Five years ago I started this blog with a post by Kengo Miyazono...
Happy birthday Imperfect Cognitions!
I am very grateful to all the people who have worked hard during this time to keep the blog active and engaging: Ema Sullivan-Bissett, Kathy Puddifoot, Andrea Polonioli, Sophie Stammers, Magdalena Antrobus, Valeria Motta, and Anneli Jefferson.
And special thanks to our regular contributors and assiduous readers.
To the next five years!
Lisa 💛
-=-=-=-=-=-=-=-=-
On the 5th birthday of the Imperfect Cognitions blog Michael Larkin (Aston University) considers some conceptual propositions of the Power Threat Meaning framework, arguing that the framework is both a step towards a more humanising concept of mental health problems, and a missed opportunity to be more inclusive. Enjoy this very rich and thought-provoking celebratory post!
Often we are disappointed because we want the thing presented to us to be the thing we hoped to receive, and not the thing that someone else wanted to give to us.
The Power Threat Meaning framework (PTM) is a manifesto for thinking differently about mental health. It has been produced by a relatively large working group, co-ordinated by two lead authors (Lucy Johnstone and Mary Boyle). The framework is described in two documents (a ‘short’ and a ‘long’ version). Both of them are actually very long.
To me, they have the feel of being unfinished: there are contradictions and omissions; there are claims which seem overstated or inflammatory. At the same time, the document has some aims, sources and insights which speak very directly to some of my own thoughts and priorities about mental health. It involves some contributors whose work I admire very much. It is a conundrum.
I’ve spent a bit of time thinking about this conundrum, and more specifically, what we might want to notice about it from a conceptual point of view, because this is a blog which is concerned with conceptual things. To get to that conceptual material, we need to first notice some context.
Something which anyone following mental health on social media will have noticed is that the PTM has been very effective as a means of generating... activity. I’m not sure that it is quite clear what that activity should be called.
These examples show that the division is an over-simplification, but I think that if we take it as one which is offered in good faith, we can anticipate ways in which professionals could work together – as most currently try to do – in order to bring different perspectives to bear in such cases. For me, it has been more striking that there are many people who are not on the PTM authors’ exclusion list, but who certainly do feel excluded. Some people with diagnoses of bi-polar disorder and depression will not feel that the ‘Bad things happen’ narrative resonates with them at all, for example.
Many with problems related to alcohol or gambling will feel similarly. The consequences of exclusion include feeling that one is being blamed for one’s situation, or suffering from some form of ‘false consciousness,’ so it is a serious matter. If we treat PTM as a proposition, then we have to consider that the next iteration of this proposal will have to resolve this issue, and do so in a way which is less divisive.
When we say that an approach is evidence-based, we usually mean that there is evidence that it works. It would be more appropriate to say that some claims in the PTM are evidence-derived, or evidence-inspired. This is dealt with in the recent Mental Elf blog on the topic. The evidence is particularly thin in Chapter 6, where PTM’s alternatives to diagnosis are proposed; it is difficult to understand why this has not been developed out of a review of the transdiagnosis literature, for example.
There is some evidence for some of its earlier tenets, but the quality of that evidence is not assessed, and the evidence for ‘using’ the PTM does not exist. It is not yet clear ‘how’ the PTM would be used, and therefore how any evidence might be gathered about its efficacy.
It’s a psychological theory.
When psychologists speak of theory, they generally mean something which is testable. The PTM proposes some explanations for distress. These are pitched at a grand scale, but do not cover all forms of psychological distress (especially those where power is less relevant, or where biology or physical trauma play a significant role alongside other factors).
It seems unlikely that the next iteration of this proposition can retain its high level of abstraction (which is presumably desirable precisely because it allows us to consider cross-cutting issues) whilst also acquiring more of the properties of a testable theory. I would guess that it is unlikely to evolve into a theory per se. This does not seem to be its purpose, but perhaps it could - and should - make some theoretical contributions in future iterations.
It’s an epistemological framework.
The PTM draws on a selective bricolage of epistemologies. By this I mean that it draws on quite a lot of different kinds of evidence. This is rare, and difficult to do, and – I think – a good thing. But the PTM isn’t proposing a specific way of thinking about what is knowable about psychological distress (or how to go about it knowing it), so it’s not an epistemological framework.
