The Power Threat Meaning Framework (PTMF), a conceptual alternative to the diagnostic model of distress co-produced by psychologists and survivors, has attracted an extraordinary level of attention since its publication in January 2018 (Johnstone and Boyle, 2018).
Much of that attention has been positive (for example, 6 translations are either completed or underway.) Some have been overtly hostile (such as allegations that the authors are power-seeking ideologues with links to Scientologists and fascists.) Some of it, although written in more reasonable tones, appears to miss the point of the PTMF entirely. While much of the social media uproar is rightly ignored, the publication of a more moderate critique in a peer-reviewed journal deserves to be addressed. I wanted to do so here, taking two key themes of critique in “Power, Threat, Meaning Framework: A Philosophical Critique” by Alastair Morgan, published in ‘Philosophy, Psychiatry and Psychology.’
There is also another reason for exploring these themes: though they are formulated as if they were unique to the PTMF, the relevance of these critiques extend beyond it and also apply to many schools of psychotherapy, as well as other non-medical approaches such as Open Dialogue. This makes clarity about the debate all the more important.
THEME 1: The necessity of the psychiatric frame
Morgan follows the psychiatric mainstream in assuming that the framing of psychological and emotional distress in fundamentally medical terms is unquestionable. One of Morgan’s key arguments, which sets the tone for the entire piece, is that the PTMF conflates ‘psychiatric disease’ and ‘psychiatric illness’ and therefore ignores ‘a long-standing distinction between the two’ (p.55) This distinction, Morgan argues, renders the PTMF’s stance against the medical framing of psychological and emotional distress redundant. For Morgan, the PTMF’s position relies on the concept of psychiatric diseases, which he defines as ‘conditions that can be identified as physiological dysfunctions.’ But, Morgan suggests, medicine is not committed to treating only diseases but also treating ‘illnesses,’ which he defines as the ‘subjective experience of ill-health.’ The implication is that even though psychiatry admittedly doesn’t deal with conditions that can be identified as physiological dysfunctions, it is justified in treating ‘subjective ill health’ because general medicine does so too, making psychiatry just like other branches of medicine.
The first thing to say is that this kind of argument is not limited to Morgan; a number of other defenders of psychiatry have relied on making semantic, definitional arguments in justifying psychiatry’s purview. The second point is that, despite what Morgan implies, there has not been a consistent set of definitions that psychiatry as a whole uses to define its territory. To take a recent example, the highly respected psychiatrist Ronald Pies uses a totally opposite set of definitions to make an equivalent argument about the necessity of the psychiatric paradigm. He defines disease in terms of ‘suffering and incapacity’ even in the absence of physiological dysfunction. For example, Ruffalo & Pies say:
“A careful reading of history teaches us that there is no “essential” definition of disease universally accepted by physicians (or by philosophers of science); however, historically, the concept of “disease” has always been more intimately tied to the degree of suffering and incapacity experienced by the individual person than to demonstrable biological dysfunction.” (Ruffalo, 2020)
In reality, definitions of illness/disease/disorder in psychiatry have fluctuated and changed, depending on the given theoretical tradition within psychiatry, or, indeed, the specific thesis of a given author. This is precisely because the history of psychiatry has been one of fundamental paradigm changes. For example, in, say, 1955 when the DSM-I was operational, ‘mental disorders’ were understood as psychosocial reactions to environmental demands, explained in psychoanalytic terms and seen as continuous with normality. In 1985, when the DSM-III was operational, ‘mental disorders’ were characterised as discrete disease entities, represented by a set of symptoms that were widely assumed to denote biological diseases. The variation signifies a core problem that, epistemologically speaking, psychiatry has never properly understood or been able to define its territory.
This is important because psychiatry’s shortcomings in delivering biological disease processes, is not, per se, the problem. Whichever way it is looked at — whether psychiatry justifies the medicalisation of psychological and emotional distress by defining ‘disease’ as ‘suffering and impairment’, or, in contrast, by claiming that the ‘subjective experience of ill-health’ justifies the medicalisation of distress even in the absence of disease — the problem remains. Without any empirical justification, psychiatry considers the whole realm of psychological and emotional distress that is traditionally covered by the DSM as de facto medical and treats it as such. This presents us with the valid question: why are we medicalising these experiences at all? This, and not a failure to recognise the role of subjective experiences of ill-health in medicine, is the point of departure of the PTMF.
