The Power Threat Meaning Framework

#PTMFramework

Slides © Lucy Johnstone & Mary Boyle (2019)

 Learning Outcomes
• Understand the core principles of the Power Threat Meaning
Framework and how it offers support and validation for non-
diagnostic approaches, including culturally-specific perspectives
and practices
• Demonstration of how the Framework perspective can be used
in practice
• Learn about applications of the Power Threat Meaning
Framework across various settings
• Access relevant documents and resources

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 Contributors to the project over a 5 year period

Lucy Johnstone, Mary Boyle, John Cromby, Jacqui Dillon, Dave

Harper, Peter Kinderman, Eleanor Longden, David Pilgrim,
John Read, with editorial/research support from Kate Allsopp

Consultancy group of service users/carers

Critical reader group to advise on diversity
Other expert contributions including examples of good
practice
https://www.youtube.com/watch?v=HhdA3xB63GE
 The Power Threat Meaning Framework

• An attempt to outline an alternative to the diagnostic model of

distress and unusual experiences
• A set of ideas and a conceptual resource, not formal
recommendations or ‘how to’ manual
• Funded by the Division of Clinical Psychology of the British
Psychological Society but not an official DCP or BPS model
• Co-produced with experts by experience, both within the core
project team and as an advisory group
• Not a replacement for all current models and practices. It offers a
wider overall framework to support and enhance them...
• ..... as well as suggesting new ways forward, both within and
beyond services
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 The Power Threat Meaning Framework

• Relevant to a wide range of stakeholders, for eg public health,

social policy, mental health, acute healthcare, education, criminal
justice settings, social care, peer supporters, experts by experience,
carers, health commissioners, researchers, voluntary sector
workers, teachers and trainers, policy makers, academics,
journalists, and the general public
• The documents are a first stage, subject to ongoing development in
the light of evaluations and feedback from particular settings
• The PTMF has attracted national and international interest,
although controversial in some quarters

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 DCP Position Statement on ‘Classification of
behaviour and experience in relation to functional
psychiatric diagnosis’ (2013)

‘The DCP is of the view that it is timely and appropriate

to affirm publicly that the current classification system
as outlined in DSM and ICD, in respect of the functional
psychiatric diagnoses, has significant conceptual and
empirical limitations. Consequently, there is a need for
a paradigm shift in relation to the experiences that
these diagnoses refer to, towards a conceptual system
not based on a ‘disease’ model’ (May 2013)

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 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

• The main document, available online only.

• Detailed overview of philosophical and conceptual
principles; the roles of social, psychological and biological
causal factors; SU/carer consultancy; and the relevant
supporting evidence.
• Chapter 8: Ways forward: Implications for public health
policy; service design and commissioning; access to social
care, housing and welfare benefits; therapeutic
interventions; the legal system; and research.
The Power Threat Meaning Framework: Overview
• The printed version (and online) consist of the Framework
itself (Chapter 6 of the main document)
Hard copy from membernetworkservices@bps.org.uk
• Appendix 1: A guided discussion about the Framework (also
available separately)
• Appendices 2-14 Good practice examples of non-diagnostic
work within and beyond services
• 2 page summary of the PTM Framework which can be adapted
for local purposes; FAQs; Appendix 1 Guided Discussion; slides
from the launch; videos of the launch talks; more resources to
come.
• The link takes you to all documents and resources:
https://www.bps.org.uk/news-and-policy/introducing-power-thre
at-meaning-framework
 The PTM Framework and trauma-informed approaches
• Draws on this research (ACEs, neurobiology of stress etc) but also
on a much wider range of philosophical, sociological and
psychological literature
• Non-diagnostic (‘PTSD’, ‘Complex Trauma’ etc..)
• Prefers ‘adversity’ (less risk of decontextualised shorthand)
• Suggests patterns of distress not only related to obvious ‘trauma
events’ but also to more insidious factors including inequality,
social exclusion, discrimination, devalued identities etc..
• Explicit links to wider institutional and organisational contexts,
macro political and socioeconomic structures and ideologies
• Importantly, suggests non-diagnostic alternatives for welfare
access, commissioning, legal work, research….etc..
Moving beyond the ‘DSM mindset’……

Away from medicalisation – assuming that models

designed for understanding bodies can be applied to
people’s thoughts, feelings and behaviour.

