The past 50 years has seen globalisation of psychiatric diagnostic (categorical) frameworks. Early versions were notoriously unreliable; when categories are unreliable they cannot be valid, meaning that they were at best useless and at worst harmful. This changed with development of the Diagnostic and Statistical Manual of the American Psychiatric Association version III (DSM III) and International Classification of Diseases version 9 (ICD9). DSM III in particular was an attempt to specify more reliable “operational definitions” of diagnoses, with considerable influence coming from the Spitzer and Endicott Research Diagnostic Criteria (Spitzer, Endicott & Robins, 1978) in the USA and the Present State Examination in the UK (Wing, Birley, Cooper, Graham & Isaacs, 1967). In these and later editions of diagnostic frameworks it had been clear that:
- The success of this strategy varied considerably across diagnoses;
- Some reliability and validity had been achieved and progress made (e.g. psychological understanding and treatment of anxiety disorders), although in other areas it has been both dismal and damaging (e.g. “Personality Disorders”);
- This strategy largely failed in biological psychiatry research, partly leading to the more recent advocacy of RDoC;
- Commercial, political and professional interests may have produced distortions.
What about the people who matter most? For service users, the outcomes of the almost universal adoption of diagnosis-led services and research varied from extremely helpful to catastrophic, and all points in between. Few would dispute that there are problems, but solutions have been elusive, which brings us to the specific rationale for the Power/Threat/Meaning Framework.
A position statement critiquing diagnostic frameworks entitled “Classification of behaviour and experience in relation to functional psychiatric diagnoses: Time for a Paradigm Shift (PDF)” was adopted by the Division of Clinical Psychology of the British Psychological Society (DCP, BPS) in 2013. Regarded by many as professionally divisive, it had little impact on clinical practice, not least because it disregarded NHS requirements and pretty much ignored the opinion of many DCP members. So now we are introduced to the Power Threat Meaning Framework (PTMF) which “is the result of a project for work towards fulfilling that aim”; thus apparently laying claim to the heralded paradigm shift. Although the document (Johnstone and Boyle, 2018) prominently displays BPS and DCP logos, it is not an official position paper. It is the report of a five year project the DCP funded. We were surprised to learn that the DCP spent £15,000 on the PTMFramework launch, implicitly advocating for its adoption without any further review or discussion within the profession.
The introduction to the PTM Framework makes it clear that the document is meant to fuel the paradigm shift. Crucial to that is said to be the construction of non-diagnostic stories which will re-integrate reactions presently regarded as disorders back into the range of universal experience. So, the intention is to replace (rather than supplement) diagnoses with personal narratives primarily focused on power issues. Strangely, however, the framework also includes seven “provisional patterns” which have all the characteristics of diagnoses.
Is this the long awaited paradigm shift? If it is to be considered so, then it should be in the context that extraordinary claims require extraordinary evidence, something we consider here. We also note that the document claims to provide “innovative and important perspectives”. A major aim of this blog is to consider whether what is important is innovative and what is innovative is important.
The position paper is based on a narrative and selective review of the evidence in several areas crucial to mental health. Reviews were unfortunately not conducted systematically. The declared intention is to use the reviews to construct a “meta-framework”. The output is a large document (414 pages PDF) with a “shorter” summary version (138 pages PDF). None of these documents have been peer reviewed nor apparently subjected to any other external review even by the DCP. As the citation information makes clear, it is the position of two authors with some other “input” from others of a like mind.
The framework strongly advocates the use of narratives to better understand meaning, and following that principle, we have sought to extract the core narrative in the main document. We found it hard to follow, but seems to run thus:
- There are serious problems with diagnosis which is often found to be unreliable with limited or no validity
- Scientific positivism (particularly but not confined to diagnostic approaches) has failed in mental health and should be discarded/disregarded
- Narratives are the best way of accessing meaning
- Bad things happening, especially in childhood, have been shown to have serious negative psychological effects on the people who are involved
- Adversity and trauma are always the result of power imbalances and abuses
- There are no biomarkers of psychiatric diagnoses
- Mental health services need to be trauma-informed because trauma affects the brain in specific ways
- Given the above, the proposed solution is to adopt PTM Framework as an alternative
- There is one Foundational General Pattern and seven “provisional, probabilistic, evidenced General Patterns within the Foundational one”; these should be used as an alternative to diagnosis.
