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Reflections on responses to the power threat meaning framework one year on

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The project group reflects on the responses to the Power Threat Meaning Framework (PTMF) one year after publication. The group welcomes the interest shown in the document, and takes this opportunity to clarify some points, reflect on and learn from others, and suggest areas for future development.
Content may be subject to copyright.
Inside…
nTeacher education
nClinical psychology training
nYouth mental health
nSocial work education
nSurviving prison
nAutism and learning disability
Contents
Regulars
1 Editorial
Ben Donner
2 Correspondence
55 DCP UK Chair’s Update
Julia Faulconbridge
Articles
3 Youth Mental Health and the Power Threat Meaning Framework:
Jigsaw’s systems perspective
Cian Aherne, Olive Moloney & Gillian O’Brien
9 Reflections on using the Power Threat Meaning Framework in peer-led systems
Amanda Griffiths
15 Time to teach the politics of mental health: Implications of the Power Threat Meaning
Framework for teacher education
Catriona O’Toole
20 Bringing the outside in: Clinical psychology training in socially aware assessment,
formulation, intervention and service structure
Helen Griffiths & Frances Baty
25 Surviving prison: Using the Power Threat Meaning Framework to explore the
impact of long-term imprisonment
Mariana Reis, Sami Dinelli & Lucinda Elias
33 Using the Power Threat Meaning Framework in social work education
Rachel Fyson, Kirsten Morley & Andrew Murphy
38 The ‘Own my life’ course: Building literacy with women about trauma through the
Power Threat Meaning Framework
Natalie Collins
42 Incorporating the Power Threat Meaning Framework into an autism
and learning disability team
Alison Flynn & Nechama Polak
47 Reflections on responses to the Power Threat Meaning Framework one year on
Lucy Johnstone, Mary Boyle, John Cromby, Jacqui Dillon, Dave Harper, Peter Kinderman,
Eleanor Longden, David Pilgrim & John Read
St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK
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© The British Psychological Society 2019
Incorporated by Royal Charter Registered Charity No 229642
01
9771747 573416
ISSN 1747-5732
ISSN: 2396-8664 (Online)
Clinical Psychology Forum
Number 313 – January 2019
Special Issue: The Power Threat Meaning Framework
Clinical Psychology Forum
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Clinical Psychology Forum 313 – January 2019 1
Editorial
Ben Donner
WELCOME to the January 2019 issue of Clinical Psychology Forum. This issue is a special one,
focusing on applied uses of the Power Threat Meaning Framework within human services
and beyond. We also have an update from the project team one year on from publication
of the original document. I think it’s fair to say the framework can be highly effective and useful
for many people, both in help-providing and help-seeking roles.
Ben Donner
Co-ordinating Editor
badonner@gmail.com
2 Clinical Psychology Forum 313 – January 2019
Correspondence
MEANINGFUL DISCOURSE is undermined
by inaccurate denitions and groupings.
Pilgrim’s statement in ‘Paying the price of posi-
tivism’ (CPF 309) that ‘behaviourism failed’ is
problematic because it lumps together all the
varieties of behavioural science into a single
movement. In fact, there were a range of
different and sometimes contradictory philos-
ophies and theories under this banner, some
of which clearly haven’t failed, at least by their
own measure of success.
Broadly, the aims of Skinner, and more
latterly contextual behavioural science (CBS),
have been to help individuals improve their
lives and society to become a fairer, kinder and
more sustainable place (see Zettle et al., 2016).
Today, CBS is making just such a difference in
almost every part of society. There are, for
instance, more than 250 RCTs evidencing the
positive benet acceptance and commitment
therapy (ACT) is having across a range of
human problems. And a quick glance at NICE
guidelines reveals a host of evidence-based
behavioural techniques and processes. Clearly
it has a long way to go, but to describe this as
failure seems harsh.
It is also incorrect (and somewhat ironic)
to cast radical behaviourism as embracing
positivism when Skinner and other functional
contextualists so consistently rejected this posi-
tion. Skinner’s thinking was informed pragma-
tism, not positivism.
Scientic laws… are not, of course, obeyed
by nature, but by men (and women) who deal
effectively with nature. The formula d=½gt2
does not govern the behaviour of falling
bodies, it governs those who correctly predict
the position of falling bodies at given times
(Skinner, 1969, p.141).
In other words, science is not about
describing the real world in any objective
sense, but rather it is about producing effec-
tive ways of talking about a subject matter to
achieve certain ends. This is the pragmatic
truth criterion that lies at the heart of radical
behaviourism and CBS, and it stands in oppo-
sition to positivism and realism.
While the origins of CBS are in the work of
early American pragmatism of James, Dewey
and Pierce, it has overcome the dogmatism
that held these early thinkers back (Hayes,
1993). Today, it can lay claim to being the fore-
most proponent of functional contextualism
in psychology, rejecting positivism, mechanism
and ontology as it seeks to build a science that
can make a positive contribution to the chal-
lenges we face.
Freddy Jackson Brown
Clinical Psychologist
References
Hayes, S.C. (1993). Analytic goals and the varieties of
scientic contextualism. In S.C. Hayes, L.J.Hayes,
H.W. Reese & T.R. Sarbin (Eds.) Varieties of scientific
contextualism (pp.11–27). Reno, NV: Context Press.
Skinner, B.F. (1969). Contingencies of reinforcement: A theo-
retical analysis. New York: Appleton-Century-Crofts.
Zettle, R.D., Hayes, S.C., Barnes-Holmes, D. & Biglan,
A. (Eds.) (2016). The Wiley handbook of contex-
tual behavioral science. Hove: Wiley & Sons.
Clinical Psychology Forum 313 – January 2019 3
Youth Mental Health and the Power Threat
Meaning Framework: Jigsaw’s
systems perspective
Cian Aherne, Olive Moloney & Gillian O’Brien
This paper details preliminary explorations of how the Power Threat Meaning Framework (PTMF) may be applied
in an early intervention youth mental health service. The PTMF is discussed under the organisation’s strategic
priority of inuencing change regarding youth mental health in Ireland.
JIGSAW is the National Centre for Youth
Mental Health in Ireland. The organisa-
tion is a registered charity which provides
individual therapeutic supports to young
people aged 12–25 years, support to the
communities in which they live, and seeks
to inuence change at policy level. Since its
inception and in response to the policy docu-
ment, A Vision for Change (Government of
Ireland, 2006), Jigsaw has been a multi-level
intervention organisation based on an ecolog-
ical systems model (Bronfenbrenner, 1979,
see Figure 1). Its intention is to work with
different systems simultaneously, towards
a society in which the mental health of young
people is valued and supported by all (see
Jigsaw, 2018).
Jigsaw’s clinical service supports people
with mild to moderate mental health dif-
culties in an attempt to intervene early,
before problems become more severe
and complex. Jigsaw services are currently
4 Clinical Psychology Forum 313 – January 2019
Cian Aherne, Olive Moloney & Gillian O’Brien
located in 13 communities across Ireland.
The services are youth-centred and operate
from a contextual (non-medical) approach
to mental health. Traditional approaches
taken by Western mental health services often
involve a focus on the individual rather than
the collective. Evidence shows, however, that
greater inequality in any society is linked to
higher rates of mental health difculties for
all (Wilkinson & Pickett, 2009). Jigsaw tries to
address this, by increasing the overall number
of young people in Ireland who experience
better mental health. To this end, Jigsaw goes
beyond service delivery to focus resources
on strengthening communities to support
young people through awareness, under-
standing and skills development for adults in
the community.
There is a synergy between the ethos and
practice of Jigsaw and the PTMF in terms
of offering an alternative to a medicalised
approach based on psychiatric diagnosis,
a focus on what people do (not what they
‘have’), and a belief that distress can be under-
stood as a meaningful response to challenging
life experiences. One of Jigsaw’s leading
strategic priorities is inuencing change.
This involves working collaboratively with
stakeholder partners to inuence change in
awareness levels, laws, policies and funding
Figure 1: Social ecological systems
Clinical Psychology Forum 313 – January 2019 5
Youth Mental Health and the Power Threat Meaning Framework: Jigsaw’s systems perspective
to advance the systemic change needed to
enable the organisation’s vision to become
a reality. With this aim, Jigsaw hosted an
event, a ‘Jigsaw Exchange’, with Lucy John-
stone, to introduce the PTMF to Ireland,
as an innovative and alternative framework
for conceptualising mental distress and
a range of troubled and troubling behaviour,
thus presenting evidence that challenges
common assumptions about mental health
inthe public domain. A public talk attended
by 400 people was held in the morning,
with the aim of prompting critical conversa-
tions about the mental health system and the
prevailing assumptions which underpin it.
In the afternoon, there was a workshop with
Jigsaw staff whereby learnings and implica-
tions for Jigsaw’s practice based on the PTMF
were discussed. Many of the ideas mentioned
in the following piece were generated from
these discussions.
Early intervention and prevention
Part of Jigsaw’s remit, as mentioned previously,
is to inuence change on a societal level. The
PTMF takes many societal factors into account
and may be helpful for Jigsaw’s navigation of
the effects of social and economic policies
on young people’s mental health. For young
people in general, it was deemed helpful that
the PTMF looks at mental health difcul-
ties as related to communities and societies
as a whole, rather than being specically
located in the individual (a notion that can
often have stigmatising connotations). It was
also acknowledged that discussion of the
PTMF may help to bring more varied public
understanding of emotional and behav-
ioural difculties. For example, Jigsaw can
position itself in the media with the view
that people’s responses to challenging situa-
tions are not ‘wrong’ but tend to make sense
and serve a purpose. This can be a helpful
message for challenging stigma. Jigsaw
provides a range of educational workshops
and it was acknowledged that the language
of these workshops could be enhanced by
being translated to a PTMF-informed style
(i.e. explaining concepts such as anger/
anxiety as being natural parts of life and how
threat responses can be useful for people at
times for survival).
A challenge for inuencing change noted
during the discussion, was that modern
society has become increasingly fast-paced,
yet the PTMF does not offer a quick-x for
a person’s difculties. While this may be
obvious, it does not lend itself to market-
able messaging or instantaneous under-
standing of what powers, threats and threat
responses are, so may get lost in the public
domain. Jigsaw’s engagement with the public
is a key part of inuencing change, and the
PTMF’s academic language can mean it is
difcult to understand and translate for
the public. Jigsaw operates youth advisory
panels (YAP) throughout the organisation,
where young people convene to inform the
service about best practice from a youth
perspective. Preliminary plans are in place
to review the PTMF language, in consulta-
tion with YAP members, to create a more
youth-friendly vernacular that a public audi-
ence might digest more readily (such as the
‘one good adult’ message from the My World
Survey; Dooley & Fitzgerald, 2012). Further
engagement with Jigsaw’s service users, other
stakeholders and corporate organisations is
intended to visualise how communication of
the framework as adapted to an Irish youth
mental health context could become more
engaging.
An advantage of the PTMF is that it offers
options other than therapy for young people
to understand and overcome their difcul-
ties. This ts well with Jigsaw’s Strengthening
Communities framework. An example of
where the PTMF has proved a helpful inu-
ence in Jigsaw is a service project aimed
at engaging and supporting the migrant
communities in its area. Young people from
these communities are far less likely to access
the service through any of its referral routes
(direct self-referral, guardian, professional),
and less likely to engage and continue
with sessions. Some hypothesised reasons
for Jigsaw being hard to reach for these
communities might be the impress of powers
6 Clinical Psychology Forum 313 – January 2019
Cian Aherne, Olive Moloney & Gillian O’Brien
which have operated in people’s lives,
including potentially unhelpful and inter-
fering well-meaning professionals, imposi-
tion of different cultural understandings,
exclusive language use regarding mental
health and perhaps fear of repeated oppres-
sion or trauma experienced previously.
We intend to co-produce an activity-based
project with young people to increase acces-
sibility of Jigsaw, and to learn more about
the ways in which mental health is under-
stood in migrant communities. Jigsaw seeks
to build these relationships, so we can better
understand what has happened to them,
what meanings they make of this and what
responses might be related to this. We hope
to show through our responses, with aware-
ness of our privileges and the powers that
might be involved, that we can listen and be
attuned to their needs.
Therapeutic work
When a young person attends Jigsaw, the
focus is on meeting that young person where
they are at and working collaboratively
with them to make sense of their experi-
ences – rather than seeking to t them into
a diagnostic category. As a learning organisa-
tion, Jigsaw hosts regular seminars to support
the sharing of new and best practices. Since
the Jigsaw Exchange event, professionals
at all levels – social workers, occupational
therapists, mental health nurses and clin-
ical, counselling and educational psycholo-
gists – have discussed the PTMF and its
implications for practice at these seminars.
Discussion has included how the framework
may inform individual therapeutic work and
applying the framework to individual case
scenario discussions. At times, professionals
have found it helpful to apply the framework
to themselves on a personal level (using
a specic example), in order to fully grasp
the ideas and how they may be used in collab-
oration with a young person attending the
service. When a young person’s narrative is
complex and confusing, feedback suggested
that the framework is useful in providing
a structure and meaning-making ‘scaffold’.
It has also been seen as empowering in
supporting a young person to make sense
of how they have responded to threats in
order to protect themselves. Furthermore,
professionals have found the PTMF helpful
for developing formulations collaboratively
with a young person. The PTMF and its
evidence base seem to give permission to
amplify alternative models and perspectives,
where dominant medical models have often
prevailed.
One of the challenges identied is that
some of the language of the PTMF makes
the ideas within it inaccessible at times.
This is partly why using it on a personal
level has proved helpful. In addition to
working on translating the PTMF along-
side YAP members and others, a suggestion
was made to develop youth friendly illus-
trations depicting the PTMF. Further chal-
lenges envisioned include discerning when
to bring the PTMF into a session. It was felt
that the concept may be overly academic
to introduce at the early stages of an inter-
vention and that it may take a couple of
sessions of getting to know an individual
before they would be comfortable with that
kind of framework or language. Much of the
language and concepts of the PTMF may be
implicitly present in sessions already, (based
on the professional’s model of practice).
It ts well with narrative, solution-focused
and strengths-based work, for example.
However, in order for the framework to be
used collaboratively, it may require tailoring
to be integrated into Jigsaw’s brief thera-
peutic model.
A recurring challenge often identied
by young people when they are referred
on from Jigsaw to other more medicalised
settings is that the mismatch of language
used in different systems can be challenging,
confusing and unhelpful. Jigsaw exists just
outside the statutory service system and
hence interactions with such services are
necessary to ensure the needs of young
people are met. Having a shared language
and understanding of mental health is a daily
tension and challenge.
Clinical Psychology Forum 313 – January 2019 7
Youth Mental Health and the Power Threat Meaning Framework: Jigsaw’s systems perspective
Research and evaluation
With their consent, Jigsaw collects data onthe
issues young people present with, which is
published regularly within the limits of
academic and scientic evaluation (O’Keeffe
et al., 2015; O’Reilly et al., 2015). It has been
proposed that the ‘presenting issues’ data may
be better framed as ‘inuences of power’ and/
or ‘threat responses’. This would reect our
practice more closely in looking at historical,
social, economic and interpersonal reasons
for current distress, and would present a more
functional and respectful terminology that
acknowledges the contexts in which an indi-
vidual may be experiencing difculties. It was
proposed that realigning our data collection
system with our practice of systematically
asking young people what has happened to
them will inuence the way in which our eval-
uation and research develops. This will give
a better sense of where young people are
coming from, rather than a singular focus on
presenting issues.
The PTMF underlines the importance and
value of gathering data which is personally
meaningful for people and goes beyond meas-
uring ‘symptom reduction’. Jigsaw routinely
gathers outcome data regarding changes in
psychological distress using the CORE meas-
ures (O’Reilly et al., 2016) and progress
towards achievement of goals using the Goal
Based Outcome measure (Jacob et al., 2015).
The next step is to consider incorporating
outcome measures that relate to social and
functional outcomes (e.g. the ability to live
one’s life in a way that has purpose and
meaning). Furthermore, Jigsaw collects demo-
graphic information and is in the process of
implementing an equality monitoring frame-
work to ensure that comprehensive demo-
graphic information is gathered from all
young people who attend the service. As part
of this, consideration was given as to whether
this should incorporate aspects of ‘adversity’
as well as diversity. This will enable Jigsaw
to evaluate the impact of social and health
inequalities on mental health, feeding back
into its priority to highlight these to inuence
change at a macro level.
Some challenges we identied related to
our research included whether or not we
should develop our language more in line
with the PTMF. These included how difcult
it might become to try to publish or promote
our research, given that diagnostics are the
mainstream unit of publication in mental
health, whereas societal measures may be
viewed as somewhat ambiguous. Addition-
ally, solidarity and communication with other
mental health organisations may be affected
by change and we depend on these rela-
tionships to support the communities with
whom we work. It was envisaged that a switch
to considerations of power and adversity
inpeople’s lives (a PTMF perspective) would
require a major ideological change for
mental health services and that psychiatric
care and PTMF informed care may be dif-
cult to integrate.
Ireland’s mental health policy, A Vision
for Change (Government of Ireland, 2006) is
currently under revision. Many of the ideas
and principles contained within the PTMF
will feature in Jigsaw’s efforts to inuence
this review, with the intention of supporting
the creation of a mental health system that
more fully acknowledges the impact of
inequalities and life circumstances on mental
health. Furthermore, there is a real need
to realign services to take account of this.
Whilst some of the ideas in the PTMF t
well with work already being done, some
ideas still require work and thought before
transposing them into a youth mental health
context in Ireland.
Authors
Dr Cian Aherne
Clinical Coordinator and Clinical Psycholo-
gist, Jigsaw Limerick; cian.aherne@jigsaw.ie
Dr Olive Moloney
Clinical Coordinator and Clinical Psycholo-
gist, Jigsaw Kerry; olive.moloney@jigsaw.ie
Dr Gillian O’Brien
Director of Clinical Governance and
Clinical Psychologist, Jigsaw Dublin;
gillian.obrien@jigsaw.ie
8 Clinical Psychology Forum 313 – January 2019
Cian Aherne, Olive Moloney & Gillian O’Brien
References
Bronfenbrenner, U. (1979). The ecology of human devel-
opment: Experiments by nature and design. Cambridge,
MA: Harvard University Press.
Dooley, B. & Fitzgerald, A. (2012). My world survey:
National study of youth mental health in Ireland
[Research repository]. Dublin: UCD Dublin.
Government of Ireland (2006). A vision for change:
Report of the expert group on mental health policy.
Dublin: Stationary Ofce.
Jacob, J., Edbrooke-Childs, J., Holley, S. et al. (2015).