This issue is occluded by Morgan’s presentation of the notion of ‘subjective experiences of ill-health’ as if this is some sort of objective, empirical category. It is not. How, specifically, do we distinguish between psychological and emotional distress that is ‘ill health’ and psychological and emotional distress that is not? There is no answer to this because there is no way of defining the difference without recourse to a natural limit, which is exactly what is missing if there is no identified disease process, to use Morgan’s definitions. Without physiological dysfunctions and signs, ‘ill-health’ can only mean ‘psychological and emotional distress as expressed in a medical context’ — such as, for example, a person describing low or anxious mood, issues with relationships and work, problems with concentration or energy to a medical professional, which is to say, within and under the medical gaze. But the very point of contention is the medicalisation of subjective experience of distress, so this definition of ‘subjective experiences of ill health,’ in other words, begs the question.
Morgan says, ‘If we accept that medicine can and should focus on caring for the suffering of the ill person, even in the absence of disease, then the argument that all illnesses must be reduced to disease in order to count as an object of medical concern is questionable’ (p. 55). This certainly follows, but it is the assumption — that the suffering that is encountered is ‘illness’ — that is being contested. And we already know very well that neither medicine nor psychiatry should focus on all suffering without boundaries. A person of a racial minority in a systematically racist society, a person in a currently abusive relationship, a child being molested—all of these will very often come with ‘subjective experiences of ill-health’, which is to say, psychological and emotional distress. But these are clearly not illnesses. The DSM too explicitly states that ‘An expectable or culturally approved response to a common stressor or loss….is not a mental disorder. Socially deviant behaviour (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders’ (2013, p.14) These too can and do result in the subjective experience of ‘ill-health.’
Naturally, we all want medicine to attend to a patient’s whole experience and for all factors to be taken into account. But when Morgan says: ‘Such an elimination [eliminating ‘illness’ in his terms from medicine] only reinforces a narrow biomedical perspective across the whole of medicine rather than understanding the need for an emphasis on attention to and care for the illness experience in its own right’ he has missed the crucial point. It is not only medicine that cares for suffering and distress; clinical psychology, psychotherapy, social work, and peer networks all can too. The only non-circular way of determining why or when medicine should take on the primary caring role in psychological and emotional distress is by relying on disease processes to provide a non-arbitrary limit. Where there is no such limit, it is arbitrary, and therefore it is entirely valid to dispute its claims.
Morgan, like others who offer similar arguments in favour of the necessity of the medical framing, further cites statistics about the treatment of disease in somatic medicine in general in support of his arguments; for example, a study showing that 30% of general somatic medical issues are not reducible to disease either. This is often taken as a fatal blow to any suggestion that the territory which the DSM covers is categorically different to that of the rest of medicine. The argument goes that if medicine can legitimately treat people in the absence of pathophysiology, then so can psychiatry. But, as with other uses of the same arguments, there is a conflation with epistemological issues. No definition covers something 100% — there are always exceptions to any rule, but the exceptions do not disprove the rule. The exception to the general medical rule is that some illnesses are not, or at least not currently known to be, reducible to disease; the exception to the psychiatric rule is that very few of what DSM covers are. If we take the study cited above at face value, 70% of general medical complaints can be reduced to disease, whereas perhaps 90% of psychiatric disorders cannot. Moreover, the discovery of a disease process underpinning what had hitherto been seen as a ‘mental disorder’ would (like syphilis in the early 20th century) move it out of psychiatry and into general medicine. It is beyond the scope of this to go into possible reasons for this difference but suffice it to say, this clearly tells of a categorical difference.
Morgan goes on to make this important distinction:
‘This is not to claim that mental illnesses are illnesses like any other. Being stricken with a form of cancer is a meaningful event in a person’s life, but the cancer itself is not a site of meaning. The person does not interrogate the somatic event of a cancerous tumour but reflects upon its impact on their life. However, in mental illness, the illnesses themselves are a site of meaning. What it means to experience depression or psychosis is fundamentally related to an experience of a person as a human being (p.55)’
It is a credit to Morgan that he observes this (categorical) difference, as many do not. However, he uses it to bring the realm of meaningful, purposeful, agential experience under the rubric of medicine. But again, the only rationale for this involves the question being begged: because psychiatry terms such illnesses, they must be illnesses. But what happens if we assume that what is ‘fundamentally related to experience of a person as a human being’ is not properly describable in the terms of medical illness? Leaving aside that we are entirely free to do so, as it is not an empirical question but a matter of definitions, there is very good reason for treating them as different categories. It is this that separates them from the rest of what medicine treats and what defines them as in the same category as other (as-yet) non-medicalised ‘normal’ forms of distress. The bottom line is that ‘psychiatric illness,’ per the DSM, and ‘psychological and emotional distress,’ per the PTMF, describe exactly the same experiences. It is only the presuppositions and frameworks through which the experiences are viewed that determine which is held to be true.
