The Power Threat Meaning Framework

[Ashley]

The Power Threat Meaning Framework document was published earlier this year, which was described as an alternative to traditional diagnosis, developed and led by a group of senior psychologists funded by the British Psychological Society’s Division of Clinical Psychology.

Click the link to read the full Power Threat Meaning Framework or a shorter overview.

The following blog was written by GIngerbreadgirl for OCD-UK.

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It is said that the average OCD sufferer waits seven years before reaching out for help. That help can come in many forms - whether speaking to a GP, a close friend, or someone at a charity like OCD-UK.  For many people, reaching out for help can be terrifying – intrusive thoughts can leave you feeling exhausted, isolated, even like you’re going mad. 

For me, finding out about OCD, learning that it is an explanation for so many of my experiences, and finally receiving a formal diagnosis, have been crucial in me getting to grips with my illness and understanding it.  Equally crucially, it has given me a useful shorthand for explaining to those closest to me why I experience such bizarre thoughts and behaviours - knowing I have a recognisable disorder has been so important to me.

I therefore find it slightly concerning that recently the proposed 'Power Threat Meaning Framework' proposes a move away from the use of diagnosis for mental health conditions, including OCD.  There is a significant group within the clinical psychology community who believe that such diagnoses are stigmatising and remove flexibility and individual context within treatment. They believe that such diagnoses being on a person's record can cause issues and prejudice later in life, and even that psychiatric conditions don't really exist and are simply part of a person's complex life circumstances. Most significantly, some (not all) of those who argue this case believe in it even if the client personally values having a diagnosis.

As I am not a healthcare professional, I don't know all the ins and outs of the current debate.  I also can't speak on behalf of sufferers of other types of mental health conditions, or even other OCD sufferers.

I agree with some aspects of this - such as the importance of seeing everyone as an individual rather than just a diagnosis, the importance of not being defined by a diagnosis, and the value of individual choice not to have a diagnosis.  However, I think it is extremely important for those who value diagnosis, and have even found it life-saving, to have this view respected. 

OCD is a unique condition with a specific type of treatment.  Knowledge of the condition is variable even among healthcare professionals.  Having a diagnosis of OCD allows an individual to have more confidence that they are accessing the right type of treatment (CBT) rather than relying on the therapist or psychologist to treat correctly in the absence of a diagnosis. 

Also, I believe it is more than possible for diagnosis to be used in conjunction with a more personal formulation. Indeed I believe it is essential that the patient's individual circumstances, personality, values, co-morbidities etc. are considered in conjunction with a diagnosis.  But this does not in my opinion mean diagnoses are harmful or somehow preclude this kind of personal treatment.

I think this debate will go on and it is unlikely for diagnosis to be removed from psychological treatment altogether, at least not any time soon.  I do believe though that is a concerning direction for clinical psychology to take as a profession, and the views of service users should be very carefully considered. 

I know I would be lost without having a name to put to my experience.  I have found information, other sufferers to connect with, and a way of dealing with my thoughts – all through stumbling on the OCD-UK website.  I would never have found this website and support without the label ‘OCD’, it has been life-changing.

- by Gingerbreadgirl.

 

 

The OCD-UK Comment

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OCD-UK Comment: We support the views shared by Gingerbreadgirl, which appear to be generally mirrored by those with OCD who have commenting on the proposed Power Threat Meaning Framework document.

We remain disappointed how some of the authors and health professional supporters of the proposed framework have routinely dismissed the views and concerns of those with lived experience of OCD since its publication.

OCD-UK would like to see far greater dialogue and consultation with a greater number of health professionals and most importantly to see the views and feelings of those with lived experience of all types of mental health problems, including those with OCD both heard and respected with future framework consultation

 

 

[gingerbreadgirl]

Thanks Ashley, I just hope they listen to all service users and not just those who agree with them.

[Ashley]

6 minutes ago, gingerbreadgirl said:

Thanks Ashley, I just hope they listen to all service users and not just those who agree with them.

Agreed, but there's also a large number of health professionals who are totally against this, their opinion is also being dismissed somewhat too. 

My personal view is that whilst I disagree with what they propose, there is some benefit to discussing and debating to improve things for us all, but the way they have steamrolled this out and been so dismissive any dissenting voices is beyond acceptable.

[snowbear]

I've just finished reading the overview document - phew! It's going to take me several more hours to go through it in detail (and that's only the shorter version  ) But I'll share my initial thoughts and understanding:

1. To see this document as a simple bid to take away diagnostic labels is to miss the point entirely. Unfortunately I suspect the general public will reduce it to an argument over that, but hopefully this important piece of work will not get derailed by some ill-informed Twitter debate.  

2. The proposed framework has been well-thought out, well-researched and is based on evidence across multiple agencies. If implemented it could have far-reaching, beneficial effects for those subject to the current mental health system, social welfare system, and the criminal justice system. 

3. The PTM framework has the same approach already in use across other agencies working in Gender-based violence, Complex Trauma, Youth and Adolescent Resilience etc. It's not as radical as it first appears, but actually very familiar best practice which is now attempting to address mental health. 

4. The document calls for a radical overhaul of ingrained establishment thinking, so is likely to be (at least initially) opposed and rejected by society at every level. In particular by those who feel they have most to lose - medical practitioners.  (I see it as similar to trying to get someone with OCD to understand full recovery requires a complete rethink of the way they've hitherto interpreted their thoughts. They get there eventually, once greater understanding has been gained.) 