Instead, a framework that understands people in their

relational, social and political environments….
……and sees them as people acting and making
meanings, within their life circumstances.
There is a lot of new research out there….but it
tends to get stuck at these points

‘Everything causes everything’

‘Everyone has experienced everything’

‘Everyone suffers from everything’

 The Power Threat Meaning Framework

Going beyond non-diagnostic ways of working one to one (such

as formulation) ...
.... to suggest a framework for describing wider evidence-based
patterns of distress and unusual experiences....
.....which help to construct individual/family/group/social
narratives, inside or outside services, supported or not by
professionals…..
…as well as suggest alternative ways of fulfilling the other
functions of diagnosis.
A more effective, evidence-based way of performing
the functions that diagnosis claims but fails to do

• Summarising the evidence about causal factors in

psychological distress and troubled or troubling behavior
• Showing how we can group similar types of experience
together
• Suggesting ways forward and interventions
• Providing a basis for research
• Providing a basis for administrative decisions such as
commissioning, service design, access to services and
benefits, legal judgements and so on

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 As well as fulfilling the expected functions of
diagnosis, these are the aims of the PTMF:

• Recognising that emotional distress and troubled or

troubling behaviour are, ultimately, understandable
responses to a person’s history and circumstances
• Restoring the link between distress and social injustice
• Increasing people’s access to power and resources
• Creating validating narratives which inform and empower
people, groups and communities by restoring these links
and meanings
• Promoting social action

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 The Power Threat Meaning Framework poses these
core 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 experiences to you?)
• ‘What did you have to do to survive?’
(What kinds of Threat Response are you using?)
In one to one clinical, peer support or self help work this then
leads to the questions:

• What are your strengths?’ (What access to Power resources

do you have?)
• …..and to integrate all the above: ‘What is your story?’
• It is convenient to think of it in terms of Power, Threat,
Meaning and Threat Response, but in fact the elements are
not independent but evolve out of each other.

• ‘Power’ implies both ‘Threat’ and ‘Threat Response’, and all

of these are shaped by their Meanings.

• Our very detailed review of the evidence about Power,

Threat, Meaning and Threat Responses forms the basis of a
provisional set of broad patterns in distress.
 “What has happened to you?”
(How is POWER operating in your life?)

Power is everywhere in human affairs, yet explicit

definitions are rare. PTMF defines power as:

• The means of obtaining security and advantage

• Being able to influence your environment to meet

your own needs and interests
 Power can operate in many different ways:
• Legal power coercion, or rules and sanctions supporting or limiting other aspects
of power, offering or restricting choices
• Economic and material power - the means to obtain valued possessions and
services, to control others’ access to them and to pursue valued activities
• Interpersonal power -power within close relationships, the power to look after/not
look after or protect someone, to leave them, to give /withdraw /withhold affection
etc
• Coercive power or power by force - any use of violence, aggression or threats to
frighten, intimidate or ensure compliance
• Biological or embodied power - the possession of socially valued embodied
attributes eg: physical attractiveness, fertility, strength, embodied talents and
abilities, physical health
• Social/cultural capital – a mix of valued qualifications, knowledge and connections,
often related to class, race and gender, which ease people’s way through life and can
be passed indirectly to the next generation
• Ideological power - involves control of language, meaning, and perspective
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 Ideological power

 Probably the least obvious and least acknowledged form of power

 Part of every other form of power
 Operates when our thoughts, beliefs and feelings are manipulated,
ignored, or disbelieved, and alternative interpretations are offered or
imposed

In everyday life, it shapes the sense we make of our circumstances. In

mental health and criminal justice systems it can:

 turn social problems into individual ones

 diagnose or define people as ‘bad or mad’

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 The particular importance of ideological power - power
Ideological
over meaning, power
language and perspective . . .

