A mental health nurse’s first response to the launch of the Power Threat Meaning Framework

The 12^th of January 2018 is a day that I very much hope will be remembered: the day that the Power Threat Meaning Framework was launched. Supported by the British Psychological Society’s Division of Clinical Psychology, it was written by a group of respected critical thinkers, including psychologists and service-users. For me, the launch was the first time seeing John Read in the flesh, whom I view as something like the godfather of published research into links between trauma and psychosis. The Framework has been five years in the writing. Several hundred people attended the event at Friends House, Euston, London, sold out in a matter of hours. It was a chance to hear from the authors and attend some workshops, and to be handed an eagerly awaited copy of the framework. At 138 pages this is actually a shortened overview of the full document (both available free online). The audience comprised a lot of psychologists but also people from many survivor groups, activist groups, nurses and various students. I did see one psychiatrist I recognised – the chair of the Critical Psychiatry Network, but it is probably fair to say that psychiatrists were not there in large numbers.

What is the Power Threat Meaning Framework?

It is nothing less than an attempt at a totally comprehensive replacement to the DSM and ICD manuals. It is always said that it is all very well to criticise the DSM and ICD psychiatric manuals (and how well they have been criticised!) but what viable alternative is there? The Power Threat Meaning Framework aims to be just that.

So is it any good?

The simple answer is yes. It is very good. It is a framework that engages with research and thinking in philosophy of science, psychology, sociology, biology and survivor movements. Feminists are already applauding. It stands up to post-colonial and neo-colonial critique. It addresses the relationship between the individual, society and state. Social workers will love it; it has social justice and human rights at its heart. It is suitable for a post-Human Genome Project biology. Given all of this, it is very hard to compare with the DSM/ICD, because psychiatry’s manuals really only make sense if all of that scholarship is ignored. The Power Threat Meaning Framework is in an entirely different league of explanation and it is no kind of exaggeration to say that it exposes the intellectual bankruptcy of psychiatry. However, it is more than that because it is not just a critique, it is a framework to consider and explain patterns of mental health (‘mental health’ may not be the best term under this framework) in the life-span of individuals and in society, and to intervene. The phrase ‘paradigm shift’ is evoked these days when anyone has a slightly new idea, or even just an old one that has been forgotten, but if anything has been written during the span of my nursing career that is worthy of that phrase, this is it.

How do I know that? Firstly, because no other framework or explanation of distress in individuals/society I have ever read has the scope and rigour of this one. Secondly, because it is a framework that does not merely suggest reform or revision to current mental health services or professions; it quickly becomes clear that this is a proposal that could not be implemented by mental health professionals as we know them, or at least that in trying they would be altered in ways that change their fundamental identities. It is transformative of society not just of mental health services.

So, it is certainly worth reading. But is it of any use?

Nothing is flawless, but the scholastic pedigree of the work moves most debate about it into the realm of whether it is of any practical use. In some ways that is an odd way to begin assess it, because one can always reply by asking whether difficulties we might have in applying a new knowledge justify preferring an old discredited knowledge and the answer to that has to be a resounding ‘no!’. So far, I have yet to see a criticism of this framework (it has evoked a frenzied storm) that seriously engages the framework itself conceptually. Arguments about how it fits or does not fit with the benefit system (it doesn’t), the Mental Health Act (it absolutely doesn’t) and existing professional groups or survivor knowledges are important. What these questions reveal is not that this new framework is poor, but further underline that the current system, with all its interlocking laws and services, is built on a disastrous set of contested concepts and politically loaded assumptions, a house of cards. If the Power Threat Meaning Framework actually did provide smooth step-by-step transitions from, say, the current benefit system and its reliance on medical psychiatry to an entirely new way of understanding how to financially support people, then it would probably not be an entirely new way of understanding; a paradigm shift is a total regime change, not something that can be slotted into existing structures. If I had had to fight to get a child of mine diagnosed in order to have some of his or her educational needs met, for example, I would not yet know what to do with this new framework. But before its publication, we did not have this kind of comprehensive and aspirational target, we just had a contested and abusive system based on elitism, science that was thrown out years ago and ignorance of vast swathes of scholarship in the humanities. In short, the Power Threat Meaning Framework is a striking and inspiring vision and I’m not sure anyone knows how to get there yet.

Isn’t this just a ‘power-grab’ by psychologists?