I'm going to plough through the full document at the weekend, but my take away message to comfort those in fear of losing their diagnosis is this:

Which of these alternatives describes you best? Which helps you make sense of your situation? Which one makes you feel understood, that help is on the way and recovery/improvement is possible?

EITHER A. Described by any combination of general patterns from the list -

1. Identities 2. Surviving rejection, entrapment, and invalidation 3. Surviving disrupted attachments and adversities as a child/young person 4. Surviving separation and identity confusion 5. Surviving defeat, entrapment, disconnection and loss 6. Surviving social exclusion, shame, and coercive power 7. Surviving single threats

OR B. Described by a diagnosis of OCD - plus or minus co-morbid diagnoses which may include - 

depression, personality disorder, schiziphreniform thoughts, paranoia, phobia, depersonalisation, general anxiety disorder, body dysmorphic disorder, somatic disorder, PTSD, adjustment disorder...

 

This document is challenging us to think differently.

It dares us to move away from the traditional view of people with symptoms of mental illness as abnormal, defective or 'ill' as the result of some biological/physical or social defect (a view which leads to stigmatisation, marginalisation and reduced belief in the possibility of recovery by the sufferer.)

It says the symptoms can instead be seen in terms of the sufferer making sense of their experiences and adapting their behaviour (and biology) to cope with the challenges posed by the social, cultural and environmental circumstances they live through. This view removes the blame/shame/guilt thinking from the equation. 

Those behind it give creditable examples of how the shift in thinking is already working well in other areas and they accept this is a framework for re-evaluation rather than a direct substitution of the present system. Far from steam-rolling anything out they openly invite suggestions on how to implement this on a practical level.

[Ashley]

1 hour ago, snowbear said:

Which of these alternatives describes you best? Which helps you make sense of your situation? Which one makes you feel understood, that help is on the way and recovery/improvement is possible?

EITHER A. Described by any combination of general patterns from the list -

1. Identities 2. Surviving rejection, entrapment, and invalidation 3. Surviving disrupted attachments and adversities as a child/young person 4. Surviving separation and identity confusion 5. Surviving defeat, entrapment, disconnection and loss 6. Surviving social exclusion, shame, and coercive power 7. Surviving single threats

OR B. Described by a diagnosis of OCD - plus or minus co-morbid diagnoses which may include - 

A means nothing to me at all. B generally makes it clear what my problem is.

Maybe I'm misunderstanding you but are you suggesting we should be open  to accepting option A? 

[snowbear]

8 minutes ago, Ashley said:

A means nothing to me at all. B generally makes it clear what my problem is.

Maybe I'm misunderstanding you but are you suggesting we should be open  to accepting option A? 

Yes, I'm suggesting we should be open to it.  

I'm kicking myself for putting the bit you quoted in my reply because I've done the very thing I accused Twitter-followers of doing and reduced a very powerful document down to a pointless argument over labels.  

Option A will make sense to those who've read the document fully, but I agree that out of context it probably does seem meaningless. But remember 'B' only means something to you because it falls within the framework you're familiar with using (the medical model of OCD as an illness.) 

Ignore my attempt to put it into simple terms. Focus on the first part, points 1-4 which summarise what the document is actually about (which isn't a narrow-minded mission to remove diagnostic labels.)

[snowbear]

By the way, II agree with everything GBG said in her blog too. She's not wrong. The diagnostic label is important  as things stand  - because it's all we have. To take that away without putting a viable alternative in its place that addresses the need to access correct therapy, claim benefits, gain the legal position that 'illness' has in the workplace (and more... ) would be a disaster.

However, this framework isn't suggesting we just scrap labels and leave sufferers to flounder. Far from it. It aims to improve the appropriateness of treatment, destigmatize the symptoms, empower sufferers AND reform society, modernise cultural values and shake up the current health, welfare, education, and criminal systems to reduce the incidence of future mental health problems. No small aim! Happily not impossible either, though it won't be easy or fast. 

[Ashley]

On ‎22‎/‎03‎/‎2018 at 23:47, snowbear said:

However, this framework isn't suggesting we just scrap labels and leave sufferers to flounder.

The way one of the authors appear to be critical at a psychologist who opened up about his own bipolar (I think it was) for using that label leaves me sceptical about motives. 

[snowbear]

Precisely why I maintain that informed discussion and reasoned debate cannot take place on social media.  

I fear it will be reduced to a slinging match between those who want to reform society to prevent, and better treat, mental illness (PTM framework supporters) and those who want to keep things as they are with poverty, mental health, criminality, social disadvantage, disability and prejudice all segregated off under one umbrella as the fault of the sufferer and therefore not a problem society needs to take responsibility for or solve. (The unwitting supporters of keeping diagnostic labelling, who innocently and in good faith believe that's the only principle they've been asked to stand behind. ) 

People who would support the principles of this document fully will think they stand in the opposite camp and fight it because the debate will be conducted in soundbites that lose the context and the bigger (more important) picture. 

Look how easily I made that mistake, trying to 'soundbite' the content. Right after digesting the full document and all it's beneficial implications. Why? Because I was trying to simplify it into a few words that a small target audience (this forum) would relate to instead of sticking with the bigger picture of major social reform and getting the whole of society to listen. If an amateur like me can get drawn into the smaller irrelevancies so easily, what hope do the authors have of trying to educate the public on what the framework is really about - especially when limited to 140 characters a time?

