1. The Power Threat Meaning Framework
#PTMFramework
(Slides: © Lucy Johnstone and Mary Boyle 2018)

2. Contributors to the project over a 5 year period
Lucy Johnstone, Mary Boyle, John Cromby, Jacqui Dillon, Dave Harper, Peter Kinderman, Eleanor Longden, David Pilgrim, John Read, with editorial and research support from Kate Allsopp
Consultancy group of service users/carers
Critical reader group to advise on diversity
Other expert contributions
Good Practice examples
The core team consists of psychologists and survivors. Unusually (uniquely?) for an attempt to develop a new conceptual framework for distress, it was co-produced with survivors Jacqui and Eleanor right from the start, and in addition benefited from input from a SU/carer consultancy group (details in Chapter 7 of main document.) The wider project group draws on input from other professions as well, including some with dual professional/service user identity. It is not a policy document, but in keeping with its principles, it is hoped that any translations into practice would represent all stakeholders, including service users and carers.

3. 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
The main document, available online only.
Detailed overview of philosophical and conceptual principles; the roles of social, psychological and biological causal factors; SU/carer consultancy; and the relevant supporting evidence.
Chapter 8: Ways forward: Implications for public health policy; service design and commissioning; access to social care, housing and welfare benefits; therapeutic interventions; the legal system; and research.
Reading this is optional! However, the ambitious aims of the project meant that it has to be based on a very detailed summary, exposition and critique of underlying philosophical principles and evidence, which can be found here. Chapter 8 may be useful in terms of discussing some practical implications of the Framework.

4. The Power Threat Meaning Framework: Overview
The printed version consist of the Framework itself (Chapter 6 of the main document)
Order a copy from
Appendix 1: A guided discussion about the Framework (also available separately)
Appendices 2-14 Good practice examples of non-diagnostic work within and beyond services
2 page summary of the PTM Framework which can be adapted for local purposes; FAQs; Appendix 1 Guided Discussion; slides from the launch.
threat-meaning-framework
As above –this consists of the Framework itself, plus examples of existing good practice – of which there is already a lot. The link at the bottom gives some easy ways to access the document via a 2 page summary, and a suggested Guided Discussion for talking through its principles with clients, peers, or in relation to oneself. Use the address to order a free copy – you do not have to be a BPS member.

5. The Power Threat Meaning Framework: videos
Trailer for the launch:
Interviews with project team and attenders at the launch:
Main talks from the launch:
The videos also offer an accessible introduction to the project. NB website address will change when these are uploaded to the BPS website

6. DCP Position Statement on ‘Classification of behaviour and experience in relation to functional psychiatric diagnosis’ (2013):
‘The DCP is of the view that it is timely and appropriate to affirm publicly that the current classification system as outlined in DSM and ICD, in respect of the functional psychiatric diagnoses, has significant conceptual and empirical limitations. Consequently, there is a need for a paradigm shift in relation to the experiences that these diagnoses refer to, towards a conceptual system not based on a ‘disease’ model’ (May 2013)
The background to the project: this Division of Clinical Psychology Position Statement which was published at the same time as DSM 5 and recommended, among other things, ‘..work in conjunction with service users on developing a multi-factorial and contextual approach, which incorporates social, psychological and biological factors’ as an alternative to the diagnostic approach. It was in order to support steps towards fulfilling this aim that the DCP accepted the project team’s application for funding.

7. Moving beyond the ‘DSM mindset’……
Away from medicalisation – assuming that models designed for understanding bodies can be applied to people’s thoughts, feelings and behaviour.
Instead, a framework that understands people in their social and relational environments….
……and sees them as people acting and making meanings, within their life circumstances.
The core aim of the project – to move beyond the problem Mary Boyle has called the ‘DSM mindset’ – in other words, the false assumption that models developed (successfully) to understand bodily dysfunction are appropriate for people’s thoughts, feelings and behaviour.

8. There is a lot of new research out there…
There is a lot of new research out there….but it tends to get stuck at these points
‘Everything causes everything’
‘Everyone has experienced everything’
‘Everyone suffers from everything’
Many people are wrestling with the same problem of how to develop more appropriate models – but psychosocial research has tended to get stuck at these points. ‘Everything causes everything’ – ie a whole range of factors (poverty, abuse, inequality) appear to raise the risk for a whole range of forms of distress. ‘Everyone has experienced everything’ – ie very few people, especially in services, have had single adversities. ‘Everyone suffers from everything’ – ie most people meet the criteria for a range of diagnoses. So far, there has been very little success in outlining more specific patterns within this very broad picture. This is what the Framework attempts to do.