The PTM is selective, so it is worth noticing a few things about what it includes and what it does not. It does not often engage with evidence which does not fit with its main argument. It does draw quite heavily on social constructionist ideas about narrative and power, most of which entered psychology during the 1980s and 1990s. This allows it to give a strong account of how narratives become part of culture.
The document engages much more cautiously with phenomenology, which means that it only offers a very weak account of the relationship between culture and experience, or experience and wellbeing. A lot of exciting conceptual work which has been developed in the meantime is overlooked.
This is what it looks like to me: a rhetorical ontological move. Theory with a capital T. We get Derrida, but not Ratcliffe; Deleuze, but not Bortolotti. We get all the cards thrown up in the air, rather than engagement with nuance and detail. I disagree with the criticism that the PTM is a failed explanatory account, because it does not really aim for explanation.
It engages with some explanatory material, but only insofar as that material supports its argument about changing the terms of the conversation about mental health. The PTM wants to re-define a subset of phenomena formerly known as ‘mental health problems’ as ‘understandable consequences of social inequality’.
Further iterations of the PTM’s ontological propositions must be able to account for these sorts of phenomena, and include the people who experience them. Personally, I think that this means that the ideological components will have to give some ground to some better-developed theoretical (with a small t) and conceptual components.
To me, they have the feel of being unfinished: there are contradictions and omissions; there are claims which seem overstated or inflammatory. At the same time, the document has some aims, sources and insights which speak very directly to some of my own thoughts and priorities about mental health. It involves some contributors whose work I admire very much. It is a conundrum.
I’ve spent a bit of time thinking about this conundrum, and more specifically, what we might want to notice about it from a conceptual point of view, because this is a blog which is concerned with conceptual things. To get to that conceptual material, we need to first notice some context.
Something which anyone following mental health on social media will have noticed is that the PTM has been very effective as a means of generating... activity. I’m not sure that it is quite clear what that activity should be called.
If we were feeling generous, we might call it a debate: an exchange of views, certainly, but rarely in the spirit of progress towards some sort of accommodation of positions. There is a lot of talk. It seems like there is some constructive debate within this talk, but also a lot of entrenchment. There are 'sides', sadly, and the entrenchment is evident on both of them.
From a conceptual point of view, I think we should treat the PTM as a proposition, and that what should follow is a series of conversations about the validity of that proposition, and whether it can be supported. If it can, what are the implications? If not, how should it be revised? To edge us towards that point, it may be useful to consider some of the areas of disagreement around the PTM, and the questions and claims which are raised about it.
From a conceptual point of view, I think we should treat the PTM as a proposition, and that what should follow is a series of conversations about the validity of that proposition, and whether it can be supported. If it can, what are the implications? If not, how should it be revised? To edge us towards that point, it may be useful to consider some of the areas of disagreement around the PTM, and the questions and claims which are raised about it.
Who is speaking?
It’s a policy.
It’s representing the British Psychological Society.
It’s representing the way that psychologists will work in future.
It isn’t a policy of the BPS; the framework has been produced by a working group; the working group have received some funding from the BPS. This doesn’t make it an official policy. The BPS funds a range of projects and activities.
Some psychologists have been very positive about the PTM; some have not. Many more will be completely unaware of it. It is difficult to see how it will shape practice (see below) in its current iteration.
Some psychologists have been very positive about the PTM; some have not. Many more will be completely unaware of it. It is difficult to see how it will shape practice (see below) in its current iteration.
It represents survivors/service-users.
It excludes survivors/service-users.
It excludes some service-users.
The two lead authors are psychologists. Several experts-by-experience have contributed to the development of the framework. Many experts-by-experience have since come forward to say that they feel very positive about the framework; many others have come forward to say the opposite. There is a substantive conceptual problem in the PTM which underpins this division in one of its core audiences, so let’s consider that next.
What does the PTM say about the causes of mental health problems?
A core claim of the PTM is that, in order to understand mental health problems, we need to understand their origins as Meaningful responses to Threat (particularly, trauma) and/or to the effects of Power (particularly social and economic disadvantage). There’s plenty of evidence which we can draw upon that supports this claim.