Horses for courses? A qualitative exploration of goals
formulated in mental health settings by young people,
parents, and clinicians. Clinical Child Psychology and
Psychiatry, 21(2). doi:10.1177/1359104515577487
Jigsaw (2018). Our strategy: 2018–2020. Available at
www.jigsaw.ie
O’Keeffe, L. O’Reilly, A., O’Brien, G. et al. (2015).
Description and outcome evaluation of Jigsaw: An
emergent Irish mental health early intervention
programme for young people. Youth Mental Health:
Special Issue, 32(1), 71–77.
O’Reilly, A. Peiper, N., O’Keeffe, L. et al. (2016).
Performance of the CORE-10 and YP-CORE
measures in a sample of youth engaging with
a community mental health service. International
Journal of Methods in Psychiatric Research, 25(4),
324–332.
O’Reilly, A., Illback, B., Peiper, N. et al. (2015).
Youth engagement with an emerging Irish mental
health early intervention programme (Jigsaw):
Participant characteristics and implications for
service delivery, Journal of Mental Health, 24(5),
283–288.
Wilkinson, R. & Pickett, K. (2009). The spirit level: Why
more equal societies almost always do better. London:
Penguin.
Clinical Psychology Forum 313 – January 2019 9
Reflections on using the Power Threat
Meaning Framework in peer-led systems
Amanda Griffiths
The article describes the use of the Power Threat Meaning Framework (PTMF) to create personal narratives
within a peer led environment, and the ways in which it can encourage reection, self-advocacy and healing.
Suggestions for further developments are made.
YORK Mental Health Peer Support
Group (Yor-Peer Support) was founded
in 2016 and in the last two years the
peer group has adopted a trauma informed
approach. The peer group consists of
between 6–12 people with lived experience
of mental health difculties, who meet twice
per month for discussion and support facili-
tated by two trained founder members. I am
a founder member with lived experience of
complex trauma, in addition to education in
psychology and training in trauma-informed
peer support.
The group’s aim is to provide a supportive envi-
ronment where self-education and self-advocacy
promote the creation of personal narratives.
Sharing life stories in a safe, non-clinical arena
with others who have endured similar experi-
ences fosters trusting reciprocal relationships
that are the catalyst to healing (Blanch et al.,
2012). The group ethos is to offer alternatives
to the medical model of mental health, which
pathologises behaviours as symptoms and thus
fails to consider what might have occurred for
someone to act in a particular way. In contrast,
rather than asking what is wrong with a person,
10 Clinical Psychology Forum 313 – January 2019
Amanda Grifths
Figure 1: Power Threat Meaning Framework template
The Power Threat Meaning Framework: Overview 91
Figure 1: Power Threat Meaning Framework Template
Power Threat Meaning Framework Template
Impact of POWER Core THREATS MEANING and discourses
What made things better or worse?
Strengths and Power resources
My story
Bodily reactions and THREAT RESPONSES and their functions
Clinical Psychology Forum 313 – January 2019 11
Reections on using the Power Threat Meaning Framework in peer-led systems
the PTMF considers behaviours by asking what
happened to the individual and what they had
to do in order to survive. This empowers people
to create stories about their unique life experi-
ences, and the adversities they may have, or may
still be facing.
Research suggests there is a higher preva-
lence of trauma both in childhood and adult-
hood for mental health service users (Kessler
et al., 2010) than in the general population
(Mauritz et al., 2013). Nonetheless, statutory
mental health providers are increasingly cham-
pioning short-term, time-limited treatments
such as those offered by Improving Access
to Psychological Therapies (IAPT) services,
despite the fact that healing from some trau-
matic experiences is almost impossible without
adequate time. Our peers frequently report
that mental health professionals seem reluc-
tant to work with them, habitually branding
them uncooperative or difcult to engage. The
assumption here appears to be that people who
have endured adverse life experiences cannot
heal. Sadly those in greatest need of help are
often the most challenging to connect with
due to the cumulative effects of their experi-
ences. Thus, they may be excluded, disempow-
ered and denied the chance to create personal
narratives and share their stories.
Whilst traditional clinical tools often create
barriers through strict referral criteria based
on categorising individuals, the group believed
that the PTMF (Johnstone & Boyle, 2018) had
the potential to remove those barriers and
empower trauma victims and survivors. I rst
used the framework to describe my narra-
tive as part of a lived expert presentation.
I had learned of its publication through social
media and having read it was able to develop
my self-awareness of how power imbalances
are operating in my life, and the subsequent
meaning and survival techniques employed
as a consequence. Impressed that the PTMF
Guided Discussion and template were so easy
to use without the involvement or support
of a mental health professional, I was keen
to ask the group their views about adapting
the framework for a peer-led environment.
The framework’s core questions are straight-
forward and uncomplicated for most individ-
uals, so we structured a peer group session to
present the Guided Discussion, template and
core PTMF questions.
This is my own narrative as a PTMF
example:
What has happened to you (How is Power
operating in your life?) – I am a survivor
of many traumatic experiences. In addi-
tion, I am being disempowered by two
very powerful systems (statutory mental
health services and children’s social care).
This resulted in two male professionals
exploiting their position of trust, power
and authority to coerce and sexually abuse
me. Subsequently, these organisations
used their power to deny my autonomy,
and pathologise my behaviours as being
symptomatic of a so called ‘personality
disorder’, which I found victim blaming.
Consequently, I had to form a subservient
relationship with a controlling psychiatric
system in order to access support to try to
heal from the effects of these harrowing
experiences.
How did it affect you (What kind of threats did
this pose?): I am unable to trust or heal from
my experiences. I struggle with relentless
post-traumatic stress, such as dissocia-
tion (blank states), hypervigilance, ash
backs and vivid disturbing dreams. I have
been prevented from articulating my story
because the impact of the abuse is being
ignored. This leaves me feeling misunder-
stood, angry, apathetic, anxious and strug-
gling to regulate my emotions. My physical
energy levels are chronically depleted
because the hyperarousal is extremely
painful and exhausting. Consequently, my
body’s ght and ight response is perma-
nently switched on resulting in autonomic
dysfunction. These psychological and phys-
ical factors combined, test my resilience
and often result in suicidal thoughts.
What sense did you make of it (What is the
meaning of these situations and experiences
to you?): I believe that I am a worthless
person who is undeserving of help and
treatment. I feel defective, that there is
12 Clinical Psychology Forum 313 – January 2019
Amanda Grifths
something is wrong with me, and I deserve
to be hurt because my character decits
are the root cause of those damaging expe-
riences. The world seems an unsafe place
as others are untrustworthy. Ultimately,
I often believe that I would be better off
dead because death seems the only means
of escape from these harrowing experi-
ences and from myself.
What did you have to do to survive (What kinds
of Threat Response are you using?): My survival
mechanisms involve forming subservient
relationships with others who are in
a position of power and authority. My body
is hyper-vigilant at all times, constantly scan-
ning for early signs of danger, threats, power
imbalances and coercion. I am cautious
and wary, often resulting in avoidance of
situations and other people. I responded
to threats to my safety and wellbeing by
automatically employing self-protective or
self-defeating behaviours. On occasions
when I have felt that I was in immediate
danger, I responded with verbal aggression
(described by some mental health staff
as ‘being abusive towards them’). I often
disconnect by dissociating or sleeping.
I restrict my dietary intake which provides
a sense of control in life. In extremely
distressing circumstances I use alcohol to
block the world out to numb the pain.
Strengths: I have a well-developed insight
into the psychology of trauma and human
distress. My intelligence and resilience
enable me to self-advocate and stand
rm against coercion. I am encouraged
through the reciprocal relationships I am
developing with my peers that motivate
me to learn new skills in order to support
others facing similar adverse life expe-
riences. Additionally, I am inspired by
trauma-informed professionals whose
ground-breaking work informs me to
develop a new understanding of my
experiences, some of whom have helped
and supported me in this process.
I have a beautiful family who give me
the strength and determination to get
through each day.
What is my story?: Numerous adverse child-
hood experiences led to subsequent trau-
matic life changing events throughout
my life. Constant repetitive cycles of coer-
cion, powerlessness and multiple forms of
abuse are affecting every aspect of my life,
thus impacting on my physical, emotional
and psychological wellbeing. My energy
levels are depleted from being consistently
broken and distressed by an authoritarian
mental health system that prejudicially
recast my pain and suffering when I needed
compassionate trauma-informed provision.
As a consequence, I am dispirited and
struggle to trust others. However, despite
the on-going clinical dispute with statu-
tory mental health services, independent
specialists have recognised the complex
post-traumatic stress I endured. My rela-
tionships with my family and my peers
are protective factors that motivate me to
nd the strength to utilise my experiences
to self-educate and self-advocate. I also
campaign for trauma-informed and trauma
specic services, and improved mental
health provision for other survivors.
Adapting the PTMF
to a peer-led environment
Peer group members were keen to learn about
the framework and to develop an under-
standing of how power imbalances, threats
to safety and the meaning formed from life
changing events might be at the root cause
of their distress. The core questions were
presented on a ipchart for the whole group
to view, based on the Guided Discussion struc-
ture. One peer member presented the session
with another facilitating the discussion. Each
question was carefully and sensitively explored
in turn. The discussion was welcomed, and
group members were keen to adapt the ques-
tions to the supportive peer-led arena. This
provided a foundation from which to begin
to conceptualise past experiences. Members
shared their personal experiences of child-
hood trauma and other kinds of adversity and
reected on how this had impacted upon
them throughout their life.
Clinical Psychology Forum 313 – January 2019 13
Reections on using the Power Threat Meaning Framework in peer-led systems
We found that the framework is applicable to
many forms of adversity, even where there is no
history of overt trauma, such as sudden unem-
ployment or homelessness, stigma and discrim-
ination, or even adapting to life changing
circumstances such as health difculties etc. We
also found that the framework can be revised to
t the individual’s uniquely personal narrative,
offering an alternative understanding to the
biological ones given to many group members.
Moreover, members were able to use the
supportive peer-led environment to develop
their narratives without clinical intervention.
Through sharing and reecting on their expe-
riences, group members developed insight into
how disempowerment and threats to autonomy,
whether physical, sexual, emotional, psycholog-
ical abuse or neglect, or any other misuse of
power, had impacted negatively on their lives.
Meaningful patterns were identied during the
discussion, revealing that disturbing past expe-
riences can continue to cause repetitive difcul-
ties in the present. This encouraged the group
to consider how core threats to safety and secu-
rity manifest, and how meanings and coping
strategies (threat responses) are employed in
order to survive. The peer group welcomed the
description of these factors as normal human
responses to challenging and traumatic events
and circumstances, since identifying universal
experiences is essential to creating a societal
shift in attitudes towards mental health. Only
then will we see a fairer society for those who
have endured more than their share of hurt.
Our discussion also led to an understanding of
how statutory services have unwittingly disem-
powered service users by failing to meet basic
needs for validation and understanding of the
lasting impact of damaging life experiences. As
a result, human responses to suffering, such
as self-harm, self-neglect, alcohol, impulsivity,
avoidance and aggression, have been patholo-
gised even where it is clearly evident that there
is a history of adversity.
Trauma-informed peer support
We found that sharing experiences
utilising the framework is an emotive and
thought-provoking way to connect with others
who have endured similar experiences, and
this may be the rst time that the narrative
and pain have truly been heard. It demon-
strates that we are not alone in our pain and
suffering, whilst offering a new perspective of
our distress. This takes us from being isolated
and lonely individuals to being part of a wider
community of equals. The focus on trau-
matic events and other difcult circumstances
seemed to offer promise to group members
that the ongoing human impacts of adversity
can be overcome (Filson & Mead, 2016). This
creates hopefulness that healing is possible
without being dependent upon diagnosis.
Notably, our peer members are keen to be
accepted as individuals without the need for
harmful labels.
Adapting the framework for use in this way
within a peer-led environment also empowers
our peers to self-educate and self-advocate.
The lived experts often commented that ‘the
framework makes sense’, because it enables
self-education that generates meaning, which
might take years to develop within the connes
of the therapy room not easily accessible to
many. With the advent of time-limited psycho-
logical therapies such as IAPT being the only
option available for many, it is important
to have supportive settings where our peers
can create their own narratives. We believe
that adapting the framework for use within
a peer-led environment achieves this.
Adaptations and areas for development
Whilst the peer group welcomed the new
PTMF perspective, they found the 138-page
Overview hard to read. Consequently, we
have based peer group sessions on short
two-page handouts, the Guided Discussion
and the template, unless otherwise requested.
Some peers felt that the PTMF Overview is
too clinically orientated for the lay person.
We would therefore welcome the oppor-
tunity to work with the authors to create
a more user-friendly version that can easily
be shared by peer groups and lived experts.
Furthermore, people with learning difcul-
ties or disabilities might benet from an
adapted version to aid accessibility. A note
14 Clinical Psychology Forum 313 – January 2019
Amanda Grifths
of caution is that the PTMF questions may
be overwhelming for those who have never
considered the impact of traumatic or life
changing experiences. A user-friendly edition
of the PTMF might include guidance and
suggestions on managing the effects of such
reections, since it is important to plan for
any possible distress that story telling might
trigger. As a consequence of the rapid devel-
opment of the trauma-informed approach
across services, our peer group is devel-
oping a survival strategies handbook to
help recognise, manage and plan for the
prevention of a crisis which may be helpful
where a narrative causes distress. Addition-
ally, the PTMF project group might consider
supporting lived expert training on its use in
survivor/peer-led environments, to minimise
the likelihood of retraumatisation.
Conclusion
Being the new kid on the block, the PTMF has
certainly attracted plenty of attention. Whilst
there have been a lot of positive reactions,
it has also received mixed responses. Many
lived experts and professionals nd the frame-
work helpful to create narratives and make
sense of life-changing experiences. However,
some prefer the psychiatric ‘mental illness’
model, whilst others have no viewpoint. We
are concerned that the hostility towards the
PTMF project group, perpetrated through
social media, may create a climate of fear and
mistrust, and that this enmity may dissuade
people from considering using the PTMF.
Therefore, we encourage our peers to form
their own views and opinions of the framework
accordingly.
In conclusion, we rmly believe that
the PTMF is extremely useful and can be
modied to extend beyond clinical environ-
ments, creating a paradigm that recognises
normal human responses to abnormal and
frightening experiences. Utilising the frame-
work within the safety of a peer support
environment offers a fresh perspective
on life-changing experiences, promoting
self-education and self-advocacy that can lead
to reconnection and healing. The univer-
sality and adaptability of the framework from
statutory services through to community
peer-led organisations also provides consist-
ency. It can function as a useful adjunct to
mainstream services and is invaluable for
peers who are either accessing or have been
discharged from mental health services. For
these reasons, we promote the use and revi-
sion of the PTMF in peer-led environments
in order to empower people beyond the
connes of current clinical practice.
Author
Amanda Griffiths
Peer Support Worker, Yor-Peer Support, York
References
Blanch, A., Filson, B., Penney, D. & Cave, C. (2012).
Engaging women in trauma-informed peer support: A
guide book. Rockville, MD: Center for Mental Health
Services & National Center for Trauma-Informed
Care. Available at www.nasmhpd.org/sites/
default/files/PeerEngagementGuide_Color_
REVISED_10_2012.pdf
Filson, B. & Mead, S. (2016). Intentional peer support:
An alternative approach. In Russo, J. & Sweeney,
A. (Eds.) Searching for a rose garden: Fostering real
alternatives to psychiatry (pp.109–117). Ross-on-Wye:
PCCS Books.
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J.,
Harper, D. et al. (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. Leicester: British Psychological
Society.
Kessler, R., McLaughlin, K., Green, J. et al. (2010),
Childhood adversities and adult psychopathology
in the WHO world mental health surveys. British
Journal of Psychiatry, 197(5), pp.378–385.
Mauritz, M.W., Goossens, P.J., Draijer, N. & Van Achter-
berg, T. (2013). Prevalence of interpersonal trauma
exposure and trauma-related disorders in severe
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tology, 4. doi:10.3402/ejpt.v4i0.19985
Clinical Psychology Forum 313 – January 2019 15
Time to teach the politics of mental health:
Implications of the Power Threat Meaning
Framework for teacher education
Catriona O’Toole
The Power Threat Meaning Framework (PTMF) provides teachers with a holistic and compassionate
understanding of the origins of emotional distress, which can support them in becoming more attuned and
responsive to their own inner lives as well as those of their students. It has radical implications for how we teach
wellbeing and mental health in schools and other educational settings.
The Mental Health of children and young
people has been identied as a global
public health challenge (Fazel, et al.,
2014; Patel et al., 2007). As a result, schools
across much of the Western world have been
identied as key sites for delivery of mental
health interventions, and wellbeing has
become a cornerstone of national curricula
across educational sectors. In Ireland, for
instance, the new Junior Cycle Framework
mandates that wellbeing receive 400 hours of
timetabled engagement over the rst three
years of secondary school, while time allo-
cated for other subjects has dropped (Maths
and English, by comparison require 240
hours; NCCA, 2017). While a commitment
to these areas is welcome, there is growing
disquiet about the way in which this new
agenda is being taken up in educational
settings (e.g.O’Toole, 2017; Simovska, 2015;
Spratt, 2017; Watson et al., 2012; Wright &
McLeod, 2015).
Within my own work, I too have become
increasingly concerned by the ways that tradi-
tional models of mental health, when applied
to school settings, have the potential to
become oppressive and tyrannical (Devanney
& O’Toole, in press; O’Toole & Simovska,
2018; O’Toole, 2017). Students are now faced
with frequent exhortations to be upbeat, to
persist in the face of challenges, to display
a growth mindset, to be enterprising and resil-
ient; all of which can, over time, give rise to an
atmosphere of toxic positivity, particularly for
those whose life experiences don’t easily lend
themselves to feelings of cheery enthusiasm.
At best, school-based mental health education
consists of little more than well-intentioned but
rather bland advice (get a good night’s sleep,
exercise, limit time spent on social media,
talk to trusted friends, and so on). At worst,
it promotes the idea of ‘mental illness as an
illness like any other’, thereby reinforcing
a biomedical explanation whilst legitimising
a wide range of individualistic and decon-
textualised intervention programmes. Many
schools, for instance, offer brief (e.g. six or
eight week), manualised psychosocial inter-
ventions; indeed, there is now a growing
industry in the marketing and delivery of
these types of school-based interventions by
private companies (Rossi et al., 2018). While
students may learn something about recog-
nising and managing their emotions, they
are extremely unlikely to engage in critical
enquiry about the origins of these emotions;
for instance, into the ways that power struc-
tures (e.g. advertising and entertainment
industries) have a vested interest in manipu-
lating and maintaining particular attitudes,
beliefs and emotions; or the ways that feelings
of diminishment, shame, anger and sadness
are bound up in the experience of inequality
and adversity.