Unsurprisingly, nothing in this new framework looks like it has been adapted from existing biological models. What may be more surprising is that there is not a lot in it that looks like mainstream psychology either (few current psychological frameworks begin with premises about the operations of power that would demand the psychologist and their client to depart on a shared journey of re-understanding their own culture, for example). Therefore 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. In fact, that allegiance problem is what we nurses have right now, and the Power Threat Meaning Framework shows why that is a false choice created by false professional divisions. It is only a ‘power-grab’ to the extent that every meticulous and well-referenced argument is a power-grab, and in that way it is certainly powerful.

And a framework that begins with a conscious exploration of the operations of power is not easily accused of being about a professional group or key individuals flexing their muscles. There are big egos in every room, there may be those with a profound sense of entitlement too, but this framework is more likely to expose them than provide them a platform. If you wish it was not written by an admittedly rather white and rather middle-class set of people from a professional background, or feel that the well-published service-user-activists who were also key authors are somehow not representative of service-users more generally (and that is an argument of which to be very cautious) once again you will find no more useful document than the Power Threat Meaning Framework to help you form your arguments and this is not a coincidence.

But what would nurses be doing if they were following this framework?

In many ways, that remains to be explored, especially in the light of the difficulties mentioned above. In one of the workshops, small groups discussed how this framework might alter the training of mental health professionals, and every small group identified (and became to some extent preoccupied by) the fact that the framework does not really support the conceptual divisions of the mental health professionals as they currently stand. There were those in the group who wondered if professions are the right kind of response to this framework, anyway. These are complicated ideas and might appear to be a stumbling block; how can we implement a set of ideas that are so different from the position in which we start? That question will certainly arise again and again, however, despite acknowledging its profound implications, people were also able to use the framework to think about incremental changes too.

Firstly, there is going to be much that needs to be thought through about the kinds of what might be called narrative competence that nurses would need to gain (and many would welcome) under the new framework. I am really looking forward to being part of that set of discussions and ideas. These ‘narratives’ are not exactly like anything we know already, because they are going to be as much about the society in which a person finds themselves as about their own events, meanings and responses. They won’t be like a ‘diagnosis’, but will be deliberately speculative, based on some recognisable patterns, which are described loosely in the document and open to further negotiation. A nurse working within the Power Threat Meaning Framework (should they still be called a nurse) will be a person who has a growing consciousness of much about the operations of power in their society and with skills of helping other people gain similar awareness. As someone who teaches mental health nurses to consider the relationship between political ideologies and ways in which mental health is understood, I know that this is not really our current knowledge-base (but I also know how interested we are going to be).

Secondly, it is quite clear that under this new framework, there will be a public health focus on mental health, something we have never really had, perhaps making ‘campaigning’ one of our nursing ‘6 Cs’. Nurses will also certainly be pushed towards re-understanding trauma and human rights through this framework.

It is going to take a lot of time and discussion to understand The Power Threat Meaning Framework and plan next steps, but how could that be otherwise given that this is not a few tweaks but a revolution in mental health? The authors are very careful to say that they see all of this work as ahead of us (see page 262, for example). Research projects and all kinds of discussion need to follow. One of my biggest concerns is that mental health nurses frequently need medical models in order to understand and process the trauma of the coercion required of us. Page 287 of the full document addresses coercion and the Mental Health Acts. However, it views the Mental Health Acts as being supported by biomedical psychiatry, and I wonder if it is often the other way around; nurses need illness models in order to cope (go home, sleep at night, believe that they are still nice people whose families would be proud of them) with what they are required/believe they are required to do in forcing treatment upon people. It is not that nurses are stupid, clinging on to poor scholarship because they do not know any better. We have all done things that would be impossible to contemplate outside of biomedical mental health services.

I once chased a terrified young woman through a hospital carpark and grabbed her. She fought me but I held her arm. It seemed to be my duty and the right thing to do at the time; none of my colleagues had followed me and it was this or letting her run away. Just then, a police car pulled up and two policemen rushed over and asked me what the hell I thought I was doing to her. I showed them my badge. We took the woman back to the ward. This particular carpark attack had a context we all understood. It is nearly twenty years later and I still wonder what she is doing now, what she remembers and what she must think of me. She was fast but I was faster. Very few of us come into nursing because we want to be involved with that kind of nightmare.

My entaglements in the Mental Health Act in no way refute the ideas of the Power Threat Meaning Framework, but to me suggests that part of its implementation will need to be some kind of truth and reconciliation process. I am a nurse and I need to know what I should have done about that girl in the car park. But as a nurse I have been hoping for this Power Threat Meaning Framework (and all of the hard work that must follow) for a long time.

Jonathan Gadsby