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Ashley

The Power Threat Meaning Framework

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On 27/03/2018 at 12:42, 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? 

On 28/03/2018 at 06:36, gingerbreadgirl said:

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.  

What's happened to you etc. aren't questions a therapist asks a client! Noooo. :no:

They're a framework for the therapist to structure their sessions, to understand where/why the person is struggling and what areas need to be discussed. It's a scaffold for the assessment part of therapy. And a way of acknowledging a person is not a disease walking around in a body, but a person living in the real world with all kinds of influences affecting their thinking. Gemma said it's ok to explain within the current framework, so fine -  in those terms it's the therapist confirming the diagnosis based on the person's story! :a1_cheesygrin: 

Words like power and threat is another step back again from this 'what happened to you?' line of questioning. It's recognised terminology used across professional and government bodies, research and even the business world. 

On 27/03/2018 at 12:42, Gemma7 said:

But why create a framework with words you aren't going to talk to people in?Perhaps because the words carry meaning.

:yes: Exactly that - they have meaning.

'Power' represents the wide variety of influences that shape all our lives from the big stuff we have no control over such as social values, cultural values, accepted and expected gender roles, legal constraints,  government financial and employment policies etc. to more personal stuff like family responsibilities, peer pressure, personal ambitions, upbringing, education... the list goes on. 

Similarly 'Threat' doesn't have to mean something bad. 'Threat' could be a nothing more than a perceived obligation, a moral code to be lived by, a choice the personal has made, a belief that xyz 'must' be achieved/done or else... or it could be as traumatising as negotiating the aftermath of child abuse, domestic violence, or war. The word 'threat' doesn't attempt to define what has happened, only that the person perceives some kind of problem in their life. It might not be threatening at all, but it can still be perceived as a problem so it would be labelled a threat in psychology terminology.

Clients don't get spoken to in those power/threat terms - that would be like a doctor explaining pain to a patient in terms of calcium ions and A-delta nerve fibres! :laugh: 

How might it translate to the first getting-to-know-you OCD therapy session?  

Therapist: Tell me about what has brought you're here. What kind of problems are you having? 

OCD person: I worry I'm going to harm my baby. :( 

Therapist: Tell me about your life. Do you have any help looking after the baby? What was your own childhood like? 

OCD person: My mum made sure I had a wonderful childhood. I've never had anything bad happen to me. University was fun - until I had to leave to have baby Billy. My husband tells me I'm a good mum every time I ask :blushing:  I only buy organic baby foods. My husband gets really cross with me then. He says his mum never overspent the family budget and I've got ideas above my station, but I read in a magazine organic is best. I wipe everything down after I've been out of the house in case there are bugs on the pram. I google baby health sites for hours while Billy's sleeping so I know what to look out for if he gets ill. I'm so lucky, I have lots of friends. Well, I had, but they don't come round any more since we moved to the council estate. They post pictures of their babies on Facebook but I can't. So I don't feel comfortable chatting at the mum's and babies group any more. I just stay at home checking the door is locked in case social services come to take Billy away. :( 

Therapist: Why would they do that? 

OCD person: I was so embarrassed when the vicar called round. Billy was dressed in hand-me-downs and screaming his head off. Then I saw the vicar talking to the health visitor in the supermarket. I'm sure he was saying I don't take good care of my son. My mum says the clothes have been worn by generations of family and I should be grateful she kept them. Sometimes I get images in my head where I'm hurting Billy. He never stops crying, but I'm scared I'll drop him so I leave him in his cot. I don't like going in the kitchen in case I'm holding a knife when the neighbour bangs on the wall shouting at me to shut that baby up. I'm scared I'll lose control and hurt..somebody. [Looks away, therapist notices her hands fiddle with thick bangles on one wrist which cover an elastoplast.] 

Therapist thinking: Power (what's happened to make her who she is and think as she does) = Social definition of motherhood, own mother as role model, gender role giving up uni to rear child, peer pressure, media pressure, financial constraints, abusive neighbour, husband's ideas of 'good mum' (is he cross enough to be violent?) 

Threats (how it's affected her) =  pressure from all sides (and self) to be a 'good mum', mild paranoia, change in social and financial status, change in role from student to mother

Meaning (what sense has she made of it) = I'm a bad mum, people will think I'm a bad mum

Threat response (what is she doing to 'survive') = anxiety around doing normal motherhood tasks, not able to socialise with whoever she wants, overspending on baby food, reassurance seeking, avoidance compulsions, cleaning compulsions, checking compulsions, social withdrawal, (possible self-harming?)

