Beyond the medicalisation of distress - a new framework

Authors: Mary Boyle and Lucy Johnstone

In October 2018, the world’s first global ministerial mental health summit will be held in London. A statement from the UK government’s Department of Health and Social Care tells us that ministers, leading academics, policymakers and patients from more than 30 countries will be invited to attend, and anticipates many positive outcomes. It is hoped that the global summit "can play a central role in changing the story for millions of people around the world experiencing mental illness" and that the summit will be "the next step on a journey to a new level of cooperation between nations so that we can improve people’s access to evidence-based services and bear down on stigma and other factors that are exacerbating this crisis."

(https://www.gov.uk/government/news/worlds-first-global-ministerial-mental-health-summit-to-be-held-in-london)

But this entirely positive presentation is at odds with widespread concerns about the Global Mental Health Movement with its aim of "scaling up" psychiatric services in low and middle income countries, where there is said to be a "treatment gap" depriving the majority of people of Western interventions. (Movement for Global Mental Health (MGMH)  The movement is based on Western notions of distress as illness, on diagnosable "disorders" which can be "treated" by drugs or psychological therapy.  Much emphasis is placed on "global disease burden" as an impediment to productivity and development, and on the importance of "treatment" to reduce economic costs and poverty. Even when some researchers and professionals try to get beyond this medicalised perspective, the Western version is still sometimes seen as more valid or "correct".  As psychiatrist Derek Summerfield, an outspoken critic of the movement, puts it, "The socio-culturally determined understandings that people bring to bear…seem little more than epiphenomenal. Underneath the cultural packaging lies the psychopathology…[the] universal and the “real” problem "¹  (p524).  This is also evident in DSM-5’s discussion of "cultural concepts of distress".  Their importance seems to lie in supporting "correct" – and by implication more scientific – DSM diagnoses, encouraging engagement with services and helping to identify "patterns of comorbidity and underlying biological substrates".

Critics^2,3 have argued that this involves a new and insidious form of colonisation, less visible, and perhaps harder to resist than old forms. Claims about science and evidence-base hide the fact that psychiatric diagnostic systems, based as they are on social and cultural judgements about normative thoughts, feelings and behaviour, are "Western cultural documents par excellence"⁴.  Instead, diagnostic systems are presented as identifying universal and primarily biological "mental disorders". The Global Mental Health Movement threatens to marginalise non-Western knowledge and practice, sometimes under the heading of extending "mental health literacy".  Some local practices such as beating or shackling are rightly depicted as inhumane, but with no mention of local Western practices such as forced drugging or ECT, which may also be experienced as violence.

Framing mental suffering as illness paves the way for the promotion of drugs as first-line treatments, opening new markets for pharmaceutical sales. This is in spite of evidence that "severe mental distress" often has better outcomes in the Global South, where psychotropic drugs are less easily available.  And while the movement emphasises the reduction of stigma – a key aim of the October summit – the evidence points clearly in the other direction, that biological or brain-based explanations actually increase stigma, not least by increasing perceptions of unpredictability, dangerousness and "otherness".

Above all, framing mental suffering as illness distracts attention from social, political and economic causes which apply across the globe, including poverty and income inequalities, child abuse and gender-based violence, racial discrimination, war and conflict, environmental degradation and disruption of family and community relations.  This is where the evidence base lies, yet far more research time and money are spent searching for the still elusive biological causes of "mental disorders".

Are there alternatives to all this which acknowledge our shared humanity and shared capacity to be harmed by social and economic adversity, while also acknowledging that the experience and expression of distress are profoundly shaped by cultural contexts?

The recently launched Power Threat Meaning Framework, co-produced by a core team of psychologists and survivors, offers one possibility.

https://www.bps.org.uk/news-and-policy/introducing-power-threat-meaning-framework

Also, view a trailer at,

https://www.youtube.com/watch?v=qCMCzAy6wOs

The Framework is a conceptual system incorporating social, psychological and biological factors as an alternative to functional psychiatric diagnosis. It draws on a wide range of research highlighting that many of the adversities associated with mental distress, including poverty, discrimination and social and economic inequalities, along with traumas such as violence and abuse, involve the operation of various forms of power.  We show that the negative operation of power may pose a range of threats to the individual, the group and the community, related to what we might think of as "core needs" such as for safety and security;  as infants and children, close attachments to caregivers;  positive relationships within partnerships, families, friendships and communities;  to have some control over important aspects of our lives, including our bodies and emotions; to meet basic physical and material needs for ourselves and dependants; to have a sense of justice or fairness about our circumstances; to feel valued by others and effective in our social roles; to engage in meaningful activity and, more generally, to have a sense of hope, meaning and purpose in our lives.