• Many people, especially those in less powerful positions, may

be deprived of sound alternative frameworks to make sense
of their own and others’ distressing or unusual experiences

• This ‘epistemic injustice’ is experienced by groups who lack

shared resources to understand their experiences, due to
unequal power relations (Miranda Fricker, 2007)

• From the PTMF perspective, the imposition of a diagnosis,

with no alternatives offered, is an example of epistemic
injustice.

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 The particular importance of ideological power - power
Powerand perspective . . .
over meaning, language

• The less access you have to conventional or approved forms

of power, the more likely you are to adopt socially
disturbing or disruptive strategies

• Power also operates positively and protectively

 friends, partners, family, communities, material resources, social
capital, positive identities, education and access to knowledge

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Some consequences of the negative operation
of power . . .

• Unpredictability and lack of control over your life

• Feeling trapped in damaging environments

• Conflict – internal, relationships, social

• Negative views and stereotypes about you and/or your

social or ethnic group

• Repeated exposure to many forms of abuse and

violence, along with humiliation, criticism, racism and
other forms of discrimination etc
 “How did it affect you?”
(What kind of THREATS does it pose?)

• Relationships
 threats of rejection, abandonment, isolation

• Emotional
 overwhelming emotions, loss of control

• Social/community
 loss of social roles, social status, community links

• Economic/material
 threats to financial security, housing, meeting basic needs
 Threat
• Environmental
 threats to safety and security, or to links with the natural
world e.g. living in a dense urban or high crime area

• Bodily
 threats of violence, physical ill health

• Value based
 threats to core beliefs and principles

• Meaning making
 threats to ability to create your own valued meanings,
imposition of others’ meanings
 ‘
“What sense did you make of it?”
(What is the MEANING of these experiences?)

• We actively make sense of our world, and our behaviour is

purposeful and meaningful. We cannot understand any
aspect of Power, Threat or Threat Response separately from
their meanings.

But what do we mean by ‘meaning’?

Meaning is never just freely chosen, it is always both ‘made and

found’ (Shotter, 1993)
Being powerless is
uncomfortable and
often highly
distressing. Some
common feelings
('meanings') that
arise from lack of
power include:
 Meaning
Personal meanings are never purely individual

 Language is shared with others

 Memories reflect lived experience
 Bodily reactions and feelings are shaped by learned habits
 Environments differ, and resources are unequally
distributed
 How we ‘should’ feel is shaped by cultural norms

Thus, meanings are shaped by adverse power

relations, threats, social norms, ideologies, cultural
assumptions etc.

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 So, we need to see personal meanings within the contexts of:

• Wider discourses (common understandings about what it

means to be ‘mentally ill’, a ‘good mother’, ‘attractive’,
‘successful’, a ‘happy family’, a refugee, a member of a
particular ethnic group, and so on)

• Ideological meanings – deeply embedded assumptions

about the world that serve certain interests (neoliberalism is
a good example.)

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 “What did you have to do to survive?’”
(What THREAT RESPONSES are you using?)

We have all evolved to be able to respond to threats, by reducing

or avoiding them, adapting to or surviving them, and trying to
keep safe.

These threat responses are biologically-based but are also

influenced by our past experiences, family context, gender, class,
ethnicity, by social and cultural norms, and by what we can
actually do in any given circumstances.
They are on a spectrum from automatic (more biologically-based)
to more personally and culturally-shaped.
 Some examples of threat responses
• Preparing to fight, flee, escape, seek safety
• Giving up (‘learned helplessness’, apathy, low mood)
• Being hypervigilant
• Having flashbacks, phobic responses, nightmares
• Experiencing rapid changes in mood and emotions
• Amnesia/fragmented memory
• Hearing voices, dissociating, holding unusual beliefs
• Restricting our eating, using alcohol or drugs, self-harm
• Denial, avoidance
• Overwork, perfectionism

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Threat responses (survival/coping mechanisms)
are often labelled symptoms of ‘mental illness’
Some of these may be seen as ‘normal’ or even desirable
(overwork, perfectionism, ruthlessness with colleagues, etc..)
They are likely to be to some degree culture-specific (self-
starvation in Westernised countries; so-called ‘culture-bound
syndromes’.)

