It doesn't need to be like this
As psychologists, we are often asked: ‘We know diagnosis is flawed, but without it how would you do X, Y, Z or make A, B, C decision?’ Can we use a ‘patterns of distress’ framework rather than a ‘diagnosis’ model, in concrete, practical ways, to reorganise health and social care, legal and welfare systems, as well as providing a basis for commissioning, public education and research?
To address this question, the British Psychological Society's Division of Clinical Psychology (DCP) has funded a project leading to the publication of the 'Power Threat Meaning' framework. Previewed at the DCP conference in London in December 2015, the report synthesises evidence about the causal roles of power, evolved threat responses, social discourses, and personal meanings and narratives.
The launch event on 12 January attracted a great deal of interest, with the 400 tickets selling out in less than 48 hours. At the same time there has been concerned commentary in social media, with some worried that this new framework is just part of an ongoing fight between psychology and psychiatry which doesn't do much to help people in distress.
The day was an opportunity to hear the framework explained in more detail by members of the project team (Lucy Johnstone, Mary Boyle, John Cromby, Jacqui Dillon, Dave Harper, Peter Kinderman, Eleanor Longden, David Pilgrim, John Read and Kate Allsopp, joined on the day by Phil Wilshire). Time was also allowed for people to discuss in smaller groups how they might apply some of the ideas and to think about how they might wish to take the framework forward in their own workplaces.
The main aspects of the Framework are summarised in these questions, which can apply 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 to you?)
‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)
In addition, two further questions help with thinking about what skills and resources people might have, and how these ideas and responses might be pulled together into a personal narrative or story:
‘What are your strengths?’ (What access to Power resources do you have?)
‘What is your story?’ (How does all this fit together?)
I have found myself so ground down by the state of much applied psychology recently, particularly my own profession of clinical psychology. I was therefore feeling quite cynical prior to attending the event, despite my admiration for many in the project team. Being already familiar with the framework, my sense was that this is not so much a new framework as a re-launching of an existing one which, however hard various individuals and groups try, keeps getting sucked down by the undertow, only to emerge again later back out at sea. This is why the project team have been so keen to spell out concrete ideas about how to do things differently; no matter how many times the current diagnostic system in mental healthcare is challenged, it very firmly remains fundamental to the way mental health services are commissioned, organised and delivered. It is therefore understandable that something more active needs to happen as the talk has not done much to shake things up. This was a common theme in the discussions in the small group I was part of after lunch.
But clinical psychology also has a part to play in the durability of diagnosis, as many in the profession continue to be complicit with the diagnostic direction of future services, including the use of things like care clusters and pathways and payment by results. This is not only due to the personal and professional interests of many psychologists who are invested in diagnosis, its association with particular psychological therapies, and therefore its relevance in marketing psychological services. It is also due to ideological power, which operates in the very same way on us as workers, as it does on the people who are referred to us; we feel threatened by things like savage cuts to services so we get with the diagnostic programme in order to protect ourselves. This again was acknowledged in our group discussions.
It is the business model which dominates mental health services, and a diagnostic model fits nicely with this. However, it does not need to be like this. The framework opens up a variety of ways in which we might adopt different practices across a variety of domains (e.g. public health, commissioning of services, managing access to services, the legal system etc). In many of these domains, there is a need to communicate to external non-psychologist stakeholders a description of people’s problems in a manner relevant to the particular domain and addressing the key issues. How might we adopt a more psychologically-informed approach to commissioning and gatekeeping access to services?
One approach here would be to focus on reliable and valid psychological descriptions of problems including some assessment of intensity and severity. In research, different kinds of research question (e.g. epidemiology, studies of psychological processes, therapy efficacy and effectiveness) could be posed which, instead of relying on diagnostic concepts, focus on specific problems and outcomes, which not only might be more valid and reliable phenomena to address but might also be much more useful in informing service provision.
We have had a hundred years of mental health services and the world is getting worse. We’re at a similar stage to diesel cars, which for so long were seen as cheap and efficient but now the reality has been exposed. The tireless commitment of the project team is impressive, yet part of me wonders whether however many coherent and workable alternatives are suggested, this tanker may take quite some turning.
For all those doubters and Eyeores like me, we were reminded that society and culture can and does change. There were also a great many ideas about practical ways to begin implementing some of these ideas, across clinical work, research, training and beyond. What was also particularly refreshing was that psychological therapies were hardly mentioned all day. So, as I’m writing this on the train journey home from the event, I am resolving to chip away at this in small ways in my own workplace. But I also know I am now part of an important movement and I am already in discussion with my local pub landlord about sharing the PTM framework at a Psychology in the Pub event. To end with a quote from Margaret Mead: ‘Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has’.
- Dr Penny Priest is a Clinical Psychologist with South Staffordshire and Shropshire Healthcare NHS Foundation Trust.
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