9. The Power Threat Meaning Framework
We already have non-diagnostic ways of working one to one (problem description like ‘Hearing Voices’; formulation.)
What we don’t have is a framework for describing wider, socially-situated, evidence-based patterns in relation to distress and unusual experiences or behaviour (whether or not officially diagnosed as ‘mental illness’.) This is what we have attempted to provide.
It is a first step and will need more work to translate it into practice.
Diagnoses in general medicine are essentially attempts to identify patterns in biological functioning. These patterns are based on medical research and are given names such as ‘diabetes’ which are then used as a basis for further refinement and research. The so-called ‘functional psychiatric diagnoses’ like ‘schizophrenia’ ‘bipolar disorder’ ‘major depressive disorder’ and so on are attempts to do the same in relation to mental distress. However it is widely acknowledged, even by the committees who draw up the diagnostic manuals, that this task has largely failed. We need a very different approach in relation to distress, unusual experiences and troubled or troubling behaviour (called ‘symptoms’ within a diagnostic model.)

10. The Power Threat Meaning Framework is not:
It is NOT
An official DCP or BPS model
A replacement for existing models. It draws together many of them within a larger overall framework.
For professional or service use only
Easy to read! (Full online version 200,000 words. Shorter printed version 50,000 words.)
It IS
A set of ideas (a conceptual resource) for everyone to draw on
Inclusive of but wider than formulation and trauma-informed practice
A first stage, in need of much work to translate it into practice
The Power Threat Meaning Framework is not:
The Framework is not a policy document or a plan for services or anything else. It is not an official DCP or BPS position or model, nor is it a set of Guidelines (suggestions for good practice) or Standards (codes of practice which are mandatory for psychologists.) Like many documents published by the BPS every year, it is a scholarly work intended to promote discussion and debate, and thus in the long term to contribute to evolving best practice.
The second stage of the project, now that the Framework is launched, is to offer it as an optional, free intellectual resource for anyone who wishes to take it further and start to translate it into practice in any way that seems useful. It recognises that there is much good practice already, and the aim is to offer further support and justification to this while also suggesting and encouraging additional ways forward.

11. A more effective, evidence-based way of performing the functions that diagnosis claims but fails to do
Summarising the evidence about causal factors in mental distress and troubled or troubling behavior
Showing how we can group similar types of experience together
Suggesting ways forward and interventions
Providing a basis for research
Providing a basis for administrative decisions such as commissioning, service design, access to services and benefits, legal judgements and so on
These are the core functions of psychiatric diagnosis – which are not successfully met by the existing system.

12. And just as importantly……
Recognising that emotional distress and troubled or troubling behaviour are, ultimately, understandable responses to a person’s history and circumstances
Restoring the link between distress and social injustice
Increasing people’s access to power and resources
Creating validating narratives which inform and empower people, groups and communities by restoring these links and meanings
Promoting social action
These additional purposes are central to the Framework. The Framework deliberately uses the word ‘narrative’ in recognition of the many possible ways of telling a story – art, poetry, music, song, and a whole range of narrative practices and community rituals across the globe. Psychological formulation is one, but certainly not the only, way of constructing or co-constructing a story, but there is comparatively little emphasis on it in the Framework - although the Framework is intended to support and enrich the practice of formulation along with many other forms of narrative creation.

13. The Power/Threat/Meaning framework poses these core questions:
'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 experiences to you?)
‘What did you have to do to survive?’
(What kinds of Threat Response are you using?)
The complex document hangs on four simple key questions – (the PTM version of the questions is in the brackets.) These are essentially an expansion of the survivor slogan ‘Instead of asking “What’s wrong with you?” ask “What happened to you?”’

14. …..and to integrate all the above: ‘What is your story?’
In one to one clinical, peer support or self help work this then leads to the questions:
What are your strengths?’ (What access to Power resources do you have?)
…..and to integrate all the above: ‘What is your story?’
And two more…

15. This is not a new version of ‘biopsychosocial
This is not a new version of ‘biopsychosocial.’ It is convenient to think of it in terms of Power, Threat, Meaning and Threat Response, but in fact the elements are not independent but evolve out of each other.
‘Power’ implies both ‘Threat’ and ‘Threat Response’, and all of these are shaped by their Meanings.
Anyone who works through the Guided Discussion will find that responding to prompts about Power inevitably implies Threat, and Threat inevitably implies Meaning… These four key elements arise out of each other, rather than being separate, additive aspects.

16. We have carried out a very detailed review of the evidence about Power, Threat, Meaning and Threat Responses. This has allowed us to outline a provisional set of broad, socially-situated, evidence-based patterns in relation to distress and unusual experiences or behaviour. These offer what has been missing so far – a way of helping to construct individual/family/group/social narratives, inside or outside services, supported or not by professionals…..of which psychological formulation is only one example, with advantages and limitations….
…as well as suggest alternative ways of fulfilling the other functions of diagnosis.
These are the core aims of the Framework and how it tries to achieve them – ie by outlining patterns which better fulfil the purposes of diagnosis but are of a very different kind from patterns of bodily dysfunction. This is provisional. Much work remains to be done on further development of the patterns, and of the Framework itself.

