PTMF's Philosophical Failure: Lessons for the Critical Community

Odds are that you are not familiar with the Power Threat Meaning Framework (PTMF). In a survey of several divisions of the American Psychological Association (published in 2022), only 1% of psychologists were familiar with PTMF. I suspect the percentage is similar or less for American psychiatrists. The relative obscurity of PTMF among psychiatric practitioners is not without justification: while it has some strengths, it just doesn’t have a lot to offer, conceptually and scientifically, when compared to approaches such as HiTOP, RDoC, complex systems, network models, developmental psychopathology, the Perspectives approach, psychoanalysis and its various schools (including relational), phenomenological psychopathology, enactivism and 4E, trauma and recovery, neurodiversity, and Mad studies, etc.

That is, if you are scientifically and philosophically well-informed, PTMF will likely strike you as scientifically insignificant, clinically vague, conceptually incoherent, and epistemically reductive.

Unlike frameworks such as DSM, ICD, PDM, RDoC, and HiTOP, all of which have institutional backing, the relationship between the British Psychological Society (BPS) and PTMF is also rather murky. The document does bear the logo and name of the organization and is hosted on their website, but technically it is a “Member Network publication” and represents the views only of the authors of the PTMF, and not the official views of the BPS. According to the BPS website, “the Framework is a set of optional ideas, not official recommendations or standards for clinical psychologists or other professionals.”

Despite all this, in certain corners of twitter, the framework is enthusiastically promoted and enthusiastically hated. It remains mired in perpetual controversy and heated debate around PTMF is almost impossible to avoid. At times it appears as if polarized outrage is the only thing keeping it alive!

The reason for the controversy is that the PTMF is not just a framework (among dozens of other models and frameworks in mental health); it is one intended by its authors to replace psychiatric diagnosis. It is intended to “serve as a conceptual alternative to psychiatric classification in relation to emotional distress and troubled or troubling behaviour.” (PTMF overview, p 5) PTMF is undergirded by the belief that not only current classification systems such as DSM and ICD are fundamentally flawed and need to be abandoned, but that the entire diagnostic project of classifying “psychopathology” is fundamentally flawed to begin with, and needs to be abandoned in favor of a non-diagnostic alternative. In other words, the stance towards psychiatric diagnosis taken by the authors of PTMF is one of active hostility.

Not only that, PTMF is allergic to the “medical model” to such a degree that it rejects notions of “disorder,” “dysfunction,” “psychopathology,” “abnormal psychology,” and indeed even “maladaptation,” even though these concepts are not intrinsically medical and have shared usage in both medicine and psychology. The problem for PTMF is that it is really difficult to talk about psychiatric phenomena without such concepts, and PTMF resultantly has to rely on euphemisms, and it sneaks in these concepts via the backdoor, using the language of “emotional distress,” “unusual experiences,” and “troubled or troubling behavior,” etc.

PTMF seeks to replace psychiatric diagnostic syndromes with its notion of “general patterns,” which are not diagnostic syndromes but “general patterns of coping and survival responses.” PTMF proposes the following seven provisional general patterns:

1. Identities

2. Surviving rejection, entrapment, and invalidation

3. Surviving disrupted attachments and adversities as a child/young person

4. Surviving separation and identity confusion

5. Surviving defeat, entrapment, disconnection and loss

6. Surviving social exclusion, shame, and coercive power

7. Surviving single threats

The document notes that there are “rough correspondences” to existing diagnostic categories, but that these are not one-to-one replacements: “for example, the second one captures some people who attract the diagnosis ‘borderline personality disorder’, the fourth pattern does the same for some people who are diagnosed with ‘schizophrenia’, the fifth corresponds to some diagnoses of ‘depression’, and the sixth describes some people who end up in the criminal justice system with a diagnosis of ‘antisocial personality disorder’.” (p 43)

So, if you are someone who is inclined to believe that we can eliminate the diagnosis of “schizophrenia” from psychiatric practice and replace it with a narrative centered on something like “surviving separation and identity confusion,” PTMF is the framework for you! Mental health professionals and patients are understandably skeptical. Remember, the claim is not that it can be valuable to conceptualize a patient with schizophrenia as having survived separation and identity confusion (which it certainly can be); the claim is that by doing so, we can abandon the entire diagnostic project of the classification of psychotic disorders, and that these patterns serve as a replacement that is clinically and scientifically adequate for the task. It is manifestly not.