Complex ideas cannot be conveyed via Twitter. 

[Ashley]

This is perhaps why your point is happening snowbear. 

12 minutes ago, snowbear said:

Precisely why I maintain that informed discussion and reasoned debate cannot take place on social media.

This was launched without any opportunity for peer discussion so in essence social media is the only real outlet open from what I can tell. 

Much of that comment, questioning and discussion seems to be routinely dismissed on social media, unless the view is supportive.

12 minutes ago, snowbear said:

Look how easily I made that mistake, trying to 'soundbite' the content. Right after digesting the full document and all it's beneficial implications.

I get that, but I had read much of the document and not sure even knowing more of the context I'm sold personally. 

 

[snowbear]

8 minutes ago, Ashley said:

I had read much of the document and not sure even knowing more of the context I'm sold personally. 

Fair enough. So let's get the community to name any concerns they have and get them out there on the table for open discussion.  

Maybe you could lead us in the debate, Ashley, by voicing your reservations and why you're not sold on it? (If you want.) 

[snowbear]

21 minutes ago, Ashley said:

This was launched without any opportunity for peer discussion so in essence social media is the only real outlet open from what I can tell. 

Not sure what you mean 'no opportunity for peer discussion'. Peer discussion starts after a paper has been published, ideally within the establishment but increasingly in the modern era the discussions take place on other platforms too. Society and the scientific community jointly need to learn how to respond to the problems that creates. Clearly one problem it creates is it reduces people to either agreeing with or dismissing out of hand whatever point is being made. Neither response is helpful in furthering debate.  

[gingerbreadgirl]

Hi Snowbear,

It's really interesting hearing your incredibly well-informed take on the document.

I must admit my blog wasn't really about the document per se (which I have only read select, out-of-context parts of) but the discussion taking place around it.  I am sure that the authors of the PTMF understand the nuanced nature of this debate.  However - there are many advocates of the document (professionals) who would like diagnosis to be taken off the table right now, with scant regard for how this would make sufferers feel. My blog is more about this section of the clinical psychology profession than the document itself.  There are practising clinical psychologists who refuse to give, honour or acknowledge a mental health diagnosis, no matter how the service user feels about that.  This is not simply a matter of being misunderstood on social media, but a clearly and passionately stated opinion.  I find this very concerning. 

[Ashley]

8 hours ago, snowbear said:

Maybe you could lead us in the debate, Ashley, by voicing your reservations and why you're not sold on it? (If you want.) 

I will take it as my holiday reading over Easter to go through it again

[Gemma7]

I do think that how people understand mental health issues needs to change. 

I think i understand the ideas behind the framework but i have some issues. Firstly, I've read lots about different therapies and theories and find that a lot of what they suggest is already put in place. I haven't read many psychological papers talking in biomedical terms for instance and they regularly talk about problems coming from how people have coped. In Break free it talks about explanations for behaviours coming from previously held beliefs and behaviours. 

Secondly, the power, threat stuff, i know that there is correlation between adversity and mental health problems but causation is still not understood. If you take someone's power, threat, meaning, you are making a lot of assumptions about how someone's problem has occurred that hasn't been shown. This is concerning in that it isn't evidence based. Now i know they mention that it's just a theory that gets tested but doesn't it have implications?

For example, if a child comes showing signs of OCD and they talk in terms of experiencing adversity, couldn't this potentially cause problems for the child, if some of the adversity they are experiencing is say parental emotional abuse? Would the child open up to that? (It's important to remember that you can break the OCD cycle without addressing why you started it.) Couldn't this approach lead to stigma being shifted rather than removed? I suppose they could adapt the therapy for the family but it could also result in people not coming back for therapy.

Also, why are they not starting with changing society's way of thinking about mental health first. Put the diagnosis argument aside until attitudes have changed. Once they have then diagnoses and language can be adapted accordingly. 

[gingerbreadgirl]

4 hours ago, Gemma7 said:

I do think that how people understand mental health issues needs to change. 

I think i understand the ideas behind the framework but i have some issues. Firstly, I've read lots about different therapies and theories and find that a lot of what they suggest is already put in place. I haven't read many psychological papers talking in biomedical terms for instance and they regularly talk about problems coming from how people have coped. In Break free it talks about explanations for behaviours coming from previously held beliefs and behaviours. 

Secondly, the power, threat stuff, i know that there is correlation between adversity and mental health problems but causation is still not understood. If you take someone's power, threat, meaning, you are making a lot of assumptions about how someone's problem has occurred that hasn't been shown. This is concerning in that it isn't evidence based. Now i know they mention that it's just a theory that gets tested but doesn't it have implications?

For example, if a child comes showing signs of OCD and they talk in terms of experiencing adversity, couldn't this potentially cause problems for the child, if some of the adversity they are experiencing is say parental emotional abuse? Would the child open up to that? (It's important to remember that you can break the OCD cycle without addressing why you started it.) Couldn't this approach lead to stigma being shifted rather than removed? I suppose they could adapt the therapy for the family but it could also result in people not coming back for therapy.

Also, why are they not starting with changing society's way of thinking about mental health first. Put the diagnosis argument aside until attitudes have changed. Once they have then diagnoses and language can be adapted accordingly. 

all really good points Gemma.