Access to power resources (what strengths has she got) = husband, family, friends, community support group, religious faith/church support, good education

 

At no point has the therapist spoken about power or threats, or suggested trauma in her life (other than being vigilant to the possibility of domestic violence and self-harm, picking up the smallest of verbal and behavioural clues as any good therapist should be.)

Well, I don't know if that helped anybody understand how the framework translates into face-to-face therapy :unsure: but it was fun to create the characters and write it. :a1_cheesygrin: I do go on a bit though, so enough for now. I'll answer the rest of Gemma's questions later. :) 

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On 27/03/2018 at 12:42, Gemma7 said:

You know you didn't criticise any aspect of the framework right? :a1_cheesygrin:

Not the framework, no. I don't have any problem with the concepts in it. During my career I saw several of these kind of frameworks come and go as my profession adapted to advances in understanding and modernised itself. But I did express my concerns over the implications of moving away from a medical framework which our social infrastructure supports. I think it's going to have to work in parallel with the current framework/systems for quite some time yet. 

16 hours ago, gingerbreadgirl said:

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.

I can't see how they're going to escape diagnostic labels. Apart from ensuring people access the right treatment, how will statistics be collected to enable funding decisions for psychology services if they just have a mixed bag of 'troubled and distressed clients'? How will research be conducted if psychologists aren't able to group their clients according to symptoms? :unsure: I think we'll have to keep some kind of labelling, even if they find a way to remove the idea its a 'diagnosis'.  

Relief of pain is a good analogy. But how doctors have understood pain has changed over time. We now know the ins and outs of nerve ionic exchange and its interaction with the tissue inflammatory cascade, how the brain perceives pain and perceives it differently depending on whether its chronic or acute. Your GP might suggest ibuprofen instead of paracetamol for infection and prescribe a TENS machine or a mirror for phantom limb pain as a result of the advances in understanding. But for the patient all that matters is the pain is treated - and it is. I guess I see this as similar; it will help psychologists to integrate advances of understanding in brain development, function and how we maintain mental well-being so they hone their treatments to maximise benefit for the client, but the clients themselves won't notice much change. 

Edited by snowbear
added a paragraph

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15 hours ago, snowbear said:

What's happened to you etc. aren't questions a therapist asks a client! Noooo. :no:

They're a framework for the therapist to structure their sessions, to understand where/why the person is struggling and what areas need to be discussed. 

But why this emphasis on past circumstances? To me it smacks of a return to "blame the mother" type psychology. (I'm being obtuse but I think the language being used in discussions surrounding this framework has got people's backs up precisely because it is so loaded.) One thing I have noticed being said again and again is "mental health problems are a response to difficult circumstances". But this puts the blame firmly on a person's circumstances - what does this say about people who have mental health problems but have never had adverse circumstances to speak of? And conversely, some people go through significant trauma and are absolutely well-adjusted.  If society shifts to seeing mental illness as purely a response to circumstances, then I can just envisage people saying "well I went through XYZ and I'm fine, why can't this person pull themselves together?" I remember when Stephen Fry attempted suicide, social media was rife with comments like "what does Stephen Fry have to feel depressed about?" 

10 hours ago, snowbear said:

I can't see how they're going to escape diagnostic labels.

I agree but there does seem to be genuine concern around this and several professionals are decidedly not in favour of this framework.  Are they all just trapped by societal trends? Have they all failed to read or understand the document? Do they not have any valid points at all?

Edited by gingerbreadgirl

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11 hours ago, snowbear said:

I can't see how they're going to escape diagnostic labels.

At least two of those that support the document have clearly said they don't like or use diagnostic labels on social media already in the last year.   This may be helpful for some mental health problems from what I am reading, but for people with OCD being given a name/label gave so much sense of relief knowing it's not them, they're not turning into a murder/paedophile etc. 

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5 minutes ago, Ashley said:

At least two of those that support the document have clearly said they don't like or use diagnostic labels on social media already in the last year.  

Yes I have seen professionals repeatedly state that they want to get rid of diagnostic labels and that already they refuse to use them. 

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Mind you one of those said he didn't believe in the NICE guidelines either and uses his own treatment method and approach for OCD. :whistling:  But I was sat in a café in Majorca last year having that debate with him so I forget exactly what he said, plus he blocked me.