Threat responses are there for a reason, and it makes more

sense to group them by function – what purpose do they
serve? than by ‘symptom.’

Both the function and the meaning of the response vary over
time and across cultures, but there are common themes.
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 Threat responses grouped by common functions
• Regulating overwhelming feelings: (e.g. by dissociation,
self-injury, memory fragmentation, bingeing and purging,
differential memory encoding, ritualising,
intellectualisation, ‘high’ mood, low mood, hearing voices,
use of alcohol and drugs, compulsive activity of various
kinds, overeating, denial, projection, splitting, somatic
sensations, bodily numbing).
• Protection against attachment loss, hurt and
abandonment: (e.g. by rejection of others, distrust, seeking
care and emotional responses, submission, self-blame,
interpersonal violence, hoarding, appeasement, self-
silencing, self-punishment).

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 Threat responses grouped by common functions
Preserving identity, self-image and self-esteem: (e.g. by
grandiosity, unusual beliefs, feeling entitled, perfectionism,
striving, dominance, hostility, aggression)
Preserving a place within the social group: (e.g. by striving,
competitiveness, appeasement, self-silencing, self-blame)
Protection from physical danger: (e.g. by hypervigilance,
insomnia, flashbacks, nightmares, fight/flight/freeze,
suspicious thoughts, isolation, aggression)

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 Restoring the link between Threats and Threat
Responses
Linking Threats–toa Threat
main purpose of the Framework
Responses
• The Power Threat Meaning Framework shows how we can
restore the links between threats and threat responses as an
alternative to the diagnostic lens which obscures them.
• At one level this is common sense. We all know that people living
in poverty are more likely to feel miserable (‘depression’); we
recognise that abuse and trauma makes it more likely that people
will hear voices (‘psychosis’ or ‘schizophrenia’); and that
Indigenous people have many reasons for despair.
• But a number of factors combine to conceal these links – from
the person and from society as a whole.
• The threat (or operation of Power) may be less obvious because
it is subtle, cumulative, and/or socially acceptable.
• The threat is often distant in time.
• 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
• 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.

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• The person in distress may not be aware of the link themselves,
since memory loss, dissociation and so on are part of their coping
strategies.
• The person in distress might have become used to overlooking
possible links, because acknowledging them felt dangerous,
stigmatising or shaming
• Overlooking or ignoring the links may be encouraged by:
 Messages about personal blame, weakness, culpability etc.
 Messages about personal responsibility, not complaining,
being strong etc.
• The use of diagnosis by professionals obscures the link
between threats and threat responses, and imposes a
narrative of individual ‘illness’ instead

• There is widespread resistance to recognising the reality

and impact of threats and the negative impacts of power

• There are many vested interests (personal, family,

professional, organisational, community, business,
institutional, economic, political) in disconnecting threats
from threat Responses - and thus preserving the diagnostic
model.
Questions
 General Patterns within the Power Threat
Meaning Framework
What kind of patterns of distress do we find if we put together
the evidence about the influences of Power, Threat, Meaning and
associated Threat Responses?
Medical diagnosis depends on patterns identified through a
medical lens. The PTMF aims to provide an alternative meta-
framework for identifying patterns or regularities appropriate for
emotional distress and troubled or troubling behaviour.
The General Patterns are, and always will be, in a state of
development. We have suggested the principles on which they
need to be based.
 General Patterns within the Power Threat
Meaning Framework
Unlike biological patterns, these regularities are organised by
meaning not by biology.
The experience of adversity sets up broad, complex, overlapping,
meaning-based patterns which are and always will be evolving. A
very different kind of causality is implied, within which it will
never be possible to make precise cause-effect predictions.
The patterns will always reflect and be shaped by specific
worldviews, social, historical, political and cultural contexts and
ideological meanings.
 Patterns of embodied, meaning-based threat
responses to the negative operation of power.
The General Patterns are described as verbs not nouns, to reflect
the fact that they represent active (although not necessarily
consciously chosen or controlled) attempts to survive the
negative operation of power. They describe what people DO not
what they ‘HAVE.’

