The shortcomings of psychiatric diagnosis have long been recognized. Serious critiques go back to the early 1960s, and misgivings have continued ever since. In recent years, these concerns have once again gathered pace. When DSM5 was launched in 2013, the USA’s National Institute of Mental Health announced that it would no longer use psychiatric diagnosis as the basis for its funding schemes. Around the same time in the UK, the British Psychological Society’s Division of Clinical Psychology called for a ‘paradigm shift’ away from diagnosis and towards more consistently psychological ways of understanding distress. Then, in 2017, a report by the United Nations concluded that we should “abandon the predominant medical model that seeks to cure individuals by targeting ‘disorders’”.
Concerns about psychiatric diagnosis are well-grounded. Both its reliability and validity have been questioned, making it a relatively poor basis upon which to assign treatments or advise on outcomes. Whilst diagnosis can open the door to treatment, it is often experienced as stigmatizing. Diagnosis tends to individualize mental distress, by obscuring its frequent connections with biographies marked by trauma or adversity. It also medicalizes distress, by attributing it primarily to hypothetical biological causes such as neurotransmitter ‘imbalances’.
Despite many decades of research—research which has benefitted from relatively generous funding, as well as from increasing access to new technologies (genome scanning, brain imaging)—there is no consistent evidence for these biological causes. The American Psychiatric Association recognize this, acknowledging that there are no biomarkers for the putative disorders that DSM5 describes.
Some psychologists nevertheless still rely upon psychiatric diagnosis. At least in part, this may be because they lack any worked-out alternative. This is why the 2018 publication by the British Psychological Society of its ‘Power Threat Meaning Framework’ is potentially significant.
The Framework was jointly produced by a team of psychologists and mental health service users, led by Dr. Lucy Johnstone and Professor Mary Boyle. It summarizes and integrates a great deal of evidence from psychology, psychiatry neuroscience, genetics, social science, trauma studies, and other relevant fields. It is a coherent alternative to a psychiatric diagnosis that applies not just to people who have been in contact with the mental health or criminal justice systems, but to all of us.
The Framework invites psychologists to understand distress and troubling behaviour as the product of life experiences as they impact upon embodied people. Imbalances and abuses of power give rise to threats. The meanings of these threats depend upon particular combinations of circumstances and resources, many of which we cannot control. For this reason, meanings are never freely chosen by individuals. Instead, to borrow the words of psychologist John Shotter, meanings are both ‘made and found’.
So the operation of power produces threats. These threats get mediated by different constellations of meaning and give rise to threat responses. From a diagnostic perspective, many of these responses are called symptoms. Within the Framework they appear as meaningful—if sometimes bizarre or self-defeating—responses to combinations of challenging or adverse circumstances. They are attempts to adapt, endure, keep safe, survive—even to thrive. The Framework considers how we make sense of these frequently difficult experiences, and how messages from wider society can increase feelings of shame, self-blame, isolation, fear, and guilt.
The main aspects of the Framework are summarized by a set of questions which can be applied to individuals, families or social groups:
‘What has happened to you?’ (How is power operating in your life?)
‘How did it affect you?’ (What kind of threats does this pose?)
‘What sense did you make of it?’ (What is the meaning of these situations and experiences?)
‘What did you have to do to survive?’ (What kinds of threat response are you using?)
Two additional questions then help psychologists to think about what skills and resources people might have, and how their experiences might best be understood:
‘What are your strengths?’ (What access to power resources do you have?)
‘What is your story?’ (How does all this fit together?)
By identifying answers to these questions, the Power Threat Meaning Framework can help people to create more hopeful understandings of difficulties they may have faced or are still facing. It helps people avoid seeing themselves as blameworthy, weak, deficient, or ‘mentally ill’. Instead, it highlights the links between distress and wider social factors (poverty, prejudice, discrimination, inequality) along with traumas such as abuse and violence, and the resulting emotional distress or troubled behavior. It also shows why those of us who do not have an obvious history of trauma or adversity can still sometimes struggle to find a sense of self-worth, meaning, and identity.
The Framework describes the many different kinds of threat responses that people use to survive, to protect themselves, and to meet their needs. Whilst many of these responses have previously been understood as symptoms of psychiatric disorders, others –such as overwork– are typically seen as more ordinary. The Framework sees these threat responses as arranged along a continuum. At one end of this continuum are responses experienced as automatic or involuntary bodily reactions or responses. In the middle are responses experienced as habits or compulsions, acquired patterns of thinking, acting, and feeling that are difficult to recognize, change or resist. At the other end of this continuum are threat responses experienced as deliberately chosen ways of coping with overwhelming emotions or difficult situations.
One of the most important aspects of the Framework is the attempt to outline typical patterns of meaning-based responses to threat. These patterns are both provisional and general, and frequently cut across psychiatric diagnostic categories. Because they integrally include aspects of meaning they are necessarily subject to change and variation, both across time and between cultures. And they are typical or ‘on average’ patterns, rather than distinct classifications of the kind posited by diagnosis. With these considerations firmly in mind, the evidence summarized in the Framework does suggest common ways in which people in a particular culture are likely to respond to certain kinds of threat such as being excluded, rejected, trapped, coerced or shamed.
It may be useful to draw on these general patterns to help develop people’s personal stories. Because they are widely shared, their identification can give people a message of acceptance and validation. They suggest a range of ways that may help people to move forward. For some people, this may be therapy or other interventions including, if they help someone to cope psychiatric drugs. For others, the main needs will be for practical help and resources, perhaps along with peer support, art, music, exercise, nutrition, community activism and so on. The patterns can also assist psychologists in designing services that meet people’s needs, and may suggest ways of accessing support that is not dependent upon having a diagnosis.
Importantly, the Framework does not ignore biology (as critics of diagnosis are so often accused of doing). Instead, it takes the continuing absence of biomarkers seriously by developing a different understanding of biology’s contribution. Within the Framework, biology is always relevant to distress because it supplies the general capacities that make threat responses possible. Rather than necessarily assume that biological influence in distress always operates in a manner analogous to illness or disease, the Framework draws upon both current biological thinking and extensive evidence to identify a range of different ways in which biology’s contribution might be understood.
The Framework also includes the influence of culture. It recognizes that culture shapes individual meaning, and that understandings of distress are influenced by cultural norms and explanations. It offers a way of thinking about these culturally-specific understandings without forcing them into a Western diagnostic model. It encourages respect for the many creative and non-medical ways of supporting people around the world, and the varied forms of narrative and healing practices that are used across cultures. Underpinning all this, the Framework offers a new perspective on distress which takes us beyond the individual and shows the continued importance of wider considerations of justice, acceptance, and equality.
It is important to note that the authors of the Framework (full disclosure: I am one of them) are clear that it is not intended to replace all of the ways we currently think about and work with distress. We are also clear that it is a work in progress, one that is offered as a resource for individuals, groups, or organizations who might find it useful – including, but not just, psychologists. The aim is to support and strengthen the many examples of good practice which already exist, while also suggesting new ways forward.