16 Clinical Psychology Forum 313 – January 2019
Catriona O’Toole
In all these ways, school-based mental
health interventions tend to obscure broader
social and structural inequalities. Mental
health problems are rmly located within the
individual child rather than within structures
and networks of power and privilege. All of
this serves to reinforce a victim blame ideology
and play into the hands of a political system
that is happy to abdicate responsibility for
addressing inequalities. Educational policy and
practice are hugely impacted by these same
political systems and are increasingly in the
thrall of a neoliberal ideology; an economic
rationality that emphasises competitiveness,
efciency, accountability and rigorous testing
regimes (Apple, 2000). Very little of this is
conducive to the mental health of students or
their teachers. Yet by emphasising the disposi-
tions and mindsets needed to succeed within
this system, school mental health initiatives
merely reinforce the status quo. In effect, what
is packaged as wellbeing and mental health
school initiatives can instead be used to prop
up a narrow neoliberal agenda in education,
aimed primarily at maintaining academic
standards and ensuring future labour market
participation.
The PTMF suggests something far more
radical. I was deeply heartened to have sight of
it just two weeks before commencing the rst
delivery of a new teaching module. With its
remarkable breadth and depth of scholarship,
the framework provided a robust, consolidated
and coherent position on mental distress, and
a sound basis for meeting the module’s core
objectives outlined below.
Wellbeing, mental health
and education module
I designed the module, ‘Wellbeing, Mental
Health and Education’ as part of a Master
of Education programme. Students were
qualied teachers working across educa-
tional sectors (early childhood, primary,
secondary and informal educational settings
like prisons) and many held, or were aspiring
to, school leadership positions. The module
had three overarching objectives: Firstly, to
present a critical approach to understanding
wellbeing and mental health, challenging the
highly individualistic, decontextualised and
reductive biomedical models that currently
dominate mental health research and prac-
tice. I sought to develop awareness of ways
that emotional distress is underpinned by
adverse experiences – like poverty, trauma,
displacement, racism, sexism, homophobia
and ‘ableism’ – as well as by the stresses of
living in what many consider to be an increas-
ingly individualistic, competitive, materialistic
and sexualised culture. The PTMF provided
the ideal basis for this exploration. Students
were asked to read the overview, along with
sections of the main document – particularly
Chapter4’s subsection on ‘Childhood adver-
sity’. They also read shorter journal articles
and blogs on related topics. Themes were
then summarised and discussed in class.
From there, I wanted to engage students in
exploring the implications of these insights for
the nature and scope of mental health initia-
tives in schools and other educational settings.
My students are not mental health profes-
sionals or aspiring therapists; hence my aim
was to support them in thinking educationally
about mental health; to grapple with what
these new conceptualisations might mean for
curriculum and pedagogy, and for their own
pedagogical relationships with the students
they teach. With this in mind, students were
assigned educational readings on the purposes
of education, critical pedagogies and critical
health literacy; and the nal summative assess-
ment for the module (the assessment had
three parts: forum dialogue, group presenta-
tions and individual essay) required students
to articulate an informed stance on wellbeing
and mental health, and discuss the implica-
tions for their own educational practice.
Thirdly, since there are many challenges
to teachers’ mental health (Jennings et al.,
2017), I wanted to create a pedagogical space
in which participants were afforded oppor-
tunities to intimately connect with their own
experience and engage with the struggles,
perspectives and experiences of their students.
Equally important is to recognise that our own
and others’ experiences are profoundly inter-
Clinical Psychology Forum 313 – January 2019 17
Time to teach the politics of mental health
dependent: Wellbeing is not and never can be
an individual affair. We used mindfulness and
other contemplative activities (e.g. mindful
breathing, compassion meditations and body
scans) to address these aspects, which I discuss
in more detail below.
Informal feedback on the module suggested
that many students found the language and
terminology in the framework very different
from what they usually encounter in mental
health discourse. For example, a shift from
discourses of disorder, maladaption, symptoms
and decits to a language of distress, power,
threats and survival strategies. They felt this
supported a different sensibility or orientation
in their encounters with their students. For
instance, one teacher who works in prison
education considered that although it is easy
for us to dismiss people in prison as ‘deviant’,
‘immoral’ or ‘dangerous’, the PTMF reframes
the way we might look at them. We are forced
to recognise that behaviours arise in response
to adversities and injustices, and this in turn
reorients us towards more compassionate,
open-hearted encounters with students.
Similarly, the shift from asking ‘What
is wrong with you?’ to ‘What happened to
you?’, or from asking ‘What are your symp-
toms?’ to ‘What did you have to do to survive?’
isprofound and immediately impactful. These
simple questions that elegantly summarise the
core tenets of the PTMF invite us to think
anew about the nature and scope of mental
health prevention and intervention efforts.
It is here that teachers recognised that the
framework has the potential to be transform-
ative in education; to offer an alternative to
the oppressive conceptions and practices that
pervade the current system.
The module will be offered again in
the 2019–2020 academic year. I also plan
on drawing from the framework in other
programmes offered in our department,
including initial teacher education and school
guidance and counselling. In future sessions
I want to deepen students’ engagement with
the PTMF and facilitate more nuanced and
critical discussions about the implications for
educational practice.
The benets and implications of the Power,
Threat Meaning Framework for education
The PTMF represents a radical alternative
to medical and diagnostic models of human
behaviour and experience. In recognising that
patterns of emotional distress and troubling
behaviour are part of a continuum of human
experience and in acknowledging these aspects
of experience emerge as coping or survival
strategies in response to particular adversities
arising within contexts of power inequalities,
the path is paved for a more humane, compas-
sionate and holistic understanding of distress.
While the PTMF has relevance for pupils and
staff who have not experienced more obvious
‘traumas’, one of its implications would be to
move to a model of trauma-informed prac-
tice in education. Indeed, there is a pressing
need for greater awareness of the nature,
extent and consequences of trauma, and for
environments where students can experience
a felt sense of safety and belonging (O’Toole,
2018). However, there are only a small number
of guidelines on trauma-informed practice
designed explicitly for schools. Those that are
available tend to focus narrowly on the impact
of trauma on memory and learning, and their
guidance is limited to a series of prescriptive
bullet-pointed recommendations for school
staff. They also tend to privilege neurobio-
logical explanations, and brush over the issues
of power and inequality that are centred in
the PTMF.
Another major shortcoming of many
resources targeted at schools is that they are
misguided about – or perhaps simply disre-
gard – the goals and purposes of education.
They therefore fail to engage the educational
community in ways that theories about mental
health, trauma or emotional distress might be
integrated with educational practice. Instead,
they tend to assume, due to the increasing inu-
ence of a neoliberal agenda, that education is
all about knowledge accumulation, academic
attainment and producing students capable of
competing in the global economy. But this is
a very narrow and instrumental conception of
education and one that has been subjected to
widespread and sustained critique by educa-
18 Clinical Psychology Forum 313 – January 2019
Catriona O’Toole
tional scholars (e.g. Biesta, 2006, 2013; Illich,
1971). Education, according to Klafki (2000), is
about the formation of one’s inner life through
engagement with the world and through crit-
ical reection on the dominant social order.
Education engages us in questions of how we
want to be in the world, not just what we (or
dominant others) want us to know. It is what
enables us to become ‘more fully human’.
Thus, education – in the true sense of the
word – offers a space for critical enquiry into
students’ own understandings of key issues
that affect them. As such, it offers possibilities
for raising awareness of the origins and deter-
minants of emotional distress, along with the
sources of power that shape our subjectivities,
our very sense of who we are, as well as and
how the fabric of our inner lives is intimately
connected to the broader social and cultural
world. Perhaps it is time then, that the focus of
mental health education shifts towards a more
robust enquiry into the politics of mental
health: engaging students as active citizens,
in ethical discussions about the real causes of
mental distress and facilitating them to take
individual or collective actions that support
their own wellbeing and that of others. This
type of enquiry should take place not just
in subjects like Personal Social and Health
Education, but across the entire curriculum.
Indeed, issues of oppression, domination,
poverty, trauma, and adversity are themes in
many of the subjects that students engage with
on a daily basis -- literature, poetry, history,
music, art and so on.
This is not to suggest that any of this
is easy. Indeed, given the autocratic struc-
tures and power imbalances that typify many
schools (like so many other institutions),
much of what is envisaged here in terms of
open, critical dialogue simply cannot be real-
ised. However, just as there is a groundswell
of support for alternative paradigms on
mental distress, there is also a strong impetus
amongst many educationalists to resist regres-
sive educational policies and create more
liberating classrooms. It is crucial then that
teachers are supported to identify ways they
can engage educationally on matters of
mental health with sensitivity and conviction.
Amongst other things this will require deeper
exploration of the types of pedagogies that
can support wholeness, compassion, social
justice and liberation.
A place for critical
and contemplative pedagogies
Although most university courses conne
students strictly within the realm of rational,
objective, third-person knowledge, I am
increasingly drawn to critical and contempla-
tive pedagogies in my teaching, which allow
for a rst-person, experiential engagement
with course content. These pedagogies seem
particularly vital when it comes to material
like the PTMF, as they provide opportuni-
ties for students to make sense of the subject
matter in relation to their own lives and expe-
riences. Contemplative pedagogies place the
student at the centre of their own learning,
and recognise that the lived curriculum – the
content of our lives and past experiences –
isas important as the content to be explored
on the page (Barbazat & Bush, 2014; Zajonc
& Palmer, 2010). They also support a critical
consciousness of oppressive conditions,
thereby educating for liberation and social
justice (Freire, 1970; and for an overview see
www.contemplativemind.org/practices/tree).
As university educators, our own peda-
gogies and embodied presence in the class-
room provide an important exemplar to our
students, inviting reection on the relation-
ships and pedagogical approaches that they
in turn wish to develop in their own teaching.
Critical and contemplative pedagogies are
ideally suited to creating safe classroom
spaces, where struggles can be voiced and
listened to without judgement, and teachers
have the courage to engage students in educa-
tional dialogue about sensitive and emotive
topics. In my experience, these pedagogies
have set the groundwork for the personal
ourishing of teachers themselves, and they
have supported teachers’ commitment toward
nurturing a personally enriching, compas-
sionate and socially just educational experi-
ence for their own students.
Clinical Psychology Forum 313 – January 2019 19
Time to teach the politics of mental health
Conclusion
The foregoing provides just a preliminary
discussion of possibilities. There is a lot more
to be done to ensure that mental health and
wellbeing are meaningfully and wholeheart-
edly integrated into educational settings. The
PTMF offers a robust alternative to current
discourses and practices. It is important now,
that advocates of this new framework engage
in meaningful dialogue with educational
scholars, curriculum and pedagogy specialists,
in order to think more deeply and thoroughly
about the implications for educational theory
and practice.
Author
Dr Catriona O’Toole CPsychol, PsSI
Lecturer in Psychology of Education, Maynooth
University, Ireland; Catriona.a.otoole@mu.ie
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20 Clinical Psychology Forum 313 – January 2019
Bringing the outside in: Clinical psychology
training in socially aware assessment,
formulation, intervention and service structure
Helen Griffiths & Frances Baty
We describe the introduction of the Power Threat Meaning Framework (PTMF) to our teaching on critical and
community psychology with particular reference to formulation, and critically consider the implementation of
this teaching.
THE UNIVERSITY of Edinburgh/NHS
Scotland clinical psychology academic
curriculum is organised according to
overarching teaching themes that relate to the
development of core competencies in assess-
ment, formulation, intervention and research,
alongside professionalism and practice. Core
teaching time is also dedicated to what we
call the ‘fundamentals’ of clinical psychology,
which considers the philosophical underpin-
nings of the profession. We believe this facili-
tates the adoption of a critical evaluative stance
which informs contemporaneous psycholog-
ical practice that is sensitive to health and
social care exigencies. As part of this broader
theme, and in line with BPS (2014) standards,
we also ensure that trainees have an awareness
of the cultural, historical and social context
of their work, and an understanding of social
approaches to intervention.
In practice, this has involved a stream of
teaching which is dedicated to community,
Clinical Psychology Forum 313 – January 2019 21
Bringing the outside in
critical and social constructionist perspectives,
rst developed in its current format in 2012.
The principal objectives are to encourage
trainees to develop an awareness of social
inequalities and their impact; to introduce
basic concepts from critical psychology and
social constructionism; to consider how these
ideas may inuence the ways in which we as
professionals operate; and to debate where
such ideas and their impact leave clinical
psychology as a profession. This comes with
a health warning that some of the challenges
raised by a critical psychology stance may be
experienced as uncomfortable. We are there-
fore keen that the sessions don’t simply become
a talking shop, but are linked to formula-
tion and specic kinds of interventions and/
or service structures. In 2018, we introduced
the PTMF (Johnstone & Boyle, 2018a) during
second year, suggesting that it can be seen,
among other things, as a theory driven formu-
lation framework that attempts to directly
address critical psychology’s concerns about
the potential neglect of the social context.
We emphasise that the PTMF, like any other
approach to formulation, requires evaluation.
Workshop structure and content
Didactic teaching in relation to critical
psychology is kept to a minimum. Instead
we utilise experiential tasks, small group
and whole cohort discussions to explore key
concepts. For example, one of the rst tasks
is to ask trainees to reect on problems of
engagement. This discussion typically begins
by locating engagement difculties and attri-
tion within individual client characteristics,
but very quickly shifts to a consideration of
the contribution of the broader service and
social context in which people seek help. This
is followed by a discussion about the impact
of inequality on a broad range of health and
social outcomes. Using Scottish data always
provokes lively debate. For example, Scotland
is one of the West’s most unequal societies with
the wealthiest households 273 times richer
than the poorest (Oxfam, 2013). Furthermore,
31percent of women workers in Scotland are
low paid, and all identied ethnic minority
groups have higher than average rates of
poverty (McCartney & Collins, 2011). Such
data is used to illustrate how inequality may
be an actual material difference or a socially
constructed one that differentiates using cate-
gories such as gender and race.
The Scottish government is explicit
about its intentions to address the impact
of inequality and childhood adversity on
numerous health and social outcomes (Scot-
tish Government, 2016). For example, the
National Trauma Training Framework (NES,
2017) supports all workers to adapt their prac-
tice to make a positive difference to people
affected by trauma and adversity. What we try
to foster in our workshops is an understanding
of how inequality not only involves exposure
to material risks such as damp housing and
poor diet, but also to psychological risks such
as feeling unsafe or socially excluded. It is
the psychological risks that have particular
relevance from a mental health perspective
(Friedli, 2009). Thus, feeling unsafe, isolated
and lacking control over key aspects of life,
as well as having reduced expectations can
lead to feeling humiliated or ashamed, afraid
or mistrustful, lonely, trapped and powerless.
In the workshops, we explore the notion that
these reactions, along with their behavioural
expressions, may reect more or less adaptive
responses to specic social contexts.
Subsequently, trainees are introduced
to key concepts from critical psychology
and social constructionism. For example,
we encourage trainees to consider how
historico-socio-cultural variables may inu-
ence the development of specic constructs.
To illustrate, we ask them to discuss the impact
of creating diagnostic categories on both the
individual who might ultimately receive that
diagnosis and on the clinician who bestows it.
Initially, we use the example of ‘drapetomania’
(see https://en.wikipedia.org/wiki/Drapeto-
mania), but then ask trainees to consider
differential responses to, for example, concep-
tualising someone as highly shy versus socially
phobic. This exercise is intended to intro-
duce trainees to the ‘archaeological methods’
proposed by Foucault (1969).
22 Clinical Psychology Forum 313 – January 2019
Helen Grifths & Frances Baty
Key to this exercise is that trainees are then
asked to apply the same level of critical analysis to
the construct ‘psychological distress’. Typically,
they report nding it thought-provoking and
challenging even to reach consensus about how
to dene ‘psychological distress’. By focusing
in on the origins of the distress, we encourage
trainees to develop a clarity about what it really
is that people nd helpful (Diamond, 2006),
and to be able to articulate this understanding
clearly. They are further encouraged to explore
the values (e.g. those related to gender and
race) frequently implicit in mental health narra-
tives through various discourse analysis tasks
(e.g.of a newspaper article discussing pertinent
issues relating to mental health). Boyle’s (2003)
deconstruction of vulnerability is used as a key
text to open up discussions about the opera-
tion of language and power, allowing trainees
to examine how some modes of psychological
experience are given privileged status above
others (Parker, 1999).
Beyond awareness-raising, the workshops
are designed to encourage exploration of how
adopting a critical psychology stance may – or
may not – require different ways of responding
to clinical scenarios. Following Smail (2006),
we wonder whether ‘clients nd a realistic
assessment of their options – one that take
account of limits imposed on their freedom
of action both by social environment and
their nature as physical beings – more reas-
suring than threatening’. In this context, the
PTMF was introduced as a more socially aware
perspective from which to formulate and create
narratives – one that provides a comprehensive
psychological understanding of distress that
can be held up as a theory driven alternative
system to diagnostic approaches.
Trainees are asked to familiarise themselves
at least with the two-page PTMF summary
before the session, but are also encouraged
to have a look at the PTMF overview (John-
stone & Boyle, 2018b). We suggest that the
PTMF encourages an explanation of distress
consistent with a lifespan approach that
takes account of proximal and more distal
risk factors as well as variables that promote
resilience. Without any requirement to share
personal details, trainees are also encour-
aged to consider their own life circumstances
using the framework template to think about
what’s happened to them (power), how this
power has impacted on them (threat) and
how they have made sense of this (meaning).
If this is not comfortable then they are asked
to think about somebody whose life narra-
tive they know well. They are also asked to
consider what social discourses may be rele-
vant to this understanding, and to contem-
plate the strengths and resources they may
have been able to draw on to make changes,
if required.
The exercise is then repeated using
prepared case material. For example, trainees
may be asked to consider the impact of sexual
assault on a young woman in her early twenties.
This allows a consideration of individual differ-
ences in response to that assault that includes
not only aspects such as memory processing,
but also the differential impact of power within
a given social context. The need to retain
a focus on the embodied nature of distress
is emphasised. For example, the individual
may require help managing intrusions such
as ashbacks, for which the clinician should
draw on the best available evidence to inform
their intervention. However, the explicit focus
of the framework on the negative operation
of power moves beyond this embodiment to
consider, for example, how legal power or
the accumulation of social capital may inu-
ence the young woman’s understanding of
what’s happened to her and how she may
respond. The core threats are thus understood
within this kind of formulation, not only to
be bodily and emotional in nature, but to
impact at the level of the relational, the social
/community and the economic. The meaning
given to the assault is deeply personal, but
this is inuenced by prevailing socio-cultural
discourses and ideologies. Threat responses
are understood within these contexts as
attempts to cope with the impact of the assault
rather than as ‘symptoms’.