They are not a one-to-one replacement for diagnostic clusters,

and people will vary in their ‘fit’ with one or more patterns –
thus, general patterns will always need tailoring to the person
(or couple/family/social group).

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 Evidence-based General Patterns

We have provisionally outlined 7 evidence-based General

Patterns which cut across:
• Diagnostic categories
• Specialties (MH, addictions, OA, Child, criminal justice,
health)
• ‘Normal’ and ‘abnormal’
• People who are psychiatrically labelled and all of us
 Seven Provisional General Patterns

1. Identities
2. Surviving rejection, entrapment and invalidation
3. Surviving insecure attachments and adversities as a
child/young person
4. Surviving separation and identity confusion
5. Surviving defeat, entrapment, disconnection and loss
6. Surviving social exclusions, shame and coercive power
7. Surviving single threats
In Westernised countries, these patterns draw on struggles with
Western norms and standards, such as:
• Separating from your family in early adulthood
• Competing and achieving in line with social expectations (eg in
the labour market; for material goods)
• Meet your needs within a nuclear family structure
• Fit in with standards about body size, shape and weight
• Fit in with expectations about gender identity and gender roles
• Avoiding ‘irrational’ experiences – (eg contradicting notions of a
unitary self)
• As an older adult – cope with loneliness and lack of status
• Bring up children to fit in with all the above
 General Pattern: Surviving social exclusion, shame and
coercive power
Within the Power Threat Meaning Framework, this describes
someone whose family of origin is likely to have lived in
environments characterised by threat, discrimination, material
deprivation and social exclusion. This may have included absent
fathers, institutional care and/or homelessness. Within this,
caregivers are likely to have been struggling with their own histories
of adversity, past and present, often by using drugs and alcohol. As a
result of all this, the person’s early attachments were often disrupted
and insecure, and they may have experienced significant adversities
as a child and as an adult, including physical and sexual abuse,
bullying, witnessing domestic violence, and harsh or humiliating
parenting styles. ‘Disorganised’ attachment styles are common.
Individuals tend to use survival strategies of cutting off from their
own and others’ emotions, maintaining emotional distance, and
remaining highly alert to threat.
Discourses and status comparisons may have imparted a sense of
worthlessness, shame and injustice, which may be managed by
various forms of violent behaviour. More unequal societies, in
which economic inequality increases social competition, allow
these dynamics to flourish. This may have a particularly strong
impact on disadvantaged men, who have greater incentives than
women to compete, achieve and maintain high social status,
while being faced with numerous indications of their lack of
success and status. Social discourses about gender roles, class and
ethnicity shape the way in which the threats are experienced and
expressed.
Questions
 Patterns and ‘culture’
The Power Threat Meaning framework predicts and allows for
the existence of widely varying cultural experiences and
expressions of distress without seeing them as bizarre, primitive,
less valid, or as exotic variations of the dominant diagnostic or
other Western paradigms.

Since it is an over-arching framework that is based on universal

evolved human capabilities and threat responses, the basic
principles of PTM apply across time and across cultures.

Within this, open-ended lists of threat responses and functions

allow for an indefinite number of locally and historically specific
expressions of distress, all shaped by local cultural meanings.
 Example of a ‘culture-bound syndrome’ DSM IV

‘Spirit possession’ is sometimes seen as equivalent to the

psychiatric concept of ‘psychosis’. One version, ‘cen’, is found in
Northern Uganda, where civil war has resulted in widespread
brutality and the abduction and forced recruitment of children
as soldiers. In this phenomenon, young people report that their
identity has been taken over by the malevolent ghost of a dead
person. ‘Cen’ has been found to be associated with high levels
of war trauma and with abduction, and the spirit was often
identified as someone the abductees had been forced to kill.