[snowbear]

On 23/03/2018 at 13:34, Gemma7 said:

I do think that how people understand mental health issues needs to change. 

Totally agree. Trying to find an alternative framework for OCD other than the medical model has been discussed on the forum before, but it's proved a difficult stumbling block because proposed alternatives never fit well with established systems like claiming benefits and employment rights. I think it's quite daring and adventurous for the Psychological Society to even attempt to introduce this. I applaud them for taking a first step towards awakening the need for social reforms that have been long overdue. Framing issues are a problem not just in mental health, but in social welfare, criminal justice and for reaching gender, race and sexuality equality too. Society is going to have to grasp this particular nettle sooner or later and I see this as an opportunity for mental health to be central to the changes instead of the usual lagging behind. 

On 23/03/2018 at 13:34, Gemma7 said:

I've read lots about different therapies and theories and find that a lot of what they suggest is already put in place. I haven't read many psychological papers talking in biomedical terms for instance and they regularly talk about problems coming from how people have coped. In Break free it talks about explanations for behaviours coming from previously held beliefs and behaviours.

The principles of power/threat/meaning are indeed well established and already applied to a number of areas including OCD books, even if it's more loosely worded in the books.  

On 23/03/2018 at 13:34, Gemma7 said:

i know that there is correlation between adversity and mental health problems but causation is still not understood. If you take someone's power, threat, meaning, you are making a lot of assumptions about how someone's problem has occurred that hasn't been shown. This is concerning in that it isn't evidence based. Now i know they mention that it's just a theory that gets tested but doesn't it have implications?

I'll address the two bits I've put in bold in a minute, but first:

The general link between adversity, trauma and mental health problems is well established by decades of research dating back to the 1960s. There's also now a considerable amount of evidence showing adversity and trauma directly effects childhood brain development, causing anatomical changes which in turn are associated with a variety of mental health issues presenting later in life.

I like this NSPCC video for an artistic summary of how this works. Building better brains    Maybe you can see how it correlates with power/threat/meaning?

This is taken from Part 2 of the overview document (Conclusions from the literature on the roles of social context and biology)...

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the general causal links between adversity and distress are indisputable. However, claims to have identified pathways between specific traumatic events and specific kinds of distress have very weak support, as would be predicted by the principles underpinning our proposed framework.

The current medical model of emotional distress as an illness leans towards a conclusion (assumption) that a specific 'trigger' or event causes (results in) a specific mental health issue, despite the lack of proof.

The PTM framework suggests an outcome of emotional distress needs to be viewed in a much broader context, taking into consideration the hidden factors which contribute, many of which are social and cultural and beyond any individual person's control.  (And start before birth and are ongoing through a person's life.) 

This section from the document makes a good summary of the sorts of influences which are often invisible to us as observers/analysts. We don't usually acknowledge them because they are so ingrained in our cultural thinking we take them for granted. 

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A number of factors combine to ensure that these links are obscured in most of what is
called ‘mental illness’, as well as in ‘offending behaviour’ and other health and social
outcomes. Briefly summarised, these are:
●● The threat (or operation of power) may be less obvious because it is subtle,
cumulative, and/or socially acceptable. These factors obscure the negative operation
of power and thus enable its perpetuation.
●● The threat is often distant in time, even though the threat response is still active.
●● The threats may be so numerous, and the responses so many and varied, that the
connections between them are confused and obscured.
●● There may be an accumulation of apparently minor threats and adversities over a very
long period of time – particularly in older adults.
●● The threat response may take an unusual or extreme form that is less obviously linked to
the threat; for example, apparently ‘bizarre’ beliefs, hearing voices, self-harm, self-starvation.
●● The person in distress may not be aware of the event(s) or the link themselves, since
memory loss, dissociation and so on are part of their coping strategies.
●● The person in distress might have become accustomed to disavowing the possibility of
a link, because acknowledging it might have felt dangerous, stigmatising, shaming or
in some other way unhelpful.
●● The disavowing of these links may be encouraged by social discourses of blame,
weakness, culpability and so on.
●● Mental health professionals are socialised to obscure the link by the application
of a diagnosis which imposes a powerful expert narrative of individual deficit and
medical illness.
●● There is resistance at all levels of society to recognising the prevalence of threats and
the negative impacts of power.
●● There are many vested personal, family, professional, organisational, community,
business, economic and political interests in disconnecting threat from threat response
and thus preserving the ‘medical illness’ model.

●● The influences above combine to deprive people of a socially shared framework of
thought within they can make sense of their own experiences in their own terms.
Cumulatively, these factors help to ensure that such experiences may ‘take place outside
the realm of socially validated reality’ and thus become ‘unspeakable’

The list is a wordy way of saying to remember that all of societies 'norms' are cultural and apply only to the era we live in. Such 'norms' are not biological, factual or eternal.

The two sections in bold are where the debate over not using diagnostic labels comes from. You can see it's such a small part of the whole. So sad when that's all people discuss and debate on social media.  

The bit I've put in red is what the PTM framework attempts to address. And this is why it works across all cultures, all eras, and for every person on the planet. Compare that to the medical model we use which in order to fit everybody has to have 'co-morbid diagnoses' and 'atypical symptoms;, and even then there's a considerable percentage of people who cannot be boxed into any combination of diagnostic categories. 