However, these two concepts – Threat, Power – can be operationalised in lots of ways (i.e. there are lots of specific types of ‘Power’ imbalance that one could measure, in relation to a lot of different forms of psychological distress), which means that the theorising here is on quite a grand scale.
There is a risk in such situations that we fail to attend to different mechanisms of action, and are carried along instead by the appeal of the overarching narrative: bad things happen to people, and some of those people then develop mental health problems. The problem for inclusion, however, is not so much with the claim itself, as with its scope and tone. The former is broad, and the latter is verging on the zealous. There are lots of places where judicious use of qualifiers (‘some’) would have set a better tone. Unfortunately, many people experience problems which do not fit this formulation, and some of those people have pointed out – quite rightly – that they feel excluded by it.
The authors do anticipate some of this reaction (p.14), but they underestimate its range and intensity:
We can see that that there is an attempt here to acknowledge that some problems will have physical causes, and that the PTM situates these as medical problems. Many academic and clinical critics of the PTM have taken pains to point out that there are cracks in the medical/psychological division here.
There is a risk in such situations that we fail to attend to different mechanisms of action, and are carried along instead by the appeal of the overarching narrative: bad things happen to people, and some of those people then develop mental health problems. The problem for inclusion, however, is not so much with the claim itself, as with its scope and tone. The former is broad, and the latter is verging on the zealous. There are lots of places where judicious use of qualifiers (‘some’) would have set a better tone. Unfortunately, many people experience problems which do not fit this formulation, and some of those people have pointed out – quite rightly – that they feel excluded by it.
The authors do anticipate some of this reaction (p.14), but they underestimate its range and intensity:
We can see that that there is an attempt here to acknowledge that some problems will have physical causes, and that the PTM situates these as medical problems. Many academic and clinical critics of the PTM have taken pains to point out that there are cracks in the medical/psychological division here.
These critics have tended to focus on relatively specific exceptions – what if, for example, you are dealing with a psychosis, and that psychosis has an neuro-inflammatory cause, but the person has to be discharged from treatment without a home to go to?
These examples show that the division is an over-simplification, but I think that if we take it as one which is offered in good faith, we can anticipate ways in which professionals could work together – as most currently try to do – in order to bring different perspectives to bear in such cases. For me, it has been more striking that there are many people who are not on the PTM authors’ exclusion list, but who certainly do feel excluded. Some people with diagnoses of bi-polar disorder and depression will not feel that the ‘Bad things happen’ narrative resonates with them at all, for example.
Many with problems related to alcohol or gambling will feel similarly. The consequences of exclusion include feeling that one is being blamed for one’s situation, or suffering from some form of ‘false consciousness,’ so it is a serious matter. If we treat PTM as a proposition, then we have to consider that the next iteration of this proposal will have to resolve this issue, and do so in a way which is less divisive.
What is it doing?
It’s anti-psychiatry.
Some of the authors may be. The document could be interpreted that way – it is long, and multi-authored, and sometimes contradictory. The underlying framework does not have to be anti-psychiatry.
It would be more accurate to say that is opposed to the use of a medical model (i.e. it rejects concepts such as illness, diagnosis, symptoms, treatments) in cases where problems can instead be understood in the terms preferred by the PTM: as meaningful responses to bad events or disempowering circumstances. The medical model is not unique to psychiatry; its concepts underpin some psychological, political and social approaches to some problems, too.
There is some fudging of this division of responsibility in the PMT, especially regarding the avoidance of a mind-body split. An up-to-date engagement with the embodied cognition literature would have undermined some of the over-simplification and supported a more coherent theoretical proposal.
However, the diagnostic framework is a taxonomy, and so the authors’ observations about the challenges of clustering problems by their regularities are fair. The PTM goes on to offer a taxonomy of its own, however, and inevitably this also clusters problems by (a different set of) regularities, and so we need a stronger formulation of the problem.