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2 minutes ago, Ashley said:

Mind you one of those said he didn't believe in the NICE guidelines either and uses his own treatment method and approach for OCD. :whistling:  But I was sat in a café in Majorca last year having that debate with him so I forget exactly what he said, plus he blocked me.

I think I probably can guess who you mean! 

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17 hours ago, snowbear said:

What's happened to you etc. aren't questions a therapist asks a client! Noooo. :no:

The problem is interpretation. Some of those following the framework will use those questions, others will use questions based on those questions. The questions are biased towards the past, therefore in many cases so to will the therapists questions who follow the framework. Once again it comes back to training and how good a therapist is at applying what they've learnt. 

 

17 hours ago, snowbear said:

Similarly 'Threat' doesn't have to mean something bad.

Threat means something bad whether we want it to or not, that's because of the English language. Someone reading the framework will use what threat means to make a judgement. The words power and threat are the wrong choices for this document. 

 

17 hours ago, snowbear said:

What was your own childhood like? 

This is the second question the therapist asked and is why the framework has issues. (It gets therapists looking for power and threat.)  It gets someone talking about something that might just be irrelevant. This woman is having problems in the here and now, her past experiences are irrelevant unless SHE brings them up, after all it is her narrative that matters (according to the framework). 

12 hours ago, snowbear said:

Not the framework, no. I don't have any problem with the concepts in it.

The framework and the concepts are two different things. This is the problem, you don't like the framework then you must not like the concepts. (Not saying your saying this but more how things occured online :)). The concepts I like, I like what they are trying to do, I don't like HOW they are trying to do it. 

 

12 hours ago, snowbear said:

I can't see how they're going to escape diagnostic labels. Apart from ensuring people access the right treatment, how will statistics be collected to enable funding decisions for psychology services if they just have a mixed bag of 'troubled and distressed clients'? How will research be conducted if psychologists aren't able to group their clients according to symptoms? :unsure: I think we'll have to keep some kind of labelling, even if they find a way to remove the idea its a 'diagnosis'.

Yeah! I agree :lol:

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56 minutes ago, Ashley said:

At least two of those that support the document have clearly said they don't like or use diagnostic labels on social media already in the last year.   This may be helpful for some mental health problems from what I am reading, but for people with OCD being given a name/label gave so much sense of relief knowing it's not them, they're not turning into a murder/paedophile etc. 

This is concerning. Unfortunately I do think the framework may give current psychologists who strongly believe in it an excuse to abandon diagnosis now when things aren't yet in place for the change. 

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21 hours ago, gingerbreadgirl said:

But why this emphasis on past circumstances? 

Use of the past tense in the framework isn't an emphasis on past circumstances. :no:  The past tense  is used in that it refers to all the contributing influences on current thinking, up to and including the present. In other words, everything that has shaped this person's thinking to result in what they currently think and the way they are currently behaving. It even includes what happens in the here and now of a therapy session. As the session unfolds it is itself also influencing how they think and therefore becomes part of the definition of 'past' as they sit there.

21 hours ago, gingerbreadgirl said:

To me it smacks of a return to "blame the mother" type psychology.  One thing I have noticed being said again and again is "mental health problems are a response to difficult circumstances". But this puts the blame firmly on a person's circumstances  

Try to get away from blame culture thinking. :no:  There is no blame involved - even when we think of it as 'mental illness due to (whatever)'

The medical framework says 'The symptoms of OCD result from...'and then it considers genetic, anatomical, neurochemical, and environmental factors as the potential cause/explanation for their interpretation of OCD being an abnormality of brain form or function (a mental illness.)

The PTM framework says, 'This person's distress and behaviour can be explained by viewing it as a natural adaptation to the sum of all the influences their brain has experienced over their lifetime.' 

A far cry from apportioning 'the blame' on circumstances, poor old mum (or an individual person's defective functioning/ill brain.)

Quote

What does this say about people who have mental health problems but have never had adverse circumstances to speak of? And conversely, some people go through significant trauma and are absolutely well-adjusted.

The PTM framework challenges the idea you need to have any kind of cause (illness/abnormality) to explain a person's thinking and behaviour.  People are simply reacting to their everyday experiences in the way every normal human brain reacts. How your brain thinks today depends on the adaptive thinking patterns it has learned during the normal process of living, not whether the circumstances it has had to deal with are 'adverse' or not.