This is a problematic narrative. Some of these assertions are partly or wholly true (1, 3, 4, 6 and 7) whilst 2 is substantially incorrect in the view of many. Most importantly, 8 does not logically follow from the preceding narrative and both it and 9 are inventions not justified by the prior truisms, and lack empirical grounding. The narrative fails to meet the criteria for either inductive or deductive reasoning. Note that in saying this we do not disagree with those premises which are supported by evidence (1, 4, 5 and 6), just that the conclusion which they are asserted to support do not flow from them. Were this a piece of academic writing (which it apparently is), a reviewer would have to conclude that the hypothesis does not follow from the introduction. Crucially, there is literally no evidence for the proposed alternative; this is argument from a vacuum.
Expert by experience commentary
I would not deny that some diagnoses are inherently problematic and actively unhelpful; so-called BPD/EUPD springs to mind. However, with my comorbid conditions (OCD and depression) both diagnoses have been useful in earmarking treatments which might work (in my case, medication, CBT and lifestyle changes). Moreover, since being diagnosed with OCD in my mid-thirties, it is clear to me that since I can remember I have had intrusive thoughts and odd worries, even before I was subjected to severe trauma through bullying at school. I would never deny that this prolonged trauma had an effect on my mental health but at the same time I believe there was more to it than purely social factors. I’d also never argue that we’ve solved the problem of psychiatric diagnosis; the DSM is, after all, not a static document. No decent mental health professional would say that the aetiology of mental health disorders is understood. We are in a reverse-therapeutic gap of sorts: we know what might work for certain conditions; but we don’t know the causes yet. And, just because biomarkers for psychiatric diagnoses have not yet been located, that does not mean they do not exist, or that we should stop looking for them.
It is also strange that both evidence-based medicine and outdated philosophies such as psychoanalysis and Foucauldian discourse are given the same weight in the Framework. Evidence-based medicine is just that: statistics have shown that it is effective for a high enough percentage of people to be useful. The same sorts of statistics can never be gathered for psychoanalysis.
In terms of narratives, I agree that they can be useful. Looking at what happened can be helpful, up to a point. Many of us, however, find it much easier to leave trauma in the past, and should not be encouraged to talk about it unless it is likely to be beneficial to do so. Much more helpful for me than psychoanalysis was CBT: not ‘what happened’ but ‘what shall we do about it’?
The notion that a utopian society would eradicate mental distress is extremely troubling. This attitude is deeply ableist and defeatist, and it also normalises severe illness. It would deny anyone experiencing mental distress a safety net. Had I been as unwell as I was in this situation, I would not have the right to be ill. And I was ill; my suffering was mental, physical and emotional.
It is, then, this flawed narrative that gives us the central assertion of the framework, which we understand to be that we should think about human distress as being determined entirely by power and its consequences. The core proposition is long and extremely complicated, so we have summarised it as best we could thus:
Psychological, emotional and behavioural problems occur because the operation of power poses threat to a person/persons, which is shaped by the meaning of the power induced threat, in turn producing learned threat responses which serve defensive psychological functions.
The implications are then spelled out, and surprisingly they clearly resemble a new set of diagnostic categories. These are labeled by the Authors as “response patterns”:
Seven Provisional General Patterns which emerge from within the Foundational Pattern. They are not one-to-one replacements for diagnostic clusters, but are based on broad regularities which cut across diagnostic groups, and which arise out of personal, social and cultural meanings.
Seven diagnostic clusters, of a type familiar from ICD and DSM, then. This impression is reinforced by their definition: “a pattern refers to associations that seem to occur above chance level”. This is reminiscent of the Maudsley-Newcastle diagnosis wars in the 1970s, in which the extent to which phenomena clustered or did not, and how if they did, was hotly and fruitlessly debated. The “patterns” in the framework appear to correspond to “syndromes”:
Within the General Patterns, it may sometimes be useful to consider sub-patterns relating to specific events or circumstances.
The seven “provisional patterns” are:
- Surviving rejection, entrapment, and invalidation
- Surviving disrupted attachments and adversities as a child/young person
- Surviving separation and identity confusion
- Surviving defeat, entrapment, disconnection and loss
- Surviving social exclusion, shame, and coercive power
- Surviving single threats.