We could understand this within the Power Threat Meaning

framework without having to call it ‘schizophrenia’ or ‘psychosis’
In contrast to the Global Mental Health Movement which is
currently exporting diagnostic models across the world, the
Framework is intended to convey a message of respect for the
many different ways people express and heal distress both
within the UK and across the globe.

Workshops on exploring, comparing and contrasting the PTMF

with indigenous understandings in New Zealand and Australia
are described here:
https://www.madintheuk.com/2019/02/crossing-cultures-with-the-power-threa
t-meaning-framework/
https://www.madintheuk.com/2019/03/crossing-cultures-with-the-power-threa
t-meaning-framework-australia/
 The PTM Framework and the relevance of:

• Histories of colonisation, slavery and intergenerational

trauma, and the resulting discrimination, loss of identity,
culture, heritage and land
• Inseparability of individual from the social group
• Relationship to the natural world
• Integration of mind, body, spirit, natural world
• Indigenous psychologies and research paradigms
• Culturally-supported practices, rituals and ceremonies
• Community narratives, values, faiths and spiritual beliefs, to
support the healing and integration of the social group
(Main, p.216-217; Overview, p 77-79.)
 The PTM Framework and narrative
Story-telling and meaning-making are universal human capacities.
The PTMF validates and provides evidence for the central role of
narrative of all kinds as an alternative to diagnosis, and as a means
of witnessing and healing, both within and beyond services.
The evidence-based General Patterns support the construction of
particular narratives of any kind
So – including but going beyond evidence-based practice and
historical truth, in order to value ‘narrative truth’ (Spence, 1982);
and whether stories seem to ‘fit’ in a way that ‘makes change
conceivable and attainable’ (Schafer, 1980).

Recovery as ‘reclaiming our experience in order to take back

authorship of our own stories’ (Dillon and May, 2003)
Examples of PTMF used and translated into practice

Clinical Psychology Forum free download:

https://shop.bps.org.uk/publications/clinical-psychology-forum-no-313-janu
ary-2018.html

Articles on using PTMF ideas in peer groups; with children and young
people; in teacher training; in social work training; with survivors of
domestic abuse; in an autism clinic; with clinical psychology trainees.
Special edition of J of Constructivist Psychology on the PTMF
https://www.tandfonline.com/action/showAxaArticles?journalCode=upcy20
Articles in Mental Health Today, Mental Health Nursing, Journal of
Humanistic Psychology, Nurse Education Today, Therapy Today, etc..
Examples of PTMF translated into practice

Enhancing existing formulation and team formulation work (AMH, OA, LD,
autism, youth offending, ‘PD’, etc)
 Adding ‘Power’ explicitly to current formulation models
 Using the Guided Discussion template for team formulations
 Developing a formulation group based on PTMF
Trauma-informed PTMF-based project on 2 inpatient wards in Northwick
Part Hospital, due to be rolled out across CNWL inpatient wards and
possibly further across London.
Guiding services for trafficked women and for refugees
Peer support groups in UK, USA, New Zealand, Australia using PTMF ideas
(including the international group Peerzone.)
Training/teaching
• Now taught on most clinical psychology courses in the UK and in Ireland.
Also on courses for undergraduate psychology, forensic psychology,
nursing and social work, teacher training, educational psychologists.
Voluntary organisations
• Interest from St Mungo’s, Women’s Aid, Jigsaw, Together for Mental
Wellbeing, and others
Translations
• Spanish (Main and Overview). Italian, Danish, Portuguese, Hungarian
and Korean planned.
Criminal justice system
• Used in court reports, service planning, groupwork, supervision
Textbooks
• ‘Abnormal psychology: Contrasting perspectives’ Raskin, 2018
• ‘Communication and interpersonal skills’ 4th edn Grant and Goodman, 2018
• ‘Psychology and Sociology in MH Nursing’ Goodman, 3rd edition, 2019
• Revised edition of ‘Psychology, mental health and distress’ Cromby, Harper
and Reavey, 2013

Boyle M and Johnstone L (2020) A straight talking introduction to the PTMF.