As I stated at the beginning, the purpose of this response was not only to defend the PTMF but to defend many schools of psychotherapy, as well as practices such as Open Dialogue, which all share certain core presuppositions in common. In this regard, any approach that assumes a relational/social model — which we find in psychoanalysis, humanistic psychotherapies, feminist psychotherapies, family therapy and dialogical approaches, among others — also dispute, in principle, that psychological and emotional distress can or should be properly framed in terms of individual medical illnesses. Amongst other things, these approaches do not see such distress as primarily to do with the individual and their internal functioning, which by itself disqualifies them from being a medical illness. Rather, like the PTMF, they assume a model that is fundamentally at odds with the medical-diagnostic framework and argue that psychological and emotional distress should, in principle, be received within, and intervened in terms of, an interpersonal, psychosocial context rather than a medical one. In all these approaches, we are not talking about ‘ill health’ located in the individual, but about disturbances or deficiencies in interpersonal and social care, in the social environment, and/or of socio-political systems as expressed through the person.
THEME 2: Power & Interpretation
The second of Morgan’s core critiques that I am going to challenge is the notion that the PTMF relies on a process of pathologisation as the medical-diagnostic framework does, implying that there is in fact no categorical difference between the two. Specifically, Morgan says that the PTMF is ‘overtly pathologising’ because it ‘refuses to listen to madness as madness’ (p.62) and instead offers a ‘demand for intelligibility…imbued with power’ (ibid). In other words, he suggests that the PTMF hasn’t escaped the very problem for which it is supposed to be a solution. Clearly, this needs unpacking.
There are several assumptions here. Firstly, and underpinning Morgan’s article as a whole, is the assumption that the PTMF was developed only or primarily for professional use. This is a fundamental failure of accuracy, and perhaps on Morgan’s part, of generosity too. The PTMF concept of narrative is, as reiterated over 200,000 words, a strong call to recognise that ‘we are all meaning-makers and story tellers’. Its adoption by peer groups (Griffiths 2019; SHIFT 2020) and its endorsement of non-Western, non-professional narrative-making practices (Johnstone, 2019) testify to this, as does the publication of a guide to constructing narratives independently from professional support (Boyle & Johnstone, 2020). Morgan thus effectively cherry-picks the few illustrations that do involve a professional in order to substantiate his conclusions.
Setting that aside for the moment, it should be quite clear, I think, that madness — or any other experiences or set of experiences that are being communicated to another — cannot be listened to as it is. There is no kind of listening — or experience for that matter — that isn’t also already a translation, an interpretation, a subjective construction through a pre-established framework of intelligibility. Indeed, listening to ‘madness as madness’ is effectively a contradiction in terms, as the concept of ‘madness’ is itself an interpretation and an imposition of intelligibility on a set of experiences that are often not viewed by the person as ‘mad’ at all. The question, then, can only actually be about degrees or types of not hearing ‘madness as madness’— i.e. degrees or types of translation of one person’s experience in the terms of another. The specific question becomes whether the PTMF is doing something that it could or should avoid if it is to call itself ‘non-pathologising.’
Morgan claims: ‘A person is not able to say, “I am being tormented by the voice of a devil” and have their experience taken seriously’ (p.61). He cites an example in which it is suggested — not mandated, which would be completely contrary to the principles of the PTMF and of therapy in general – that such experiences might be understood metaphorically. It is important to say that this is the only place in the PTMF where metaphor as a possibility is invoked, something which is clearly not intended as a blueprint for practice.
