Month: January 2018

First things first, I’m not a “Critical Psychiatrist” but I am a critical psychiatrist in the sense that as a psychiatrist I don’t just blindly accept assertions, I try and evaluate the evidence behind statements. For this Power Threat Meaning Framework (PTMF) I am focussing on the evidence for this suggested alternative for diagnosis (the authors seem to be inconsistent saying it is just a suggested conceptual alternative take it or leave it on social media but in the PTMF itself it suggests using diagnosis is unethical). I will look at the evidence for reliability and utility (usefulness) for clinical, research, administrative and social functions for this classification of mental health problems.

When I read the PTMF I only scanned the bits about diagnosis and biology, from the fragments I saw it seemed a highly selective and inaccurate interpretation of the evidence so to save my blood pressure I will move on from them.

Reliability of mental health classification is usually measured as how often clinicians/ researchers agree on the same way of classifying the same person’s problems. The PTMF repeatedly attacks the reliability of diagnosis whilst seeming ignorant that diagnosis is more reliable than psychological formulation-based classifications (but psychodynamic formulation has similar reliability to diagnosis). Disappointingly there is little information in PTMF about its’ reliability and no news about any research on its’ reliability to be published later. The authors have had 5 years which was ample time to have done some research on reliability e.g. providing vignettes (case descriptions) online and getting participants to formulate the cases using the PTMF and then comparing the similarity of responses. Without reliability data the usefulness of PTMF for lots of functions is badly impaired – how can we know that the problems classified in a particular way in the research would be the same way we would classify them in clinical practice.

The next issue is applicability to the problems people seek help with from services. The authors accept that some problems may not be suitable for the PTMF such as direct effects of brain diseases, short term effects of drugs or core features of autistic spectrum conditions. They may be used for other problems that may arise secondary to these problems, for example low mood caused by the effects of brain diseases on people. Unfortunately, the PTMF does not seem always applicable to all the other problems people present with. For example, it notes the links between trauma and psychosis (but minimises the importance of other factors that operate in conjunction with childhood trauma to produce psychosis) but does not mention that childhood trauma does not cause psychosis in 65% of people who present with psychotic symptoms or that not all clinical features of psychosis are associated with childhood trauma.

PTMF does seem useful for some problems that people have especially if power imbalances or trauma cause the problem. Unfortunately, because of the overselling of PTMF there is no information given as to what proportion of problems presenting to services are best dealt with using the PTMF. Apart from those problems listed as being excluded the authors gave me the impression that they felt the PTMF was the best solution for all problems. (People often have more than one problem and the same person may have some problems helped best with using PTMF and other problems dealt with better using other methods e.g. CBT or diagnosis/ medication). They are also so deeply wedded to their ideology that they recommend stopping specialised mental health teams like EIT. EIT is associated with better outcomes for patients like improved experience of care, improved access to therapy, improved social outcomes and reduced suicide. Better models of care are to be sacrificed on the altar of the authors’ ideology.

There is a lot of references and discussion of social factors and mental health. These clearly showed an association between social factors and mental health but they did not show a sufficiently strong relationship to prove the implied hypothesis that viewing problems through the PTMF is a sufficient and complete explanation of all the problems people present with i.e. other psychobiological factors are involved. Some are reasonably proven – such as the social nature of reason for high rates of people in UK Black communities meeting schizophrenia criteria or for childhood trauma and people meeting personality disorder criteria. There’s also an unfortunate suggestion that ADHD should be viewed primarily through the PTMF which is at odds with research evidence and what patients themselves report about their own understanding and experiences.

The feasibility of using the PTMF in short appointments (of 15-30 minutes) or in emergency work including overnight when time / cognitive resources are under pressure and many issues such as risk or excluding medical causes of problems is limited. The constructs used have little predictive information for outcomes or choosing treatments such as medication (though research in the future may change this). For medication the PTMF uses the misleading “disease centred” vs “drug centred” model whereas most psychiatrists in my experience do not think the medication is reversing a disease process but has research evidence of reducing symptoms or other improvement in outcomes. There is a strange order of questions in the PTMF (asking the person’s story last after 4 questions trying to frame the person’s problems in terms of the PTMF when surely asking the person’s story first would make more sense).

The PTMF avoids drawing thresholds as part of its philosophy of trying to avoid putting people in boxes and separating problems as different from everyday experiences and responses. Unfortunately, this is a problem as one of functions of classification is to establish the problem as sufficiently severe to justify something- such as access to a service, or exemption from sanction or eligibility for benefits. Now this is often combined with other dimensional measures such as for example levels of impairment but being classified as for example having a psychiatric diagnosis makes it more likely to other people that you will meet criteria for these advantages. A diagnosis of agoraphobia makes it more likely to not be able to leave the house unaccompanied and subsequent social impairment.

