How should we understand our mental health needs? A new approach has been unveiled this year. You may have heard of it. You may not be fully across it. Journalist Mark Brown, who lives with a bipolar II diagnosis, has waded through the lengthy provisional document. Here he attempts to make sense of one the most significant mental health stories of the year.
In a moment reminiscent of Laurence Fishburne's Morpheus telling Keanu Reeves' Neo that everything he has believed true is false, The Power Threat Meaning Framework arrived with a fanfare in February 2018, telling the world of mental health to consider the idea that, like the Matrix in the Wachowski Sisters' 1999 blockbuster, mental health diagnosis wasn't real.
"According to the authors, mental health diagnoses are not verifiable in the way physical health diagnoses are; diagnosis brings shame and robs people of the opportunity to make their own meaning."
Published by a division of The British Psychological Society, The Power Threat Meaning Framework was five years in the making and involved the work of a group of senior psychologists and service user campaigners. It argues that mental health diagnosis is part of a continuum of oppression and marginalisation and that it is a tool for ensuring those who wield negative power are not challenged by those against whom that power is deployed.
Instead, the Framework is an attempt to build an alternative way of categorising human responses to past and present adverse circumstances that does not rely on the idea that someone has a deficiency that should be corrected. The text discusses diagnosis of mental health conditions as an epistemic violence; that is, a set of ideas imposed by a powerful group upon a subordinate group, reinforcing their oppression. For the authors, when groups within society are devalued, oppressed or marginalised epistemic injustice denies them "the opportunity to make sense of their own experiences due to unequal power relations and lack of shared social resources.” This injustice “may occur in a context of historical and inter-generational oppression of a whole social or cultural group by, for example, warfare, colonialism or in extreme cases, genocide” (page 219).
- See also: A disorder for everyone?
- See also: Do you identify as having a disorder, or as having survived something?
- See also: Disorders explained
The Framework of the title is a set of seven general patterns under which people's experiences can be classified as a way of formalising understandings of how people’s responses to difficult experiences relate to how they feel. Instead of asking 'what is wrong with you?' the framework suggests four alternative questions: 'What has happened to you?'; 'How did it affect you?'; 'What sense did you make of it?'; and 'What did you do to survive it?' The Framework assumes that what a diagnosis calls symptoms are kinds of survival technique. Each of these questions is subtitled with the role it plays in the framework: 'How is power operating in your life?' 'What kind of threats does this pose?' 'What is the meaning of these situations and experiences to you?' and 'What kind of threat response are you using?'
It's difficult to summarise the Power Threat Meaning Framework. The main document is over four hundred pages long. The summary is near to a hundred pages. One of its authors surmised that I was writing this piece and approached me preemptively to ensure my piece was accurate. The authors have complained of being misrepresented, claiming that people are ascribing to the Framework things it does not say or intentions it does not have. Debate about the Framework on twitter has at times been vicious. While there is continual debate about whether individual diagnoses are valid ways of describing particular experiences and often bruising discussions between various groups in society about whether the treatments related to these diagnoses are effective, most members of the general public accept mental health conditions exist.
A large amount of the page count of the Framework is devoted to reasons why clinical diagnoses in mental health are invalid and unhelpful. According to the authors, mental health diagnoses are not verifiable in the way physical health diagnoses are; diagnosis brings shame and robs people of the opportunity to make their own meaning; and diagnosis makes distress the problem of the individual, letting society off the hook of examining what it does to people.
Alternative 'patterns' of emotion and behaviour
The General Patterns, the meat of the Framework, take up around sixty pages. While the authors of the framework may not claim it is a theory of everything, attempting to extract any any element of it for examination is difficult. Each element of the framework is at once concrete and provisional, to be taken as seen and also not to be regarded as set in stone. Discussing the General Patterns is best done by looking at what they actually say.
Of the seven general patterns, Provisional General Pattern 2 "Surviving rejection, entrapment, and invalidation" is the one closest to my own life. I'm someone who grew up up not straight, gender dysphoric and precociously clever in the west end of Newcastle before the internet which meant growing up in a world where there was no one like me and being myself was an invitation to violence. I'm someone who lost a parent young and experienced emotional abuse. I'm someone who spent a big chunk of time frighteningly poor. I'm someone who has lived in situations where it was dangerous to be who I am.
General Pattern 2 is described as "a broad pattern of relationship threats and threat responses which give rise to core meanings of rejection, entrapment and invalidation. A central survival dilemma is maintaining attachments and relationships versus distrust and fear of rejection, hurt or harm. These situations arise more frequently in power contexts of poverty, social inequality, unemployment, gender inequalities, and war."
