Philosophy, Psychiatry, & Psychology

Proposing narratives that reflect our values and address what we believe to be, and what in fact in this case are, valid concerns is no doubt an attractive venture. But good intentions are not enough, and often it is careful analysis that shows why this is the case. Alastair Morgan's (2023) essay Power, Threat, Meaning Framework: A Philosophical Critique is a bright example of philosophy-in-action; it demonstrates, to use a popular expression, that the road to hell is paved with good intentions. In this commentary I argue that while the concerns of the authors of the Power Threat Meaning Framework (PTMF) are valid, their proposed solutions lead us to yet another master narrative.

The PTMF presents itself as an alternative to psychiatric diagnosis (Johnstone & Boyle, 2018). The conceptual, scientific, and anthropological limitations of psychiatric diagnoses have been identified and debated for several decades. Conceptually, there remain difficulties in drawing clear boundaries that separate mental disorder from its absence. Scientifically, the search for discrete biomarkers for particular conditions has proved elusive, with continuing reliance on phenomeno logical classifications, and ongoing complaints that psychiatric categories lack validity. Anthropologically, while mental distress and related forms of experience occur in all communities around the world, existing classifications reflect the cultural psychologies and conceptions of the person of their societies of origin in North Europe and North America. Authors of the PTMF document discuss and cite aspects of these critiques in their document. They intend for the PTMF to address some of these shortcomings and in this way to provide a better way of understanding and managing mental health difficulties.

In this commentary, I shall focus on one aspect of the PTMF, which is the narrative aspect, i.e., the PTMF as a story we can tell about mental health difficulties. Authors of the document foreground this narrative aspect and dedicate ample space to it. The authors, and rightly so, take issue with the implications of diagnostic narratives on the meaning and intelligibility of mental health phenomena:

psychiatric diagnoses change what people feel and do into something they have (e.g., 'schizophrenia') or are (e.g., a damaged or defective kind of personality.) Diagnosis can also remove meaning [End Page 69] and intelligibility from thoughts, feelings and actions.

(2018, p. 29)

Further on in the document the authors point out, again correctly, that diagnosis is itself a kind of meaning, although an exclusionary one:

Diagnosis is not a description on which a range of narratives can easily be built. Rather, diagnosis itself incorporates a powerful narrative about the nature and causes of troubling experiences and behavior, about the kinds of patterns to be found amongst them.

(2018, p. 90)

So, the concern is not that diagnosis removes meaning entirely but that it offers one specific and rather narrow perspective grounded in ideas such as incapacity, illness, and psychological and biological dysfunction. This perspective can result in loss of agency and diminished possibilities for self-understanding and so can be both disempowering and reductive (ibid.). Accordingly, diagnosis cannot always do justice either to the phenomenon itself or to how people experience it and the sort of meanings they are inclined to draw from it. It cannot do justice, that is, to people's own constructions of what they are going through, a point most acutely felt with the conditions known as 'schizophrenia' and 'bipolar disorder.' Now, of course, in some cases people find agency and self-understanding through diagnosis, something we see today through the ascription of ADHD and Autism-spectrum diagnoses, among others. But in many cases diagnosis can be a hindrance to agency and self-understanding, a point repeatedly made by activists and service-users (see Rashed, 2019, Chapter 1, for a review).

The PTMF critique of diagnostic narratives, in so far as meaning-making is concerned, can therefore be parsed out along two lines: 1) A critique of the content of diagnostic narratives. 2) A critique of the extent to which diagnostic narratives are open to modifications of their content to offer a reasonably flexible blueprint for people's experiences with the minimum amount of distortion. Psychiatric diagnosis, and here I agree with authors of the PTMF, does not fare well on either criterion. But neither does the PTMF, as I will argue in what follows along with Morgan (2023).

On the first criterion, the content of the PTMF faces similar criticisms to psychiatric diagnosis. Now there is no doubt that the PTMF foregrounds a social and relational understanding of the behaviors and experiences of persons in a way that is often missed by the rigid and undiscerning use of diagnosis (Johnstone & Boyle, 2018, p. 90). And it is evident when you read the main document that the authors engage with vast and sophisticated intellectual ground as befitting of the complexity of mental health. Yet, as Morgan (2023) points out, little of this intellectual ground makes it through to the final model, which comes across as a rather reductive account that tries to encompass the entirety of human adversity and distress. The PTMF model begins with identifying the operation of power in a person's life, proceeds to identify the threats posed by the negative operation of power and the emergence of emotional distress, and then discerns the meanings, or the "sense", given to these situations by the person. Finally, it identifies the 'threat responses' employed by the person to survive the adverse circumstances. In this model, 'threat responses' constitute what would be considered mental health 'symptoms' or 'distress' and include phenomena such as unusual beliefs, extremes of mood elevation, emotional instability, voices, and self-harm.