PTMF, therefore, has a very particular appeal. It appeals to individuals, including professionals and patients, who detest and distrust psychiatric practice (perhaps because they have had really negative and traumatic experiences with psychiatric care), who conceptualize psychiatric diagnosis in an exclusively biomedical, biologically reductive, and essentialistic manner, who seek to challenge psychiatric authority by insisting on a categorical exclusion of psychiatric diagnosis, and who don’t care much if the alternative being proposed and rhetorically wielded is actually adequate to the clinical and scientific challenge of describing, explaining, and managing psychopathology in all its forms.

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In this context, I want to highlight a brilliant new paper — Power, Threat, Meaning Framework: A Philosophical Critique — by Alastair Morgan in the March 2023 issue of Philosophy, Psychiatry, & Psychology. The paper, along with two commentaries (by Mohammed Abouelleil Rashed and Havi Carel) and Morgan’s response, is open-access for the next 10-days or so (you can download the pdf and save it for future reading if you like). Morgan’s paper is one of the first extended philosophical critiques of PTMF, and his analysis is wonderfully clear and insightful.

Morgan also does a great job summarizing his arguments, so I am going to quote extensively from his paper:

“My focus in this paper is on three philosophical issues that are raised by the PTMF: the questions of illness, meaning and power.

First, is the question of mental illness. The PTMF unfolds a broadly Szaszian critique of the concept of mental illness but, like Szasz and his many followers, it fails to distinguish between concepts of illness and disease or discuss the ways that illness and disease are related; it broadly treats them as synonyms. My argument in this section is that the PTMF unfolds a description of mental distress that is very similar to other accounts of mental illness/disorder in the philosophical literature; accounts that are broadly concerned with a concept of illness without disease. Despite its claims to dispense with the concept of disorder completely, I argue that the PTMF does have an account of mental illness/disorder but does not give a clear articulation of how its judgments of distress arise. It does not reflect upon its own value-laden ascriptions which are no less problematic than that of mainstream psychiatry.

Second is the question of meaning. My critique has two elements. I will argue that the fundamental philosophical account of experience in the PTMF is a reduced functional, adaptive account that downplays important phenomenological and existential accounts of experience. The second element of my critique of meaning is a hermeneutic one and focuses on the interpretive approach to sense-making within the PTMF. I will argue that this approach is conceptually confused.

Finally, there is the concept of power. The centrality of power in understanding the production of experiences as disordered is undoubtedly the greatest contribution and strength of the PTMF. However, the problem here is the concept of threat. I will argue that the tendency within the document to reduce the concept of power to the concept of threat can lead to a linear view of causality, however, much that view is disavowed in the PTMF document. My overarching critique is that the PTMF fails to reflect on its own production of power or the value-laden nature of its interpretations of distress.”

And another summary:

“There are four main problems with the philosophical presuppositions of the PTMF. First, it sets itself up as an approach that is non-pathologizing; however, it has a concept of “troubled and troubling behavior” that entails an account that is very similar to other concepts of mental illness that do not construe it as reducible to organismic disease. However, it does not acknowledge that its own judgments of distress are just as value-laden as those of mainstream psychiatry.

Second, this evaluative judgment of distress is based on a reduced concept of experience, wedded to evolutionary theory, adaptation, and behavioral reactions. The core account of experience within the PTMF is largely a determinist account of survival responses to threats that adds on an ill-formed account of narrativity. There is little understanding of existential sense-making or of the phenomenological structures of experience.

Third, the attempt at making sense of madness does not solve but displaces the problem of ununderstandability. The account of interpretation in the PTMF is an account that is restricted in its epistemic openness to the other person and tends to reduce such an encounter to the framework of understanding of the interpreter themselves, without an acknowledgement of the power involved in such interpretations.

Finally, the PTMF articulates a form of explanatory reductionism; every form of mental distress is reducible to the negative operation of power.”

The false promise of PTMF is readily apparent from a clinical example presented in the PTMF document and dissected by Morgan. This is what PTMF says:

“To give an example: elements of service users’ narratives may be completely implausible in terms of conventional evidence (for example, a belief that they are being tormented by the voice of the devil). In such situations, therapy often consists of a slow process of negotiating a different, less disabling narrative, which is equally unproven and unprovable—perhaps that the ‘devil’ is really a manifestation of unresolved abuse by a perpetrator. Or perhaps the person may be able to draw on a different metaphor within their own cultural belief system. In time, this new story may acquire narrative truth and may thus help to open the person up to new ways of understanding and managing their distress.” (Johnstone & Boyle, 2018, p. 201)

Morgan notes that this example is “perplexing for many reasons.”