Formulating case material in this way is
followed by wide-ranging discussions about
the kinds of intervention they inform, what
Clinical Psychology Forum 313 – January 2019 23
Bringing the outside in
outcomes are helpful, and how they may be
evaluated. Importantly, trainees are also asked
to consider whether these kinds of formula-
tions differ from more standard practice. For
example, to what degree should the focus
of intervention be ‘symptomatic’ or distress
reduction? If distress arises as an embodied
response to life circumstance, to what extent
should therapeutic intervention rather focus
on empowering the individual to bring about
a change in their environment in order to
benet from materially less risk? One trainee
commented that they found a ‘marbles on
a wobbly table’ analogy useful; that is, how
long do you keep trying to juggle the table
to keep the marble from falling before actu-
ally addressing the stability of the table itself.
But what kinds of intervention would be
involved in this shift of focus? In this example,
ensuring the young woman has the psycho-
social resources to be able to attend, for
example, a self-defence course may be impor-
tant. This might involve addressing barriers
to attendance, such as ashbacks, low mood
and/or anxiety, as well as structural barriers
such as lack of money, transport or childcare.
Part of the intervention may therefore not
necessarily look radically different from more
traditional forms of therapy. However, the
desired outcome/endpoint, feeling safer in
her own community, may have meaning that
is much broader than, for example, anxiety
reduction. This implies discussion about the
degree to which psychologists could impact
more directly at a community or broader soci-
etal level.
We also ask trainees to consider to what
extent any such shift is possible given the
context of access targets for psychological
therapies in Scotland. On one hand, the
Scottish government’s endorsement of the
adverse childhood experiences agenda and
trauma-informed services may open up oppor-
tunities for the profession to promote psycho-
logically coherent interventions that fully take
account of the social context. However, how
do trainees/qualied staff balance service
needs and the demands of their individual
job plans with theory based formulations that
drive psychological interventions at systems/
community/society levels? And if the target of
psychological intervention shifts in these ways,
how do we then evaluate our impact? What are
the important outcomes?
Evaluation and reection
Our critical psychology workshops, including
the one on the PTMF, are evaluated through
our usual academic quality assurance processes,
and appear to be very positively received
across our trainee cohorts. During more
informal verbal feedback, trainees particu-
larly valued the practical links that were made
and the clinical examples provided. Despite
our initial reservations, trainees appreciated
having critical psychology teaching inthe very
rst week of teaching, giving them the option
to view their training experiences through
a particular kind of lens. From the facilitators’
perspective, explicitly linking the PTMF to the
critical psychology teaching material provided
strong theory-practice links. The framework
neatly drew together the pertinent literature,
distilling theoretical concepts and the avail-
able evidence into clear concepts that have
both a breadth of vision and a practical utility.
Importantly, we argue that the language and
conceptual thinking of the PTMF embeds the
agency of the person seeking help into any
formulation. Having taught the broader crit-
ical psychology sessions since 2012, the authors
also note that key critical psychology concepts
have gone from being ‘alternative’ to ‘main-
stream’, backed by a major DCP publication.
This supports the hope that a psychosocial
understanding can offer a robust, practical
front-line approach within wider mental health
systems rather than being simply an ‘add on’.
The workshops, and the PTMF specically,
have helped trainees to think about the role
of psychology at a service development level
as well. This aspect will be extended in future
workshop development.
Although the workshops frequently seem
to generate more questions than answers,
we consider this to be commensurate with
the profession’s history of training crit-
ical consumers and producers of research,
24 Clinical Psychology Forum 313 – January 2019
Helen Grifths & Frances Baty
capable of developing, evaluating and rening
psychologically informed interventions across
different settings. It is from this perspective
of scientic curiosity and creativity that we
encourage our trainees to engage with the
issues highlighted by the PTMF, including
evaluating its role in promoting formulations
that have validity and clinical utility.
Author
Helen Griffiths
Programme Director, University of Edinburgh/
NHS Scotland Clinical Psychology Training
Programme; Helen.Grifths@ed.ac.uk
Frances Baty
Head, Adult Mental Health Psychology
Service, NHS Fife
References
Boyle, M. (2003). The dangers of vulnerability. Clinical
Psychology, 24(4), 27–30.
British Psychological Society (2014). Standards for
doctoral programmes in clinical psychology. Leicester:
British Psychological Society.
Diamond, L.M. (2006). Careful what you ask for:
Reconsidering feminist epistemology and autobi-
ographical narrative in research on sexual iden-
tity development. Journal of Women in Culture and
Society, 31(2), 471–491.
Foucault, M. (1969/2002). The archaeology of knowledge.
London: Routledge.
Friedli, L. (2009). Mental health, resilience and inequal-
ities. Copenhagen, Denmark: World Health
Organization.
Johnstone, L. & Boyle, M. with Cromby, J., Dillon,
J., Harper, D. et al. (2018a). 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. Leicester: British
Psychological Society.
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J.,
Harper, D. et al. (2018b). The Power Threat Meaning
Framework: Overview. Leicester: British Psycholog-
ical Society.
McCartney, G., & Collins, C. (2011). Health inequal-
ities in Scotland: Looking beyond the blame
game. Oxfam [website]. available at https://
policy-practice.oxfam.org.uk/publications/
health-inequalities-in-scotland-looking-beyond-t
he-blame-game-146173
NHS Education for Scotland & Scottish Government
(2017). Transforming psychological trauma: A skills
and knowledge framework for the Scottish workforce.
Edinburgh: NHS Education for Scotland.
Parker, I. (1999). Critical psychology: Critical links.
Annual review of Critical Psychology, 1(1), 3–18.
Oxfam Humankind Index (2013). The new measure of
Scotland’s prosperity, second results. Oxford: Oxfam GB.
Scottish Government (2016). Fairer Scotland action plan.
Edinburgh: Author.
Smail, D. (2006). Is clinical psychology selling its soul
(again)? Clinical Psychology Forum, 168, 17–20
Clinical Psychology Forum 313 – January 2019 25
Surviving prison: Using the Power Threat
Meaning Framework to explore the impact
of long-term imprisonment
Mariana Reis, Sami Dinelli & Lucinda Elias
This paper discusses the way in which the Power Threat Meaning Framework (PTMF) was used in a unit for
offenders with labels of so called ‘personality disorder’, to allow individuals to explore their experiences of prison.
IN THE UK there has been a rise in the
number of prisoners serving indetermi-
nate sentences and an increase in the
average length of these sentences (Creweet
al., 2017). Despite the amount of studies
focused on desistance from crime, very little
attention has been paid to individuals’ expe-
rience of prison and the impact that impris-
onment has on them. This paper describes
a pilot eight session group, the Surviving
Prison group, taking place on the London
Pathways Unit (LPU) at HMP Brixton. The
group aimed to explore the participants’
experiences of prison.
The LPU is a treatment and progression
unit and part of the Offender Personality
Difculty (OPD) Pathway1. The service is for
men from London who are deemed high
risk of harming others and who are stuck in
the prison system (i.e. have had opportuni-
ties at parole to be released or moved to an
open prison but the parole board deemed
their risk to be too high). They are offered
fortnightly key work sessions, a programme
26 Clinical Psychology Forum 313 – January 2019
Mariana Reis, Sami Dinelli & Lucinda Elias
of groups and a range of social activities.
One of the key strengths of the service is its
focus on relationships and social learning.
An independent evaluation has found that
men on the LPU showed an awareness of
the factors that increase their risk of reof-
fending, that they had an improved atti-
tude towards authority, and that they had
a greater sense of self-worth. Regarding
impact on recidivism, recent data shows that
of the men released from the LPU between
2015 and June 2018, 71percent are still in
the community and only 14 per cent were
recalled for a new offence.
By virtue of being a service for men who
have struggled to progress through the prison
system, indeterminate sentenced prisoners
tend to be signicantly over-represented
– in July 2018, 81 per cent of LPU resi-
dents were serving indeterminate sentences
(23per cent Life sentence and 58 per cent
imprisonment for public protection sentence
(IPP) sentence). Furthermore, most indeter-
minate sentenced prisoners on the LPU are
over-tariff. A tariff is the minimum period
of punishment specied by the sentencing
judge. Over-tariff prisoners have had
a chance to present themselves tothe parole
board in order to ask for a move toanopen
prison or the community, but it was deemed
by the parole board that their risk had not
reduced enough for a progressive move to
be granted. It was felt that, on the LPU, there
was no space to support men to explore the
impact of long-term imprisonment, and the
Surviving Prison group was designed to meet
this need.
As part of the service, the Surviving Prison
group was designed and delivered by the
authors, based on the Power Threat Meaning
PTMF. The framework was chosen as the
basis for the Surviving Prison group as, argu-
ably, individuals facing imprisonment are in
a disempowered position and are likely to
face adversity and threat due to the hostile
nature of custodial settings. The framework
acknowledges the impact of this on individ-
uals and encourages people to make sense
of their experiences and behaviour from
a non-judgemental and curious stance. Italso
emphasises the importance of personal
meaning and agency.
Participants
All men on the LPU (26) reviewed an
information sheet detailing the aims of the
group and had the opportunity to partic-
ipate voluntarily. Seven (27 per cent)
signed-up aged between 44 and 58 years
(Mean age=51) and they completed all the
group sessions. Three were white British
and four came from BAME groups. Six
group members were serving indeterminate
sentences (three serving a life sentence and
three serving an IPP sentence), and one was
serving a determinate sentence. All inde-
terminate sentenced men were over-tariff,
ranging between 3 and 19 years (Mean =
7years 9months).
The group ran for eight 90-minute sessions
and was jointly delivered by a forensic psycholo-
gist, an assistant psychologist and an LPU
prison ofcer. Given the relational nature of
the LPU model, all groups are co-facilitated
with trained prison ofcers and the men value
this aspect of groups. In terms of delivery
style, the facilitators used a curious approach
by showing an active interest in participants’
experiences and emphasised the role of group
members as experts. The group had three
main focuses.
Part 1: Initial experience
of long-term imprisonment
This was explored by posing the following
questions:
What do you nd most difcult about
being in prison?
What is the biggest challenge you had to
face in prison?
How did you make sense of your sentence?
How do you make sense of still being in
prison?
Group members were provided with paper to
answer these questions. Facilitators collected
the responses and organised them by
themes on a board, respecting participants’
Clinical Psychology Forum 313 – January 2019 27
Using the Power Threat Meaning Framework to explore the impact of long-term imprisonment
anonymity. This was followed by a group
discussion and making sense of the informa-
tion presented visually.
Part 2: Exploring the impact
of long-term imprisonment
Using the PTMF, this was explored by posing
the questions illustrated in Table 1. Group
members were given a copy and asked to
work on their individual tables in pairs before
feeding back to the whole group. Feedback
was again organised visually.
Part 3: Exploring individual narratives
Group members were encouraged to inte-
grate their discussions into an individual
narrative using the question: ‘What is your
story?’. This was shared with the group who
acted as witnesses. Group members were given
the option of presenting it verbally, in written
form, or visually. This approach was chosen
inline with narrative therapy principles, which
have been identied as helpful for thinking
about forensic services and how power oper-
ates within these institutions (Gardner-Elahi &
Zamiri, 2015). Narrative therapy has also been
linked to desistance (Maruna, 2001), as it offers
alternative identities beyond an‘offender’ iden-
tity, addressing some of the disempowering
processes inherent to forensic institutions.
Findings
Part 1: Initial exploration of the experience
of long-term imprisonment
What do you nd most difcult
about being in prison?
Themes identied were ‘Trust’, ‘Power struc-
ture’, ‘Uncertainty’, ‘Isolation’ and ‘Failure’.
These were derived collaboratively by the
group. Under ‘Trust’, group members spoke
about prison not being a trusting environment
but also about struggling with trusting them-
selves in a prison context. The theme of ‘Uncer-
tainty’ related mainly to group members not
knowing when they will be released from prison
What is the biggest challenge
you had to face in prison?
Four main themes were identied: age, change,
being judged and fear. Under the theme of
‘Age’, a group member mentioned that ‘prison
is a young man’s game’ and most people spoke
about their perception of the code of conduct
in prison and how that has changed. All group
members spoke powerfully about being fright-
ened in prison on a regular basis. Under ‘Being
judged’, participants talked about others
having misconceptions about them.
How did you make sense of your sentence?
Responses by participants ranged from denial,
loss of hope, feeling bad inside and a worry
about the ability to cope with the sentence.
How do you make sense of still being in prison?
Group members acknowledged that some
of their own behaviours have kept them in
prison. Participants also spoke about change
as a conscious choice – ‘I felt hopeless. When
I decided I wanted to get out I realised some-
thing had to change’ and described this
as a difcult process – ‘Some changes you
don’t necessarily want to happen’.
Part 2: Further exploration using the PTMF
Individuals spoke openly about a range of
threats they have faced in prison. Interest-
ingly, most threats were easily grouped under
Table 1: Power Threat Meaning Framework working document
Power
What happened
to you in prison?
Threat
What was the
threat?
Meaning
What sense did
you make of the
threat?
Threat response
What did you
have to do to
survive?
Strengths
What are your
strengths?
28 Clinical Psychology Forum 313 – January 2019
Mariana Reis, Sami Dinelli & Lucinda Elias
Figure 1: Threats experienced by group members since they have been in prison
Sense%
of%self
Segregation
Self,doubt:,
Will,I,be,able,to,
cope?
My,life,is,unimportant
Loss,of,
elements,of,
self
Feeling,
trapped,
Power%by%
force
Physical,threat
Violence
Basic,rights,not,
respected
Lack,of,
safety
Hostility
Intimidation
Legal%power
Restrictions,on,
freedom
Lack,of,value
Ideological*
power
Loss$of$
opportunities
Attack$on$my$
sense$of$wrong$
and$right
Being$silenced
Racial$attacks
Relational*
power
Isolation
Neglect
Injustice
Lack$of$
privacy$and$
dignity
Loss$of$
relationships
No$boundaries
Social*power
Loss$of$white$
privilege
Religious$attacks
Clinical Psychology Forum 313 – January 2019 29
Using the Power Threat Meaning Framework to explore the impact of long-term imprisonment
Figure 2: Threat responses to violence, bullying and intimidation
Figure 3: Threat responses to distress
Threat:(Violence,(
bullying,(intimidation
Aim:(Protection(from(
physical(danger
Turning'a'blind'eye Verbal'abuse
Spread'rumours'
about'others
Prepare'to'fight
Humour'(show'
it'doesn’t'affect'
me)
Portray'self'as'
dangerous'and'
ruthless
Drugs
Violence
Become'a'bully
Appeasing'
others,'
submitting
Retreat,'
withdraw,'
dissociation
Threat:(Distress
Aim:(
Communicating(
distress(and(
eliciting(care
Intimidation
Break-prison-
rules
Withdraw
Violence
Drugs
Put-in-for-
transfer
Segregation
Gangs
Excessive-
use-of-gym
Smash-
things
Drop-people-out
30 Clinical Psychology Forum 313 – January 2019
Mariana Reis, Sami Dinelli & Lucinda Elias
forms of power suggested by the framework
(i.e.power by force, legal power, social power/
social capital, ideological power and relational
power. Sense of self was added as a theme to
capture feedback from participants relating
to their view that since being in prison, they
have felt their sense of self and individuality
under constant attack. Figure 1 summarises
the feedback.
In exploring the meaning that partici-
pants attributed to these experiences of the
operation of power, four main themes were
identied: ‘Anger’, ‘It’s a game’, ‘Uncer-
tainty’ and ‘Vulnerability’. The men said
that they felt constantly tested and often
cornered. One group member stated –
‘I am in a battleeld’. Under the theme
of uncertainty, the men mentioned feeling
that everything is unpredictable and not
in their control. Participants were then
asked to explore how they responded to
the threats they experienced. In order to
assist their thinking, the men were asked to
explore their threat responses in relation to
different groups of threats outlined in the
PTMF (Johnstone & Boyle, 2018).
Group members described various
responses to the different groups of threats.
The responses to bereavement, loss and aban-
donment included withdrawal, self-harm and
panic. In response to ‘Injustice’ and ‘Power-
less’ group members described making their
own rules, ghting the system and protesting.
The responses to attack on identity and
self-esteem included drug dealing, denial of
offence and violence. Figures 2 and 3 show
the reported threat responses to ‘Violence’,
‘Bullying and intimidation’ and ‘Distress’.
Part 3: Exploring individual narratives
The last task of the group entailed group
members telling their stories of what has
happened to them in prison. All members
fed their stories back to the group. Some used
their group material and fed this back verbally
to the group (see Table 2 for an example
of a completed table), whilst others wrote
a narrative of their story and read it aloud to
the group.
Discussion
The aim of this paper was to describe the
results of a group which translated the PTMF
into applied practice to assist prisoners
in thinking about the impact of long-term
connement and reinforce narratives of
empowerment and desistance. The Surviving
Prison group was designed because as clini-
cians working with indeterminate sentenced
prisoners, we felt we had been ‘missing the
obvious’ when it comes to thinking about
the impact of long-term imprisonment. The
PTMF was chosen as the theoretical basis for
the group due to its acknowledgment of the
impact of trauma, adversity and threat, and its
emphasis on personal meaning.
The Surviving Prison group was well
received by its group members and the
informal feedback was positive. For example,
participants stated:
‘I enjoyed listening to other people’s stories and
looking at my own journey through prison.’
‘This group gave us a platform to speak about
things that I have not had the opportunity to
speak about previously.’
The authors found that the framework can
be easy to explain and translate into clin-
ical practice. We also found it encouraging
that the framework allowed individuals to
acknowledge and own their challenging
behaviour, whilst putting it into context;
more so than the group content, we found
that group processes were particularly impor-
tant. The open-ended questions provided
by the framework seemed to allow group
members to speak openly about their expe-
riences and most of the learning occurred
from group discussions. In terms of group
delivery, we found that facilitators mapping
group members’ input in vivo and being
curious about it elicited thinking and allowed
meaning-making by the group as a whole,
which felt like a rich and useful process.
These principles and approaches have also
been supported by collective narrative prac-
tice (Denborough, 2008).
Clinical Psychology Forum 313 – January 2019 31
Using the Power Threat Meaning Framework to explore the impact of long-term imprisonment
Of note is that the group was facilitated
in a therapeutic unit within a custodial
setting, where the norm is that all groups are
co-facilitated by prison ofcers. All prison staff
are trained to work within the parameters
of a relational approach and are receptive
to the LPU model. The men on the unit are
also familiar with working alongside prison
ofcers, and these relationships are at the core
of the model. It would be worth facilitating the
Surviving Prison group to men in custody who
are not in a therapeutic unit. Although this
may introduce different challenges as the men
are less familiar with working alongside prison
staff, this group of men, arguably, have limited
opportunities to process their custodial expe-
riences. Facilitating a group based on the
PTMF would also be in line with the National
Offender Management Service’s efforts to
support the delivery of rehabilitation services
in custody (NOMS, 2015).