Whatever that formulation does, it must be sufficiently nuanced to recognise that not all diagnostic categories do the same things. Sometimes the taxonomy does only collate descriptions. It can also be loaded with explanatory knowledge about aetiology, but this is not always the case, because such knowledge is not always available. So the target is more complex than it appears here. Blogs by Vaughan Bell and Eiko Fried have covered these issues in more detail, if you wish to explore further.
It’s the alternative to diagnosis.
The PTM isn’t aiming to do all of the same things as diagnosis (e.g. it does not allow us to identify populations with common problems for the development of evidence-based interventions) – or vice versa.
It’s an explication of the theory that underpins formulation
A formulation can be used alongside or instead of a diagnosis, to inform a psychological intervention in a given case. The PTM does not offer a sufficient theoretical or evidential account of the causes or outcomes of the processes it describes, nor enough of a practical focus, to guide a specific formulation, on its own. Some of its ideas could be incorporated into a formulation process, however, and it does make suggestions about other existing tools and practices which could sit alongside it.
It’s evidence-based.
There is some fudging of this division of responsibility in the PMT, especially regarding the avoidance of a mind-body split. An up-to-date engagement with the embodied cognition literature would have undermined some of the over-simplification and supported a more coherent theoretical proposal.
However, the diagnostic framework is a taxonomy, and so the authors’ observations about the challenges of clustering problems by their regularities are fair. The PTM goes on to offer a taxonomy of its own, however, and inevitably this also clusters problems by (a different set of) regularities, and so we need a stronger formulation of the problem.
Whatever that formulation does, it must be sufficiently nuanced to recognise that not all diagnostic categories do the same things. Sometimes the taxonomy does only collate descriptions. It can also be loaded with explanatory knowledge about aetiology, but this is not always the case, because such knowledge is not always available. So the target is more complex than it appears here. Blogs by Vaughan Bell and Eiko Fried have covered these issues in more detail, if you wish to explore further.
It’s the alternative to diagnosis.
The PTM isn’t aiming to do all of the same things as diagnosis (e.g. it does not allow us to identify populations with common problems for the development of evidence-based interventions) – or vice versa.
It’s an explication of the theory that underpins formulation
A formulation can be used alongside or instead of a diagnosis, to inform a psychological intervention in a given case. The PTM does not offer a sufficient theoretical or evidential account of the causes or outcomes of the processes it describes, nor enough of a practical focus, to guide a specific formulation, on its own. Some of its ideas could be incorporated into a formulation process, however, and it does make suggestions about other existing tools and practices which could sit alongside it.
It’s evidence-based.
When we say that an approach is evidence-based, we usually mean that there is evidence that it works. It would be more appropriate to say that some claims in the PTM are evidence-derived, or evidence-inspired. This is dealt with in the recent Mental Elf blog on the topic. The evidence is particularly thin in Chapter 6, where PTM’s alternatives to diagnosis are proposed; it is difficult to understand why this has not been developed out of a review of the transdiagnosis literature, for example.
There is some evidence for some of its earlier tenets, but the quality of that evidence is not assessed, and the evidence for ‘using’ the PTM does not exist. It is not yet clear ‘how’ the PTM would be used, and therefore how any evidence might be gathered about its efficacy.
It’s a psychological theory.
When psychologists speak of theory, they generally mean something which is testable. The PTM proposes some explanations for distress. These are pitched at a grand scale, but do not cover all forms of psychological distress (especially those where power is less relevant, or where biology or physical trauma play a significant role alongside other factors).
It seems unlikely that the next iteration of this proposition can retain its high level of abstraction (which is presumably desirable precisely because it allows us to consider cross-cutting issues) whilst also acquiring more of the properties of a testable theory. I would guess that it is unlikely to evolve into a theory per se. This does not seem to be its purpose, but perhaps it could - and should - make some theoretical contributions in future iterations.
It’s an epistemological framework.
The PTM draws on a selective bricolage of epistemologies. By this I mean that it draws on quite a lot of different kinds of evidence. This is rare, and difficult to do, and – I think – a good thing. But the PTM isn’t proposing a specific way of thinking about what is knowable about psychological distress (or how to go about it knowing it), so it’s not an epistemological framework.