On 23/03/2018 at 13:34, Gemma7 said:

For example, if a child comes showing signs of OCD and they talk in terms of experiencing adversity, couldn't this potentially cause problems for the child, if some of the adversity they are experiencing is say parental emotional abuse? Would the child open up to that? (It's important to remember that you can break the OCD cycle without addressing why you started it.) Couldn't this approach lead to stigma being shifted rather than removed? 

Absolutely that would cause problems, but where does it say that a therapist would talk to a client in those terms? (It doesn't.) The therapy approach centres around the person 'making sense of things'. A strong parallel with our OCD roadmap where meaning/interpretation is central to understanding how obsessions and compulsions interlink. The PTM framework isn't at odds with current best practice in CBT - it supports and encourages it.  

I agree with you that it's possible to break the OCD cycle without addressing why you started it.   'Why you started it' always ends up with putting blame on trigger events or adverse circumstances and it's invariably a too simplistic and narrow view of causation.   But the PTM framework is the opposite of this.

The PTM framework says we aren't suffering 'an illness' as the result of our circumstances or life events. Nothing is to blame. Nobody is to blame. You said above 'there's no evidence of causation', but this is an opportunity to break free from the medical framework habit of looking retrospectively at the problem and seeking causation/blame.

With the PTM framework there's no assumption of cause involved. Instead it focuses on the here and now and the way forward. Isn't that what we're always telling people to do on the forum?  

This new approach invites us to set aside blame-culture thinking and view a person in emotional distress as adapting to their circumstances, responding to significant or ongoing life events, all perfectly normally and as you would expect any human to respond.

Ditch the idea there's an abnormality to fix in the sufferer (an illness.) Ditch the idea of blame (including blaming adversity.) The suffering has come about as a normal developmental response, a biologically expected survival strategy. The resolution of an individual's distress is to provide appropriate support and an environment which allow them to make sense of their experiences and feelings and enable them to respond with different behaviour (adaptive thinking and reasoning instead of maladaptive coping strategies.)

I'm starting to sound as namby-pamby as the document itself so I'll stop there.   Just one last thought,

On 23/03/2018 at 13:34, Gemma7 said:

why are they not starting with changing society's way of thinking about mental health first. Put the diagnosis argument aside until attitudes have changed. Once they have then diagnoses and language can be adapted accordingly. 

This framework is itself intended to be a step towards changing society's way of thinking about mental 'health'. It's a well-researched, evidence-supported alternative to the medical framework currently in use.

Changing attitudes requires a change in how we frame mental, emotional and behavioural issues; how we think of them, how we talk about them, how we relate to them. Society cannot change it's attitudes until they stop seeing these things within the illness/defective person framework. We have to stop trying to find a direct substitution for 'the diagnosis' and try to think in completely different terms, using completely new language. 

And in case anybody starts to think I'm getting at Gemma, I'm most definitely not. She's got great insight and has raised excellent questions. I'm quoting her because her post gave me a perfect 'framework' to base my thoughts/reply on. Thank you, Gemma.   

Let's all keep the discussions going! 

[Ashley]

8 hours ago, snowbear said:

This framework is itself intended to be a step towards changing society's way of thinking about mental 'health'. It's a well-researched, evidence-supported alternative to the medical framework currently in use.

If that's the case they need to rewrite it in plain English for society. Much of the framework in my opinion is hard to understand, confusing and wordy.

From what I do understand I am not convinced it will  help people understand their OCD at all and may lead to people failing to understand they have OCD.  

But if you feel there's merit snowbear I'll sit down again and try 're reading the full document when I can.

[Gemma7]

8 hours ago, snowbear said:

The principles of power/threat/meaning are indeed well established and already applied to a number of areas including OCD books, even if it's more loosely worded in the books. 

Ok so if this is the case, what is the purpose of it if research has already made the change? To provide a framework? But perhaps the framework was already there. 

8 hours ago, snowbear said:

The PTM framework suggests an outcome of emotional distress needs to be viewed in a much broader context, taking into consideration the hidden factors which contribute, many of which are social and cultural and beyond any individual person's control.  (And start before birth and are ongoing through a person's life).

Again this is already part of current understanding and therapy. What i don't understand is why this framework is needed too?

8 hours ago, snowbear said:

The PTM framework says we aren't suffering 'an illness' as the result of our circumstances or life events. Nothing is to blame. Nobody is to blame. You said above 'there's no evidence of causation', but this is an opportunity to break free from the medical framework habit of looking retrospectively at the problem and seeking causation/blame. 

But CBT doesn't say these things either, who has these opinions? Maybe they just need better training. It seems to me that calling things power and threat will increase the likelihood of someone looking at what is to blame not reduce it. What stigma might be caused by this change in perspective? Does the framework address this in any way?

 

8 hours ago, snowbear said:

This new approach invites us to set aside blame-culture thinking and view a person in emotional distress as adapting to their circumstances, responding to significant or ongoing life events, all perfectly normally and as you would expect any human to respond. 

I agree but I already think good therapy does this. The problem is though that their normal response is a survival response because of power and threat. That's the way it is described but not everyone will like that language either. It is implying negative events even if we don't know that mental health problems are brought about by only negative events. Isn't that making an initial judgement? 

 

8 hours ago, snowbear said:

This framework is itself intended to be a step towards changing society's way of thinking about mental 'health'. It's a well-researched, evidence-supported alternative to the medical framework currently in use. 

