Our current system of understanding mental health is typically based around psychiatric diagnosis. You go to your doctor and your doctor gives you a label like “social anxiety disorder” or “borderline personality disorder”. These labels are, on the whole, stigmatising and unhelpful.
Worse, they are not grounded in evidence-based medicine. After a hundred years of lookng, we cannot find the biomarkers for mental illness. Depressed people do not have lower serotonin, for example. Nor are there genetic markers. As far as we can tell (and research has been well-funded and plentiful), mental health issues are not an “illness” in the traditional medical sense.
So then we say “okay but they are functional”. Something happens to someone which activates underlying vulnerabilities and they develop social anxiety. But this does not hold up, either. There are no clear pathways of things that trigger specific labels (the everything causes everything problem) and the majority of service users meet the criteria for multiple labels (the everyone suffers from everything problem).
As a result, we don’t know what causes any of these labels (no biomarkers or pathways), what they look like (people’s symptoms transcend multiple labels) or what to do about it: most first line treatments like anti-depressants or single-diagnostic CBT seems to make things worse.
Much of psychology already recognises this problem and has suggested dropping the word “disorder” and changing the question from “what is wrong with you?” to “what has happened to you?” Trauma-informed approaches are opening up a much greater scope for what counts as trauma.
The Power Threat Meaning Framework goes beyond that. It asks how power been used in someone’s life (think oppression), what threat that created, what meaning the person made of it and what threat responses were activated. It suggests that all troubling experiences and behaviour, from mild anxiety and depression, to hearing voices, self-harm and eating disorders, can be understood from this perspective.
It also suggests that all behaviour is on a continuum, from “normal” to “clinical”. This is important because while some critics might agree mild anxiety is part of normal human experience, they often bawk at the idea that hearing voices or dissociation is typical. Even though most people regularly “zone out” (dissociate) on a regular basis.
The PTM Framework offers what it calls a general foundational pattern and seven provisional general patterns. These allow us to explore useful patterns without detracting from an individual’s personal narrative.
- Identities
- Surviving rejection, entrapment, and invalidation
- Surviving disrupted attachments and adversities in care
- Surviving separation and identity confusion
- Surviving defeat, entrapment, disconnection and loss
- Surviving social exclusion, shame, and coercive power
- Surviving single threats
The PTM Framework is a contribution to the movement away from psychiatric diagnosis which still has much work to do, and the document acknowledges this.
But we are already seeing improvements. Many services, such as educational support and some NHS mental health services, look at individual need rather than labels and many have switched away from using disorder-specific measures to general outcome measures.
I don’t claim to have done justice to this document in any way in this blog post. You should go read it; it’s fantastic, if quite a technical read.