PCCS Books
The PTMF Committee – supporting interest in the PTMF

The PTMF Committee is a sub-committee of the Division of Clinical

Psychology and reports to the DCP Exec committee. It has 14 members and
meets every 2-3 months. It was set up to develop and collate relevant
resources, offer mentoring (eg via ‘Train the Trainer’ days), link with EbEs
and other stakeholders, ensure integrity to the principles of the PTMF and
encourage sharing of ideas and good practice, including in other countries.
All documents, training resources, videos, articles, good practice examples
etc available here:
https://www.bps.org.uk/news-and-policy/introducing-power-threat-meanin
g-framework
What does this add to a routine formulation?
The unhelpful aspects of the dominant narrative of psychiatric
diagnosis and its wider context of meta-narratives about science.
The contradictions in combining psychiatric diagnostic narratives with
psychosocial ones.
The role of social discourses, especially those about gender, class,
ethnicity and the medicalisation of mental distress, and how these
discourses can support the imposition of others’ meanings.
The impacts of coercive, legal, and economic power.
The nature and impact of power inequalities in psychiatric settings.
The prevalence of abuse of interpersonal power within relationships.
The role of ideological power as commonly expressed through
dominant narratives and assumptions about individualism,
achievement, personal responsibility, gender roles, and so on.
 What does this add to a routine formulation?
The mediating role of biologically-based threat responses.
The importance of function over ‘symptom’ or specific problem.
The role of power resources in shaping threat responses.
Culture-specific meanings and forms of expression.
Self-help and social action along with, or instead of, professional
intervention.
The importance of group and community narratives to support the healing
and re-integration of the social group.
Recognition of the personal and provisional nature of all narratives and the
need for sensitivity, artistry and respect in supporting their development and
expression.
A meta message that is normalising, not pathologising (either medically or
psychologically): ‘You are experiencing a normal, understandable and indeed
adaptive reaction to threats and difficulties. Many others in the same
circumstances have felt the same.’
 Trying it out…. An exercise

Guided discussion for helping to apply these ideas to people’s

real lives – inside or outside services.
• Either: Use yourself as an example (whether or not you
have a MH history) but take care of yourself!
• Or: Use someone else as an anonymous example (friend,
family member.) NB Confidentiality

Either: Pairing up with someone else

Or: Doing it on your own
 Trying it out…. An exercise

Use the Guided Discussion to think about someone’s story

•Read the summary
•Divide into groups with each group thinking about Power
influences, plus one of either Threat, Meaning, Threat
Responses, or Strengths.
•Write thoughts on flipchart paper.
•Summarise the group view.
•Reflections on the process
•Update on the person’s story
 ‘Taking the ideas forward’ exercise

At the end of the event:

• Divide into groups according to interest/setting
• Think about what you want to take forward (anything from
small changes to more ambitious ones)
• Think about what challenges/obstacles you might face
• Think about what strategies/support you might need to
overcome them

Fill in the evaluation form and indicate whether you would

like ongoing support from the PTMF committee
 Consultation group of service users/carers

The PTM Framework was co-produced with the survivor

members of the core team from the first meeting. It draws
extensively from survivor literature and has benefited from
other SU contributors.
In addition, we consulted with a group of 8 service
users/survivors and carers. They were sent a brief outline of the
Framework and then invited, via a one-to-one discussion, to
reflect and give feedback on it from the perspective of their own
lives, experiences and mental health difficulties.
Their comments were then used to refine the framework
further. They were paid for their time.
 The consultant group (see Chapter 7 main document
for more details)

Aiming for a range of backgrounds and experiences:

4 men 4 women
Age range 21- 54
5 White British, 2 African Caribbean, 1 non-British (unspecified
for the purposes of the project)
A range of diagnoses in childhood and/or adulthood from
anxiety to ‘schizophrenia’
Most had not been exposed to ‘critical’ perspectives in any
detail, and were not mental health activists or campaigners.
 ‘
“What has happened to you?” (How is Power operating in
your life?)