I welcome changing society's way of thinking although i don't see it as purely beneficial given my other concerns.

This framework also wasn't well-researched because it didn't include enough service-user input. These are the people it will affect. It also isn't supported across the psychological community and we can't suppose that all those who criticise it are just trapped by the medical model. 

Interesting debate though

[snowbear]

11 hours ago, Ashley said:

If that's the case they need to rewrite it in plain English for society. Much of the framework in my opinion is hard to understand, confusing and wordy.

Yes, they probably do.  These documents weren't written as an education tool for the public, but as a starting point for discussion for the psychological society and professionals involved in treating people with emotional distress and troubling behaviours (aka 'mental illness'). It's standard professional theory speak -  wordy and long-winded by default in order to cover the necessary ground. I think if you're used to reading such papers it's a lot easier to follow and easier to pick out the wood among the trees. Fascinating and fun even.  

After much more discussion - when it's ready to be implemented at a practical level and rolled out to every practising therapist in the country - then they'll write the public education version in soundbites and easy language. (By then the public will already have unwittingly done much of the ground work for themselves by shifting their thinking to be more in line with the framework.) 

Which brings us back to what we said about the perils of debate taking place on the social media platform - professional bodies aren't yet geared up to the implications of holding their discussions in public. Neither are politicians - which is how Trump came to be elected! 

11 hours ago, Ashley said:

From what I do understand I am not convinced it will  help people understand their OCD at all and may lead to people failing to understand they have OCD.  

I have similar concerns.   But it's not irreconcilable with what's being proposed. It's not a new way of doing things so much as a new way of thinking about/relating to/explaining /talking about things. CBT as we know it will continue as before, but perhaps people will be more willing to accept they can be helped by talking therapy instead of feeling talking therapy alone can't 'cure' to what they view as an 'illness'. 

In it's present form this isn't ready to roll out on a practical level. The authors acknowledge that in the paper and openly invite suggestions on how to bridge the gap between this (largely accepted) theory and how we implement it practically in a society whose institutions and systems are currently totally at odds with it. 

I believe this framework is in line with the research and is a valid and viable way forward. In 10, 20 or 50 years everybody will have accepted it as the most obvious way to view mental issues and wonder why it took us so long to adopt it. HOWEVER, there's a huge amount of work still to be done.

A good parallel to draw is how not so long ago everybody (professionals and sufferers alike) talked about POCD, ROCD, HOCD. Now the more enlightened among us understand the theme is irrelevant and what makes it OCD is the thinking/meaning. We've shifted how we relate to OCD and how we talk about it - it's all just OCD. 

It may help you understand the framework if you view it as the same thing happening to 'mental illness' as we achieved with the acronyms. It's a way of describing things that shifts the focus away from 'symptoms' and 'cause' and moves it to a more helpful starting point of 'this is normal people making sense of the difficulties they've encountered in their world'. In essence it's about not wasting time trying to treat the R/P/H ideas within 'mental illness' , but get down to the all-important cognitive work of understanding the meaning people give to their thoughts/experiences. 

Remember too the document isn't about OCD, but a review of how we relate to and explain all forms of 'mental illness'. Arguably OCD isn't a mental illness at all but a thought disorder.   

I wouldn't spend too much time reading the whole thing again (unless it floats your boat), but rather just be prudent how you word things when you feel the urge to react on social media. You don't want to have to retract a hard-line standpoint when the wood finally starts to emerge from the forest.  

[snowbear]

11 hours ago, Gemma7 said:

what is the purpose of it if research has already made the change? To provide a framework? But perhaps the framework was already there. 

Again this is already part of current understanding and therapy. What i don't understand is why this framework is needed too?

The purpose is to find a way to make the research implementable. The framework for that isn't there. 

For example: acute psychosis used to be thought of (and still is by many) as a chemical imbalance resulting from a mix of genetic, environmental and social factors. The person having crazy thoughts and strange behaviours was (if you like) the victim of a disease process happening in their brain. If you take that approach you reach for the pills and the straight-jacket. It's a medical problem to be dealt with by whatever medical means are available. 

About 20 years ago psychiatry started to understand that schizophrenia and acute psychosis are normal reactions to an adverse situation, not 'abnormal reactions'. That rocked the medical profession/psychiatry at the time, but the theory is no longer under dispute, even though in practise psychiatrists continued to talk about it as a disease.

The more up-to-date/open-minded psychiatrists started to use talking therapy to treat these most 'medical' of the mental illnesses. And were flabbergasted by the results - recovery of normal thinking was achieved, relapses reduced, people went into remission and stayed there longer than had happened with drugs... how to explain this? For 20 years they've explained it by saying 'talking therapy works as a medical treatment.' Everybody patted themselves on the back and the world kept turning while continuing with the dichotomy of  beliefs 'there's a medical problem at the centre of these symptoms' AND 'the symptoms are a normal response and not an abnormality.'

Since the 1960s psychiatrists have been asking, how does talking therapy work?  This launched the wealth of modern psychology research and as the results started coming in there was a realisation that 'psychosis' turns out to be a perfectly normal human reaction to a particular set of circumstances. You can induce an acute psychotic state in a perfectly healthy brain very easily by subjecting healthy individuals (who have no genetic predisposition, no history of adversity and no exposure to trauma) to a range of controlled conditions. And you can reverse it by teaching them how to cope with the experience (talking therapy.) 

