I have been receiving emails from Time to Change telling me it’s O.K. to talk about mental health wherever I am. That’s a relief because I want to give a brief response to the launch of the Power, Threat, Meaning Framework (PTMF) which I attended in January 2018 in London. It’s the result of several years work by a team of mainly academic clinical psychologists with the added input of some service-user consultants.
The framework is set out as an alternative to psychiatric diagnosis. This sounds straightforward enough until one asks ‘alternative’ in what sense? The PTMF certainly does a good job of reviewing the social causes of what the authors have grouped together (by default) as “mental health problems”. No one could object to attempts to understand why people get to be diagnosed in the first place. The PTMF is therefore something that policy makers should take seriously. However, as regards diagnosis in the sense of labeling someone with a disorder, the PTMF doesn’t seem to question the fact that a large segment of the population can be labelled as distressed, troubled, or as troubling others. It also proposes general descriptive patterns that could serve to categorise this group. This is not, therefore, an alternative to the practice of diagnosing per se. It seems to follow that the PTMF doesn’t see an alternative to a societal need for a group of professional experts to administer to the distressed. It is even suggested that the replacement for medicalising practices could be located in local authorities where, presumably, psychologists would take the lead role rather than psychiatrists. I hesitate to support replacing target-driven NHS managers with the whims of town hall councillors and bureaucratic local government officials. Social workers have to operate from this base and their public image is not great despite the hard work they put in to support poor, helpless, or dependent individuals. It seems likely that the ‘distressed and troubled’ would become another class of unfortunates – too poor to afford private health insurance that covers psychotherapy or specialist treatment centres. The NHS does at least attempt to provide a uniform and universal coverage that is free to those who satisfy criteria of sufficient need. In any case, psychiatry is not forced to adopt the biomedical model even though it is difficult to conceive how this particular leopard could change its spots.
For all its focus on power, the PTMF still seems to be advocating a system of the powerful dispensing to the relatively powerless. The constant reference to ‘distress’ evokes an image of a person who needs to be cared for, who is perhaps, depressed, anxious, or traumatised. The sufferer is encouraged to reflect on their personal history and what they actually did to confront adversity and build a new narrative. It emphasises the meaning that a person has given to experiences of surviving abuse and trauma, and to focus on their personal narrative of resistance and coping. The PTMF offers a set of general principles to help them in this self-analysis but given that each person has a unique biography, generalities can only go so far. The framework could be enlightening but it doesn’t tell you what to do when up against it. In fact, a person might not become ‘distressed’ but turn to alcohol, substance abuse, violence, crime, or bitter resentment. However much a person self-reflects or benefits from a consciousness-raising group, in the final analysis, a narrative has to lead to practical action. It may be necessary to challenge past personal accounting and make a decision to change. As one questioner in the audience asked: doesn’t the PTMF framework leave the person as a passive victim of adversity?
I was hoping to hear something about the formulation of the problems of single individuals but the PTMF is rather silent on this topic, even suggesting that a formulation could represent the imposition of an unwanted analysis by an expert. This downplays the collaborative and dialogical nature of formulation. If a person refuses to engage in dialogue, they are unhelpable until they change their mind about this. He or she might turn to religion or numbing medication instead. Of course, not all forms of distress require psychological expertise, especially when wrongs need to be righted by taking legal action or by conducting a political campaign. For people who are willing to engage in therapy, I believe that mental health professionals have much to contribute in solving a number of common problems. For instance, despite their somewhat narrow theoretical base and implicit support of medicalisation, clinical psychologists have produced many useful ideas and methods that are disseminated widely in the media and through self-help books. The latter are read by people who not necessarily aware of their academic origin. It is rather disappointing to see in the PTMF document that successful therapy is attributed to the ‘relationship’, as if professionals have some kind of inspirational power to make people better. Instead of this top-down position, professionals could work in partnership with or in support of voluntary and community initiatives for solving problems. As an alternative to ‘diagnosing and treating’, more power could be given to people who know their problem from the inside, encouraging them to generate their own solutions. The role of government could be to fund and support groups of people with a similar kind of problem. However, this is not the direction in which current mental health policy is heading.
The PTMF would clearly like to replace the concept of mental illness but there is a risk that an alternative might attempt to explain everything in life that presents itself as a problem. This is clearly too ambitious and impractical. In any case, problems may have little in common. Would the approach to dealing with a gambling habit, an episode of panic, domestic violence, a cleaning ritual, or a distorted body image share much in the way of general principles? Perhaps each type of problem requires a different framework. From a social policy perspective, there are decisions to be made about the extent to which a person is made personally responsible and accountable, how far changes in legislation would help, and, as noted earlier, what could be done at the level of social provisions and the support of community action.
In brief, the PTMF does not seem to acknowledge the role of professional helping in systems of social control, in the sense of returning the ‘distressed’ to ‘normality’. The influence of power in society is also viewed in mostly negative terms. Social control can operate positively by encouraging and rewarding virtuous behaviour, by providing education, training, and hopefully inspiring and creating opportunities for positive ends. This is not to underestimate the role of negative power in producing adversity, threat, trauma, and abuse. The latter undoubtedly account for a very large proportion of people who end up in current mental health services. However, as some in the service user resistance movement have pointed out, the activities of helping professionals (and not solely medical ones) can also amount to a form of negative social control. It would be helpful for any radical employment of an alternative framework to diagnosis to address the role it would play in processes of social control.