‘The most helpful aspect has been the power, and had this been
up for discussion it would have changed the course of what
happened…for me’ (E).
‘[The] power part of the framework is the fulcrum of it’ (F).
‘It would have felt like a weight off my shoulders to feel that the
person I was talking to was recognising the things… that were
predominantly the cause of my problems… somebody hearing
me say, ‘I have absolutely had the sharp end of the stick in
certain power-related situations ………That would have been an
incredibly helpful alternative to what did happen’ (C).
 “How did it affect you?” (What kinds of Threat does this
pose?)

‘Threats’ included relationship traumas, poor housing, violent

neighbourhoods, physical disability, welfare systems, racial
discrimination and poverty.
“What sense did you make of it?” (What is the Meaning of
these experiences to you?)

‘Intuitively I always understood my experiences this way. How

scared, suspicious and fearful I was made sense to me, I’d
experienced various threats, including my first memory, pretty
much constantly throughout my life in all the different spheres I
existed, and another dramatic threat on the day I started to hear
voices….My voices, constantly threatening to harm me, and
berating me as justification for why they would harm me, felt
like an expression of the fear I’d spent my life denying I felt, and
mirrored the general pattern of threats I’d experienced.’
Consultants spoke frequently about the damaging impact of
having others’ meanings imposed on their feelings and
behaviour within mental health services:
‘…absolutely everything I had to say, including that the drugs
were making things worse, [staff] made me, and more
specifically my brain, the problem, rather than my traumatic
experiences’ (F).
Consultants saw the processes of meaning-making and
permission to speak as being linked, and as offering the
potential for avoiding diagnosis, accessing more appropriate
intervention, adopting more adaptive coping responses and
feeling more positive about oneself.
 “What did you have to do to survive?” (What kinds of
Threat Response are you using?)

B stated that it was extremely useful to provide a context for

consciously exploring/addressing one’s responses to threat, and
what the origins of these might be: ‘…..dealing with real things
that are happening right now, rather than persuading [you that
you’re] a bit crazy, take the pill, shut up about it.’
 General Comments

Consultant A approved of the simplicity of the framework (‘it is

simple yet clever at the same time’), and how three discrete yet
overlapping constructs could be used to capture ‘many different
strands’ of one’s experience.

B felt the framework made an ‘enormous’ amount of sense and

was ‘very strong and useful…and really, really helpful’,
particularly the threat component. B also approved of the way
that the framework facilitated open discussion of
‘unmentionable’ events and could help people feel a sense of
permission to disclose: ‘that it’s okay to talk about these things,
it’s okay to tell people about them…to name them.’
 Strengths of the PTM Framework

• preventing or making more difficult the imposition of others’ meanings

• giving ‘permission’ to speak about certain life experiences
• encouraging more positive and helpful coping responses
• partly as a result of this, potentially fostering a quicker ‘recovery’

If the Framework had been offered at first contact with services:

‘I can guess I would have felt stronger afterwards. To be able to see a
professional… Ask me, genuinely, about any problems I’d had, power related
situations or threat related situations… [and] telling me ‘these are absolutely
valid things to be hugely unhappy about and very valid things to have
suffered because of’ (C).
 Queries and aspects to improve

• Language and conceptual complexity

• Possible additional threat responses
• Risk of interpreting as imposing another professional model
• Need for wider cultural change if the PTM Framework is to
have an impact.
Consultant C pointed out that the PTM Framework could be
problematic for people who might prefer a diagnosis which did
not explore their personal history, and seemed to provide clear-
cut answers rather than this more complex picture.