Mad in America: Rethinking Mental Health

Lucy Johnstone - The Power Threat Meaning Framework

Mar 5, 2018

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This week, we interview Dr Lucy Johnstone. Lucy is a clinical psychologist, trainer, speaker and writer, and a long-standing critic of the biomedical model of psychiatry. She has worked in adult mental health settings for many years, alternating with academic posts.

Lucy has authored a number of books, including 'Users and Abusers of Psychiatry’(Routledge 2000), and ‘A Straight-talking Introduction to Psychiatric Diagnosis’ (PCCS Books 2014) as well as a number of articles and chapters on topics such as psychiatric diagnosis, formulation and the role of trauma in breakdown. She has a blog on Mad in America.

Lucy kindly took time out talk to me about the new Power Threat Meaning Framework, an ambitious attempt to outline a conceptual alternative to psychiatric diagnosis which was published on January 12th this year by the Division of Clinical Psychology of the British Psychological Society.

In this episode we discuss:

Lucy’s background and what led her to be interested in mental health work, particularly in terms of being critical of current practice.
The importance of acknowledging the reality of people’s experiences of distress along with questioning the dominant explanations for that distress.
The fact that the diagnostic model has never been supported by evidence.
How imposing a diagnosis often can be very damaging to people, by turning ‘people with problems’ into ‘patients with illnesses.’
Why we need to move towards the survivor slogan of “Instead of asking “What is wrong with you?” ask “What has happened to you?”’
The inception of the Power Threat Meaning Framework, which was funded by the Division of Clinical Psychology of the British Psychological Society, and the five-year journey to its release earlier this year.
The composition of the core project team: Lucy, Mary Boyle, John Cromby, Jacqui Dillon, John Read, Peter Kinderman, Eleanor Longden, Dave Harper, Dave Pilgrim and a research assistant Kate Allsopp. The core team consists of psychologists and survivors/campaigners, many of whom are well known to MIA readers. Also involved were a consultancy group of service users/carers; a group of critical readers with a particular focus on diversity; and a number of others who contributed to particular sections or supplied good practice examples.
How the Framework itself is not an official DCP or BPS position or policy document, nor is it a plan for services or for any other specific form of implementation. Rather, it is offered as a co-produced academic and conceptual resource to anyone who wishes to take on these ideas and principles and develop them further or translate them into practice.
The Framework is necessarily dense because of its aim to move right away from the “DSM/ICD mindset” which is deeply rooted in Western culture. However, there are various accessible summaries of its core principles (see below.)
How we already have a number of ways of supporting someone non-diagnostically, but what we didn't have before was a sound, evidence-based alternative to what diagnosis claims, but fails to do, which is to outline patterns in distress.
How the Framework acknowledges the irreducible complexity of a person’s responses to their circumstances.
The derivation of the title: The Power Threat Meaning Framework.
The four main questions, which are:
- What has happened to you? Translated as “How is Power operating in your life?”
- How did it affect you? Translated as “What kinds of Threats does this pose?”
- What sense did you make of it? Translated as “What is the Meaning of these situations and experiences to you?”
- What did you have to do to survive? Translated as “What kinds of Threat Response are you using?”
- Finally “What are your strengths?” or “What access to Power resources do you have?” and to pull it all together, “What is your story?”
These are not separate questions, since each of them implies and arises out of the others.
That the aim is for people to be able to use these ideas and questions for themselves, not necessarily through an interaction with a professional.
How the PTM Framework does not recognise a separate group of people who are ‘mentally ill’ but describes how we are all subject to, and affected by, the negative impact of power in some aspects of our lives.
How it is particularly important to recognise the role of ideological power, or power over language, meaning and agendas.
How the PTM Framework includes the concept of formulation, which is a semi-structured way of putting together someone’s story, but is much wider in scope and for that reason uses the preferred term “narrative” – which may be individual, group or community.
How diagnosis often obscures someone's story, and how the Framework aims to help create narratives that restore the links between personal distress and social injustice.
What the PTM Framework says about DSM and ICD attitudes to conceptualisations of distress in non-Western cultures.
That since we are meaning-making creatures, at a very basic level the principles of power, threat, meaning and threat response apply across time and across cultures, although all expressions and experiences of distress are culturally-shaped.
The regrettable exporting of Western psychiatric models across the world.
How the Framework does not exclude or deny the role of biology, but integrates it as a mediator and enabler of all human experience, although not something that is always accurate or helpful to view as a primary cause.
The reaction to the Framework, both positive and negative. The team very much welcomes feedback, much of which has been very helpful. Some of the more extreme reactions can be understood as predictable responses to the threat posed by the Framework to ideological power.
How the reaction outside social media has been overwhelmingly positive.
Emphasising again that the Framework is (unlike diagnosis) presented as a completely optional set of ideas, and a work in progress. The project team is very pleased that there is such widespread interest in taking these ideas forward in people’s own lives and settings.
People are encouraged to explore these ideas for themselves via the links below. More resources will be added in due course.