Because this group was a pilot on the LPU,
group members were advised that post-group
reports would not be written, and their engage-
ment in the group would not be reected
in reports for parole purposes. However,
a possible limitation of continuing to run this
group on the LPU, or running it in the wider
prison, is that group members will be more
guarded in their responses as they may fear
information will be included in their parole
reports and will impact on their progression.
In conclusion, the authors suggest the PTMF
can be easily translated into clinical practice and
that it can be effectively used in custodial settings
to explore the impact of connement, adversity
and threat on individuals. Despite the constraints
inherent to custodial environments, the authors
would also suggest the framework has a place in
fostering personal agency in these settings. By
assisting individuals in understanding themselves
better via creating new narratives, practitioners
are promoting ownership, self-compassion and
self-belief, all of which are important factors in
empowering people to make positive choices
which can ultimately lead to change (Maruna,
2001; White & Epston, 1990). Future research
could use a formal qualitative methodological
approach to examine participants’ responses to
the use of the PTMF in forensic settings.
What happened to me
in prison
The sense I made of it What I had to do
to survive
My Strengths
Restriction of freedom
Not being around
loved ones
Felt abandoned and
isolated
Economical pressure,
could not provide for
people outside
No support from staff
Threats of violence
Racial and religious
tensions
No privacy
Oppression
Afraid, fearful
Injustice
Treated unfairly
Shame
I am in a battlefield
I am in an
unpredictable
environment
Confused
Unsafe
They will label me
I am worthless
This is like sports to
them
Denial
Make my own rules
within the rules
Being on guard,
vigilant and paranoid
Fight
Protest
Isolate, withdraw,
retreat
Detach
Feeling entitled
Selling drugs
Joining gangs
Smoke weed
My God
My family
Myself: I have patience,
I respect people,
when something goes
wrong I think and
reflect on it, I am
kind, very mindful, I
am not judgmental, I
support people, I like
doing my part for
my community, I am
always open to new
things.
I like taking care of
myself by going to
the gym, prayers and
activities available.
I value people
Table 2: Completed table based on Power Threat Meaning Framework
32 Clinical Psychology Forum 313 – January 2019
Mariana Reis, Sami Dinelli & Lucinda Elias
Authors
Dr Mariana Reis
Forensic Psychologist, Oxleas NHS Founda-
tion Trust, working at HMP Brixton on the
London Pathways Unit; mariana.reis@nhs.net
Sami Dinelli
Prison Ofcer, HMP Brixton; currently
works on the London Pathways Unit;
sami.dinelli@hmps.gsi.gov.uk
Lucinda Elias
Trainee Psychological Wellbeing Practi-
tioner with Talking Therapies, Psicon;
lelias16@hotmail.com; formerly Assistant
Psychologist, LPU
Endnote
1 Although the ofcial name is Offender Personality Disorder Pathway, we prefer to use the word
‘difculty’ in our academic writing.
References
Crewe, B., Hulley, S. & Wright, S. (2017). Swimming
with the tide: Adapting to long-term imprison-
ment. Justice Quarterly, 34(3), 517–541.
Denborough, D. (2008). Collective narrative practice:
Responding to individuals, groups and communities who
have experienced trauma. Adelaide: Dulwich Centre
Publications.
Gardner-Elahi, C. & Zamiri, S. (2015). Collective narra-
tive practice in forensic mental health. Journal of
Forensic Practice, 17(3), 204–218.
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J.,
Harper, D. et al. (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. Leicester: British Psychological
Society.
Maruna, S. (2001). Making good: How ex-convicts reform
and rebuild their lives. Washington: American Psycho-
logical Association.
National Offender Management Service (2015). Rehabili-
tation Services Specification – Custody. Leicester: Author.
White, M. & Epston, D. (1990). Narrative means to thera-
peutic ends. New York: W.W. Norton.
Clinical Psychology Forum 313 – January 2019 33
Using the Power Threat Meaning Framework
in social work education
Rachel Fyson, Kirsten Morley & Andrew Murphy
This paper summarises the roles of social workers in relation to mental distress and the legal framework in which
they operate. We then discuss the potential of the Power, Threat, Meaning Framework (PTMF) in social work
education and more generally as a resource for social workers in practice.
ALL social workers at times work with
people who are experiencing or have
experienced mental distress. This
includes not only social workers employed
within specialist Child and Adolescent Mental
Health Services, Community Mental Health
Teams or inpatient services, but those working
across all settings. In children’s services,
parental mental distress is part of the so-called
‘toxic trio’ of factors commonly present
in cases of child maltreatment; the others
being substance misuse and domestic violence
(IPC, 2015).
In adult services, mental distress is
common amongst service users, including
when it is not the primary reason for referral.
This is because many people, such as those
with learning disabilities, those with physical
or sensory impairments and those who are
old, frail and housebound are often experi-
encing the consequences of social exclusion,
loneliness and, at times, abuse (Stevens et al.,
2018). Across all service user groups, social
workers work disproportionately with people
from poor and disadvantaged communities,
who are more likely than wealthier people
to experience mental distress (Macintyre
et al., 2018).
The relevance of social work to mental
distress is recognised in law. The Mental
Health Act 1983 required an Approved Social
Worker to lead assessments under the Act.
More recently, the Mental Health Act 2007
replaced the Approved Social Worker with
the Approved Mental Health Professional
(AMHP), opening up the role to a wider range
of professions. However, the vast majority
of AMHPs continue to be social workers,
with the latest available data suggesting only
5per cent of AMHPs are non-social workers
(ADASS, 2018).
AMHPs are trained to maintain a rm
focus on social perspectives in a Mental Health
Act Assessment (MHAA). Social determinants
of mental distress ‘are taken into consid-
eration by an AMHP in order to highlight
a different perspective, usually as a balance to
the medical one’ (Matthews et al., 2014, p.8).
However, despite the frequency of mental
distress amongst those who are subject to
social work interventions, it is known that
social workers can struggle to maintain social
perspectives on distress (McNicoll, 2013).
This may particularly be the case when social
workers are based in multidisciplinary teams
where practice can often be predicated on
medicalised understandings of distress and
a reliance on DSM-V (American Psychiatric
Association, 2013) or ICD-10 (World Health
Organization, 1992) classications.
Part of the web of reasons that some social
workers might nd it hard to maintain a social
perspective is that prior to the publication of
the PTMF (Johnston & Boyle, 2018), there
was no obvious unifying framework that fully
accounted for the social origins of distress.
Although social work training has always
emphasised the social aspects of distress,
social workers previously had to draw on
a range of theories to support their work
34 Clinical Psychology Forum 313 – January 2019
Rachel Fyson, Kirsten Morley & Andrew Murphy
– including the social model of disability
(Swain et al., 2013), psychodynamic theory
(Payne, 2014) and sociological theories
such as ‘deviance’, which explore the causes
and meanings of behaviour that breaches
social norms (Dillon, 2014), particularly in
health-dominated multidisciplinary settings
such eclecticism, was regarded as no match
for the dominant medical model.
Other elements of power are also at
play here, including gender (typically male
doctors and female social workers), and
perceived professional seniority (as indi-
cated by differential pay grading, with social
work salaries roughly on a par with those
of nurses but lower than those of clinical
psychologists and substantially lower than
those of doctors). Moreover, in multidisci-
plinary discussions with social workers, some
psychiatrists have explicitly contrasted the
length of their professional training with that
of social work as justication for the differ-
ential status of their decision making. In
this context, it is worth noting that although
for more than a generation the majority of
social workers have been graduates, social
work became a graduate-only qualication
as recently as 2005. It is worth briey consid-
ering how this situation arose, touching on
both the historical development of social
work practice and more recent developments
in social work education.
Social work emerged as a profession
during the nineteenth century, from char-
itable responses to the squalor and depri-
vation in newly industrialised cities (Fraser,
1984; Thane, 1996). Early social work activity
focused largely on alleviating poverty and
preventing child maltreatment and family
breakdown, with consideration of the causes
of these social phenomena only gradually
emerging (Fraser, 1984). At the same time,
the new profession of psychology was contin-
uing to develop ways of testing ‘intelligence’
and promoting the use of segregated settings
to house those judged to be lacking (Wright,
2011). Statutory powers for social workers
employed by local authorities to intervene
in people’s lives developed slowly from the
early twentieth century onwards. However,
the title ‘social worker’ only acquired legal
protection, with associated requirements
for professional registration, in 2005. The
current regulator for social workers and social
work education programmes in England is
the Health and Care Professional Council
(HCPC), though its responsibilities are due
to be transferred to a new organisation,
Social Work England, in late 2018 or early
2019. There are separate regulatory bodies
for social work in each of the countries of
the UK.
Social work qualifying programmes can
be offered as either three-year undergrad-
uate (BA, BSc) or two-year postgraduate
(MA, MSc) degrees. All social work qual-
ifying programmes are required to meet
the HCPC’s cross-disciplinary Standards of
Education and Training (HCPC, 2017), as
well as the social work-specic Standards of
Proficiency: Social Workers in England (HCPC,
2017). University degree programmes
include academic modules, skills days and
170 days of supervised practice placements.
It is a requirement that service users and
carers are involved in the management
and delivery of social work education. In
addition to university degrees, fast-track
employment-based social work qualifying
programmes provide postgraduate routes
to qualication, with specialisation ineither
social work with children and families
(Step-Up, Frontline) or adult mental distress
(Think Ahead).
Recent years have seen repeated reforms
of social work education in response to
high-prole child death cases, notably
those of Victoria Climbié in 2000 (Laming,
2003) and Peter Connelly in 2007 (Jones,
2014). Amongst the many changes has
been a requirement to ensure that teaching
enables qualied practitioners to meet the
requirements set out in knowledge and skills
statements, published by the Chief Social
Workers. Separate knowledge and skills
statements exist for social work with chil-
dren and families and for social work with
adults. Both knowledge and skills statements
Clinical Psychology Forum 313 – January 2019 35
Using the Power, Threat, Meaning Framework in social work education
emphasise the importance of social workers
understanding the causes and consequences
of mental distress.
The Knowledge and Skills Statement for Child
and Family Social Work (Department for Educa-
tion, 2014) states that social workers should
be able to:
Explain the impact that: mental ill-health,
substance misuse, domestic violence, physical
ill-health and disability can have on family
functioning and social circumstances; apply
a working knowledge of the presentation of
concerning adult behaviours which may indicate
increasing risk to children and the likely impact
on, and inter-relationship between, parenting
and child development. (ibid, paragraph 3)
Whilst the Knowledge and Skills Statement for
Social Workers with Adults (Department of
Health, 2015) states that:
In particular, social workers need to under-
stand the impact of trauma, loss and abuse,
physical disability, physical ill health, learning
disability, mental ill health, mental capacity,
substance misuse, domestic abuse, aging
and end of life issues on physical, cognitive,
emotional and social development both for
the individual and for the functioning of the
family. (ibid, paragraph 6)
However, there is no further guidance on
how mental distress should be presented
within the curriculum or what social work
students should be taught about the causes
and consequences of mental distress. Given
this, it is perhaps unsurprising that research
evidence suggests social work students often
feel ill-prepared for this aspect of practice
(McCusker & Jackson, 2016).
At the launch of the PTMF, Dr Ruth Allen,
CEO of the British Association of Social
Workers, said:
I think this Framework is really, really welcome.
It is going to substantiate and provide a richness
of explanation to some of the things that social
workers have known for a very long time […]
It is going to enable us to have discussions
across the different professions about how we can
come together around a different way of under-
standing mental health problems and mental
distress. (See www.bps.org.uk/news-and-
policy/introducing-power-threat-mean-
ing-framework)
Importantly, the PTMF’s exploration of power
has resonances with the fundamentals of social
work, including the profession’s emphasis
on human rights, respect for diversity and
acknowledgement of how power affects
human relationships. The PTMF can also be
readily connected with social work’s emphasis
on seeing the individual within the context of
their life situation, including socio-economic
structures, considering experiences of oppres-
sion, inequality and power dynamics on both
a micro and macro scale. It also enables
exploration of ways that an individual has
had to survive, adapt and respond to life
experiences, and looks for opportunities to
intervene and disrupt consequent patterns
of behaviour which are unhelpful or risky for
the person.
At the University of Nottingham, the
PTMF has been welcomed as an opportu-
nity to reshape our teaching and we are
introducing new modules on both our BA
and MA Social Work programmes, enti-
tled ‘Understanding Mental Distress’ and
‘Mental Distress: Social Contexts’ respec-
tively. We are using the PTMF for its utility
and because it is based on evidence which
unequivocally demonstrates the connection
between life experiences and mental distress.
The impetus for these changes has been
driven in part by the increasing numbers of
students who have asked for teaching which
enables them to better understand this area
of social work practice. However, we are
also aware that many students arrive with
understandings of mental distress that have
been shaped by the acceptance of psychi-
atric approaches that dominate mainstream
discourse. For these reasons, our modules
will be broadly based on the following
elements:
36 Clinical Psychology Forum 313 – January 2019
Rachel Fyson, Kirsten Morley & Andrew Murphy
1. Dispelling myths: Critiquing biomedical
models and functional diagnoses; ques-
tioning the utility of psychiatric medication
and detention in light of the evidence base
2. Introducing PTMF: Exploring the parallels
between social work values and how power
is conceptualised within the PTMF
3. Developing and maintaining relationship-based
practices: Drawing directly on the PTMF, this
element focuses on the key task of assess-
ment and shows how, instead of asking
‘What is wrong with you?’, the focus should
instead become ‘What has happened to
you?’; ‘How did it affect you?’; ‘What sense
did you make of it?’ and, crucially, ‘What
did you do to survive it?’
4. Learning from service users: Individual
perspectives on the both the positive utility
and negative consequences of diagnostic
labels; individual experiences of helpful
and unhelpful professional interventions
5. Assessment – Reflecting on students’ own life
experiences: Drawing on the PTMF, and
more particularly on the PTMF’s use of
concepts developed by social workers
Michael White and David Epston (1990),
the assessment for this module will require
students to demonstrate an understanding
of the importance of personal narratives,
by reecting on the similarities and differ-
ences between their own personal narra-
tive and that of a service user (presented
as a composite case study), and the power
dynamics which have shaped each life.
The aim is to ensure that all social workers who
graduate through our programmes will have the
skills and knowledge to work in ways that create
spaces in which a service user can share their
narrative. The social worker will gain an under-
standing that a person’s responses to adverse life
experiences can be seen as survival strategies and
importantly, to have the condence to maintain
a social perspective on mental distress regard-
less of the setting in which they work. We believe
that using the PTMF in our teaching will be the
cornerstone of achieving this goal because of
the way it combines conceptual clarity, academic
rigour and service user perspectives.
It is not known how many other social
work qualifying programmes have adopted the
PTMF as the basis for their teaching on mental
distress. However, information about PTMF
has been circulated to all universities which
teach social work via the Joint Universities
Council on Social Work Education. Anecdotal
evidence suggests that some programmes
have already adopted the language of mental
distress (rather than ‘mental health’) and have
a specic module focused on this topic; some
have modules which still use the medicalised
language of mental (ill) health, while others
have no specic module focusing on mental
distress or mental health, but instead integrate
these concepts into the broader curriculum.
However, it is known that students on the
fast-track Think Ahead programme do receive
teaching about the PTMF.
Despite the ubiquity of mental distress
within social work practice, prior to the publica-
tion of the Power, Threat, Meaning Framework
there was no straightforward or comprehensive
way of supporting students to understand the
social origins of distress. Inprofessional prac-
tice, this lack of an overarching framework
made it difcult for social workers to maintain
a clear focus on social causes and to defend
the importance of this perspective in multi-
disciplinary settings. Introducing the PTMF
within social work qualifying programmes
offers the opportunity for a new generation of
social workers to condently assert the impor-
tance and value of social approaches to mental
distress. It is our belief that this will be of great
benet to service users and professionals alike.
Authors
Rachel Fyson
Professor of Social Work, University of
Nottingham
Kirsten Morley
Assistant Professor of Social Work, University
of Nottingham; qualied Approved Mental
Health Professional
Andrew Murphy
Assistant Professor of Social Work, University
of Nottingham; qualied Approved Mental
Health Professional
Clinical Psychology Forum 313 – January 2019 37
Using the Power, Threat, Meaning Framework in social work education
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dardsofprociency-SocialworkersinEngland.pdf
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straight. Bristol: Policy Press.
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38 Clinical Psychology Forum 313 – January 2019
The ‘Own my life’ course: Building literacy
with women about trauma through the
Power Threat Meaning Framework
Natalie Collins
This article will examine the use of the Power Threat Meaning Framework (PTMF) with women who have
been subjected to abuse and the practitioners who support them. Approaching the framework from a practitioner
perspective, the merits of the framework and the impact it has had in training with practitioners will be reected on.
A
FEW years ago, I was delivering groups
for women who had been abused by
a partner. In conversation with one
of the support workers in the service, I was
informed that one group participant was not
entitled to a support worker attending court
with her because her ex-partner only posed
a ‘standard’ risk to her. The woman’s needs
were not considered, only how dangerous her
ex-partner was. On another occasion, a woman
shared with the group that her partner had
left her so paranoid through hiding things,
lying to her and telling her that she was crazy,
that she had been diagnosed with various
mental health disorders. She was unable to risk
leaving him for fear that the authorities would
remove the children from her and place them
with him as a result of her diagnoses.
I have spent the last decade variously
working with women who have been subjected
to abuse by a partner, with male perpetra-
tors of abuse, and through developing the
Clinical Psychology Forum 313 – January 2019 39
The ‘Own my life’ course
DAY Programme (www.dayprogramme.org) to
train practitioners to work with young people
to educate them about abuse and exploita-
tion. I have become convinced that one of
the biggest issues facing those who have been
subjected to abuse is the ways they (and their
distress) are pathologised by support workers,
doctors, psychologists, their family and friends,
and society more generally.
A woman’s behaviour, choices and strat-
egies may seem ‘abnormal’, but they usually
have a clear logic and are often rooted
in natural human physiological responses to
trauma. For instance, when a woman remains
in a relationship with an abuser, this can
appear illogical. The main question I am
asked about my work (both in professional
and personal contexts) is, ‘Why doesn’t she
just leave?’. Interestingly, nobody ever asks me,
‘Why doesn’t he just stop?’. People are much
quicker to see her behaviour (in not leaving)
as problematic, than the behaviour of signi-
cant numbers of men who rape, violate, phys-
ically assault and emotionally abuse a person
that they profess to love.
Around 90percent of men who kill a female
ex-partner do so within a year of her leaving
(Ofce for National Statistics, 2017), in which
case it could seem highly logical to remain in
a relationship with someone rather than being
murdered by them. An abuser deliberately
isolates his partner, stripping her condence,
controlling her nances and manipulating her
into believing she cannot live without him.