It is said that the general patterns are not “one on one” replacements for psychiatric diagnoses, but this assertion is followed by the following extraordinary text:
Some of the General Patterns have rough correspondences to existing diagnostic categories – for example, the second one captures some people who attract the diagnosis ‘borderline personality disorder’, the fourth pattern does the same for some people who are diagnosed with ‘schizophrenia’, the fifth corresponds to some diagnoses of ‘depression’, and the sixth describes some people who end up in the criminal justice system with a diagnosis of ‘antisocial personality disorder’.
This is because psychiatric diagnoses do, to a very limited extent, reflect common psychosocial response patterns, albeit described in medical terms.
How surprising to see BPD referred to in this way in this document of all documents! The authors of this blog would like to see this diagnosis abandoned, not re-defined.
It is also indicated, again without evidence, that the patterns are based on the causes and “functions” of responses; that is, they are responses which meet social/psychological needs. The similarity with psychoanalytic “defence mechanisms” is striking. Trying to root psychological understanding of current distress in hypothetical causal factors and “function of responses” seems to us to be particularly problematic, something abandoned by most mental health professionals decades ago. Psychology and Psychiatry does not deal with causes because the evidence is simply not there.
Expert by experience commentary
It seems obvious to me that if we cannot say that the causes of mental distress are physical/biological, because there is no evidence, then neither can we say they are purely social/trauma based, because there is also no evidence. The authors of the Framework cannot rely on evidence only in cases where it suits them.
The initial conclusions of PTMFramework are uncontroversial and it is of course helpful to remind services of their importance:
- Start with service users by helping them to tell their story
- Move away from hard line diagnostic practice
- Involve service users and survivors more in developments
However, these do not flow from the framework itself but are all highly appropriate values for mental health services and professionals and many mental health services already do this. Rather harder are the broader political conclusions which are:
- Tackle and eliminate oppressive austerity
- Tackle and eliminate all forms of discrimination and power abuse
- Tackle and eliminate child abuse and neglect
- Emphasise prevention in mental health policy.
Few would disagree with these, but again they neither flow from the Framework nor lead to it.
The main strength of the PTM Framework is the way it brings the issue of power in mental health into sharp focus. This is an important and often neglected issue which deserves serious treatment in itself. However, issues of power are mainly an assumption for the framework, rather than the substance of a comprehensive psychological and sociological analysis; we consider this to be an unfortunate lost opportunity.
Expert by experience commentary
It is refreshing to see ‘power’ placed at the forefront of this so-called paradigm shift – I’ve been subject to the sorts of imbalances of power that are inextricably bound with mental health difficulties. So, reading the PTM Framework, I expected to find robust plans for empowering service users: but instead what I came across was obfuscatory language designed to repel even those of us educated to PhD level; a description of an extremely opaque consultation with service users; and references to obscure and inaccessible philosophies; most notably that of Foucault. This is not the way to empower a broad range of service users: one is put off almost immediately at the thought of reading even the shorter 138-page summary. One must ask, then, where the power actually lies within the PTM Framework.
Limitations are legion. The documents are very hard indeed to read. After considerable effort it is clear that the narrative is seriously flawed. This is unfortunate given the importance afforded to narrative by the authors. Overall, the documents are meant to comprise reviews pointing to particular conclusions and recommendations. The reviewing varies greatly in quality, but it is never systematic and often very ideologically driven. There is a muddle in terms of the extent to which “positivism” (i.e. research-led) constructs are rejected or adopted; in several places the authors seek to draw on research findings in what seems to us to be misleading ways. There is another major lost opportunity in the way the crucial Service User chapter was developed and presented. It has some of the methodological trappings of qualitative research and it comes as a surprise that this is not done; it is not made clear, but seems that that whole section is the authors’ take on unspecified interviews.
Expert by experience commentary
The service user consultation is opaque in terms of selection process; we are told that:
Consultants were recruited through informal service user and professional networks, aiming for diversity in terms of gender, age, ethnicity, and socioeconomic status. One person was known to a project member through their campaigning work but most of the others had not been exposed to critical perspectives in any detail. This meant that although we did not have advance knowledge about their views on psychiatric diagnosis, we were able to recruit people with a range of perspectives. For the most part, potential consultants were contacted by someone who already knew them and asked if they were interested in participating…
A group of eight participants over five years is far too low a number to gain any meaningful quantitative statistics on the Framework. The impression given is that service user participation was deliberately kept to a bare minimum in order to tell the desired narrative of the authors. Somewhat ironically, the balance of power within the consultation process is also unclear. How was information presented to the participants in order to make meaningful and informed decisions on the Framework? No information is given about HOW the service users views were included; interviews are mentioned, but without detail.