17. …and then a chance to try it out in practice.
A closer look at what we mean by Power, Threat, Meaning and Threat Responses
…and then a chance to try it out in practice.
Optional exercise at the end!

18. 'What has happened to you?’ (How is Power operating in your life?)
The means of obtaining security and advantage
Being able to influence your environment to meet your own needs and interests
There are many definitions of power. These are two of them.

19. Some forms of power . . .
Legal power may involve coercion but also rules and sanctions supporting or limiting other aspects of power, offering or restricting choices
Economic and material power involves having the means to obtain valued possessions and services, to control others’ access to them and to pursue valued activities
Interpersonal power refers to power within close relationships, the power to look after/not look after or protect someone, to leave them, to give /withdraw /withhold affection etc
Biological or embodied power operates through the possession of socially valued embodied attributes eg: physical attractiveness, fertility, strength, embodied talents and abilities, physical health
Coercive power or power by force involves any use of violence, aggression or threats to frighten, intimidate or ensure compliance
Social/cultural capital – a mix of valued qualifications, knowledge and connections which ease people’s way through life and can be passed indirectly to the next generation in a kind of symbolic inheritance process
Ideological power involves control of language, meaning, and perspective
There are many ways of clustering types of power. This is how the Framework does it. We are used to considering some of these in relation to mental distress, less used to others.

20. Probably the least obvious and least acknowledged form of power
The particular importance of ideological power - power over meaning, language and perspective . . .
Probably the least obvious and least acknowledged form of power
It is part of every other form of power
It is when our thoughts, beliefs and feelings are ignored, discounted or disbelieved and alternative meanings may be imposed instead
It shapes the ways we make sense of our life situations
In mental health and the criminal justice system, it is often used to turn social problems into individual ones and diagnose or define people as ‘bad or mad’
The Framework places a great deal of emphasis on the central role of ideological power. (Maybe give examples of what an ‘ideology’ is? Eg a set of beliefs – a bit like neo-liberalism – which are not easily open to proof or disproof, but which support and are supported by a range of interests, and which exert their influence through the use of language and meaning. Thus, there may be a strong emphasis on individual responsibility, people on benefits may be described as ‘scroungers’, and these terms and ideas may be used to justify dismantling welfare systems. ) The Framework sees the diagnostic model of distress as an example of an ideology – there is little or no evidence to support it, but its language and ideas are used (not necessarily consciously or deliberately) to re-frame social problems as individual ones. Many critics over the years have argued this.

21. The particular importance of ideological power - power over meaning, language and perspective . . .
Many people, especially those in less powerful positions, may be deprived of sound, evidence-based, alternative frameworks in order to make sense of their own and others’ distressing or unusual experiences This is a form of ‘epistemic injustice’ – experienced by groups who lack shared social resources to make sense of their experiences, due to unequal power relations (Miranda Fricker.)
This use of ideological power – to define someone’s reality for them – is rarely discussed or visible. ‘Epistemic injustice’ is a concept originally developed by philosopher Miranda Fricker to describe the ways in which women’s views and perceptions may be subtly but systematically undermined (they are ‘irrational’, etc..) A prime example of the negative use of ideological power is the imposition of a psychiatric diagnosis – routinely presented as fact, with no offer or opportunity to explore alternative perspectives, and possibly punishment for disagreeing. It is hoped that PTM will help to counter this particular use of ideological power, by offering service users and others access to sources of knowledge and information that are not usually available to them.

22. ….and in due course, access to this Framework!
The particular importance of ideological power - power over meaning, language and perspective . . .
The less access you have to conventional or approved forms of power, the more likely you are to adopt socially disturbing or disruptive strategies in order to survive adversity
Power also operates positively and protectively – friends, partners, family, communities, material resources, social capital, positive identities, education and access to knowledge
….and in due course, access to this Framework!
Important not to lose sight of the many positive and protective aspects of power. The Guided Discussion emphasises these alongside the more negative aspects.

23. Some consequences of the negative operation of power . . .
Unpredictability and lack of control over your life
Entrapment – unable to escape damaging environments
Conflict – internal, relationships, social
Negative views and stereotypes about you and/or your social group
Repeated exposure to violence, aggression, humiliation, criticism etc
Some we commonly recognise….others are less often considered.

24. ‘How did it affect you?’ (What kind of Threats does this pose?)
Relationships eg threats of rejection, abandonment, isolation
Emotional – eg threats of overwhelming emotions, loss of control
Social/community – eg threats to social roles, social status, community links
Economic/material – eg threats to financial security, housing, being able to meet basic needs
Consideration of Threats arises inevitably out of reflecting on Power. Some we are used to taking into account, others less so.