Wider societal messages may leave her feeling
she has failed if she ends the relationship, and
for women with children, the stigma of single
motherhood and her children no longer
having their father can be a signicant moti-
vating factor in feeling unable to leave. Along-
side all of this, when humans are subjected
to stress or trauma, maintaining attachment
is a physiological need. As trauma expert
Zoe Lodrick explains, ‘…terried people do
not move away from danger toward safety…
people eeing threatening situations move
toward ‘home’, the familiar, or their attach-
ment object’ (Lodrick, 2010). The woman
may be traumatically attached to her abusive
partner, making it feel almost impossible to
leave. The threat the abuser poses, his tactics,
the wider societal messages, and her own phys-
iology make it entirely logical that a woman
would stay with an abuser.
I began to formulate ways of working with
women with the core value of ‘depathologi-
sation’, recognising that women who have
been subjected to abuse generally act normally
within abnormal situations. This formulation
became the Own My Life Course, a 12-week
course for women who have been subjected to
abuse. Securing three years’ funding for the
project, it is a train-the-trainer model, in which
practitioners can attend a three-day training
course and then be able to deliver the Own
My Life Course with women in groups and in
one-to-one contexts. As I was developing the
course earlier this year, I was excited to become
aware of the PTMF, which provides not only
a robust and evidence-based model for articu-
lating the need to depathologise distress, but
also offers a new framework for helping people
make sense of their lives and struggles. That the
PTMF not only looks at interpersonal power
issues, but also societal oppression, including
sexism and racism, convinced me that I needed
to include it within the Own My Life Course,
not just as an underlying principle, but to make
sure that every woman who accesses the course
can understand the framework for herself.
Another core value of the course is to build
literacy with women about trauma. I have done
this through creating short whiteboard anima-
tions within the course that explain complex
concepts (e.g.the Stress Cycle and the FiveFs:
ght, ight, op, friend and freeze). After
I had spent time getting to grips with the
PTMF documents, Lucy Johnstone gener-
ously offered her expertise via e-mail, so that
I could ensure I had enough understanding
of the framework to be able to communicate
it effectively. What resulted is an 11-minute
video which rst of all explains the differ-
ence between the medicalised framework and
the PTMF, and then goes on to outline it.
The second half of the video uses shame as
an example of meaning making that is often
done as a result of humiliation. I was grateful
40 Clinical Psychology Forum 313 – January 2019
Natalie Collins
to Phil Leask, author of Losing Trust in the
World: Humiliation and its consequences (Leask,
2014), for offering his wisdom in developing
this part of the video.
The Own My Life Course is due to be
piloted in four locations across the UK in 2019,
with further training available for practitioners
in 2020 after the pilots have been evaluated
and the learning from them incorporated
into the course. However, I have already used
the Power Threat Meaning video in my work
with the Domestic Abuse and Exploitation
(DAY) Programme. Using the same train-the-
trainer model, youth practitioners and those
who work to address domestic abuse attend
the DAY Programme training to use it with
young people. Within this training, I have
used the PTMF video and the feedback from
practitioners has been hugely positive. After
watching, one practitioner stated that twenty
years previously she had been in a serious car
accident and had been on anxiety medication
since then. She wondered whether the anxiety
was actually hypervigilance and hypersensitivity
brought on by the effects of the car accident.
She explained the medication hadn’t stopped
the anxiety and said she was going to inves-
tigate non-medical therapies for the past
trauma of the car accident. Other practitioners
described having ‘light bulb moments’ after
watching the video; they could immediately see
the relevance for the children, young people
and parents they were working with.
As a practitioner, I cannot overstate the
importance of the PTMF. It is so valuable to
have a robust, well-evidenced 400-plus page
report to refer to when stating the obvious:
that what someone is subjected to impacts
every aspect of their lives and how they experi-
ence the world. This is particularly important
in a society in which labels and diagnoses are
fast becoming the only way that someone can
access support and/or validation that their
suffering and pain is real. Making the frame-
work available to as many people as possible
has become something of a mission for me.
I really believe that it can change lives and
open up the possibility to move away from
the pathologisation of people, to a new space.
A space where someone’s distress can be vali-
dated, and they can be cared for in ways that
do not ignore or minimise what has been done
to them through other people’s choices, struc-
tural inequality, or difcult circumstances.
There are two questions that the framework
asks in terms of moving forward. The rst is,
‘What is your story?’. The Own MyLife Course
seeks to enable women to regain ownership of
their lives from an abuser who has controlled
them. He is generally motivated by a belief
that he owns his partner and is entitled to
get what he wants from her. Each participant
receives an ‘Own My Story’ journal, with all the
content from the course alongside exercises
that encourage reection and self-directed
learning. Encouraging women to own their
story is something that is hugely important
within the course. AsSalman Rushdie has said,
‘Those who do not have power over the story
that dominates their lives, power to retell it,
rethink it, deconstruct it, joke about it, and
change it as times change, truly are powerless,
because they cannot think new thoughts’ (New
York Times, 1991).
The second question the framework asks
is, ‘What are your strengths?’. Rather than
focusing on a ‘decit model’, the Own My
Life Course seeks to have a ‘strengths-based
model’ that helps women identify that they are
extraordinary to have made it through, rather
than failed because someone chose to abuse
them. Whilst these were already elements
within the course before I was introduced
to the PTMF, it has been extremely useful as
I have developed the course to have these
explicit questions to hand.
The full benet of the Own My Life
course (and the inuence of the PTMF on
it), remain to be seen, as we start the pilots
and as the training for practitioners becomes
available. For now, I remain hugely grateful for
a framework that articulates and evidences the
importance of ‘depathologising’ people’s lives.
Author
Natalie Collins
Gender Justice Specialist
natalie@nataliecollins.info
Clinical Psychology Forum 313 – January 2019 41
The ‘Own my life’ course
References
Leask (2014). Losing trust in the world: Humiliation
and its consequences. Psychodynamic Practice: Indi-
viduals, Groups and Organisations, 19(2), 129–142.
Available at www.tandfonline.com/doi/full/10.108
0/14753634.2013.778485
Lodrick (2010). Generic testimony – Sample state-
ment. Zoe Lodrick – Sexualised trauma specialist
[website]. Available at www.zoelodrick.co.uk/
services/expert-testimony/sample-statement
Excerpts From Rushdie’s Address: 1,000 Days
‘Trapped Inside a Metaphor’ (1991, 12
December). New York Times. Available at www.
nytimes.com/1991/12/12/nyregion/excerpts-fro
m-rushdie-s-address-1000-days-trapped-inside-
a-metaphor.html
Ofce for National Statistics (2017). Statistical bulletin:
Domestic abuse in England and Wales – Year
ending March 2017. Office for National Statistics
[website]. Available at www.ons.gov.uk/peoplepop-
ulationandcommunity/crimeandjustice/bulletins/
domesticabuseinenglandandwales/yearending-
march2017
42 Clinical Psychology Forum 313 – January 2019
Incorporating the Power Threat Meaning
Framework into an autism and learning
disability team
Alison Flynn & Nechama Polak
This article presents our personal experience of using the PTMF in a National specialist service working with
children, adolescents, families and adults with a diagnosis of Autism Spectrum Condition (ASC), or intellectual
disability. We suggest that regardless of one’s understanding of the nature of ASC, the PTMF offers a broader,
contextual understanding of a person’s experience.
THE TAVISTOCK Autism and Learning
Disability Team works with children,
adolescents and adults with a diagnosis
of Autism Spectrum Condition or Intellec-
tual Disability. The team’s heritage is in The
Tavistock Autism Workshop, where clinicians
began to challenge the notion that people
who present with social communication dif-
culties or restricted and repetitive patterns
of behaviour could not access psychotherapy
(Reid, 1999).
Today’s team includes a treatment pathway
offering psychodynamic, systemic, cognitive
behavioural, compassion focused and narrative
therapy. The diagnostic assessment pathway
takes a therapeutic approach (Engelman et al.,
2016) and uses the DSM-5 diagnostic criteria
(American Psychiatric Association, 2013).
Clinical Psychology Forum 313 – January 2019 43
Incorporating the Power Threat Meaning Framework into an autism and learning disability team
Epistemological context of autism
Although the PTMF presents as an alternative
to functional psychiatric diagnoses, it acknowl-
edges that a neurodevelopmental compo-
nent is likely to play a role in more severe
cases of autism (Johnstone & Boyle, 2018,
p.70). The PTMF also highlights the ongoing
debate about the essential nature of Autism
Spectrum Condition amongst researchers,
clinicians and service users (see the Univer-
sity of Exeter ‘Exploring Diagnosis’ project
at http://blogs.exeter.ac.uk/exploringdiag-
nosis). For these reasons, the PTMF does not
present itself as an alternative framework to all
uses of the diagnosis of ASC.
Clinicians, service users and their networks
must nd ways to negotiate a path between
various and sometimes opposing understand-
ings of the nature of ASC. We are critical of
our own power to undermine service users’
condence to know and make meaning of
their own reality (Giddens, 1991; Fricker,
2007), while at the same time being aware
of the social and cultural inuences which
contribute to that meaning making.
To hold multiple and sometimes competing
understandings of ASC in mind, we adopt
a pragmatic relationship to evidence and
theory, using it to support our clinical work
rather than determining it – what Martin Baro
called ‘realismo-critico’ (Kagan et al., 2011;
Kagan & Burton, 2016). With every service
user, we begin to think about the essential
nature of ASC again, co-creating and coordi-
nating meanings (Pearce, 2005). The PTMF,
a meaning making tool, is complementary to
this work.
The referral
From the point of referral, we have found it
is important to ask: What brought a person to
be diagnosed? When did they receive the diag-
nosis? Whose idea was it? What question was
it hoped a diagnostic understanding would
answer? How do referring services choose
the people they refer for therapy or assess-
ment? How are people streamed into specialist
services from education and mental health
systems as a whole?
We try to ask questions that are sensi-
tive to the effect of wider ecological power
on the referral (Bronfenbrenner, 1979).
The PTMF speaks to this, highlighting the
enormous rise in ASC diagnoses and raising
a concern that demands made by industrial-
ised, service-oriented economies for people to
display ‘emotional behaviours such as (faked)
sociability, warmth, and gratitude’, etc. create
a normative set of social communication skills
that many people will not meet (Roberts,
2015, in Johnstone & Boyle, 2018, p.70). We
also consider ways in which referrals might be
triggered by an intersection of these neolib-
eral values and increasingly scarce special
education provision and resources in refer-
ring boroughs or schools (Timimi, 2010).
Assessment and formulation
At the point of assessment, we have found that
the PTMF questions open up conversations
about social norms and values. In some cases,
the question ‘What did you have to do to
survive?’ reframes ASC ‘traits’ as meaningful
threat responses.
For example, a person concerned about
difculties taking the perspective of others
reframed their recent arguments about poli-
ticians excluding minorities as meaningfully
related to a personal history of bullying and
a lifetime of messages about being different.
This formulation connected them with their
values for inclusivity and fairness. The PTMF
questions helped us to reframe ‘rigidity’ on
this subject as an act of creative resistance in
response to power (Afuape, 2011).
People with ASC frequently encounter inter-
personal, social and political threats. Our clin-
ical experience resonates with the pattern of:
Surviving exclusion and competitive defeat as
non-typical or non-conforming: The narrower the
range of acceptable ways of being, and the more
individualistic and competitive the social norms,
the harder it is for people who are non-typical in
various ways to nd a social role and place for
themselves and the more likely they are to experi-
ence feelings of failure, inadequacy, shame and
exclusion. (Johnstone & Boyle, 2018, p.344)
44 Clinical Psychology Forum 313 – January 2019
Alison Flynn & Nechama Polak
We have used this pattern to inform formula-
tions that position mental health as secondary
to experiences of social inequality and exclu-
sion; for example, in letters to Job Centres
requesting reasonable adjustments to job
search procedures (H.M. Government, 2010).
We are lucky to work with a Social Worker,
Kirsty Gelder Smith, who has supported
people to negotiate, apply and appeal within
an increasingly restrictive and complex bene-
ts system (Watts, 2018).
Psychodynamic groups
Many adults accessing the therapeutic
pathway decline NICE recommended ther-
apies such as cognitive behaviour therapy
(Murphy et al., 2016) and opt for psycho-
dynamic groups. Our Service Evaluation
projects have found that rather than seeking
concrete, structured therapies, many
service users value this exploratory space.
Although each group is different, common
themes are finding a place in society and
processing ‘feelings of failure, inadequacy,
shame and exclusion’ (Johnstone & Boyle,
2018, p.344). Repeated experiences of ‘not
getting it right’ can be deeply impactful but
often invisible, the group often processes
the effect of this.
These groups often illustrate the inter-
section of one’s understanding of ASC and
mental health. Like Hudson et al. (2017,
pp.145–146), we have noticed that those
who see ASC solely as a biomedical impair-
ment can be at a higher risk of viewing their
difculties as ‘not amenable to interven-
tion’, and may experience a loss of personal
control. A primary task of the group often
becomes reclaiming identity and taking up
one’s power and agency for change.
Attachment and trauma
Diagnostic clinic
Hudson et al. (2017) present an excellent
overview of the ‘co-morbidity’, secondary
mental health problems and the circular
causation linking attachment patterns,
trauma and ASC. The Tavistock Learning
Disability (LD) and ASC Team has structured
the assessment clinic to prioritise compre-
hensive, relational and systemic reports with
clear recommendations, which takes up a lot
of clinical time.
We do not assess for attachment difculties
specically and do not use the Coventry Grid
or interview (Moran, 2010; Flackhill et al.,
2017). We hold a ‘both – and’ position in rela-
tion to ASC, attachment and trauma (Gravitz,
2018; Haruvi-Lamdan et al., 2018).
We have introduced the PTMF questions
at the initial assessment meeting with service
users and their families, and thus far have
found them to have good sensitivity to attach-
ment, trauma and other factors to explore in
the assessment.
Assessments require a lengthy formulation
meeting – one hour minimum. We consider
circular patterns of attachment and ASC,
maintaining awareness that developmental
formulations have a pathologising historical
context (e.g. the discredited ‘refrigerator
mother’ hypothesis; Bettelheim, 1967), whilst
holding in mind a sub-group of children who
having experienced traumatic events, have
withdrawn from the social world as a threat
response (Reid, 1999) and require a different
intervention (Lyons et al., 2017).
The Tavistock ASC and LD Team receives
many requests for second opinion diag-
nostic assessments. Families often report that
receiving an attachment-based formulation for
their child was upsetting. Therefore, even if our
second assessment identies a relational pattern
as contributing to a person’s presentation, we
are careful to coordinate our understanding
with that of the family (Pearson, 2005). We
appreciate the PTMF pattern which explicitly
broadens this type of formulation socially and
inter-generationally:
Surviving disrupted attachments and adver-
sities as a child/young person in which the
child’s early relationships and/or environments
were compromised due to a complex mixture of
power factors such as intergenerational histo-
ries of trauma and adversity, lack of material
resources, social pressures and social isolation.
(Johnstone & Boyle, 2018, p.333)
Clinical Psychology Forum 313 – January 2019 45
Incorporating the Power Threat Meaning Framework into an autism and learning disability team
Given families’ reported experience of
attachment-based formulations, we have
also tested the acceptability of Compassion
Focused Therapy’s three circle model as an
alternative framework (Gilbert, 2014).
Our clinical experience thus far is that it:
retains an afliative relational component;
retains the PTMF emphasis on meaningful
threat responses at the individual/social/
political ecologies (Bronfenbrenner,
1979); and
has been well received by families and
young people .
Complex trauma
The Autism Act (2014) introduced the right
of adults in the UK to have a diagnostic autism
assessment. We have observed a huge rise in
the number and complexity of adults referred
to our team with recent ASC diagnoses. Our
clinical experience suggests an unintended
consequence of commissioning new adult
diagnostic services is that adults who present
with complex trauma have easily and in our
view, sometimes inaccurately, received this
label (Gravitz, 2018; Haruvi-Lamdan et al.,
2018).
This is the ‘second problem’ identied by
Sami Timimi for clinical practice (Milton &
Timimi, 2016), that specialist categorisation
can function as an exclusion from main-
stream services. For many adults with ASC
diagnoses, ‘What has happened to you?’ links
with a long, complicated journey through
mental health services increasingly restricted
to particular diagnoses. Where someone
presents with complex trauma, a late ASC diag-
nosis can do epistemic injustice, re-framing
their survival responses to external threats as
symptoms of an innate neurodevelopmental
disorder (Giddens, 1991; Fricker, 2007). On
the ip side, our specialist National service
has not seen an increase in the referral of
Adults with ASC who were previously misdi-
agnosed with severe and enduring mental
health conditions. We are concerned that
this group experience similar harm (Lai &
Baron-Cohen, 2015).
Mindful of Sami Timimi, we maintain critical
awareness of our specialist team’s contribution
to this process. A survey in our own trust found
Adults with ASC were likely to be excluded from
other Tavistock Services and other community
adult services. Whilst we feel it is benecial to
offer some speciality in ASC presentations, we
try to ensure that acceptance to our team does
not replace existing services. For example, we
require adult referrals to remain open to a local
adult mental health team.
Conclusion
We are aware that the PTMF has proved
controversial in a number of areas, including
Autism Spectrum Conditions. However, we
have found the PTMF a helpful addition to all
stages of our work in an Autism and Learning
Disability team. It has allowed us to negotiate
different understandings, broaden our area
of enquiry and remain engaged with social,
cultural and political inuences.
Authors
Dr Alison Flynn
Clinical Psychologist, Autism and Learning
Disability Team, Tavistock and Portman NHS
Foundation Trust
Dr Nechama Polak
Clinical Psychologist and Adult Psychother-
apist, Autism and Learning Disability Team,
Tavistock and Portman NHS Foundation Trust
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Clinical Psychology Forum 313 – January 2019 47
Reflections on responses to the Power
Threat Meaning Framework one year on
Lucy Johnstone, Mary Boyle, John Cromby,
Jacqui Dillon, Dave Harper, Peter Kinderman,
Eleanor Longden, David Pilgrim & John Read
The project group reects on the responses to the Power Threat Meaning Framework (PTMF) one year after
publication. The group welcomes the interest shown in the document, and takes this opportunity to clarify some
points, reect on and learn from others, and suggest areas for future development.
WE ARE PLEASED to be welcoming this
issue of Forum exactly a year since the
launch of the Power Threat Meaning
Framework (PTMF; Johnstone & Boyle, 2018a;
Johnstone & Boyle, 2018b). As readers will be
aware, it comprises a lengthy and dense set of
documents which inevitably present complex
arguments. The ambitious aim of the project
was to outline a conceptual alternative to the
diagnostic system, so this level of detail and
complexity was unavoidable. However, we
have offered accessible ways invia a two-page
summary, the talks from the launch, and
the ‘Guided Discussion’, along with inter-
views and videos (www.bps.org.uk/news-and-
policy/introducing-power-threat-meaning-
framework) and more are in the process of
development.