“If the person denies that they are speaking metaphorically in this situation, then we fundamentally misunderstand and disrespect them by stating that they are using metaphors.”

“What is puzzling is that such a redescription does not depend on any unveiling of the reality of a set of adverse circumstances underlying the strange beliefs as the alternative hypotheses put forward in the therapeutic encounter are “equally unproven and unprovable.””

“The interpretive process appears philosophically and ethically incoherent. The interpretive process is incoherent philosophically as it draws on a mélange of theories of truth (correspondence, pragmatist and coherence) without reflecting on this or attempting some kind of synthesis. It is ethically incoherent as it appears to be saying that it does not matter if we can prove the reality of a narrative of adversity as long as it makes sense, but surely, for the person involved, whether such a narrative of adversity is recoverable as a real event or set of events is highly important.”

And here below is one of my favorite passages from Morgan’s article:

“The demand for intelligibility is a process imbued with power. It refuses to listen to madness as madness and then redescribes experiences as metaphors and only acceptable when they enter a consensual framework. This is not a medical approach (it is not based on the person accepting they have an illness) but it is overtly pathologizing and demands an insight of a different kind; that what the person is experiencing is not real and needs to be reframed and redescribed.”

Bravo! No framework worth its salt tackling “power” and “meaning” can be blind to its own power and its own demands for intelligibility.

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These problems identified by Morgan are important because they are also common features of much of contemporary UK critical discourse (exemplified well in the rhetoric of Drop the Disorder). The following, in my opinion, are some of the lessons relevant to critical discourse in psychiatry and the development of non-medical alternatives.

• In psychiatry and clinical psychology, we cannot avoid the fact that we are dealing with phenomena that involve harm (distress, disability, impairment, disruption, etc.) and involve folk judgments that something has gone wrong, that the individual is experiencing a state that is out of the ordinary, that violates our usual expectations of what is typical, rational, meaningful, proportional, or understandable within a certain context. Such judgments form the core of illness and disorder concepts, even if we choose not to use these terms. We cannot wish them away. We cannot pretend that these judgments do not exist or that they are not value-laden.

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  “To be clear, the problem here is not that the PTMF fails to unfold a value-free concept of mental distress (this is impossible) but that it fails to give any account of how it produces its own judgments of distress. When it does try to briefly articulate such judgments, they start to look very similar to many standard definitions of mental illness/disorder. The rhetorical claim to drop the disorder which adherents to the PTMF use as a mobilization against psychiatric practice is hollow…” Alastair Morgan, Power, Threat, Meaning Framework: A Philosophical Critique

• The Szaszian project of tying medical authority to disease concepts is in error — give it up. It is a fantasy that we can exclude psychological distress and impairment from the domain of medicine merely by defining “disease” in a particular manner. Mental illness belongs in the medical domain, although it doesn’t belong exclusively in the medical domain.

Psychiatry and Medical Authority: Part One

• Stop pretending that psychiatric diagnoses can only be interpreted in biomedical and reductionistic terms, and that they are categorically invalid and inherently stigmatizing. Focus on our best conceptual understanding of psychiatric diagnosis — not because we are obligated to use diagnoses under any and all circumstances (we are not), but so that we do not feel obligated to dismiss them when they are the appropriate conceptual tool for the task at hand.

Psychiatric Diagnosis: A Reintroduction

• There is a need for continued development of conceptualizations and frameworks for understanding psychological distress and disability in non-medical terms. Neurodiversity and Mad Pride are great examples of non-medical approaches. In a sense, so is psychoanalysis, although it remains enmeshed with psychiatry for both historical and conceptual reasons. Such frameworks are essential and needed. In order to meaningfully navigate medical and non-medical frameworks, we should embrace a radical pluralism.

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  “To reduce this plurality of perspectives to a single dominant narrative, whether it is medical or inter-personal, is to impoverish our existence and to deprive us of the tools we need to make sense of our selves in relation to our worlds.” Awais Aftab, Understanding Depression: A Pluralistic Approach

• Structural problems require structural solutions. They cannot be solved by treating them as conceptual problems. Social, political, and economic structures are the source of many problems in psychiatric practice and are a major driver of poor psychiatric care. They cannot be modified simply by a change in the ideological attitudes of psychiatric practitioners. To pretend otherwise is a recipe for psychiatric psychodrama.

Psychiatric Psychodrama

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Post publication clarification: While PTMF is less well known in the US, it does wield considerable influence among clinical psychologists in the UK, and many working in the British context who are concerned about the framework’s pernicious effects on clinical practice do not have the luxury of ignoring it as an online phenomenon.

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