What Has Happened to You? The Power Threat Meaning Framework and the Helping Relationship

Two orientations toward distress

Other YFL essays set out evidence that the quality of the helping relationship is associated with healing and outcomes, with a contributory role and contested direction of cause. A separate question precedes the relationship: what orientation does a helper bring to it? The Power Threat Meaning Framework (PTMF) contrasts "What has happened to you?" with an orientation summed up here as "What is wrong with you?". The Overview describes it as the question at the heart of medicalisation, meaning the treatment of distress as a medical matter (Johnstone & Boyle, 2018, pp. 10, 20), which treats it as the orientation of the medical model, not as a form of words put to people. The contrast is also the title of the introduction to a 2020 special issue on the framework (Harper & Cromby, 2020).

What the framework is

The PTMF was developed over five years as a project funded by the Division of Clinical Psychology of the British Psychological Society, the UK professional body for psychologists. Its lead authors are Lucy Johnstone, a consultant clinical psychologist and independent trainer, and Mary Boyle, Professor Emeritus of Clinical Psychology at the University of East London, with Cromby, Dillon, Harper, Kinderman, Longden, Pilgrim and Read (Johnstone & Boyle, 2018). The group combined senior psychologists and people with experience of using services.

The published materials include a main document of about 411 pages and a shorter Overview (Johnstone & Boyle, 2018). The British Psychological Society states that the framework is not an official position or model of either the Division or the Society (British Psychological Society, n.d.).

The four questions are: 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?) The Overview states that, translated into practice with an individual, family or group, two additional questions need to be asked, about strengths and about the story that integrates the rest (Johnstone & Boyle, 2018, p. 10). It also credits the question "What has happened to you?" to the trauma-informed approach, citing a 2012 publication of the Blue Knot Foundation, an Australian organisation, so the question predates the framework (Johnstone & Boyle, 2018, p. 16).

The framework sets out provisional general patterns, described by its authors as highly probabilistic and as patterns of embodied, meaning-based threat responses to the negative operation of power, not patterns in biology as in medicine (Johnstone & Boyle, 2018).

What has been said about its evidence

One year after launch, the project group reported a widely positive reception alongside critique. They identified as most contentious a sentence about whether it can still be justified to present psychiatric diagnoses as valid. They replied that the framework is not unevidenced, while it questions narrow definitions of evidence and the assumed neutrality of mainstream psychology and psychiatry (Johnstone et al., 2019).

The Overview itself describes the general patterns as provisional and incomplete, and expects them to change with further research and practice-based evidence (Johnstone & Boyle, 2018, p. 88). It also says that client responses must be central to judging personal narratives and formulations (p. 82).

Alastair Morgan (2023), a philosopher at the University of Manchester, published a philosophical critique in Philosophy, Psychiatry, & Psychology that raised objections including to the way power is reduced to threat in the framework. Commentaries followed in the same issue, including Carel (2023) and Rashed (2023), and Morgan replied.

What has been tested in use

A retrospective service evaluation on one NHS adult acute inpatient unit in London compared the year before with the four years after weekly PTMF team formulation (a team working out together a shared account of a person's difficulties) and weekly psychological stabilisation training were introduced. The authors report significant reductions in monthly self-harm incidents (p < 0.01), seclusion (p < 0.05) and restraint (p < 0.05), and note that comparison with a control group would need its ethical implications considered (Nikopaschos et al., 2023). Because the two components were introduced together, the contribution of the PTMF cannot be separated.

A registered qualitative study explored staff experiences of PTMF team formulation meetings in psychosis services, and a summary reports that participants described clients being discussed in a way that brought out their humanity (Health Research Authority, 2023).

Examples in the Overview. The Overview's Appendices 2 to 14 are described as examples of work not based on diagnostic perspectives, and are not evaluations of the framework itself (Johnstone & Boyle, 2018, p. 89). For team formulation, the Overview reports staff enthusiasm as the most strongly endorsed finding, with emerging evidence of less staff burnout and fewer incidents of "challenging behaviour", and says more research is needed into service users' experience and outcomes (p. 108). The Outcome-Oriented CAMHS (Child and Adolescent Mental Health Services) model is described by its lead, a consultant psychiatrist, with outcome data on over 4,000 discharged cases and a before-and-after comparison (p. 105). That is a service leader's account within an appendix. Open Dialogue, a Finnish team-based approach to mental health care, is reported to have naturalistic outcome studies (studies of ordinary practice), not randomised trials, with a randomised trial under way when the Overview was written (p. 123).