The PTM is selective, so it is worth noticing a few things about what it includes and what it does not. It does not often engage with evidence which does not fit with its main argument. It does draw quite heavily on social constructionist ideas about narrative and power, most of which entered psychology during the 1980s and 1990s. This allows it to give a strong account of how narratives become part of culture.
The document engages much more cautiously with phenomenology, which means that it only offers a very weak account of the relationship between culture and experience, or experience and wellbeing. A lot of exciting conceptual work which has been developed in the meantime is overlooked.
For example, for an approach which formulates mental health problems in terms of distress, it does not engage with major contemporary work on emotion (no Lisa Feldman Barrett; no enactive or embodied cognition theorists), which again means it is very limited in what it can offer – conceptually, theoretically and evidentially – to join up the dots between context and experience (i.e. between bad things happening and subsequent psychological distress).
It’s an ontological / ideological framework.
It’s an ontological / ideological framework.
This is what it looks like to me: a rhetorical ontological move. Theory with a capital T. We get Derrida, but not Ratcliffe; Deleuze, but not Bortolotti. We get all the cards thrown up in the air, rather than engagement with nuance and detail. I disagree with the criticism that the PTM is a failed explanatory account, because it does not really aim for explanation.
It engages with some explanatory material, but only insofar as that material supports its argument about changing the terms of the conversation about mental health. The PTM wants to re-define a subset of phenomena formerly known as ‘mental health problems’ as ‘understandable consequences of social inequality’.
Perhaps this explains the sometimes contradictory nature of the document. For interventions informed by Critical Theory, sometimes disruption may be more important than dialogue or precision. Sadly, in this case, the disruption is also a source of distress for some.
Can it be appraised on these ontological terms? If we can step back temporarily from the issues raised above, then the overarching message of Chapter 4 seems very useful, in that it foregrounds a psychological account of mental distress, without invoking the individual differences paradigm.
Can it be appraised on these ontological terms? If we can step back temporarily from the issues raised above, then the overarching message of Chapter 4 seems very useful, in that it foregrounds a psychological account of mental distress, without invoking the individual differences paradigm.
This isn’t the only lens which is useful to us for understanding threats to psychological wellbeing, but it is an important one. In terms of the explanatory companions to the ontological claim, social inequality and trauma do seem to have powerful negative consequences for wellbeing – but they don’t account for all cases of distress or dysfunction.
It seems to me that the main weaknesses of the document are in the transition to, and presentation of, the model itself, in Chapter 6. Partly this is because the choice to conceive of threat as always arising from an operation of power is an ideological one. It is poorly matched to the earlier commitments which the authors have made to providing a system which better reflects the experiences of people in distress, and/or in need of support.
It is reasonable to claim that most forms of distress arise from ‘threats’ only if threat is used in a less loaded sense, and can include say ‘incongruence’ (e.g. as a threatening state). If not, and threats must arise from inequity, then experiences such as compulsivity, phobia, dysmorphia, or elevated mood appear to be excluded.
At times, this looks like an error of abduction, rather than one of omission. The logical error (e.g. see p. 25) is the implication that, if the ‘most extreme kinds of distress’ (that’s an interesting formulation by the way, which might cause the authors some concern deployed in other contexts) can be understood in this way, then so can some of the ‘less extreme’ kinds. Setting aside the unfortunate and unintended implication of a distress hierarchy, there is no logical reason to believe that this would be the case.
Indeed some people in receipt of support from mental health services are not in distress – and here the social model of disability remains relevant– unless the support or adaptations they require are either not available, or are withdrawn. Power is certainly relevant for this example, but the underpinning narrative about the historical and social origins of distress? - less so.
Similarly, there may be distress, but it may not be experienced by the person using services - it might be surfacing elsewhere in the system around that person – for example, in the frustration felt by a parent, the loneliness felt by a sibling, or the hopelessness felt by a professional.
It is reasonable to claim that most forms of distress arise from ‘threats’ only if threat is used in a less loaded sense, and can include say ‘incongruence’ (e.g. as a threatening state). If not, and threats must arise from inequity, then experiences such as compulsivity, phobia, dysmorphia, or elevated mood appear to be excluded.