The operation of power - 'what happened to me' - in this pattern is described as "prolonged interpersonal maltreatment, abuse, invalidation and neglect in situations of lack of control, dependence, isolation and entrapment. In these situations the person was/is helpless and powerless in the face of emotional and/or physical threat, while often being dependent on the perpetrators for survival."
The threat - 'how it affected me'- is suggested as covering such experiences as "rejection, invalidation, abandonment, attachment loss, entrapment, emotional overwhelm/dysregulation, powerlessness, physical danger and bodily invasion, physical ill-health and depletion."
According to General Pattern 2, people like me would usually describe this as feeling like " lack of safety, fear, rejection and abandonment, shame, guilt, emptiness, badness and unworthiness, alienation, betrayal, hopelessness, helplessness, and meaninglessness."
The threat responses - 'what I did to survive' -, usually described as symptoms, range from "dissociation, amnesia, disrupted attention, de-realisation, emotional numbness, bodily numbness, hearing voices, drug and alcohol use, self-harm, impulsivity, somatic sensations, splitting and projection of feelings, rapid changes of mood, unusual beliefs, suicidality" through "dominance and seeking control, distrust, vigilance for rejection, rejection of others, isolation/avoidance of others, self silencing, self-hatred, self-blame, appeasement, compliance" and on to "seeking attachments; maintaining a sense of control; protection from danger, meeting emotional needs/self-soothing; preserving identity, self-image and self-esteem; and communication about distress and eliciting care through self-injury and anger".
Gendered responses theory
The framework claims General Pattern 2 is most frequently observed in women, who "in many western cultures... show a tendency to direct distress inwards" while "men... direct it outwards... As a generalisation, women are more likely to turn anger inwards into self-harm, eating disorders, etc., and men are more likely to turn it outwards in violence towards others." Sub patterns for this general pattern include "surviving domestic abuse (women); "surviving as a refugee, asylum seeker, trafficked or displaced person; and surviving intergenerational and historic trauma." The description finishes by saying that people like me probably also fit the General Pattern 3 "Surviving disrupted attachments and adversities as a child/young person."
Does the above sound like me? Yes, but there is a degree to which each of the general patterns is like the description of a Myers-Briggs personality test result or horoscope, with each having at least some characteristics that are relatable to most people who have experienced mental ill-health or distress.
Having an historic diagnosis of bipolar II and a more recent realisation of how much trauma has shaped me doesn't feel significantly more epistemically violent or oppressive than the General Pattern set out above. It still says most men aren’t like me, which was at the core of many of my adverse experiences growing up. For me, while The Framework got a fair few things 'right' in a way that would have been helpful in formulating a next step were I seeking help or support, there is no guarantee that this would have played out in the same way during a consultation. What I did to survive may differ from what I am doing to survive now, although the assumption is that one will colour the other. Having read the rest of the general patterns and The Framework in its entirely, it is weak on the injustice and power exercised against queer people and those who have differing experiences of gender, which seems odd given its otherwise strong tone of liberation from oppression.
The Framework isn’t really intended as a tool for me, though. Hidden toward the later quarter of the Framework is a section that better outlines one of the drivers for the creation of the Framework in a section that discusses formulation and narrative. Formulation in this context would be the way that a professional understood the story being told to them of someone's life, both past and present, in way that suggest paths forward. The Framework is a tool to give formulations a structure that parallels the way diagnostic clusters give medical diagnoses of mental health conditions a structure, allowing evidence based practice to be applied consistently across clinicians and therapists. In that way it seeks to give formulation the same level of power as diagnosis.
In the end, for all of the emancipation promised by The Power Threat Meaning Framework, it still cannot remove the power embodied by a professional making decisions about how to understand the experiences of someone in need. In theory, the Framework should guarantee that a formulation would feel true to me. In its current form it still has the potential for the person carrying it out to bring their own prejudices and ideas about people like me into that initial discussion and, in the worst case, impose them upon me.
In its present form, The Power Threat Meaning Framework feels more like a liberation for psychologists from their own professional discomforts, both as agents who wield power and a profession in competition with others for power in mental health. If I were in a situation where a professional has power over me; it is incorrect to assume that a formulation based upon matching with The Framework's general patterns will be better by default than a clinical diagnosis.
It is true that for some people a diagnosis may not be a story that fits or is useful to them. But it is also true that where a person finds a diagnosis useful in building their own meaning and finding things that help they are entitled, as some already have, to ask the authors of The Power Threat Meaning Framework ‘what is it you're liberating me from and who gave you permission?’
How does this story make you feel? Share your thoughts using #MHTchat. We'll be discussing live on Twitter from 12pm UK time on Wednesday, August 22nd.