Implications for practice
This blog began by examining the assertion that the Framework was intended to provide, in the words of the authors, “innovative and important perspectives” and whether the announced need for a “paradigm shift” has been met. We sadly must conclude that what is important is not innovative and what is innovative is not important.
“Paradigm shifts” occur when scientists encounter anomalies that cannot be explained by the previously held theoretical positions which had dominated the research. The scientific discipline descends into a state of crisis which leads to the trying out of new ideas. The PTM Framework is not a paradigm shift by any stretch of the imagination.
Sadly, then, there are no new implications for practice. The principal recommendations for practice are to highlight the need to deal with adversity (mainly through political change), to acknowledge the importance of trauma, seek parity of esteem between physical and mental health, to reduce stigma in mental health and to reduce the use of coercion. There is no evidence that a shift from diagnosis to the use of Seven Provisional Patterns would achieve any of these entirely desirable aims any more than it would achieve world peace.
Summary and conclusion
The Framework is hard to understand; the core statement was run through a readability analysis (readabilityformulas.com) and registered as having a Flesch Reading ease score of -9.9 which the site categorised as “Impossible to comprehend”. It is clearly highly inaccessible to those it is supposedly aimed at. We were urged by one of the authors to read the entire document before commenting, something we have done. The way it is expressed de facto serves to conceal the underlying narrative, something we presume is unintentional. Nevertheless, the effect is to obscure the meaning, which is an ironic and paradoxical outcome. Spread over more than 400 pages, we consider that the logic claimed to underpin the Framework is not valid. There is quite literally no evidence for the validity of the framework itself, or for the seven provisional patterns proposed as an alternative to psychiatric diagnostic categories. The authors assert that the gathering and synthesis of evidence (positivism) which lies at the heart of psychiatry and psychology should in any case be rejected. We regard the rejection of positivism as the ultimate baby and bathwater situation. Those who seek help from mental health professionals typically need evidence for effectiveness so that they can choose how best to engage with the range of help offered.
The Framework relies on empirically unsupported claims regarding the “cause and function” of psychological distress. This is something which has eluded the field for its entire existence. All is not lost, however. Progress in psychological interventions at every level has been made by efforts to understand why, for some people, distress becomes particularly severe and particularly persistent to the point that they need help and support to deal with it. The range of effective psychological treatments we have are all based on such an understanding and this has been the emphasis of the applied science of clinical psychology and increasingly in psychiatry over the last four decades. There are real and exciting possibilities of understanding causes and therefore developing primary and secondary prevention interventions. These are almost entirely complementary to the demonstrably effective strategy of helping people to deal with factors which maintain their problem in ways which empower them to be able to bring about changes towards their preferred goals. By contrast, the PTM Framework has opted to take a quite different path, set out by a hybrid social constructionist, anti-psychiatry, anti-science and political agenda. The PTM Framework is more manifesto than scholarly document. What is needed is evidence such as that in the excellent recent paper by Perkins et al (2018). These are complex matters not best dealt with by polemics.
Johnstone L, Boyle M, with Cromby J, Dillon J, Harper D, Kinderman P, Longden E, Pilgrim D, Read J. (2018) The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis (PDF). Leicester: British Psychological Society.
Perkins, A, Ridler, J, Browes, D, Peryer, G, Notley, C, and Hackmann C (2018) Experiencing mental health diagnosis: a systematic review of service user, clinician, and carer perspectives across clinical settings. The Lancet Psychiatry https://doi.org/10.1016/S2215-0366(18)30095-6
Spitzer RL, Endicott J, Robins E. (1978) Research Diagnostic Criteria: Rationale and Reliability. Arch Gen Psychiatry.1978;35(6):773–782. doi:10.1001/archpsyc.1978.01770300115013
Wing, J. K., Birley, J. L., Cooper, J. E., Graham, P., & Isaacs, A. D. (1967). Reliability of a procedure for measuring and classifying “present psychiatric state”. The British Journal of Psychiatry, 113(498), 499-515.