The suggestions for using PTMF for administration, statistics, legal purposes or accessing benefits are ill-thought out and often do not use PTMF itself to fulfil the roles. Third-party payment health systems such as the NHS (or insurance-based models) require administrative data from healthcare providers to provide a justification for funding them. PTMF suggests using broad activity and severity data (not part of PTMF) but administrative data also requires information on nature of presenting problem that PTMF doesn’t provide. Diagnostic codes may not always provide a lot of differential information (but if somebody’s only diagnosis was mixed anxiety and depression it seems unlikely third-parties would pay for 2 years of expensive inpatient secure rehabilitation for instance). Diagnostic codes are already used by the rest of the NHS for the rest of health and diagnostic codes would still be needed in mental health for conditions PTMF admits it’s not suitable for e.g. Alzheimer’s disease or drug intoxication. We could try and have two different systems in mental health but this seems an unnecessary transaction cost and added complication for most mental health services. Similarly, for statistics why have separate systems for collection of data -and PTMF is unable to provide such data anyway relying on alternatives.

As for legal purposes, courts are likely to prefer diagnostic constructs with in-built thresholds with evidence of association with outcomes they are interested in as well as some dimensional assessments. Schizophrenia is more likely to be associated with fitness to plead problems than mild depression. Psychopathy / antisocial personality disorder is more likely to be associated with re-offending and being hard to predict offending than panic disorder. Of course, other assessments help but the legal system is geared towards making categorical judgements which fit well with diagnostic constructs.

The most challenging section for PMF is access to welfare benefits. People with mental health conditions often suffer long-lasting or temporary but recurrent impairments that make it hard for them to work. Benefits/ welfare agencies are under pressure not to pay out benefits. For claimants to overcome this resistance they need to prove their functional impairment. Now of course as PTMF says there needs to be statements of degrees of impairment even with a diagnosis. But a diagnosis has research evidence of association with degrees of impairment – see the example of agoraphobia mentioned earlier – thus helping to validate professional’s statements of degrees of impairment. Diagnosis also fits in with how the benefits agency assesses impairments in the rest of health. A diagnosis from a professional plus statement of degrees of impairment help the benefits applicant prove to the sceptical benefits officer of entitlement to claim. The PTMF provides no adequate replacement and risks people being denied benefits they are entitled to and suffering severe financial hardship.

There are some frankly awful suggestions in PTMF about disagreeing with diagnosis on benefits applications forms or saying people have recovered when applying for benefits. The suggestions on changing the benefits system ignores applicants need to deal with the system as it is now. As for Universal Benefit Income, this is unlikely to be provided at a level that is necessary for people with health conditions who often need more money than the average person. For example, people may need to pay for taxis rather than walk or take the bus because they are too anxious to do so or need to pay for cleaning as they lack the energy or motivation to do so because of their health condition.

In short, whilst PTMF offers a useful technique for helping some problems that present to mental health services it is not useful as a classification for administration, statistics, research (but can be researched as a technique), legal purposes or access to benefits. It is not a practical system for short appointments or emergency work. It is not a replacement for diagnosis for many of its’ functions.

This is covered by a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License

Power Threat Meaning Threat Power Power Power!

By Scheherazade

2018 has started with a bang. Well, at least within the small islands of UK’s mental health activism. On Twitter, Facebook and other social media forums, discussions are going on about another ‘paradigm shifting’ publication from the Division of Clinical Psychology of the British Psychological Society in the UK: The Power Threat Meaning Framework. Scheherazade was among the crowd that gathered at Friends House, Euston, on 12th January to listen to the speakers at the launch. We were given a 141-page ‘overview’ document. A 400+ page full document was published on Monday 15th January. Scheherazade has not yet read this document, but promise to do so in the next 1001 nights.

For now, here’s the story of the launch.

Something old, something new?

At the launch, the Power Threat Meaning Framework (PTMF) was presented as a ‘new’ way of thinking about why people experience distress and as an ‘alternative’ to psychiatric diagnosis. We were told that it is for ‘all of us’, not just for those who are caught up in the mental health or criminal justice systems. It is even for those ‘non-western’ countries and their ‘culturally-specific’ understandings of distress which are now under threat by the export of western diagnostic models (No need to get really bogged down by the history and legacy of colonial psychiatry and psychology because that was so long ago, right?!).

There is much in the framework that was presented that Scheherazade agrees with. Much of it is a collation of what has already been researched, evidenced and campaigned for over the last several decades by user/survivor groups, critical psychiatrists (yes, them too) and critical psychologists, feminists, community development campaigners, philosophers, literary critics and cultural theoreticians. The operation of power in what is considered ‘normal’ and ‘pathological’ in societies; in how these are defined and managed; in how the psy-disciplines, mental health and related social care services function; in political, social and economic responses to those considered mad or mentally ill; in notions of care and caring communities—all these have been central to discussions about how we understand and work with madness and distress.