25. Bodily – e.g. threats of violence, physical ill health
Environmental – eg threats to safety and security, to links with the natural world – e.g. living in a dense urban or high crime area
Bodily – e.g. threats of violence, physical ill health
Value base – e.g. threats to your beliefs and basic values
Meaning making – e.g. threats to ability to create valued meanings about important aspects of your life/ imposition of others’ meanings
See discussion about ideological power – we are less used to considering threats to values and meaning making.

26. ‘ ‘What sense did you make of it
‘ ‘What sense did you make of it?’ (What is the Meaning of these experiences to you?)
Human beings actively make sense of their world, and their behaviour is purposeful and meaningful But what do we mean by ‘meaning’?
Most MH professionals will be used to reflecting on meaning with their clients in one form or another – e.g. through therapy. But the project expands on traditional understandings of ‘meaning.’

27. Meanings are never just personal and individual
INDIVIDUAL MEANINGS ARE NEVER JUST FREELY CHOSEN
Instead, meaning is both ‘made and found’ (Shotter)
Meaning is inseparable from:
Bodies and feelings
Memories
Language
Social relationships
Environments
Power, Threat and our responses to those threats
The project does not make the typical distinctions between thoughts, emotions and bodily feelings (e.g. the experience of shame involves all 3 of these aspects.) Many non-Western cultures do not make these distinctions either.

28. Our personal meanings are shaped by:
We cannot understand any aspect of Power, Threat or Threat Response separately from their meanings.
Our personal meanings are shaped by:
Social discourses (common understandings about what it means to be ‘mentally ill’, a ‘good mother’, a ‘happy family’, a refugee, and so on)
Ideological meanings – deeply embedded assumptions about the world that serve certain interests (neoliberalism is a good example – and biomedical theories about ‘mental illness’ are another.)
As professionals or therapists we typically focus on individual, personal meaning – which may be helpful. But we rarely ask where these meanings come from. (Example: women who have been raped commonly experience shame, guilt and self-blame. This can only be understood in terms of wider social messages about women’s and men’s sexuality and sexual expression and who is responsible for its expression – and those discourses in turn serve the purpose of obscuring the prevalence of violence in women’s lives. A parallel example for men might be the high suicide rates in blue collar middle-aged men who have been made redundant. We might link this to messages about men’s socialisation into not expressing feelings or asking for help, as well as the human impact of economic policies and the interests they support.) Groupwork may be a particularly helpful way of exploring these messages and building solidarity.

29. ‘What did you have to do to survive
‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)
We have all evolved to be able to respond to threats, by reducing or avoiding them, adapting to or surviving them, and trying to keep safe.
These threat responses are biologically-based but are also influenced by our past experiences, by cultural norms, and by what we can actually do in any given circumstances.
They are on a spectrum from automatic (more biologically-based) to more personally and culturally-shaped.
These ideas draw on Trauma-Informed perspectives and research. Our biology mediates and enables, but does not in any simplistic sense cause, emotional distress. Like trauma-informed approaches, the Framework recognises that bodily responses and reactions cannot be separated from any aspect of human experience. In relation to actual or perceived threat, we have all evolved to use certain automatic responses – fight, flight, freeze, dissociate etc. These responses lie on a very rough continuum from those that are felt to be under some degree of conscious control to those which are not. At the former end we can find a range of more consciously-adopted and culturally-specific responses (using alcohol, self-harming, restricting one’s eating etc..)

30. Some examples of threat responses
Preparing to fight, flee, escape, seek safety
Giving up (‘learned helplessness’, apathy, low mood)
Being hypervigilant
Having flashbacks, phobic responses, nightmares
Having rapid mood changes
Amnesia/fragmented memory
Hearing voices, dissociating, holding unusual beliefs
Restricting our eating, using alcohol
Denial, avoidance
Overwork, perfectionism,
Threat responses are more traditionally called ‘symptoms.’ However, within PTM, socially valued reactions such as overwork can also, in some contexts, be seen as threat responses. Conversely, some experiences that are almost invariably seen as ‘pathological’ can be seen from a PTM perspective as valued aspects of someone’s life (eg hearing voices.)

31. Some of these may be seen as ‘normal’ or even desirable (overwork, perfectionism, ruthlessness with colleagues, etc..) They are likely to be to some degree culture-specific (self- starvation in Westernised countries; so-called ‘culture-bound syndromes’.) Threat responses are there for a reason, and it makes more sense to group them by function – what purpose do they serve? than by ‘symptom.’ Both the function and the meaning of the response vary over time and across cultures, but there are common themes.
From a PTM perspective it makes little sense to ask (or research into) questions like ‘What causes depression/hallucinations/eating disorders?’ Threat responses may serve different purposes at different times for different people (albeit with some common themes.) It makes more sense to see them in terms of the function or purpose they are serving in any given situation.