The reductive nature of this model is astutely noted by Morgan when he writes:

To conceptualize mental distress as purely a threat response to the negative operation of power reduces experience to a set of determined reaction formations and doesn't enable an understanding of how existential responses in mental illness can encompass a range of experiences that cannot be reduced to self-maintenance and protection.

(2023, p.

Indeed, if we place a typical understanding of the diagnostic/illness narrative next to the PTMF narrative they begin to look very similar in terms of the risk of undermining people's agency. Consider this description by Johnstone and Boyle of one of the problems with the diagnostic/illness narrative, which is that it

offers a particular construction of the person, often as biologically different and vulnerable, as someone who has become… 'through no intention or action of his or her own … the setting for the operation of impersonal, harmful cause—effect processes.'

(2018, p. 90) [End Page 70]

Compare with the central move in the PTMF narrative, which is to reposition the subject as a victim, a passive recipient of forces that activate evolved threat responses for protection and survival. All of this occurs behind the person's back, so to speak, as something intrinsic to the human organism. Moreover, because the person is often unaware of the negative operations of power in his past or of the link between this and his current experiences of distress, he has to be offered this analysis of his predicament. He is being told—and here I am using the same quote used by authors of the PTMF to critique psychiatric diagnosis—that he has become "through no intention or action of his or her own … the setting for the operation of impersonal, harmful cause—effect processes" (ibid.). The PTMF narrative can undermine agency by repositioning the person as a victim and by reconfiguring his already meaningful beliefs and experiences as threat responses that have outlived their usefulness.

The narrative of the PTMF is problematic on the first criterion, but it does not fare well on the second criterion either. Like psychiatric diagnosis, it can diminish possibilities for self-understanding; it cannot provide a blueprint for people to understand their experiences with minimal distortion. As Morgan argues, the PTMF "refuses to listen to madness as madness" (2023, p. And this is a crucial point, for one of the central problems of psychiatric diagnosis, to which the PTMF presents itself as the solution, is that the former is closed off to madness. This predicament extends to the PTMF narrative, as Morgan demonstrates.

The reason that the PTMF is closed off to madness lies in the model itself and in its characterization of experience (e.g., voices, thought insertion) and belief (e.g., unusual or persecutory beliefs) as "threat responses." For example, if I express that Mostafa is placing thoughts into my mind, a person adopting a diagnostic framework may translate this into 'you have a psychotic disorder'; while a person adopting a PTMF perspective may translate this into 'you are experiencing a threat response that seeks your survival in the face of the negative impact of power.' In both cases, the central defining feature of my experience—that a person called Mostafa is placing thoughts into my mind—has been radically distorted. It has been redescribed in such a way that it loses its referents and becomes something else entirely. Referring to the PTMF approach to analyzing the experience of being "tormented by the voice of the devil," Morgan writes:

Following the denial of the intelligibility of the experience, and the casting of it into the realm of metaphor, we then redescribe it in terms that are more amenable to the PTMF; either as a complex psychological response to abuse or we find a more acceptable belief from the person's cultural background that is less "disabling" in our eyes.

(2023, p. 61)

The PTMF narrative, like diagnostic narratives, is not "a description on which a range of narratives can easily be built" (Johnstone & Boyle, 2018, p. 90). The sort of narratives that can play that role and function as a blueprint for experience are those that have been developed by mental health activists and service-users. "Mad Narratives" are counter-narratives of emotional, behavioral, experiential, and psychological diversity that endeavor to make sense of madness without re-describing it into something else (see Rashed, 2019, pp. 188–193). They seek to provide a broader interpretive context for "madness as madness," to re-invoke Morgan's expression. The PTMF is another professional narrative that carries the hallmarks of a potential master narrative. A master narrative is made up of concepts, ideas, values, and associated practices that come to dominate a significant aspect of our collective imagination and lives. Psychiatric diagnoses have come to play that role in many societies, with problematic consequences for meaning, purpose, and identity. But the PTMF, for all the good intentions of its authors, risks becoming the next master narrative: it explicitly aims to replace the current one (i.e., diagnosis), and it wants to capture all of human adversity under its gaze. But if we can learn one thing from the current state of affairs, it is that we should be wary of master narratives in mental health. [End Page 71]