The framework is not ofcial British Psycho-
logical Society policy, nor ofcial policy of the
Division of Clinical Psychology, and inoffering
it as a conceptual resource and a focus for
discussion we had no idea what kind of recep-
tion it would get. As it has turned out, it has
been successful in stimulating interest and
debate beyond anything we could have hoped
for. A dozen blogs on the PTMF appeared in
the rst fortnight, and even in the relatively
short time since publication, there are various
examples of translating it into practice across
a range of different elds, as illustrated in
this issue. There is already a Spanish version,
with Italian and Danish translations planned,
and the authors have received many invita-
tions to give talks across the UK and further
aeld in Ireland, Denmark, Spain, Greece,
New Zealand and Australia.
It is worth emphasising the frame-
work’s status – unlike the dominant diag-
nostic model – as an optional perspective;
a conceptual resource which people may
or may not wish to engage with or begin to
translate into practice. Confusion appears
to have arisen in some quarters about the
descriptions of the PTMF as an ‘alternative’.
Clearly we are attempting to describe what an
alternative – in the sense of a system which
could replace the diagnostic one – would look
like. Whether and how it is implemented,
as a complete ‘alternative’ in this sense, or
perhaps more realistically in the short-term as
an option running alongside the diagnostic
one, or simply encouraging thinking about
alternatives within current services, is not our
decision but a position to be reached within
particular settings in discussion with relevant
stakeholders.
The PTMF builds on many other ideas
and existing practices (some of which are
illustrated in Appendices 2–14 of the over-
view). The aim is to offer additional vali-
dation and support for these and other
48 Clinical Psychology Forum 313 – January 2019
Lucy Johnstone, Mary Boyle, John Cromby et al.
examples, as well as potentially suggesting
developments and additional ways forward. If
its ideas take us a few steps down the road to
more humane, evidence-based and effective
approaches to many forms of thoughts, feel-
ings and behaviours that are currently diag-
nostically labelled, it will be because people
(service users, professionals, policy makers
and others) believe that it meets a need and
want to take its ideas further.
Responses to the framework
Inevitably, and as predicted, the response has
not all been positive, and we wish to take
the opportunity to address some of the feed-
back and critiques, both constructive and
less so, of what is necessarily a developing
document. We will return to the latter
at the end of the article. Readers may also
like to refer to the Frequently Asked Ques-
tions, which address some common queries
and anxieties (www.bps.org.uk/news-and-
policy/introducing-power-threat-meaning-
framework).
The sentence that has arguably been seen
as most contentious is: ‘…it can no longer be
considered professionally, scientically or ethi-
cally justiable to present psychiatric diagnoses
as if they were valid statements about people
and their difculties’ (Johnstone & Boyle,
2018b, p.85). We stand by this statement about
professional responsibility to be open about
these debates and about the current status of
diagnostic categories. It is the very least that is
required in relation to a system that has been
described by those who draw it up as neither
‘safe or scientically sound’. (Frances, 2014).
This uncomfortable state of affairs may cause
understandable confusion and uncertainty.
Nevertheless, service users, and indeed all of
us, have the right to know about it.
This professional obligation does not,
as alleged, involve policing ordinary people’s
language uses, since as we have also made
clear: ‘We support individuals’ right to make
their own choice of terminology’ (p.85).
However, as we note, ‘At present this right
typically works one way only: those who
want their difculties dened in diagnostic
terms are unlikely to be denied this.’ Strong
responses from those who nd their diagnosis
useful (a position which we respect) have at
times seemed to imply a picture of people
being routinely stripped of their labels. But
the actual situation is as one service user
described: ‘Service users who identify with
their diagnosis – you have pretty much an
entire mental health system that agrees and
supports your perspective. Those of us who feel
utterly hopeless and oppressed by our diag-
nosis – where do we go?’ (@bootlegboudica,
17 September 2018.)1
More subtly dismissive are claims that
the framework is ‘sociopolitical’ ‘extremist’
and ‘polemical’. We make no apology for
producing a framework which is sociopolitical
in the sense that it situates people’s distress
rmly in that context and links directly to
ideas about social justice and community and
social action. And it does offer a critique in
a very controversial area, which frequently
invites the term ‘polemical’. But it is not unevi-
denced – although it does question the narrow
denitions of ‘evidence’; the separation of fact
and value and the assumed neutrality of much
mainstream psychology and psychiatry.
The framework, diagnosis
and the provisional patterns
Some comments on the framework, while
admitting that diagnostic systems were awed,
implied that an alternative was not necessarily
needed. However, psychiatric classication
and diagnosis have not persisted over so many
years in the face of almost continuous criti-
cism without many protective strategies, which
are unlikely to be abandoned in the near
future. These include claiming that diagnosis
is necessary for communication, to develop
and select treatment and to ‘be scientic’, but
also include being open about some problems
and giving an impression of tackling them.
A particularly effective claim, widely used
since DSM-III, is that diagnostic categories are
‘just descriptions’. Taken together, strategies
like these create an impression of diagnostic
systems of one type or another as natural
and inevitable. So natural and inevitable that
Clinical Psychology Forum 313 – January 2019 49
Reections on responses to the Power Threat Meaning Framework one year on
senior devisers of the system are able to admit
very publicly that it has comprehensively failed
in its own terms (American Psychiatric Associa-
tion, 2013) – only for things to carry on pretty
much as before.
Supporters of psychiatric diagnostic systems
have, knowingly or otherwise, been able to
make use of this protection; for example,
presenting ofcial diagnostic systems as imper-
fect but improving, with some diagnostic cate-
gories more ‘successful’ or acceptable than
others, as compatible with formulation and as
playing an important if not essential role in the
development of psychological understanding
and treatment. Many of these responses have
emerged in criticisms of the PTMF. So too has
the claim that, because some medical diag-
noses, such as migraine or bromyalgia, are
not based on known biological patterns, then
psychiatric categories are as valid as those in
general medicine. All of these claims depend
on ignoring or overlooking the fundamental
problem that has led to the current state of
crisis; in other words, framing psychological
and emotional distress and many forms of
troubling behaviour in medical terms.
This reluctance to talk about the ideas
and assumptions underlying psychiatric diag-
nostic systems is very much encouraged by
the systems’ interdependence with versions
of positivism. It’s not surprising then, that
some criticism of the framework is couched
partly or more or less entirely in the language
and requirements of positivism, at least as
interpreted by modern psychology. This is
illustrated in the words of one critic who
described positivism as ‘the gathering and
synthesis of evidence’, as if this process were
a straightforward and neutral undertaking.
It is exactly this view that the PTMF chal-
lenges; it arises partly from psychology’s and
psychiatry’s reluctance to acknowledge posi-
tivism as a philosophy rather than a set of
self-evident rules for discovering facts about
the world.
If this is the unexamined starting point,
it is much more difcult to consider or even
notice some key prior assumptions under-
lying diagnostic systems; for example, that
the methods and frameworks of the phys-
ical and medical sciences, and metaphors
derived from them, are appropriate for stud-
ying people’s thoughts feelings and actions,
or that these are characterised by features
and processes (including ‘mental disorders’)
that can be objectively described in universal
causal terms across time and place. It also
makes it more difcult to consider ques-
tions about what constitutes evidence, how it
should be presented and what it means about
the privileging of certain kinds of quanti-
cation and measurement, the possibility of
separating facts from values and ‘self’ from
others and the external world, and so on. In
the main framework document, we discuss
these issues and their implications in detail.
These two areas of relative silence –
about assumptions underlying diagnostic
systems and positivism more generally – are
reected in some of the comments on our
suggested provisional patterns. To claim they
are just like diagnostic clusters, or labels for
people, or that they appear to correspond to
syndromes, shows a failure to move beyond
the diagnostic lens. In fact, we discuss in
detail the fundamental differences between
our regularities in distress and diagnostic
clusters, and the very different ideas about
causality that inform them.
Asking people to let go of the hope of
nding medical-type patterns in distress
organised by biology or ‘psychopathology’,
and suggesting instead patterns organised by
meaning, necessitates abandoning the false
hope of nding discrete, universal causal path-
ways which are a precise t for any individual,
and which are stable across time and cultures.
It means moving from clusters based on what
people supposedly have or are, towards clus-
ters based on what they do and experience
in particular contexts. It means abandoning
medical terms such as ‘symptoms’, ‘disor-
ders’, ‘comorbidity’, ‘dual diagnosis’ and
even ‘transdiagnostic’. This is a considerable
conceptual leap, but we argue that it reects
and allows for the indenite complexity of
human agentic, meaning-based responses to
their changing circumstances.
50 Clinical Psychology Forum 313 – January 2019
Lucy Johnstone, Mary Boyle, John Cromby et al.
Is the framework meant to replace
all current practice?
We have emphasised that the framework is not
intended as a wholesale replacement for current
practice. Some current approaches are directly
compatible with PTMF principles and we give
a number of examples. We have also suggested
ways in which the framework might enlarge
and enhance existing practice, providing new
ideas and encouraging a less individualistic
focus. However, we disagree that diagnosis has
been necessary for progress in psychological
understanding and interventions, or that it
is needed in order to identify the ‘correct
treatment’. It is difcult to see how it could
be, given persistent problems with validity and
the very large amount of overlap across cate-
gories and heterogeneity within them. In fact,
it may well be a limiting factor, distracting
attention from this variability and what it might
mean. There has been undoubted progress;
for example, inunderstanding and alleviating
problems such as panic, distressing rituals, low
mood, post-traumatic distress, problems with
alcohol and drugs to name a few. However,
matching therapeutic strategies to particular
problems rather than hypothesised disorders
can be done just as well without diagnostic
language and assumptions. This can also free
us up to develop different kinds of under-
standings; for example, about the relationship
between social contexts and people’s difculties
or about the relationships amongst difcul-
ties which cross diagnostic boundaries. In fact,
taking the example of hearing voices, there
has arguably been more recent progress from
a non-diagnostic approach than from the last
50 years of diagnostic-based research. In the
main document, we discuss many reasons why
diagnosis persists, including the expectation,
or demand, that it is used to dene research
participants or assess interventions. All of this
can give an impression of necessity, which
isnot justied by the evidence.
Is the framework all about formulation?
Contrary to suggestions that the PTMF
is promoting formulation as a particular
psychological skill, it occupies a very small
part of the documents. The concept and term
‘narrative’ was purposely chosen in order to be
inclusive of story-telling as a universal human
capacity and ‘the almost innite number of
examples of narrative and dialogical practices
across the globe’ (Johnstone & Boyle, 2018b,
p.74). It is not obvious how this argument
can be seen as a bid for professional (of any
brand) dominance. Narratives can be of many
kinds – including medical ones – but people
can only choose from ones that are cultur-
ally available to them. As with previous DCP/
BPS documents, our aim is to expand this
choice by moving beyond narrow psychiatric
or indeed psychological ones.
Some people have made the point that
not everyone wishes to tell, or can tell, a
‘story.’ That is certainly true. Our argument –
which applies to formulations as well as narra-
tives in a more general sense – is that there
isa crucial difference between a system based
on diagnosis, and one based on the assump-
tion that people’s experiences and expres-
sions of distress arise out of reasons, functions
and meanings, all of which are deeply rooted
in their relational and social environments.
Making sense of this, sometimes alongside
a validating witness who may or may not be
a professional, can be profoundly healing, and
the General Patterns are intended to support
this process. But while we argue for opportu-
nities to do this, that choice is always an indi-
vidual one. There is no proposed requirement
for anyone to ‘produce a personal story’.
Is the framework all about trauma?
The framework has been widely described
as focusing on trauma. This is seen both
positively (it encourages us to attend to
what has happened to people) and nega-
tively (it’s ‘just about trauma’ – what about
people who haven’t experienced specic
trauma?). Wecertainly do focus on the poten-
tial impact of many experiences which are
generally described as ‘trauma’ (although
our preferred word is ‘adversity’ because of
its inclusivity), including sexual abuse and
assault, childhood physical abuse, domestic
violence and bullying. And we note that
Clinical Psychology Forum 313 – January 2019 51
Reections on responses to the Power Threat Meaning Framework one year on
the approach of many ‘trauma-informed
services’ is compatible with many aspects
of the framework. But we also note reser-
vations about the term ‘trauma’, about its
medical overtones and potential to create
a misleading impression of discrete, possibly
very unusual, extreme or life-threatening
events impinging from outside rather than of
continuous or repeated very negative experi-
ences, embedded in people’s lives and rela-
tionships. We have tried to show how these
often everyday features of our lives, which
may be taken as normal, can create and
maintain many forms of distress or troubling
behaviour, even when more obvious forms
of ‘trauma’ are not evident. In fact, eluci-
dating the meaning of distress or troubling
behaviour in such contexts – often relating to
social norms and expectations – is a strength
of the PTMF. Some of these expressions of
distress will attract diagnostic labels, others
will not. In line with this, we stress that the
provisional patterns represent continua and
can be relevant to people who have never had
contact with mental health services or who
have not had experiences they would describe
as ‘trauma’.
Is the framework evidence based?
We discuss a great deal of evidence in rela-
tion to our arguments, drawn from many
different sources. We point to the value of
some positivist-based research and draw on
it in our analysis, but without necessarily
accepting unspoken assumptions about
diagnostic categories, the meaning of meas-
urement scales, and so on. Questioning posi-
tivism’s underlying assumptions is not the
same as rejecting empirical research. However,
we do draw on research across disciplinary,
methodological and epistemological bounda-
ries, including forms of evidence which have
traditionally been marginalised, such as histor-
ical analyses and survivor and other personal
accounts. This exibility has puzzled some
and been welcomed by others. We agree that
we have not produced a new epistemology;
this was not our intention. We hope that
discussion of the large amount of evidence
we have presented in support of the frame-
work and patterns will develop as the frame-
work is applied in different settings and as
non-medicalised, non-diagnostic alternatives
become more available.
‘Race’, culture and ethnicity
We were grateful to our Critical Reader Group
for their detailed comments on these issues.
This large and complex area is considered
in depth in chapters 2 (‘Philosophical and
conceptual principles’), 3 (‘Meaning and
narratives’) and 4 (‘The social context’) of
the main document. In any future editions of
the document we will be pleased to expand
this with additional references to key gures
from non-Western psychologies, as suggested
in some of the feedback since publication.
The very sensitive area of race and ‘culture’
has attracted critical responses, both in rela-
tion to the document content itself, and
in relation to the process of developing it.
There are learning points in both areas.
It may need re-emphasising that the
General Patterns provisionally outlined
in this version of the framework are appli-
cable mainly within Western or Westernised
contexts. This follows from our core conten-
tion that patterns of distress are organised
by meanings at personal, social and cultural
levels: ‘Since patterns in emotional distress will
always be to an extent local to time and place,
there can never be a universal lexicon’ (John-
stone & Boyle, 2018b, p.11). While the total
group of authors and contributors was drawn
from a range of backgrounds and ethnicities,
it is a majority white group, with all of us living
in a society dominated by certain Western
cultural values, including those of diagnostic
models. Since, as we have shown, expressions
of distress necessarily reect their particular
cultural context, the General Patterns that
we have developed will inevitably do so too.
It would not have been appropriate to do
or to claim otherwise. At the same time, we
have argued that some of the very basic prin-
ciples of PTMF are relevant across cultures
– those to do with core human needs, evolved
biologically-based responses and capacity for
52 Clinical Psychology Forum 313 – January 2019
Lucy Johnstone, Mary Boyle, John Cromby et al.
meaning-making. Versions with better local t
(if it was felt they might be useful) would need
to be developed by the social or cultural group
in question.
Whether or not these developments
happen, the framework conveys a message of
respect for different ways people express and
try to heal their distress both within the UK
and across the globe. There is no suggestion
that PTMF needs exporting along the lines of
the global mental health movement. However,
we have been pleased at the welcome it has
received from some workers with indigenous
peoples, who see it as validating their use of
culturally-appropriate perspectives and prac-
tices. We were also pleased to be invited to
contribute a blog about the PTMF by the
#WhatWENeed campaign, as part of a challenge
to the globalisation of diagnostic models
(www.tciasiapacific.blogspot.com/2018/10/
beyond-medicalisation-of-distress-new.html).
Two of the authors are undertaking a tour of
New Zealand and Australia, where it is hoped
to present the framework alongside indige-
nous understandings of distress. We anticipate
that this will result in a rich dialogue, with
implications for further development of our
conceptual resource.
The welfare/benets aspect
Service users have inevitably been alarmed by
reports such as that psychologists will hence-
forth be refusing to endorse claims based on
diagnostic categories due to roll-out of the
PTMF. Our actual position is ‘In the short and
medium term, psychiatric diagnoses will still
be required for people to access services, bene-
ts and so on. These rights must be protected’
(Johnstone & Boyle, 2018a, p.18). However,
while acceptable to some, other service users
deeply resent the need to take on a diagnostic
label in order to obtain essential resources or
services (Beresford et al., 2016), and diagnosis
often fails to secure this outcome anyway.
Chapter 8 of the main document outlines
the pros and cons of a range of welfare
system alternatives, starting with creative
use of the existing system and leading up
to more radical ideas such as universal basic
income. We acknowledge that patterns and
personal narratives would not be suitable to
such a purpose – nowhere have we suggested
that people should be required to produce
a‘trauma story’ in order to qualify. One possi-
bility is that ‘for specic purposes, non-medical
problem descriptions such as ‘hearing hostile
voices’ or ‘suspicious thoughts’ or… ‘feeling
suicidal’ or ‘self-harming’ could be appro-
priate substitutes for diagnostic language
(Johnstone & Boyle, 2018a, p.315), compat-
ible with and helpful for welfare and other
statutory purposes.
None of these ideas is presented as
a recommendation or easy solution, and all
are recognised as having limitations as well
as advantages. We recognise the argument
that dropping diagnostic categories could
be used to promote a neoliberal agenda of
withdrawing support; but it is also true that
diagnostic labels have not prevented the
current dire situation in which welfare recipi-
ents have been driven to destitution and even
suicide (www.theguardian.com/society/2018/
nov/16/uk-austerity-has-inicted-great-misery-
on-citizens-un-says). For all these reasons, the
PTMF aims to start an important and neces-
sary discussion about ways in which the bene-
ts system might start to move away from
diagnostic assumptions.
Service user involvement in the project
To the best of our knowledge, this is the rst
attempt to outline a major new conceptual
framework that is co-produced with service
users, both as members of the core team and
as consultants to the project. They collec-
tively represented a range of class, gender
and ethnic backgrounds and diagnostic attri-
butions. A number of other contributors
also had service user experience (but did
not choose to state this in every case). The
project itself draws extensively on service
user/survivor testimony and literature as part
of its challenge to traditional notions of what
counts as ‘evidence’.