Insofar as we accept the set-up, however — that of ‘professional help’ in this specific kind of example — we need to ask what would it mean to take such a statement literally and what kind of help would follow from doing so? Well, quite simply it would mean believing that what the person is saying is happening is happening. In other words, the suggestion seems to be — indeed, it can only be — that such a person hearing it should literally join the ‘psychotic experience’. Taken literally, then, the listener or interpreter is going to be very preoccupied by how everything they thought up until that about the mind is now turning out to be false. They might presumably also become beset by religiosity or a new-found preoccupation with metaphysical concerns. What about statements that concern ‘conspiracies’ — that the person is, for example, being hunted by a clandestine organisation and that you, the professional, are part of it? This is going to have a pretty profound effect on the person’s subsequent actions! I won’t labour the point. A professional response that doesn’t introduce some ‘as-if’ quality, in fact, would have a good chance of aggravating the distress, possibly even putting the person in danger. So, the point cannot be hearing madness as madness, or if it is, I would suggest that it would be a very problematic position for a mental health professional to take.
Leaving this example aside, we need to ask how, in a general sense, would only hearing what the person is saying and not doing anything with it provide any sort of ‘change-inducing’ help — again, on the assumption that we are talking about the context of a ‘helping role’? We would essentially be left with just giving the person back the experience they expressed. What would be the point of that? Something has to be different — indeed a difference has to be introduced — for anything to change, for there to be any kind of ‘help.’ Indeed, any framework, whether that is something like the DSM, the PTMF or a psychodynamic, humanistic or cognitive behavioural approaches, is always going to involve a redescription of experience. It is their most basic purpose. Furthermore, if it is in a ‘helping role’ there is always going to be a power differential, again by definition, which is something that the PTMF, like most forms of therapy, is explicit about. This is not a design flaw, oversight or contradiction in the PTMF, in other words, but a basic feature of the helping context, which applies to any and every example of professional or therapeutic input.
Now, if the suggestion is that there should just be no such help, that the professional helping role should be dissolved, then fine. But that is a very different question. The irony, which deserves to be mentioned again, is that it is the PTMF that explicitly questions the degree to which there necessarily should be this power-laden kind of help. Should there be the kind of mental health professionals and mental health services that there are at all? Why did such a system emerge in the first place? Are cultures that do not have these broadly speaking better off without them? The PTMF does not provide answers to these fundamental questions, but very much encourages us to ask them.
The question, as such, is not about if there is a redescription of someone’s experiences involving power, but what kind (insofar as the context being that of the helping professional role). Specifically, the question is whether the kind of redescription that might emerge from the use of the PTMF in such a setting is an act of pathologisation. It is helpful here to bring Rashed’s commentary to Morgan’s paper here. Rashed, who agrees with Morgan and builds on some of his points, says:
‘If I express that Mostafa is placing thoughts into my mind, a person adopting a diagnostic framework may translate this into ‘you have a psychotic disorder’; while a person adopting a PTMF perspective may translate this into ‘you are experiencing a threat response that seeks your survival in the face of the negative impact of power.’ In both cases, the central defining feature of my experience—that a person called Mostafa is placing thoughts into my mind — has been radically distorted’ (Rashed, 2023; p.71)
The suggestion, much like for Morgan, is that the PTMF involves an equivalent act of pathologisation to the DSM. Again, we should reiterate here that in contrast to the routine imposition of a diagnostic reality by psychiatry and the mental health system at large, there is nothing whatsoever in the PTMF that suggests the imperative to persuade others to take on particular forms of narrative, whether PTMF-based or not. Similarly, no ‘translator’ is assumed or required by the PTMF. This seems to be completely overlooked by both.
Coming back to Rashed’s argument, we have to be clear on what is being compared. The psychiatric equivalent of a PTMF statement ‘You are experiencing a threat response that seeks your survival in the face of the negative impact of power’, in the unlikely event of being offered in this blunt format, would be something like ‘These experiences are symptoms of a largely genetically informed brain-based, biological dysfunction that may have been ‘triggered’ by environmental stressors.’ The equivalent response to ‘You have a psychotic disorder’ by contrast, would be something like ‘These confusing, disturbing experiences that you are experiencing can be thought of as meaningful responses to (extreme) experiences you’ve had in your life.’ Now, it is true that the PTMF practitioner in this hypothetical example would be offering a translation of the person’s report into something else (which as we have said is unavoidable in this context). But is this an act of pathologisation?