At times, this looks like an error of abduction, rather than one of omission. The logical error (e.g. see p. 25) is the implication that, if the ‘most extreme kinds of distress’ (that’s an interesting formulation by the way, which might cause the authors some concern deployed in other contexts) can be understood in this way, then so can some of the ‘less extreme’ kinds. Setting aside the unfortunate and unintended implication of a distress hierarchy, there is no logical reason to believe that this would be the case.
Indeed some people in receipt of support from mental health services are not in distress – and here the social model of disability remains relevant– unless the support or adaptations they require are either not available, or are withdrawn. Power is certainly relevant for this example, but the underpinning narrative about the historical and social origins of distress? - less so.
Similarly, there may be distress, but it may not be experienced by the person using services - it might be surfacing elsewhere in the system around that person – for example, in the frustration felt by a parent, the loneliness felt by a sibling, or the hopelessness felt by a professional.
I am unhappy with the way that conventional stories of causality deal with this (are we going to say that the service-user causes the carer’s distress? Surely not) and the alternative taxonomy proposed by the framework does not offer a significantly different alternative to those stories - yet.
One of the things that I like about the PTM is quite subtle, and perhaps indicates the way forward: ‘there is no assumption of pathology.’ I think this is helpful phrasing. It does not rule out the possibility of pathology, but also does not take it as it’s starting point.
Many people working within the diagnostic system will say that they do not take it as their starting point either, and we can – if we wish – take that in good faith too. But I think it is possible to see – and show – that the underpinning, systemic implementation of such practices often works the other way – creating a sense that pathology is likely to be implicated as a cause unless it can be ruled out.
This raises questions about what we mean by ‘pathology’, so I’ll add that for me it invokes the context of disease, and the idea of properties of the individual person (usually biological, and generally understood in mechanistic terms) which have ceased to function as they should.
As I’ve implied already, perhaps one of the problems we have, is that the psy professions’ language for conceptualising causality is impoverished. The PTM’s nods to emergence and process are encouraging, but they are tagged on. They need to be developed and integrated as the drivers of anything which is going to achieve what the PTM sets out to achieve. The core message here is laudable:
I like this, and the things that follow from it. It’s not new - Jaspers and Binswanger discussed this kind of thing – but it’s human, and it’s hopeful. On its own, however, it won’t do. It won’t suffice as an ontological account, or an explanatory one.
One of the things that I like about the PTM is quite subtle, and perhaps indicates the way forward: ‘there is no assumption of pathology.’ I think this is helpful phrasing. It does not rule out the possibility of pathology, but also does not take it as it’s starting point.
Many people working within the diagnostic system will say that they do not take it as their starting point either, and we can – if we wish – take that in good faith too. But I think it is possible to see – and show – that the underpinning, systemic implementation of such practices often works the other way – creating a sense that pathology is likely to be implicated as a cause unless it can be ruled out.
This raises questions about what we mean by ‘pathology’, so I’ll add that for me it invokes the context of disease, and the idea of properties of the individual person (usually biological, and generally understood in mechanistic terms) which have ceased to function as they should.
As I’ve implied already, perhaps one of the problems we have, is that the psy professions’ language for conceptualising causality is impoverished. The PTM’s nods to emergence and process are encouraging, but they are tagged on. They need to be developed and integrated as the drivers of anything which is going to achieve what the PTM sets out to achieve. The core message here is laudable:
I like this, and the things that follow from it. It’s not new - Jaspers and Binswanger discussed this kind of thing – but it’s human, and it’s hopeful. On its own, however, it won’t do. It won’t suffice as an ontological account, or an explanatory one.
For example, some people will be experiencing an abnormal reaction to normal circumstances. They will: I’ve seen this, and lived with the consequences in my own family. And both of these versions will hold true not only for some instances of distress, but also some instances of success. The young Winter Olympian who overslept and still won a medal was experiencing an abnormal reaction to normal circumstances. All of us oversleep occasionally. But if we are unlucky enough to do this on the dawn of an important test of skill and competence, few of us would expect to excel.
Further iterations of the PTM’s ontological propositions must be able to account for these sorts of phenomena, and include the people who experience them. Personally, I think that this means that the ideological components will have to give some ground to some better-developed theoretical (with a small t) and conceptual components.