There is so much I can agree with in this paper – it is an insightful piece of work but whether it warrants either the accolades that seem to be expected by some of its authors or the brickbats that have been thrown at it already is, in my opinion, doubtful.
I think the paper will be helpful in a public health kind of way, guiding policy makers in putting together a more coherent approach to some aspects of the development of more effective mental health services but whether it will help therapists and clients in the room to work better together for the benefit of the distressed individual is another matter.
First of all, it is yet another static model firing at a moving target. It is an improvement on the fixed single barrel sniper rifle of psychiatry whose diagnoses are inevitably going to label the individual, though those labels can be helpful in this current climate of categorisation, litigation and limitation, but the PTMF is little better than the “duck foot” gun favoured by security guards in the C18th that sprayed a limited but wider area with several bullets in the hope of hitting a number of targets.
I want to make a few observations about the development of the concept of trauma and why I think that this new framework is little more than a yet another particular feature in the view seen from the railway carriage of human development racing through the countryside of social evolution.
Human beings as a species have been experiencing trauma throughout their existence. That human beings could experience psychological damage related to traumatic experiences was not recognised in any meaningful way until the beginning of the 20th century. Since then trauma, in the form of the diagnoses of post-traumatic stress disorder, adjustment disorder, et cetera has been increasingly recognised as phenomena experienced by individuals in response to events that are frightening and out of the ordinary. It is necessary to ask the question as to how these behaviours became abnormal and the medicalisation of behaviours in response to trauma occurred.
During the 20th century vast social changes took place and particularly after the Second World War the world became a much safer place (Pinker 2011, Harari 2015). For the first time in our lives the majority of human beings could expect to live out their lifespan in relative comfort and safety. As a consequence of this improvement in security and safety, particularly in the West, unpleasant experiences such as war, violence and natural disaster became much less common and when they did occur far fewer people were injured or killed. Furthermore, many forms of trauma and abuse were being exposed, and still are, and thus the commonality of violence and abuse against the vulnerable became less common. It is also increasingly becoming a subject awareness for the population and increasingly disapproved of. Many forms of abuse that have been previously acceptable are now treated as crimes, for example the abuse of women in one form or another for sexual pleasure by men.
That more people are now traumatised by abnormal and horrific experiences is not so much a tribute to professionals recognising these events but that they are brought into profile by a much more benign environment that causes them to stand out. There are also the traumas of everyday life such as road traffic collisions, injury at work and other personal injuries that in themselves have become much more apparent due to the increase in regulation of activities that might be considered dangerous but were part of everyday life previously. One only needs to look at the nature of health and safety on building sites, in industrial settings and even in office settings to see how much more physically benign these environments now are. Road traffic collisions are a particular example as the number of deaths has declined consistently over the last 30 years, though there may be a number of reasons for this, for example, the improved safety features of cars and restrictive driving regulations play a large part.
That these events now stand out in our lives as worthy of attention by medical and psychological professionals is a tribute to how society and its lawmakers have contributed to making this aspect of the environment much safer. However, it does not mean that these behavioural responses by people who have experienced unusual and traumatic events are now the remit of the medical profession in the form of a disorder. These responses remain a normal and when thought about carefully, a logical response to an unpleasant experience. Allen Frances makes the observation:
“Our brains and our social structures are adapted to deal with the toughest of circumstances-we are fully capable of finding solutions to most of life’s troubles without medical meddling, which often muddles the situation and makes it worse. As we drift evermore toward the wholesale medicalisation of normality, we lose touch with our strong self healing capacities-forgetting that most problems are not sickness…” (Frances 2013)
Unfortunately, like most theories of human psychology this power threat meaning framework remains threatminded and backward looking. Assessment and formulation are subjective, capricious and based upon the ability of the practitioner to ask the right (and sufficient) questions about a person’s history and the trauma.
Assessment and formulation is also based upon the accurate memory and honesty of the client. I for one would never disclose my darkest secrets and thoughts to a relative stranger, nor is my memory sufficiently good to remember the details of what happened to me. Furthermore, my memories are coloured by my own emotions and experiences since that time. So, any description of those events is clearly questionable, which is why uncorroborated evidence is not admissible in legal situations. For example, notes of medical and psychological interventions have to be written as soon as reasonably possible after the event (within 24 hours) Loftus’ work for example gives us plenty of examples. A short trawl of Twitter researching the experiences of people who have suffered trauma and are in the mental health system very quickly throws up plenty of examples of thoughtless, unhelpful assessments and history takes.
The framework itself is complex and open to misinterpretation, as has already happened in the discussions I have seen on social media. How a therapist is supposed to hold all that framework and theory in their head while working in the room is beyond me. Furthermore, if it were to become a taught model it is going to be open to the interpretation of the tutors with their own innate bias and preferences. Again, something we have seen time and again expressed in the classroom and upon social media.
The paper is repetitive, and this seems to me to be largely to ensure that as many of the great and good get a referenced mention in the document, after all we have to keep as many powerful and influential academics onside as possible, don’t we?