The role of power in how people respond to ‘problems of living’ such as capitalism, patriarchy, racism, white supremacy, cis-gendered (hetero)sexism, ableism etc. and their impact on people including exclusion, discrimination, being confined within state institutions, being forced or coerced into treatment, being subjected to social engineering and Eugenics, being left to rot and die in rich countries boasting of welfare systems—all these and more have been part of many campaigns worldwide and many efforts to change the way we treat vulnerable people in our communities.

But terming problems of living and how people respond to them as ‘threats’ and ‘threat responses’ was new to Scheherazade. To Scheherazade’s non-psy-disciplined mind, it sounded like a somewhat contrived psychologisation of the way power impacts on people’s lives and how they react to it. So, Scheherazade wondered: Psychiatrists routinely defined people’s responses to problems of living as symptoms of illness. Were psychologists now proclaiming (not for the first time but louder than usual, perhaps) that they should have more rights to formulate them in their own languages and within their discourses? How is that going to help anyone who is actually caught in these factional politics for the right to define and manage other people’s distress?   

Mirror, mirror on the wall

Ideological power, we were told, was the most important functioning of power because it is the least visible and least acknowledged and is part of every other form of power. Most importantly, it is central to the experience of invalidation. Scheherazade agreed wholeheartedly and waited for some acknowledgement of the ways in which ideological power operated within psychology. Surely when embarking upon such a momentous journey of changing the narrative, there will be some form of self-reflection involved?

Nope. Not once was the operation of ideological power in psychology as a discipline or as a knowledge system addressed or even acknowledged. (The launch of PTMF happened two days after the controversy around the Eugenics conference at UCL). Or its functioning as part of the machinery tasked with managing distress and distressed/disabled people (for example, in workfare coercion in the UK). There was no examination of how the professional and ideological power of psychology might operate in therapeutic settings. A question from the audience about ‘how we might get our own house in order’ was met with a ‘come and join us’ comment. Does this mean that the disempowering aspects of psychology as a discipline, knowledge base and practice could be fixed by a ‘few good (wo)men’ approach rather than any considered thought about structural, institutional and political power? A further question from the audience asked precisely that: What sort of structural and institutional changes would be needed to put this framework into practice? This was answered by one of the co-authors by narrating an inane anecdote about how he faced off a critic on Twitter by saying ‘yes, we want to change the world’.

Meanwhile, as the day progressed, concepts such as ‘learned helplessness’, ‘self-stigma’, ‘apathy’ etc. kept being repeated, niggling like bone fragments in a perfectly spiced shami kebab. These are powerful psychological concepts, as harmful to the person to whom these are attributed as the psychiatric language of symptoms—as individualising, invalidating and disempowering. Decades of scholarship from psychiatric survivors and others about the harmful effects of such formulations exist, especially in the context of self-harm, eating difficulties, ‘personality disorders’, depression, ‘schizophrenia’… Scheherazade was confused why psychology presented itself as the fairest of them all when it was clear that they hadn’t even looked in the mirror! What was the point if, despite exhorting to connect the social, cultural, ideological and individual contexts together, ‘sick’ is to be replaced with ‘sick role’ and symptom talk with behaviour talk?  
It was time to hear about the framework’s practical application.

Hunger games (with fishing nets)

Social justice, we were told, was the corner stone of the PTMF, although no social justice groups were involved in its production. A social work expert showed us slides about red herrings and fishing nets—all very symbolic about social care policies and human rights, apparently—and asked us: “Do we want a system where people have to demonstrate how much they are suffering in order to be objects of charity who can then receive their basic rights?” Of course not, Scheherazade agreed fervently with everyone else in the room until she realised that the ‘charity’ referred to was really the basic minimum support and care that any self-respecting welfare state should provide for its vulnerable people—you know, things like affordable housing, disability support, the means to eat and to look after your family, not to be coerced into unsuitable and harmful work, not to die in the process of trying to stay alive, not to be killed by the recovery industry.

So having set up social security as charity, the expert went on to show us how the PTMF can help. We were told that current social policies do not specify diagnostic categories in order to be eligible for social support. They only talk about impairment, disability, health condition etc. that restrict a person from achieving outcomes that impact on wellbeing or impact on their daily living. So, all we have to do is to prove impairment, disability or adverse health condition by using the new constructs—for example, “experiencing temporary and enduring or regularly occurring severe mental distress.” And hey presto, we have a non-biomedical, completely fair system, what Cormac Russell called “communities of hospitality that have a genuine place of welcome for the people who’ve been pushed farthest to the edge…” Yeah, right! Now Scheherazade got the red herring connection!