As you say yourself, not everybody going through the same experience will react the same way. Some people's brains have learned to think in a pattern that results in anxiety and behavioural problems, other brains have learned to cope differently with the same kind of challenge and have no anxiety. Neither one is 'unhealthy' in terms of biological survival of the species. They are just different ways the brain evolved to cope with the infinite variety of challenges that being alive in an unpredictable and ever-changing world poses.

21 hours ago, gingerbreadgirl said:

If society shifts to seeing mental illness as purely a response to circumstances

The PTM framework is not responsible for the way(s) society at large will twist it and interpret it. :( Neither is the medical model responsible for the fact society regularly interprets 'x is a potential cause for y symptoms' as implying 'something is to blame'.  :dry:  Neither framework invites blame, nor do they imply it. 

Applying the medical model we get, 'Whatever the majority of society accepts as normal is the definition of healthy.' Or you can turn it around and say, 'Whatever is deemed healthy is how we define normal'. 

But not every society agrees on what is normal. Behaviours which get diagnosed as 'mental illness' in one culture will be spoken of as 'witchcraft/possessed by devils' in another culture and are revered as 'the gift of second sight' in some parts of the world. How a society views normal behaviour and what it views as 'illness' also changes over time. When I was a child British society still thought of a girl who got pregnant outside of marriage as worthy of a diagnosis of 'morally insane' and she could be locked up in a mental institution for the rest of her life as 'treatment' for her (social) illness. Back in the 1950s they gave electrical shocks to homosexuals to 'cure' them of their 'perverted illness.' Both social judgements of their day on what constitutes 'normal/healthy' behaviour. Both treated (using the medical framework) as 'mental illness', because society had no other way of classifying (thinking about) such behaviour at the time. 

We change beliefs/values by shifting the way the society thinks rather than the details of what they think. (Same as we overcome OCD by changing the way we think rather than focusing on the particular topic(s) someone has been obsessing about.) :) 

This PTM framework offers an alternative interpretation to the idea that certain thinking and behaviours should be considered 'abnormal' (and therefore a mental illness which needs to be treated/corrected to make the person 'normal' again.)  

It invites us instead to consider the way a troubled person is thinking and behaving as a natural adaptation, but one which results in them being distressed. Understanding the thinking patterns a person has developed in response to their environment and supplying them with an alternative will enable them to develop different behaviours and live without distress.

Patterns of thinking are in themselves adaptations to the challenges the human race has faced throughout history in order to survive as a species. (Which is where the document's reference to survival' comes in. Nothing to do with individual circumstances or a trauma suffered. 'Survival challenge' doesn't have to mean an adverse event, just something we have to adapt to in order to stay alive.) :)

Providing new challenges such as an alternative interpretation of their thoughts and insight to a range of non-compulsive behaviours [aka cognitive therapy] and giving them the opportunity to practise these alternative adaptations [aka behavioural therapy] - can relieve their 'distress and troubled/troubling behaviour.' 

Is this beginning to make more sense to anyone, or am I the only person here who sees this is just another way of describing CBT? :unsure: 

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19 hours ago, Ashley said:

for people with OCD being given a name/label gave so much sense of relief knowing it's not them, they're not turning into a murder/paedophile etc. 

I agree - as I said in my concerns about how this framework is used in practice (as opposed to agreeing with the theory it puts forward.) There's going to have to be something for the sufferer to identify with as 'Ah-ha, this explains what's happening to me'. 

19 hours ago, gingerbreadgirl said:

I have seen professionals repeatedly state that they want to get rid of diagnostic labels and that already they refuse to use them. 

And we're seeing more and more people report on the forums 'my therapist won't agree with the doctor that it's OCD' or 'CAMHS wouldn't confirm it was OCD'... :( Not helpful. :no: 

The problem though doesn't lie with the theoretical framework being proposed, but in how some therapists/psychologists are applying it.

Is this based on their personal misunderstanding of it? Or based on a misunderstanding of what they were being taught in training? Or based on some well-meaning ideology that doesn't meet the practicalities of refusing to use diagnostic terms around clients? Or based on the fact the message within the framework has been in practical use for years while simultaneously giving a nod to the diagnostic label a client has been given in order to get them into therapy and now they have an excuse to publicly stop using the diagnostic terms?   I'm not sure what is driving this trend to abandon diagnostic labels before a suitable alternative in 'PTM speak' has been introduced. As Gemma said...