That raises the question 'is psychosis a disease at all?' Or is there a better framework to explain it that doesn't medicalise the response within the brain?

This framework 'theory' is the result of decades of 'how can we reconcile the parallel thinking we've been living with?' For many it's more of an ah-ha! moment   than an oh no! moment. 

12 hours ago, Gemma7 said:

The problem is though that their normal response is a survival response because of power and threat. That's the way it is described but not everyone will like that language either. It is implying negative events even if we don't know that mental health problems are brought about by only negative events. Isn't that making an initial judgement? 

Just as now - where CBT doesn't delve into the how you got this way blame game or go looking for a history of abuse to explain OCD behaviours  - implementation of the PTM framework doesn't involve sitting opposite patients talking about power and threat. It doesn't require any kind of judgement, nor is it blaming negative events for where the person is at. This language is a scaffold for the therapist to guide them in helping the person tell their story in their own words - how they experienced it, and what it means to them.

Quote

This framework also wasn't well-researched because it didn't include enough service-user input. These are the people it will affect. It also isn't supported across the psychological community and we can't suppose that all those who criticise it are just trapped by the medical model. 

Interesting debate though

No, it hasn't included a service-user poll or sought public opinion. That doesn't mean it's not a well researched theory!

Nobody's ever done a public opinion poll on Big Bang theory or the existence of black holes, but gradually people have adopted the theories as 'accepted knowledge'. That doesn't mean there aren't eminent physicists who think Stephen Hawking had it all wrong, Einstein hadn't got it quite right either and that string and quantum theory will forever remain an inexplicable dichotomy. Another interesting debate!  

[Gemma7]

11 hours ago, snowbear said:

The framework for that isn't there. 

According to who? There hasn’t been another framework released before but that doesn't mean that people haven't been working to a framework before. Alot of the shifts in thinking have come before this framework. Those shifts must have used some language. 

 

11 hours ago, snowbear said:

Just as now - where CBT doesn't delve into the how you got this way blame game or go looking for a history of abuse to explain OCD behaviours  - implementation of the PTM framework doesn't involve sitting opposite patients talking about power and threat. It doesn't require any kind of judgement, nor is it blaming negative events for where the person is at. This language is a scaffold for the therapist to guide them in helping the person tell their story in their own words - how they experienced it, and what it means to them.

The language is a scaffold, its called the power threat framework, but never uses the words power and threat to talk about mental health issues? So how are people going to talk about stuff? How is this framework going to be talked about without using the words?

The words power and threat have a meaning, right? Surely you agree on that point? 

You also forget that this framework is going to be used to educate the public, but they won't use power and threat. What words will they use, I don't think that's clear. 

What criticisms do you have Snowbear, you can't think everything they say is absolutely right in every way? If this is rolled out now (but keeping diagnosis for the immediate time), what impacts do you forsee that are negative? None? 

[snowbear]

18 hours ago, Gemma7 said:

According to who?

Yeah, good point - according to me at the moment I wrote that.  

Quote

There hasn’t been another framework released before but that doesn't mean that people haven't been working to a framework before. Alot of the shifts in thinking have come before this framework. Those shifts must have used some language. 

Exactly. This framework is a summary of conclusions drawn from those earlier shift-in-thinking discussions. It uses the same language those first shifts-in-thinking created.

18 hours ago, Gemma7 said:

The language is a scaffold, its called the power threat framework, but never uses the words power and threat to talk about mental health issues? So how are people going to talk about stuff? How is this framework going to be talked about without using the words?

This framework is going to be used to educate the public, but they won't use power and threat. What words will they use, I don't think that's clear. 

This excerpt from p20 of the document explains it better than I can, I think.  

Quote

The PTM Framework replaces ‘What is wrong with you?’ with four key questions:

●● ‘What has happened to you?’ (How is Power operating in your life?)
●● ‘How did it affect you?’ (What kind of Threats does this pose?)
●● ‘What sense did you make of it?’ (What is the Meaning of these situations and experiences to you?)
●● ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)

Translated into practice with an individual, family or group, two additional questions need to be asked:
●● ‘What are your strengths?’ (What access to Power resources do you have?)
●● ...and to integrate all the above: ‘What is your story?’

Without mentioning actual words like power, threat, or threat response it's still possible to speak to the sufferer (and the public) in non-diagnostic terms. Without too much difficulty we could ditch a language scaffold which starts from the basis, 'there's something wrong with you, you have an illness, here's the diagnosis.'

 

18 hours ago, Gemma7 said:

What criticisms do you have Snowbear, you can't think everything they say is absolutely right in every way? If this is rolled out now (but keeping diagnosis for the immediate time), what impacts do you forsee that are negative? None? 

As I see it, keeping the diagnosis poses a difficulty for instigating this alternative (non-medical) approach. This is a problem which will need further discussion and some lateral thinking from psychologists and government bodies alike. Keeping the diagnosis means the public will continue to think in terms of 'I have a diagnosis, something is medically wrong with me, I have to be fixed' even if they were to no longer get classified as having a mental illness by their therapist when they access therapy. 

BUT if we just abandon the diagnostic system without reforming social welfare and employment systems at the same time it would spark a much bigger disaster . How would people without a diagnosis access benefits when they can't work? How would people ensure their employment rights to time off and adaptation of the workplace/job if society says they don't have an illness/disability?