Even those who (like Scheherazade) vehemently critique biomedical constructs and diagnostic labels are agreed that, as long as social care and welfare policies are punitive, coercive and life-threatening, simply removing diagnostic labels and practices will not be effective in saving lives and ensuring the basic human and civil rights of the people in need of support. In Scheherazade’s humble opinion, it was imperative to involve those who have been campaigning for a very long time about social policies and welfare issues (for example, the MHRN, DPAC, BARAC) as well as experts on welfare rights who actively work with people trying to negotiate these social policies in real time. It would have shown the authors the reality of the nightmarish world of evidencing impairment, disability and/or health condition to the DWP’s satisfaction. It could have helped them avoid the embarrassing and, frankly, harmful flippancy shown at the launch about how the system currently treats those who try to seek support from the state that is legitimately theirs to seek.

Who is afraid of the survivor movement?

That brings us nicely to the much-anticipated reveal of service user involvement in the process that led to the PTMF document. Admittedly, there are two survivors amongst the self-confessed ‘charismatic originators’ of the PTMF, and another one who, like Lindsey Lohan’s ‘poorist’ trip to Delhi, had ‘experienced’ the effects of anti-psychotic medication in a well-publicised stunt and randomly claims such expertise. Who else had been consulted? Apparently, a sum total of eight service users, in the course of five years.

What intrigued Scheherazade was the specific mention that the service users involved “were not mental health activists or campaigners.” And, the speaker—herself a celebrated survivor—hastened to add, although they were “not exposed to critical perspectives in detail,” they were “brilliant and intelligent people.” Scheherazade will leave you to ponder the inherent sanism in that declaration, but let’s examine why, in a process of service user involvement, not being mental health activists or campaigners is considered a positive requirement. Is it because activists and campaigners would be ‘biased’? If so, why is this only a problem for service users and not the professionals involved who, it could be argued, have more to gain from winning the turf war between psychiatry and psychology? Given that there were only eight people involved, would it not have been more useful to ensure that those consulted were well-placed to represent the diverse voices of service user communities that the framework would affect, especially those people affected by the current welfare and benefits system and social exclusion perpetrated by white privilege?  

The unbearable whiteness of paradigm shifting

Scheherazade was aware that this was the second publication from the DCP in the last five years that claimed to shift the paradigm. The previous one, Understanding Psychosis, published in 2014 also made an effort to collate some critiques of bio-medical models. It was, however, criticised for its racist language and for its failure to involve people from racialised groups and engage with their scholarship. A public apology was issued and a revised version was published last year. Lessons were learned, it seemed.

Here was another paradigm shifting happening, the work of which was apparently going on while conversations between the critics of the previous report and its authors were taking place. Some of the authors of that report who facilitated the conversation with its critics are co-authors of this report too. And yet, here we are, another DCP funded project with not one person of colour in the author group.

There were some people of colour in the audience—think how much black pepper Delia Smith recommends for a vat of white sauce, you’ll get an idea. White people display ‘social/cultural capital’ (defined in the PTMF as ‘a mix of values, qualifications, knowledge and connections which ease people’s way through life and can be passed indirectly to the next generation…’) through self-selection and unreflexively excluding persons of colour. This leads to ‘ideological power’ (defined in the PTMF as ‘control of language, meaning and perspective’) which allows for unexamined threatening behaviour. When white people are in self-congratulatory mode and secure in their self-made context of power, they tend to make jokes—jokes that the unsuspecting random person of colour who happens to be in the vicinity experiences as ‘threats’. For example, white people make ‘boss/slave’ jokes and think they are hilarious. Scheherazade knew all of this and yet when the joke came along, it was no less threatening. A big ‘what’s-she-like-haha’ deal was made of how bossy one of the authors was and how another author was her personal slave, to the appreciative laughter and applause from the white audience. And when it was time for Q&A, she invited the previous speakers to the stage by pointing to them (all white, of course) and saying: “This slave, this slave, that slave and that slave, come on to the stage.”

And when the tentative effort to address the issue of whiteness in one of the breakout groups met with resistance, Scheherazade knew that some paradigms are never to be shifted. Threat responses: Anger, giving up (aka ‘learned helplessness’), some more anger, and a pint of vodka.

Saludos!

About Scheherazade: Scheherazade (Sherzad to close friends) was born all over Asia, some parts of Africa and in Disneyland. Her threat responses have been formulated as talkativeness, manipulation, deception and a propensity to invent stories. Her life’s work has been plagiarised in all kinds of languages. She currently resides in Catherine Zeta-Jones, Sulaf Fawakherji, Maria Montez and several other bodies.