Where it meets the helping relationship

The relationship evidence in other YFL essays concerns the alliance within therapy and the experience of parents in child protection. Parents interviewed in one Canadian province by Dumbrill (2006) described workers as using power over them or with them, and Forrester and colleagues found low empathy and a confrontational style in social workers' conversations with parents (Forrester et al., 2008a, 2008b). Those findings concern how a conversation is conducted, not what an opening question does to it.

Hypothesis, not finding. An orientation toward what has happened to a person may feel less like an assessment of the person than an orientation toward what is wrong with them, and may therefore support engagement. The reverse is also plausible: in a mandated setting, "What has happened to you?" is asked by someone with statutory power, and a parent may hear it as an investigation. Neither has been tested.

Judging the framework

The PTMF offers a question and an account of why it matters. How it should be judged is open: as a conceptual alternative to diagnosis, or as a practice to be tested. Whether an opening question matters more than the relationship in which it is asked is also open. It has not been shown that using the question changes what happens in a helping relationship. YFL offers this as information for readers to weigh, not as instruction.

In practice, YFL's essays Does the Helping Relationship Heal? What the Evidence Shows and Alliance Evidence in Mandated Work: What Transfers to Child Protection set out what is known about the relationship itself, and Cures Ahead of the Evidence: When Interventions Judged Beneficial Were Tested and Small Effects at National Scale: The Prevention Paradox and the Helping Relationship set out why a framework that sounds humane still needs a fair test.

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References

British Psychological Society. (n.d.). Power Threat Meaning Framework: Frequently asked questions. Division of Clinical Psychology.

Carel, H. (2023). Vulnerabilization and de-pathologization: Two philosophical suggestions. Philosophy, Psychiatry, & Psychology, 30(1), 73-76.

Dumbrill, G. C. (2006). Parental experience of child protection intervention: A qualitative study. Child Abuse & Neglect, 30(1), 27-37.

Forrester, D., Kershaw, S., Moss, H., & Hughes, L. (2008a). Communication skills in child protection: How do social workers talk to parents? Child & Family Social Work, 13(1), 41-51.

Forrester, D., McCambridge, J., Waissbein, C., & Rollnick, S. (2008b). How do child and family social workers talk to parents about child welfare concerns? Child Abuse Review, 17(1), 23-35.

Harper, D., & Cromby, J. (2020). From 'what's wrong with you?' to 'what's happened to you?': An introduction to the special issue on the Power Threat Meaning Framework. Journal of Constructivist Psychology, 35(1), 1-6.

Health Research Authority. (2023). The Power Threat Meaning Framework and the understanding of psychosis (IRAS 319009), research summary.

Johnstone, L., & Boyle, M., with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D., & Read, J. (2018). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. British Psychological Society.

Johnstone, L., & Boyle, M., with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D., & Read, J. (2018). The Power Threat Meaning Framework: Overview. British Psychological Society.

Johnstone, L., Boyle, M., Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D., & Read, J. (2019). Reflections on responses to the Power Threat Meaning Framework one year on. Clinical Psychology Forum, 313, 47-54.

Morgan, A. (2023). Power, threat, meaning framework: A philosophical critique. Philosophy, Psychiatry, & Psychology, 30(1), 53-67.

Nikopaschos, F., Burrell, G., Clark, J., & Salgueiro, A. (2023). Trauma-informed care on mental health wards: The impact of Power Threat Meaning Framework team formulation and psychological stabilisation on self-harm and restrictive interventions. Frontiers in Psychology, 14, 1145100.

Rashed, M. A. (2023). The 'Power Threat Meaning Framework': Yet another master narrative? Philosophy, Psychiatry, & Psychology, 30(1), 69-72.