While no process is perfect, we believe
that criticisms about ‘only X number of survi-
vors were consulted about changing the entire
Clinical Psychology Forum 313 – January 2019 53
Reections on responses to the Power Threat Meaning Framework one year on
system’ are based on a misunderstanding.
As previously stated, the PTMF is not formal
policy or a plan for services. Any such plan –
which at present is only hypothetical – would
obviously need, in keeping with the principles
of the framework itself, the involvement of
a much larger group of stakeholders, with
service users and carers taking a central part.
The framework is not just about profes-
sional services, and it was our hope that
some user groups might take on this perspec-
tive themselves, quite separately from the
mental health system. We are delighted that
several peer groups have done so and found
it helpful. There have also been many posi-
tive blogs from individual service users (see
www.sociologyandmeblog.wordpress.com/blog;
https://blogs.canterbury.ac.uk/discursive/
ive-beenwaiting-for-this-since-i-was-a-child;
and www.progressnotperfection.co.uk/2018/
01/12/power-threat-meaning). Other service
users clearly feel differently, as is their right.
Professional power
We discuss the operation of power in relation
to psychology and psychiatry, particularly in
Chapters2,3 and8 of the main publication.
This tends to focus on ideological power inrela-
tion to the production of theory, research and
cultural narratives of distress, and legal power
in relation to mental health legislation. On
reection, we think we should have addressed
the issue of power in relation to professional
practice – especially the power of clinical
psychologists, who make up the majority of
the core group – more directly. Partly to avoid
a predictable scrap about ‘This is psychologists
trying to replace psychiatrists as top profes-
sion’, we decided not to discuss any specic
profession in favour of more general points
about power in relation to both psychology
and psychiatry as disciplines and producers
of ‘knowledge’. Power as applied to clinical
psychology is implicitly critiqued at many
points, and specically through critical consid-
eration of practices traditionally associated
with it, such as formulation and the national
roll-out of some psychological therapies. We
were perhaps too reticent about discussing
the serious implications for all mental health
professions of moving away from a medicalised,
diagnostic practice. Weagree with the blogger
who wrote: ‘…one of my thoughts as a nurse is
this framework does not give us an allegiance
problem – that is, whether to carry on largely
supporting the psychiatrist and their manuals
or switch to the psychologist and this new
framework – since all three professions (and
others) are made untenable in their existing
forms’ (www.criticalmhnursing.org/2018/01/
26/a-mental-health-nurses-first-response-
to-the-launch-of-the-power-threat-meaning-
framework/#more-1364). However, we accept
that this still leaves a gap that needs lling in
any future edition.
Social media responses
Some readers will be aware that social media
reactions have been mixed. It is hard to know
how representative they are, given the tendency
of online forums to amplify certain voices
and views. Accusations of being both Marxist
and alt-right, or of promoting both neoliberal
and Scientology agendas have been intriguing.
However, the very personal and often sexist
attacks by some professionals, along with alle-
gations about silencing discussion, obstructing
the consultation process and so on, have been
disappointing to say the least. We have also
been sad to see some survivors dismissing
others who contributed to the project (about
15 in all, including the consultation group)
as unrepresentative – perhaps not dissimilar
to the kind of discounting that professionals
have often been guilty of in relation to survivor
views. Controversies that touch on both ideo-
logical interests and personal identities will
inevitably be uncomfortable, and yet given the
power and reach of diagnostic models, these
are discussions we must have.
Looking to the future
We are pleased that the PTMF is being used
to validate and support existing good work,
as well as suggest new ways forward. We hope
the planned PTMF working party reporting to
the DCP Executive Committee will be able to
support the following:
54 Clinical Psychology Forum 313 – January 2019
Lucy Johnstone, Mary Boyle, John Cromby et al.
Ensuring wide stakeholder involvement
in further developments, especially with
service users, with people from different
cultural and ethnic contexts, and with
professionals of all backgrounds.
Producing accessible versions suitable for
particular groups (service users, people
with learning disabilities, children, the
general public and so on).
More work on practical alternatives to diag-
nostic terminology in the area of benets,
the law, and other statutory agencies.
A research agenda aimed at further devel-
oping and validating the General Patterns
and their evidence base.
Evaluation of other aspects of the PTMF
in practice using a range of methodologies
as suggested in our section on research
(Johnstone & Boyle, 2018a, pp.308–313).
Encouraging research based on or using
the PTMF.
Linking with groups who may wish to
develop the PTMF, in line with their own
cultural beliefs and contexts.
Linking with journalists, policy makers,
campaigners, and other key players and
organisations in the mental health eld.
Final reections
While we have at no point claimed to have
produced a ‘paradigm shift’, we do feel that
widespread interest in PTMF is a sign that
people are actively looking for alternatives.
As the articles in this issue show, people
from a range of professional and service user
contexts are taking on the PTMF ideas and
adapting them for their own purposes, exactly
as we had hoped. The level of attention paid
to this lengthy and detailed academic discus-
sion document can be taken as a sign of the
challenge it presents in a number of highly
sensitive areas, from ideological interests and
professional status, to personal identities.
While this debate is not easy, and there are no
simple solutions, we believe it is essential that
it happens, and are pleased to have contrib-
uted to this process.
Authors
The Power Threat Meaning Framework project
team: Lucy Johnstone, Mary Boyle, John Cromby,
Jacqui Dillon, Dave Harper, Peter Kinderman,
Eleanor Longden, David Pilgrim, John Read;
LucyJohnstone16@blueyonder.co.uk
Author’s note
1 @bootlegboudica has given us permission to
use this tweet.
References
Beresford, P., Perring, R., Nettle, M. & Wallcraft, J.
(2016). From mental illness to a social model of madness
and distress. London: Shaping our Lives.
Frances, A. (2014). One manual shouldn’t dictate mental
health research. Available at www.newscientist.com/
article/dn23490-one-manual-shouldnt-dictate-
us-mental-health-research.html#.U0_jR3JeF1s
Johnstone, L. & Boyle, M. with Cromby, J., Dillon,
J., Harper, D. et al. (2018a). 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. Leicester: British
Psychological Society. Available from www.bps.org.
uk/PTM-Main
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J.,
Harper, D. et al. (2018b). The Power Threat Meaning
Framework: Overview. Leicester: British Psycho-
logical Society. Available from www.bps.org.uk/
PTM-Overview
American Psychiatric Association (2013, 3 May). State-
ment by David Kupfer, MD – Chair of DSM-5 Task
Force discusses future of mental health research [Press
release]. Available at www.madinamerica.com/
wp-content/uploads/2013/05/Statement-fro
m-dsm-chair-david-kupfer-md.pdf
Clinical Psychology Forum 313 – January 2019 55
DCP UK Chair’s Update
Julia Faulconbridge
IN THIS COLUMN – that I am writing in November but you will be reading in January – I want to
update you on the plans that the DCP Executive Committee are developing for 2019 following
the discussions in the Representative Assembly. The Representative Assembly consists of the
Executive Committee and the Chairs of all our faculties and branches.
As I have reported before, we now have an agreed interim agreement for funding key roles
through to the end of 2019, when this will be reviewed in the light of the BPS Society Review and
increased stafng in the BPS. Our aim is to use 2019 to re-establish the DCP on an active footing,
pilot ways of improving our connectivity and communications to maximise our effectiveness, and
to try to increase our membership.
It is important to recognise that the model we have developed for funding key roles is not
sustainable beyond the short term, unless we get a signicant growth in the membership. The
decision has been made to fund as many roles as we can in 2019 to increase our capacity to rebuild
the DCP and this will need to be reviewed for 2020.
There will (I hope), be a new Chair elected along with several other vacant roles so that we
should have a fully functioning Executive following the AGM.
DCP Priorities for 2019
These were agreed at the Representative Assembly in October. We want to increase the effective-
ness of the DCP in terms of both its outward facing activities and the range of support and benets
we bring to the membership. The following areas are where we intend to focus our resources,
whilst recognising that new issues can develop in ways that are unpredictable at this stage:
Children’s and young peoples mental health and wellbeing (supporting the Policy Campaign
being developed following this winning the Senate vote).
Workforce and training.
Inclusivity and diversity.
Member wellbeing.
Redeveloping the Experts by Experience strategy.
Prevention and public health.
We also intend to have a membership drive. Amongst the younger members of our profession,
there has been a very signicant drop in membership that has been developing over a number of
years. We need to reverse this trend.
Structures
Now that we have a funding mechanism in place we are making plans for the structure of the Exec-
utive Committee, the branches and the faculties for 2019 and deciding how to distribute funding
across the various parts of the DCP.
We need to develop structures that improve our connectivity and enable us to get more done.
The Executive Committee should be a body that different networks and subcommittees report
into and which directs/oversees work as appropriate. We want to strengthen the role of the Repre-
sentative Assembly so that, as this year, the networks are more integrated and inuential in setting
the overall strategy across the DCP. Plans include:
56 Clinical Psychology Forum 313 – January 2019
Julia Faulconbridge
DCP Executive Committee
Creating subcommittees that will enable us to draw in more DCP members to take our priori-
ties forward. They will be able to contribute in their area of interest/expertise without needing
to become a committee member with all the extra commitments that entails. This model has
worked very well with the Training Subcommittee, which is now expanding to cover Workforce
as well, and the EbE Strategy Subcommittee. We are in discussions about the creation of an
Inclusivity and Diversity Subcommittee and hope to develop more groupings to cover the
various priority areas,
Having a member of the Executive Committee who is the lead for each priority area.
English branches
The aim is to develop a stronger, effective England structure that can work with national bodies
like NHS England. This is much harder to achieve across England compared to the other
nations, who already have this level of inuence. The would be led by the DCP England Chair.
The branches will also be strengthening their regional links with heads of services, training
courses and relevant local bodies.
Putting on events and supporting their membership will continue to be a key part of the role.
We will also be trying to reactivate the branches in the East Midlands and the North West that
are currently not operational.
Faculties
All Faculties provide a community of interest for their members, but there is variation in how
much they have a wider role (e.g.how much they are engaged in trying to inuence policy
in their area of interest, produce publications, represent their members and their expertise
in national settings). We are looking at ways to support the faculties to achieve more for their
members, and focus on what they need, including funding for faculty Chairs.
For 2019, the faculty Chairs will have a representative for the role of Faculty Lead on the Exec-
utive, who will be funded at an additional 0.5 days/week. This person will sit on the Executive
Committee and will lead to work with the faculties in improving connectivity, joint working,
reconguring the numbers, etc.
There will be further discussions with the Representative Assembly in January, leading to a two-day
DCP strategy meeting in February that will agree the business plan to take this forward next year.
Julia Faulconbridge
Chair, Division of Clinical Psychology
dcpchairjpf@gmail.com
Clinical Psychology Forum
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Division of Clinical Psychology Contacts
National Officers
Chair: Julia Faulconbridge – dcpchairjpf@gmail.com
Vice Chair: Esther Cohen-Tovée – DCPUKViceChairECT@ntw.nhs.uk
Chair Elect: Position vacant
Honorary Treasurer: Simon Gelsthorpe – dcptreasurer@bps.org.uk
Director, Membership Services Unit: Sheelagh Rodgers – dcpmsudirector@bps.org.uk
Director, Professional Standards Unit: Position vacant
Director, Policy Unit – Position vacant
PR & Communications Lead – Position vacant
Chair, Conference Committee: Laura Golding – l.golding@liverpool.ac.uk
Experts by Experience Network – contact c/o Helen Barnett – dcpsuclc@bps.org.uk
Ordinary Members: Judith Samuel – dcpldlead@bps.org.uk
Co-opted Members: Alan Blair, Richard Pemberton, John Rose & Lexi Thorpe
Service Area Leads
Adult: Position vacant
Child: Vacant
Clinical Health: Position vacant
Learning Disabilities: Judith Samuel – dcpldlead@bps.org.uk
Older People: Vacant
Devolved Nations
England: Position vacant
Northern Ireland: Petra Corr
Petra.Corr@northerntrust.hscni.net
Scotland: Alison McMullan
alison.mcmullan@nhs.net
Wales: Adrian Neal
Adrian.Neal@wales.nhs.uk
English Branch Chairs
East of England: Frances Blumenfeld
fblume@essex.ac.uk
East Midlands: Vacant
London: Roman Raczka
Roman.Raczka@lbhf.gov.uk
North East: Barry Ingham
barry.ingham@ntw.nhs.uk
North West: Vacant
South Central: Chris Allen
chris.allen@berkshire.nhs.uk
South East Coast: Richard Pemberton
richardpemberton@gmail.com
South West: Alex Dibley
alexandradibley@googlemail.com
West Midlands: Lawrence Moulin
lawrencemoulin@outlook.com
Yorkshire & Humber: Annette Schlosser
a.schlosser@hull.ac.uk
Pre-Qualification Group
Alice McNamara (Co-chair)
Sandy Metwally (Co-chair)
dcppqc@bps.org.uk
Faculty Chairs
Children, Young People & their Families:
Katie Hunt
katie@katiehuntpsychology.co.uk
Psychology of Older People: Sarah Butchard
dcpolderpeopleslead@bps.org.uk
People with Intellectual Disabilities: Judith Samuel
dcpldlead@bps.org.uk
HIV & Sexual Health: Sarah Rutter
sarah.rutter@pat.nhs.uk
Psychosis & Complex Mental Health:
Linda Wilkinson & Selma Ebrahim
Linda.Wilkinson@shsc.nhs.uk
Selma.Ebrahim@ntw.nhs.uk
Addictions: Jan Larkin
Jan.Larkin@turning-point.co.uk
Clinical Health Psychology: Anne-Marie Doyle
Anne-mariedoyle@nhs.net
Eating Disorders:
Amy Wicksteed
amy.wicksteed@shsc.nhs.uk
Forensic: Kerry Beckley
kerry.beckley@lpft.nhs.uk
Oncology & Palliative: Marilyn Owens
marilynowens@nhs.net
Leadership & Management: Amra Rao
psychologicalhorizons@gmail.com
Holistic: Jane Street
jane.street@swlstg-tr.nhs.uk
Perinatal: Helen Sharp
hmsharp@liverpool.ac.uk
If you have problems reading this document and would like it in
a different format, please contact us with your specific requirements:
Tel: 0116 252 9523; E-mail: P4P@bps.org.uk.
For all other enquires please contact the Society on:
Tel: 0116 254 9568; E-mail: mail@bps.org.uk.
Inside…
nTeacher education
nClinical psychology training
nYouth mental health
nSocial work education
nSurviving prison
nAutism and learning disability
Contents
Regulars
1 Editorial
Ben Donner
2 Correspondence
55 DCP UK Chair’s Update
Julia Faulconbridge
Articles
3 Youth Mental Health and the Power Threat Meaning Framework:
Jigsaw’s systems perspective
Cian Aherne, Olive Moloney & Gillian O’Brien
9 Reflections on using the Power Threat Meaning Framework in peer-led systems
Amanda Griffiths
15 Time to teach the politics of mental health: Implications of the Power Threat Meaning
Framework for teacher education
Catriona O’Toole
20 Bringing the outside in: Clinical psychology training in socially aware assessment,
formulation, intervention and service structure
Helen Griffiths & Frances Baty
25 Surviving prison: Using the Power Threat Meaning Framework to explore the
impact of long-term imprisonment
Mariana Reis, Sami Dinelli & Lucinda Elias
33 Using the Power Threat Meaning Framework in social work education
Rachel Fyson, Kirsten Morley & Andrew Murphy
38 The ‘Own my life’ course: Building literacy with women about trauma through the
Power Threat Meaning Framework
Natalie Collins
42 Incorporating the Power Threat Meaning Framework into an autism
and learning disability team
Alison Flynn & Nechama Polak
47 Reflections on responses to the Power Threat Meaning Framework one year on
Lucy Johnstone, Mary Boyle, John Cromby, Jacqui Dillon, Dave Harper, Peter Kinderman,
Eleanor Longden, David Pilgrim & John Read
St Andrews House, 48 Princess Road East, Leicester LE1 7DR, UK
t: 0116 254 9568 f: 0116 227 1314 e: mail@bps.org.uk w: www.bps.org.uk
© The British Psychological Society 2019
Incorporated by Royal Charter Registered Charity No 229642
01
9771747 573416
ISSN 1747-5732
ISSN: 2396-8664 (Online)
Clinical Psychology Forum
Number 313 – January 2019
Special Issue: The Power Threat Meaning Framework
... Consequently, there have been important conversations about the categorisation of climate-related distress, and the risks of terms such as 'climate anxiety' and denial being used in ways that individualise and decontextualise responses to climate breakdown (e.g., Adams, 2021;Barnwell, Stroud, & Watson, 2020;Pihkala, 2020;Woodbury, Buzzell & Chalquist, 2020). These concerns are situated within a wider critique of medicalised understandings of distress that pathologise emotions and other responses, obscuring connections to various forms of social injustice (e.g., Boyle, 2013;Dillon, 2019;Fernando, 2017). Conversely, some professionals have argued that increased anxiety and grief about climate breakdown should not be interpreted as an indication of 'mental ill-health' but instead recognised as an understandable reaction to the dire situation humanity is facing (e.g., Association of Clinical Psychologists-UK (ACP-UK), 2021; Adams, 2021;Hickman, 2020; Royal College of Psychiatrists (RCPsych), 2021). ...
... While the reception of the PTMF has mainly been positive, it has also attracted criticism for inaccessibility and limited guidance about how it might be translated into practice (Johnstone et al., 2019). From our perspective, its failure to discuss climate change and environmental harm is a serious omission. ...
Article
Full-text available
Climate change poses an existential threat to today’s and future generations. Within this context, important debates are taking place about the risk of individualising and de-contextualising both climate-related distress and denial. Seeking to re-centre context and power, we tentatively share our thoughts on how the Power Threat Meaning Framework (PTMF) might provide a useful lens to understand different responses to climate change. The paper draws on existing research, theory and experiences to elaborate on the domains of the PTMF, which include Power, Threat, Meaning, Threat Responses and Strengths. We focus on ideological and ecological power, with the latter proposed as a new aspect of power to be considered for future iterations of the PTMF. We illustrate how the different domains of the PTMF can be brought together to generate meta-narratives by offering a climate trauma pattern. We hope this article will be of use to activists, academics and professionals in supporting non-pathologising understandings of different reactions to climate breakdown while also suggesting ways to move forward.
... Already it has been cited over 100 times according to Google Scholar. There has been debate and, inevitably, some criticismsee Johnstone et al. (2019) for a summary and reflection. Members of the author team have delivered talks and training workshops across the UK and in countries including Denmark, Spain, Ireland, Greece, New Zealand and Australia. ...