32. Threat responses grouped by common functions
Regulating overwhelming feelings: (e.g. by dissociation, self- injury, memory fragmentation, bingeing and purging, differential memory encoding, ritualising, intellectualisation, ‘high’ mood, low mood, hearing voices, use of alcohol and drugs, compulsive activity of various kinds, overeating, denial, projection, splitting, somatic sensations, bodily numbing). Protection against attachment loss, hurt and abandonment: (e.g. by rejection of others, distrust, seeking care and emotional responses, submission, self-blame, interpersonal violence, hoarding, appeasement, self-silencing, self- punishment).
PTM suggests some broad ways of clustering threat responses in terms of their function in meeting certain core human needs when people are, or have been, under threat. Two examples are given. Each threat response may also appear under different clusters, and/or may serve several functions for a person.

33. Linking Threats to Threat Responses
Restoring the link between Threats and Threat Responses – a main purpose of the Framework
Linking Threats to Threat Responses
Psychiatric practice obscures the links between threats and threat responses by imposing a diagnosis and then ‘treating’ an ‘illness.’ The Power Threat Meaning Framework shows how we can restore those links.
At one level this is common sense. We all know that people living in poverty are more likely to feel miserable and desperate (‘depression’) and we now recognise that abuse and trauma makes it more likely that people will hear voices (‘psychosis’ or ‘schizophrenia.’)
But a number of factors combine to conceal these links – from the person and from society as a whole.
Key points – restoring the link between threat and threat responses. While in many situations we recognise these links, the imposition of a diagnosis simultaneously obscures them and supports a focus on individuals and their ‘illnesses.’

34. The threat is often distant in time.
The threat (or operation of Power) may be less obvious because it is subtle, cumulative, and/or socially acceptable.
The threat is often distant in time.
The threats may be so numerous, and the responses so many and varied, that the connections between them are confused and obscured.
There may be an accumulation of apparently minor threats and adversities over a very long period of time
The threat response may take an unusual or extreme form that is less obviously linked to the threat; for example, apparently ‘bizarre’ beliefs, hearing voices, self-harm, self-starvation.
Brief list of factors that serve to disconnect threat from threat response….

35. Overlooking or ignoring the links may be encouraged by:
The person in distress may not be aware of the link themselves, since memory loss, dissociation and so on are part of their coping strategies.
The person in distress might have become used to overlooking possible links, because acknowledging them felt dangerous, stigmatising or shaming
Overlooking or ignoring the links may be encouraged by:
Messages about personal blame, weakness, culpability etc.
Messages about personal responsibility, not complaining, being strong etc.
….more…..

36. Mental health professionals are trained to obscure the link by giving and using diagnoses which imposes a powerful expert narrative of individual deficit and illness
There is widespread resistance to recognising the reality and impact of threats and the negative impacts of power
There are many vested interests (personal, family, professional, organisational, community, business, institutional, economic, political) in disconnecting Threats from Threat Responses - and thus preserving the ‘illness’ model.
…..more. Obviously PTM does not see mental health, criminal justice or other professionals as deliberately and consciously obscuring these links. This is a bigger problem of ideological power operating (in this case) through diagnostic language and its assumptions.

37. General Patterns within the Power Threat Meaning Framework
What kind of patterns do we find if we put together the evidence about the influences of Power, Threat, Meaning and associated Threat Responses?
NB These patterns will always be overlapping, provisional and changing – because they are organised by meaning not by biology.
The patterns will always reflect and be shaped by specific worldviews, social, historical, political and cultural contexts and ideological meanings.
To return to the start of the presentation – a main purpose of PTM is to offer a radically-different way of conceptualising and provisionally identifying patterns in distress, unusual experiences, and troubled or troubling behaviour. The key phrase is ‘…organised by meaning not by behaviour.’ This is the fundamental difference from medical, biologically-based patterns (although PTM patterns do include biology as mediator and enabler – but not as primary causal factor as in ‘depression is caused by a chemical imbalance’ etc..) As soon as we grasp this, we can see why expressions of distress are so varied across time and culture (eg, what happened to ‘catatonia’, ‘hysteria’ and other once-common ‘mental illnesses’?)

38. Patterns of embodied, meaning-based threat responses to the negative operation of power.
The General Patterns are described as verbs not nouns, things people DO not HAVE, to reflect the fact that they represent active (although not necessarily consciously chosen or controlled) attempts to survive the negative operation of power. They are not a one-to-one replacement for diagnostic clusters, and people will vary in their ‘fit’ with one or more patterns – thus, general patterns will always need tailoring to the individual. This allows for consideration of protective aspects, along with strengths, skills, and access to material, relationship and social resources and supports
Another major difference from medical patterns – this is about what people DO (verb) not what they HAVE (noun.)