The paper criticises psychiatry for its logical positivism and then goes on to use the same approach to showcase its own ideas.
The paper remains problem focused in much the same way that psychiatry is; it just does away with the labels. There have been many people have criticised the increasing medicalisation of human emotion and experience in an attempt to check the onward march of psychiatry into normality as Frances’ quote above illustrates. Focusing upon problems merely emphasises problems.
My immediate response to power threat meaning is that clinical psychologists have not attempted to check that march on normality but simply to attempt to impose a new paradigm upon that onward march.
Professionals having a narrow view is a criticism aimed at medical diagnosis, yet surely the same criticism can be made of this theoretical framework as well? Certainly, the social media discussions illustrate a very clear, “you are either for us or against us!”
There is a further fundamental problematic assumption in this document. There seems to be a sense of what is normal and what is not normal. An arbitrary line drawn between acceptable behaviours and responses and those that are traumatic. As I have pointed out in the past and this has been illustrated shockingly in the last few weeks in relation to what is acceptable in the way that women are treated. Acceptable behaviour by human beings one to another is constantly evolving and what was acceptable 300, 200, 100 even 10 years ago is not acceptable today. Therefore, what may have been considered acceptable 50 years ago for example is no longer acceptable today and thus now becomes traumatic. This is a complex area. I have already seen examples in the press of people questioning this evolution or even perception of abuse to be shot down immediately by proponents of power threat meaning without discussion or apparently much thought.
While there is a nod in the document to individual strengths, most of the attention is focused on problems and trauma. There seems to be very little attention to the things that people are coping with that are helping them survive. Where the paper does allude to this I get the sense that it is unnecessarily complicated and the need for professional “expert interpretation” seems to override client experience. My own experience is that these interpretations often get in the way; these tend to be assumptions that are accepted by the client on the basis that the expert knows best. This attribute to the professionals is carried throughout the document with the idea that the professional can empower the client. This is at best a dubious idea and at its worst illustrates the need for the professional’s sense of control and power which is one of the things the framework is trying to deal with and dissing the psychiatric profession for.
The writings within the document seem to suggest that there are patterns but is constantly recognising that these are not consistent patterns and “The implication is that ‘comorbidity’ is not a nosological problem to be solved, but a reflection of the fact that people can use multiple ways to respond to adversity and threat.” I don’t understand; if people respond in multiple ways to what may appear to be the similar stimuli then how can a pattern be imposed upon it?
One of the most interesting statements in the whole document is:
“The evidence cited in the main publication supports the contention that humans are social beings whose core needs include: To experience a sense of justice and fairness within their wider community.
The Power Threat Meaning Framework states explicitly the following core needs:
To have a sense of security and belonging in a family and social group.
To be safe, valued, accepted and loved in their earliest relationships with caregivers.
To meet basic physical and material needs for themselves and their dependants.
To form intimate relationships and partnerships.
To feel valued and effective within family and social roles.
To experience and manage a range of emotions.
To be able to contribute, achieve and meet goals.
To be able to exercise agency and control in their lives.
To have a sense of hope, belief, meaning and purpose in their lives.
…all of which will provide the conditions for them to be able to offer their children…
Secure and loving early relationships as a basis for optimum physical, emotional and social development and the capacity to meet their own core needs.”
While they are all very laudable and clearly we would all want them in our own ways, these are political aspirations for a society and not usually the remit of theoreticians and therapists. They are a very middle-class, professionally based set of aspirations and criteria. These are WEIRD criteria! They are also based upon current Western thinking. Another aspect that the paper claims to be aware of yet seemed rather confused in its thinking about it.
While I may be at appear to be at odds with the paper, I do agree with much of what it says particularly with respect to the statements above. It is high time that psychologists stepped away from the almost entirely individualistic approach to matters psychological and began to look at the wider aspects of the impact that communities, security and a sense of future will have upon any population anywhere in the world. It is time for psychologists to become overtly political, begin to study and research in detail what it is that actually impact upon our well-being and how that might be better derived. Following a neoliberal and individualistic pathway is not going to change levels of well-being in this country or globally. It is time to stop thinking about threat and to begin to build opportunity, security and a sustainable future.
So, in conclusion while I can agree with many of the aspirations of the paper, I find it confusing, repetitive and unclear about what it wants to be and even how it intends to achieve it. It is far too academic and technical, it is based upon an understanding from the viewpoint of the ivory tower and seems to take little into consideration of the common person stood at the base of the tower who may be either “waving or drowning”.
I’m quite sure that most people will never read it properly, many will never understand it and I doubt very much whether it will ever be taken up seriously as a challenge to psychiatry.
Frances, A. (2013) Saving Normal, Harper Collins, London.
Harari, Y. (2105) Homo Deus, A Brief History of Tomorrow, Penguin, London.
Pinker, S. (2011) The Better Angels of Our Nature: Why Violence Has Declined, Penguin Books, London.