Accessing health care is paradoxically the easiest problem to solve because mental illness would be replaced with 'distressed/troubled' and CBT could be instigated on that basis without a specific diagnosis. But even then, who do you go to if you are distressed/troubled? Society is set up in such a way that the first port of call is a family member, a priest, or a doctor. Who do those without social support or religious faith turn to if we demedicalise their thinking and behaviours? Will IAPT services step into the breach as everybody's first port of call?? (Forgive me for laughing.  ) 

The suggestion we might instantly throw diagnostic labels in the bin is obviously ridiculous. Any fears the public (or psychologists debating it on social media) have about getting forced to do that are based in as much reality as the craziest of OCD fears.

I think diagnostic labels will remain for many years to come. Meanwhile psychologists (who this is aimed at) will gradually adopt the new framework and unobtrusively change the word structure they use. The public might slowly get used to hearing things presented in the new framework language of someone having 'emotional distress and troubling/troubled behaviours' instead of having 'a mental illness'. (Well, that's the plan. In reality the public will probably always just think 'something's not right with that strange-acting weirdo in the corner.'  ) 

In therapy, clients will be eased away from the idea they are 'patients having treatment for a diagnosis of OCD', and have their expectation of a fix/cure for 'what is wrong with them' replaced by an understanding they are 'making sense of their world and responding with normal behaviours, but there are better ways to do it.'

We already contribute to that in multiple ways on the forum every time we:

- remind people that CBT is an interactive process and not something done to them.

- steer people away from the belief they are 'broken' and shift their focus away from the idea they have a genetic fault/have different brain anatomy/ have a chemical imbalance which is to blame for causing their OCD

- explain OCD can't be eliminated by drugs alone

- educate people that OCD is a thinking disorder that causes distress and troubling behaviours (compulsions), not a personality quirk about happily organising and being tidy.

Seen in that light it seems to me we've already been singing from the PTM framework ourselves for quite some time!  

[Gemma7]

7 hours ago, snowbear said:

This excerpt from p20 of the document explains it better than I can, I think. 

I really dislike those questions. As an OCD sufferer, if those questions had been posed to me at the time of diagnosis i wouldn't have had a clue what to say. They imply knowledge about yourself that people simply haven't got, why not simply ask what's bothering you right now? Why the focus on past tense? Why the word survive? Why are these questions better? What impacts will these questions have? This is where service-user input would have helped.

 

7 hours ago, snowbear said:

Without mentioning actual words like power, threat, or threat response it's still possible to speak to the sufferer (and the public) in non-diagnostic terms.

But why create a framework with words you aren't going to talk to people in?Perhaps because the words carry meaning. I really would be more for this framework if it didn't include a load of words that I think lend towards different stigma. 

 

7 hours ago, snowbear said:

Without too much difficulty we could ditch a language scaffold which starts from the basis, 'there's something wrong with you, you have an illness, here's the diagnosis.'

I know i can really see the benefit of that, but can we have a different framework please  The problem I see is, I agree that there needs to be a shift like this, but i still don't like the framework. Why is that? If they can't convince someone who already sees mental health issues as resulting from experiences than how is this going to convince those who don't? 

You know you didn't criticise any aspect of the framework right?  What do you think of the fact that I strongly dislike its choice of words? 

7 hours ago, snowbear said:

Seen in that light it seems to me we've already been singing from the PTM framework ourselves for quite some time!

Or we work within the current framework 

[gingerbreadgirl]

18 hours ago, Gemma7 said:

I really dislike those questions. As an OCD sufferer, if those questions had been posed to me at the time of diagnosis i wouldn't have had a clue what to say. They imply knowledge about yourself that people simply haven't got, why not simply ask what's bothering you right now? Why the focus on past tense? Why the word survive? Why are these questions better? What impacts will these questions have? This is where service-user input would have helped.

I agree I'm also not keen in these types of questions.  I think if I was asked these questions I would probably attempt to answer them to be polite but really would have no idea of the answer.  There does seem to be an emphasis on cause, and the implication that mental health problems can be traced back to some kind of trauma (and what's more that the patient will have readily accessible knowledge of this.)

I also dislike the terms "power" and "threat" - regardless of whether they will be used in practice, they are up front and centre with this framework and to me they again imply (rightly or wrongly) that mental health problems are linked to trauma.  To me this seems stigmatising in a different way.  I have never experienced any kind of trauma and I would struggle to link my problems back to anything to do with "power" or "threat".   I'm not necessarily claiming that mental health problems are medical or that they aren't linked to experience - but I think these causes are often unclear and ultimately irrelevant.

Interestingly I met a psychologist at the weekend and we got talking about this.  She works in clinical research specialising in personality disorders.  She said that the clinicians she works with are often very reluctant to diagnose people with a personality disorder and prefer to focus on separate aspects (such as depression) due to the stigma; she also agrees that psychiatric problems are usually the brain's way of protecting against some kind of perceived threat (even conditions such as schizophrenia).  However she has serious concerns that moving away from diagnostic labels will reduce the availability of proper treatment.  She compared it to physical pain, which she said can often occur as the result of environmental effects on the body, but that is ultimately irrelevant when you need relief here and now.

Edited March 28, 2018 by gingerbreadgirl