39. Evidence-based General Patterns
We have provisionally outlined 7 evidence-based General Patterns which cut across:
Diagnostic categories
Specialties (MH, addictions, OA, Child, criminal justice, health)
‘Normal’ and ‘abnormal’
People who are psychiatrically labelled and all of us
This aspect of PTM needs more development. However, we hope the provisional patterns we have identified at least serve to illustrate some key principles, and to offer a starting point for further elaboration. Each pattern is supported by evidence as described in Appendix 1 of the Main PTM document. Each pattern also includes possible sub-patterns (refer people to read these for themselves if interested.) There is no such things as a ‘pattern for people currently labelled with ‘BPD’’ or any other diagnosis. The patterns are overlapping, and describe broad regularities not definitive cause-effect links. People may find themselves identifying with one, two or more of the patterns. The general patterns can be used as a resource to support the construction of personal stories, and to convey a sense of validation and shared experience, as well as providing an evidence base for narrative and formulation work. The emphasis is on ALL of us facing, at some point in our lives, the negative impact of power – not on a separate group of the so-called ‘mentally ill.’

40. Seven evidence-based General Patterns
The provisional patterns – refer people to further reading in the PTM documents. Each pattern is described in detail, along with its characteristic (but not unique) constellation of Power, Threat, Meaning and Threat Response aspects. It can be seen that pattern 5, for example, may describe core aspects of the experiences diagnosed as ‘depression.’ However, people with that diagnosis may find their experiences described better by a different pattern, and conversely, pattern 5 may be felt to describe the experiences associated with other diagnoses and none. With the same caveats, pattern 4 may (or may not) describe the experiences of some young people diagnosed with ‘psychosis.’ It can also be seen that pattern 6, for example, may describe the characteristic threat responses of many men in the criminal justice system. But the same caveats apply – this is not a ‘pattern for offenders’; some ‘offenders’ will find their experiences and reactions better described by other patterns; and the pattern can be recognised in many who have never had contact with the criminal justice system.

41. Separating from your family in early adulthood
In Westernised countries, these patterns draw on struggles with Western norms and standards, such as:
Separating from your family in early adulthood
Compete and achieving in line with social expectations (e.g. in the labour market; for material goods)
Meet your needs within a nuclear family structure
Fit in with standards about body size, shape and weight
Fit in with expectations about gender identity and gender roles
Avoiding ‘irrational’ experiences – e.g. about a unitary self
As an older adult – cope with loneliness and lack of status
Bring up children to fit in with all the above
The PTM Framework as it stands was developed in a Western context. As such, its general meaning-based patterns inevitably draw from and are shaped by certain core (and often unquestioned) Western standards and social norms, some of which are listed here. At some level, people’s distress in this cultural and historical context is likely to arise from a clash between (actual or perceived) inability to live up to these norms and standards. Thus, the (unrealistic?) expectation of separating from one’s nuclear family of origin aged around 18/19 is often at the root of distress expressed in various ways at that age in ‘psychosis’, ‘eating disorders’ and other forms. Pathology may be ascribed to those whose experience is of having a number of ‘selves’ – while this is unusual in Westernised cultures, it is not so everywhere (in the UK and worldwide.)

42. Patterns and ‘culture’
The Power Threat Meaning framework predicts and allows for the existence of widely varying cultural experiences and expressions of distress without seeing them as bizarre, primitive, less valid, or as exotic variations of the dominant diagnostic or other Western paradigms.
Since it is an over-arching framework that is based on universal evolved human capabilities and threat responses, the basic principles of PTM apply across time and across cultures.
Within this, open-ended lists of threat responses and functions allow for an indefinite number of locally and historically specific expressions of distress, all shaped by local cultural meanings.
A major dilemmas for DSM and ICD is how to understand culturally-unusual (from a Western perspective) experiences and expressions of distress which don’t fit neatly into DSM or ICD categories. Much effort has been wasted speculating on whether these are ‘really’ forms of ‘schizophrenia’, ‘depression’ and so on. The solution is to put them into an appendix of ‘Culture-bound syndromes.’ From a PTM perspective, ALL expressions of distress are ‘culture-bound’, and so it is not a problem to accept the different ways that it may be manifested. At a very basic level, as members of the same species, we share certain biologically-primed responses to threats to our core needs. Beyond that, local norms and cultural assumptions (within and beyond the UK) will inevitably shape the threat reactions we employ.

43. For example:
‘Spirit possession’ is sometimes seen as equivalent to the psychiatric concept of ‘psychosis’. One version, ‘cen’, is found in Northern Uganda, where civil war has resulted in widespread brutality and the abduction and forced recruitment of children as soldiers. In this phenomenon, young people report that their identity has been taken over by the malevolent ghost of a dead person. ‘Cen’ has been found to be associated with high levels of war trauma and with abduction, and the spirit was often identified as someone the abductees had been forced to kill.
We could understand this within the Power Threat Meaning framework without having to call it ‘schizophrenia’ or ‘psychosis.’
‘Spirit possession’ is given as an example of a ‘culture-bound syndrome’ in the appendix of DSM IV. This description of one version of spirit possession illustrates one of the purposes of PTM – to convey a sense of respect for the many non-diagnostic, culturally-specific ways in which distress is experienced, expressed and healed, rather than seek to incorporate them into the dominant diagnostic discourse – and still less to export this diagnostic discourse and its related practices across the world as is happening under the Global Mental Health Movement.