18 hours ago, Gemma7 said:

This is concerning. Unfortunately I do think the framework may give current psychologists who strongly believe in it an excuse to abandon diagnosis now when things aren't yet in place for the change. 

 

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18 hours ago, Gemma7 said:

The problem is interpretation. Some of those following the framework will use those questions, others will use questions based on those questions. Once again it comes back to training and how good a therapist is at applying what they've learnt. 

Totally agree. :yes: 

18 hours ago, Gemma7 said:

Threat means something bad whether we want it to or not, that's because of the English language. Someone reading the framework will use what threat means to make a judgement. The words power and threat are the wrong choices for this document.

Yeah, the dictionary definition and everyday understanding of 'threat' implies bad. Particularly when used around health issues. But in business models and many other frameworks it simply stands for 'opposing views' or 'things which don't fit with the current way of doing things'. Even the word 'opposition' can be interpreted as 'an opportunity for review/positive change'. 

Sales personnel, advertisers, suppliers, inventors, manufacturers (and more) use the business framework interpretation of 'threat' as simultaneously meaning 'a dangerous challenge to what we're doing now and a heads-up to the opportunity to adapt and make more profit.' So not necessarily bad after all. Just depends on which framework you apply. :) 

But I see your point that given the context, the word choices of power and threat might not be the best in the dictionary had to offer... :unsure: 

18 hours ago, Gemma7 said:
On 28/03/2018 at 18:20, snowbear said:

Therapist: Tell me about what has brought you're here. What kind of problems are you having? Tell me about your life. Do you have any help looking after the baby? What was your own childhood like? 

This is the second question the therapist asked and is why the framework has issues. (It gets therapists looking for power and threat.)  It gets someone talking about something that might just be irrelevant. This woman is having problems in the here and now, her past experiences are irrelevant unless SHE brings them up, after all it is her narrative that matters (according to the framework). 

Gemma, this was my fault entirely and nothing whatsoever to do with the framework. As a creative writer I attempted to provide a scenario with imagined dialogue that might bring the framework to life for those struggling to see how it could be applied in practise without using the words power and threat. :blushing:  In practise CBT therapists do ask questions about the present day (as you say, unless and until the person raises the relevance of their past.) Sack me from the drama script-writing team for misrepresenting reality. :( 

18 hours ago, Gemma7 said:

The concepts I like, I like what they are trying to do, I don't like HOW they are trying to do it. 

I'm not disagreeing! We only differ slightly in where we draw the line between 'what' and 'how'. :) 

Which is why I think discussing it on this thread is important. We (OCD-UK and OCD sufferers) need to have it straight in our own minds what the practical problems of rolling this framework out might be; which bits we see as an irreconcilable problem and which bits aren't as big an issue as we first feared.

We want to be able to give the psychology society an informed and reasoned debate (on social media if needs be if that's the only place we get to talk to them :dry: ) and not end up having a few people derailing the work of the charity to get everybody seeing a CBT therapist 'experienced in treating OCD' (which would be hard to get government funding for if therapists themselves won't use the term.)

What we don't want is to see them changing their practice in ways that increase the difficulties sufferers already face. 

Nor do we want this to become a social-media-mud-slinging-argument between two sides - neither of whom are absolutely clear what it is they're arguing over. (As we said above, some psychologists seem to be interpreting this wrongly or are not correctly understanding the training they've been given.)

I would like the forum users to help decide which bits are a problem in practise (however brilliant and insightful they might be in theory) and how we move forward in a way that incorporates the best of these ideas but in a way that sufferers benefit from it. And on that last point I'm pretty confident everybody here will be in agreement.  :) 

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Just been reading through the content of this forum and I think it’s very good in its discussions about how policies and procedures by state organisations affect our wellbeing.

I read PTM when it first came out and used the concept of power to explain to my GP why I decided a few years previously to retire early from work. It lead to a good discussion.

I think that some diagnoses are more dysfunctional than others. I would include schizophrenia and personality disorder in that the societal response is hugely negative. In comparison the diagnoses of OCD I think is positive in most cases. People can use the diagnosis to accomplish greater wellbeing. And this is reflected in surveys that reveal that people find the diagnosis helpful in the main.

I think that the biomedical model has a lot of power. It has negative and positive consequences. But it provides legitimation for employment protection measures and welfare benefits.

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