm (#PTFMFramework) will need to be evaluated for effectiveness. But given its focus, a focus on making sense and understanding from the perspective of the person in context, I can conceive it just might indeed work. At least, an alternative is now on offer to the diagnostic mental illness model.

Dr Renée Bleau is a BPS Chartered Psychologist and credentialed (academic) in Psychodynamic Psychotherapy.

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