44. Other aspects of the Framework
Detailed descriptions of the General Patterns and sub- patterns within them.
Implications for Public Health policy; Mental health policy; Service principles; Service design, commissioning and outcomes; Access to social care, housing and welfare benefits; Therapeutic interventions; The legal system; Research.
Examples, templates.
See website address given earlier, and Chapter 8 of the main document.

45. General pattern: Surviving rejection, entrapment and invalidation
This describes a broad pattern of threats and threat responses which are associated with core meanings of rejection, powerlessness, being trapped, unsafe, emotionally overwhelmed, and invalidated. There has often been prolonged interpersonal maltreatment, abuse, invalidation and neglect in situations of lack of control, dependence, isolation and entrapment. The person was/is helpless and powerless in the face of emotional and/or physical threat, while often being dependent on the perpetrators for survival. These situations may start with carers who were not able to create secure early relationships due to their own social, material and personal circumstances, and/or to protect children from exposure to significant abuses of power; and/or they may occur outside the family of origin and/or in adult life. There is likely to have been significant traumatisation and re-victimisation as an adult.
Edited example of a General Pattern (if time.)

46. More details of this General Pattern:
Power
There has often been prolonged interpersonal maltreatment, abuse, invalidation and neglect in situations of lack of control, dependence, isolation and entrapment. In these situations the person was/is helpless and powerless in the face of emotional and/or physical threat, while often being dependent on the perpetrators for survival. These situations may originate with carers who were not able to facilitate secure early relationships due to their own social, material and personal circumstances, and/or to protect children from exposure to significant abuses of power; and/or they may occur outside the family of origin and/or in adult life. There is likely to have been significant traumatisation and re-victimisation as an adult. Backgrounds include neglectful and/or abusive early relationships; prolonged bullying as a child; domestic violence; combat. Other backgrounds include being a prisoner of war; being a victim of trafficking; survivors of organised sexual abuse; survivors of cults.

47. Threat
Core threats are rejection, invalidation, abandonment, attachment loss, entrapment, emotional overwhelm/dysregulation, powerlessness, physical danger and bodily invasion, physical ill-health and depletion.
Meaning
The threats are commonly associated with meanings such as: lack of safety, fear, rejection and abandonment, shame, guilt, emptiness, badness and unworthiness, alienation, betrayal, hopelessness, helplessness, and meaninglessness.

48. Threat Responses
Regulating overwhelming feelings (e.g. through dissociation, amnesia, disrupted attention, de-realisation, emotional numbness, bodily numbness, hearing voices, drug and alcohol use, self-harm, impulsivity, somatic sensations, splitting and projection of feelings, rapid changes of mood, unusual beliefs, suicidality)
Protection against attachment loss, hurt and abandonment (e.g., dominance and seeking control, distrust, vigilance for rejection, rejection of others, isolation/avoidance of others, self-silencing, self-hatred, self-blame, appeasement, compliance.)
Protection from danger (e.g. hypervigilance, anger and rage, anxiety, suspicious thoughts)

49. General Pattern: Surviving social exclusion, shame and coercive power
Within the Power Threat Meaning Framework, this describes someone whose family of origin is likely to have lived in environments characterised by threat, discrimination, material deprivation and social exclusion. This may have included absent fathers, institutional care and/or homelessness. Within this, caregivers are likely to have been struggling with their own histories of adversity, past and present, often by using drugs and alcohol. As a result of all this, the person’s early attachments were often disrupted and insecure, and they may have experienced significant adversities as a child and as an adult, including physical and sexual abuse, bullying, witnessing domestic violence, and harsh or humiliating parenting styles. ‘Disorganised’ attachment styles are common. Individuals tend to use survival strategies of cutting off from their own and others’ emotions, maintaining emotional distance, and remaining highly alert to threat.
Edited example of a general pattern – if time. Particularly relevant in forensic and criminal justice work.

50. Social discourses and status comparisons may have imparted a sense of worthlessness, shame and injustice, which may be managed by various forms of violent behaviour. More unequal societies, in which economic inequality increases social competition, allow these dynamics to flourish. This may have a particularly strong impact on disadvantaged men, who have greater incentives than women to compete, achieve and maintain high social status, while being faced with numerous indications of their lack of success and status.

