Here is my second post on the Power Threat Meaning Framework. I decided to write this because I am disappointed. I hoped for a document which would be much more measured, careful, and without the rhetorical acrobatics which I’ve seen in such texts before. So, as I have already offered much critique of how the ICD-10 is written, for good measure, I’m offering critique of a document which aims to replace it.
Just as in the previous blog, I want to focus again on the Power Threat Meaning Framework section, and in particular on the introduction. This time I’m focusing on the Overview, it’s shorter, easier to focus on. Because I’m just writing a blog, I’m focusing on a tiny fragment of the document.
So, let’s start with the following statement. The document states that
…it is argued that any attempt to outline alternatives to the psychiatric diagnostic system should have the following characteristics (….):
- Suggest alternative language uses, while arguing that there can be no one-to-one replacements for current diagnostic terms.
If language matters, how can you possibly write this? How can you possibly assume that “there can be no one-to-one replacements for current diagnostic terms”? Such a statement is plainly false. And here is the evidence. The ICD’s depressive episode can be replaced by:
- Depressive syndrome
- Depressive event
- Depressive occurrence
I could continue and with a quite a few other possibilities ranging from ‘depression’ to ‘profound clinically significant sadness’. Oh yes, there can be one-to-one replacements for current diagnostic terms. But this is such an obvious counterpoint that it is very difficult to assume that the authors didn’t realise that. So, is this just a sleight-of-hand of a sentence which, in fact, makes a different point altogether? Yes, I think, it basically says that the authors don’t think such replacements should be made. But that’s a very, very different point. It is a point about the authors’ opinions and values and not at all about language! But, as I argued before, somehow points about language are easier to make. And probably look better too. There is more there (e.g. the bewildering use of ‘argue’), but there is also much more to write.
Have a look at the following sentences, now. The alternative should:
- Be based on the identification of broad patterns and regularities in the expression and experience of distress and troubled or troubling behaviour, as opposed to specific biological (or psychological) causal mechanisms linked to discrete disorder categories.
- Show how these patterns are evident to varying degrees and in varying circumstances for all individuals across the lifespan.
- Not assume ‘pathology’; rather, describe coping and survival mechanisms which may be more or less functional as an adaptation to particular conflicts and adversities in both the past and present.
Could I have working definitions of ‘troubled’, ‘troubling’, ‘evident’ and ‘functional’? Is ‘troubling’ to be taken at face value and shyness, which can be very troubling, now comes under the Framework? Occasionally, I blush, which is troubling, shall I come and see a shrink? Amazingly, the word ‘troubling’ pathologises so much more! ‘Troubling’ means that sky is the limit. Or is there a level of troubling that is necessary for behaviour to become ‘troubling’? If so, what is it? How will it be assessed? Who will have the last word? For whom should it be troubling and who decides on placing the label (again, I did look for an answer)? Because let’s be clear, yes, of course it is a ‘label’. Now, instead of ‘psychosis’, we shall use ‘troubled’ and ‘troubling’ quickly transferring all the stigma onto the new words. The moment you give ‘such behaviour’ a name, it will become stigmatising – that’s what history of psychiatry tells us. History of psychiatry is a history of ever changing words and never changing stigma. But, hey, who wouldn’t like to be stigmatised by ‘troubling’?
Could I have a brief approximation of ‘broad patterns’ (in the main document they are also called ‘general patterns’, unless these are yet different) and how they’re different from regular patterns? Who decides and on what basis which patterns are broad and which are not so broad (I did look for an answer in the main document and couldn’t find it) and which are to be focused on? I’m afraid, all these are as much weasel words as those you will find in the ICD-10. For example, I keep telling whoever will listen that the diagnostic criteria of the depressive episode do not define what ‘definitely abnormal’ is in the definition of depressed mood. But how is it different from ‘troubled’ or ‘troubling’? Who decides then? You?
Incidentally, I would remove the quotes from the word ‘pathology’, as I’m not clear what the system should reject now, pathology or ‘pathology’. In other words, does the system reject pathology taken seriously or not seriously? I just wonder how much of ramming down the throat can the reader take.
However, let’s have another look at
Show how these patterns are evident to varying degrees and in varying circumstances for all individuals across the lifespan.
I mean, really? For all individuals across the lifespan? That’s a bit bold, innit? I’m not going to take a cheap swipe about infants, but even without the babies, it’s a bit ambitious, no? How do you actually find out that a pattern is ‘evident’ (I still have no idea what it means) for all individuals? Do you mean the entire population of the world or just the UK? If the UK, it’s only 60+ million people, so I suggest you start immediately, it’s a very long-term project. Might be never ending. If it’s the world population you aim for, I’m afraid this project might be doomed, both logistically and financially.
To be honest, this is a sentence that really irritated me. It’s so completely removed from any reality that it’s impossible to take it seriously. It’s pure rhetoric and very disappointing.
There is more. Take these:
- Assign a central role to personal meaning, emerging out of social and cultural discourses and belief systems, material conditions and bodily potentialities.
- Assign a central role to personal agency, or the ability to exercise influence within inevitable psychosocial, biological and material constraints (especially if supported within healing relationships and communities).
- Acknowledge the centrality of the relational/social/political context in decisions about what counts as a ‘mental health’ need or crisis in any given case.
How central is central? Does it mean that what I say goes? If so, why do I need the psychologist? And then if my ‘personal meaning’ is central, how does it relate to the ‘troubling’ and ‘troubled’ behaviour? Because if I’m central, I don’t give two hoots about how troubled you are with my behaviour. Moreover, can there be ‘personal meaning’, given that the authors stress its discursive embeddedness (the difference between cultural and social discourses escapes me)? What’s personal in it, then? I have no idea what ‘personal agency’ means and why it is explained through influence. Why?! Incidentally, I find the assumption that human agency is only to do with influence very, shall I say, troubling. Pun intended.
I could continue, actually, but I think I’ve made my point. This is also why I don’t like the document. Too often it hides what it says, has claims which cannot be sustained, is ambivalent, puts contested claims into assumptions behind statements. In contrast, I hoped for a document which would be transparent, which would not rely on all the tricks I have already seen e.g. in the ICD-10 and other programmatic documents of both psychiatry and psychology. The Framework’s idea is not best served by a document which all too often is a smokescreen.
Finally, I got some stick for the previous blog, among other things, I was told that my critique was personal. I want to emphasise that this is not the case. I don’t know the two authors in person, I’ve never even met them. Apart from one, I’ve not met any of the remaining contributors. My reaction to the document is driven by the claims it makes. If this is the document which is to tell me how I must talk and feel about my experience, I think it should get a lot of attention. It must get a lot of attention. And if it can be torn to pieces, it should get torn to pieces.
I also want to stress that the Framework document has no automatic entitlement to greatness. I wish that were acknowledged. My blog aims to help this acknowledgement on its way.