Clearly, ‘You have a psychotic disorder’ is pathologisation. There is an inherent judgement of abnormality, as well as, usually, some sort of attribution or implication of a pathology (i.e. pathological biological processes). What about the hypothetical PTMF-informed suggestion? It’s certainly not the latter, but is it the former? I would suggest that it clearly isn’t. It is offering an explanation, a translation, yes, but — as with the PTMF as a whole — it is explicitly offering a way of making such experiences understandable, and therefore, within their context, normalising them. It is saying that the experience is ‘normal’ in that no discontinuous pathological process needs to be invoked to understand/explain it — it is continuous with ‘normality.’ It is also saying it is ‘normal’ in the sense that there isn’t something ‘wrong’ with the person themselves, given the situations they have contended with.
There is a last point here that should be addressed. In the mind of Rashed, and presumably for Morgan too though he does not specify, the PTMF is not being compared to the various psychotherapeutic models or other non-medical approaches such as Open Dialogue, but to service-user-led ‘mad narratives.’ In his commentary, Rashed defines ‘Mad Narratives’ as ‘counter-narratives of emotional, behavioural, experiential, and psychological diversity that endeavour to make sense of madness without re-describing it into something else,’ (p.71) referencing his book. In his book, Rashed (2019) details three key kinds — ‘healing voices’, ‘dangerous gifts’ and ‘spiritual transformation’, which he says are “more faithful to madness.. preserving something of the phenomenology of madness [italics added]” (Rashed, 2019; p.190).
Clearly, an important question is whether such ‘mad narratives’ are able to offer what they charge the PTMF with being unable to? As we can see from the juxtaposition of these sentences, Rashed is inconsistent. Clearly, these mad narratives do not hear ‘madness as madness’ either, as they are themselves frames of intelligibility that involve redescription. The difference here, rather, only that it is service users on their own, rather than service users and mental health professionals both, that are providing such narratives. This is exemplified by the fact that the PTMF involved service users in its inception and in its writing, two of whom in fact ironically have been involved in developing one of Rashed’s mad narratives, ‘hearing voices’ — indeed, he references one of them, Jacqui Dillon, in that very section.
What this shows, I think, is that the impetus behind these critiques isn’t really about the PTMF as a framework at all, but about who has what power. If it is framed in this way, it seems that it is the whole range of psychological, psychotherapeutic and non-medical approaches to psychological and emotional distress that are being taken issue with. Specifically, the notion that non-medical mental health professionals should be allowed to meaningfully contribute to the narrative of another’s — particularly ‘mad’ others’ — experiences as a means of providing help. This feels like a separate discussion, and a much more serious one, where the PTMF seems to figure as a kind of scapegoat. All these other much more established approaches would have something strong to say to such a radical position, which might be why it is the PTMF that is often the target. This feels especially relevant to point out given that, of all of these approaches, it is the PTMF that most actively and explicitly seeks to reduce the role of mental health professionals in aiding people in their psychological and emotional distress.
Finally, a note on the claims of reductivism in the PTMF that Morgan raises. The introduction to the Overview of the PTMF explicitly states that it is proposing ‘a conceptual alternative to psychiatric classification in relation to emotional distress and troubled or troubling behaviour’; in other words those experiences that, in a particular setting and situation, are labelled as ‘mental illness/disorder.’ It describes these as arising through highly complex, overlapping pathways, shaped by meaning at many levels, changing over time and across cultures, and played out through a variety of embodied reactions and responses. It offers a very sophisticated, significant and multilayered analysis. Morgan’s notions that the PTMF ‘articulates a form of explanatory reductionism; every form of mental distress is reducible to the negative operation of power’ (p.64) ‘is committed to a theory of explanation based on the contention that all mental distress is an outcome of traumatic/adverse events’ (p.57) and that ‘post traumatic stress disorder’ is ‘…a hermeneutic model for all mental distress’ (p.63) simply do not have any currency in the context of its extensive pages. Such statements, in fact, are the precise opposite of the PTMF’s position, as even the most superficial reading shows.
The PTMF – as its authors emphasise – will not appeal to everyone and need not, and, as Johnstone explained in a recent interview, ‘We have no wish, and no power, to impose it’ (Aftab, 2020). The least we can do is to form our own judgements about it, and the many other non-diagnostic traditions it builds on and supports, based on what it actually says, and with an open mind about the radical revisioning that it suggests.