51. More details of this general pattern…
Power
There have been multiple experiences of the negative operation of almost all forms of power giving rise to multiple social and relational threats and adversities, both past and present. This is commonly exacerbated by being sent to other threatening institutions such as prison. The wider context is one of competitive but economically and socially unequal societies, in which people, especially men, are faced with constant indications of failure and exclusion. Social discourses about gender roles shape the way in which the threats are experienced and expressed.
Threat
The individual (family/social group) within this pattern was and is faced with core threats such as social exclusion and disconnection, physical danger, emotional overwhelm/dysregulation, emotional neglect and invalidation, humiliation, powerlessness, abandonment, material deprivation, and bodily invasion.

52. Meaning
The threats are commonly associated with meanings such as: fear, shame, humiliation, inferiority, worthlessness, and powerlessness, although there may be limited awareness and acknowledgement of this. Suspicious thoughts have been shown to arise out of feelings of powerlessness, injustice, shame, anger, entrapment, unworthiness and social exclusion. Fear of abandonment, emotional emptiness, emotional numbness, guilt and alienation may also be present.

53. Threat Responses
Preserving identity, self-image and self-esteem (e.g. dominance, violence, suspicious thoughts, sexual aggression, externalising, hypervigilance, distrust.)
Regulating overwhelming feelings (e.g. denial, projection, reduced empathy and reduced awareness of emotions, suspicious thoughts, dissociation, numbness, somatic experiences, hearing voices, self-harm, drugs and alcohol, self-harm. Impulsivity, rage as a mask for fear, sadness, shame and loneliness)
Protection from physical danger (e.g. suspicious thoughts, distrust, dominance, aggression, hypervigilance, avoidance, self-isolation)
Maintaining a sense of control (e.g. maintain emotional and/or physical distance, use aggression as a defence against shame and humiliation, dominance, threats)
Protection against attachment loss, hurt and abandonment (e.g. appeasement, emotional distance, dominance, suspicious thoughts, violence, sexual aggression, sensitivity to humiliation and shaming, reduced empathy, impulsivity)
Preserving a place within the social group (e.g. aggression, gang membership)

54. What does this add to a routine formulation?
The entrapping effect of the dominant narrative of psychiatric diagnosis and its wider context of meta-narratives about science.
The contradictions in combining psychiatric diagnostic narratives with psychosocial ones.
The role of social discourses, especially those about gender, class, ethnicity and the medicalisation of mental distress, and how these discourses can support the imposition of others’ meanings.
The impacts of coercive, legal, and economic power.
The nature and impact of power inequalities in psychiatric settings.
The prevalence of abuse of interpersonal power within relationships.
The role of ideological power as commonly expressed through dominant narratives and assumptions about individualism, achievement, personal responsibility, gender roles, and so on.
For psychologists – how might the PTM principles expand our routine formulation practice?

55. What does this add to a routine formulation?
The mediating role of biologically-based threat responses.
The importance of function over ‘symptom’ or specific problem.
The role of power resources in shaping threat responses.
Culture-specific meanings and forms of expression.
Self-help and social action along with, or instead of, professional intervention.
The importance of group and community narratives to support the healing and re-integration of the social group.
Recognition of the personal and provisional nature of all narratives and the need for sensitivity, artistry and respect in supporting their development and expression.
A meta message that is normalising, not pathologising (either medically or psychologically): ‘You are experiencing an understandable and indeed adaptive reaction to threats and difficulties. Many others in the same circumstances have felt the same.’

56. The Guided Discussion (Appendix 1 in the Overview)
A tool for reflection and discussion, not a rigid protocol
To be used sensitively and flexibly, starting at any point, and adapting the language as appropriate
Quicker than it looks to complete, since the areas overlap
Open to development – current version is mainly AMH focused
Pacing and timing are important, especially in clinical/peer settings. Can be started at any point (e.g. it may be easier to start with ‘Threat responses’ or ‘What made things better or worse?’) and can take as long/as many sessions as necessary
Introduction to a possible group exercise using Appendix 1 of the Overview. Suggested timing: 10 mins to introduce the exercise. 30 mins to try it out (there will not be time to work through the whole Guided Discussion, but a focus on Power and then on Strengths will give the flavour, and also help to end the exercise on a positive note.) 20 minutes feedback (general, not personal details.)

57. Trying it out…. A possible exercise
Guided discussion for helping to apply these ideas to people’s real lives – inside or outside services.
Either: Use yourself as an example (whether or not you have a MH history) but take care of yourself!
Or: Use someone else as an anonymous example (friend, family member.) NB Confidentiality
Either: Pairing up with someone else
Or: Doing it on your own

58. Particular attention to aspects that are often overlooked:
The various forms of Power
Ideological power and meanings
‘Normal’ threat responses
The role of diagnosis and service responses
After about 20 minutes… go forward to the ‘Strengths’ section.
If time – compare the result with one of the General Patterns

59. Feedback about the experience – how was it. Did you learn anything new
Feedback about the experience – how was it? Did you learn anything new? Did you notice things that you hadn’t known about/thought about before? How might this help you or the person find ways forward?
Feedback about the guided discussion format