Faced with threat, humans can draw on a range of evolved and acquired threat responses that help ensure emotional, physical, relational and social survival. These embodied responses can range from evolved, largely automatic biological responses such as fight/flight/freeze/dissociate, to language-based or consciously chosen responses much more open to shaping by local norms and meanings, and so more culture-specific. These include suspicious thoughts, self-harm, repetitive rituals, restricted eating, and taking drugs. In Western diagnostic systems, it is these threat responses that are often labelled as symptoms, rather than being seen as understandable attempts to protect, endure and survive.  In thinking about the impact of threats, we emphasise ideological power, or in other words power over language, meaning and perspective, highlighting the central role of meaning in shaping the operation, experience and expression of power, threat, and our responses to threat. The Framework takes the view that the imposition of a psychiatric diagnosis – concepts that are acknowledged to lack validity, and which obscure the link between life circumstances and our responses to them – is a prime example of the use of ideological power.

A key purpose of the PTM Framework is to aid the provisional identification of broad, evidence-based patterns in distress, unusual experiences and troubled or troubling behaviour. These are not  universal patterns in biology, but patterns of embodied, meaning-based threat responses to the negative operation of power. The patterns fulfil one of the main aims of the Framework, to restore the links between meaning-based threats and meaning-based threat responses. They are described by verbs, as what people do, and the functions these actions serve, rather than disorders they have.  The patterns are overlapping, not separate; they cut across diagnostic groups, don’t assume "pathology", and arise out of personal, social and cultural meanings.  We suggest seven provisional General Patterns including "Surviving disrupted attachments and adversities as a child/young person"; "Surviving separation and identity confusion"; and "Surviving single threats".

How is this relevant to global mental health? The PTM Framework offers a possible solution to the dilemma about the application of Western psychiatric diagnostic systems to non-Western cultures and expressions of distress. We argue that all the elements in any pattern of distress are shaped by culture, meaning and developmental stages. This means that these patterns will always be provisional and to some extent local, specific to an individual, a social group, a community, a culture and a historical period. There are no separate "culture bound syndromes" – all expressions of distress are culture bound as are judgements about what are seen as problematic, or adaptive actions and feelings. The Framework doesn’t just allow, but predicts the existence of widely varying cultural experiences and expressions of distress without positioning some of them as true "disorders" and others as "culture bound" variations.  As such, it encourages respect for the numerous ways in which distress is manifested and healed around the world.

We also argue that the expressions and experiences of distress within a society in any historical period will be likely, at some level, to reflect a mismatch (perceived or actual) with its values and expectations, as conveyed through social norms, discourses and ideological meanings. In Western industrialised societies (and to an extent in rapidly industrialising societies) we might expect common patterns of distress to centre around themes such as struggling to: achieve in line with accepted definitions of success; separate and individuate from one’s family of origin in early adulthood; fit in with standards about body size, shape and weight, fulfil wage labour roles; meet normative gender expectations; compete successfully for material goods, meet emotional and support needs within a nuclear family structure; as an older person, cope with retirement and isolation and so on.  We might also find common patterns of distress relating to the core human needs most likely to be threatened by the negative impacts of industrialisation and neoliberalism, such as social exclusion, marginalisation and community fragmentation.  And, in Euro/North American cultures, we might expect to see an increased risk of attracting a diagnosis as a response to experiences that challenge Western concepts of personhood, such as expressing "irrational" beliefs, unusual spiritual experiences, and experiences such as hearing voices which do not fit with the notion of a unitary self.

The Power Threat and Meaning elements can be seen as providing a meta-framework based on evolved human capabilities and threat responses. This includes universal capacities for creating meaning and exercising agency, within material and biosocial limitations and cultural understandings. How these elements come together to produce particular patterns of distress across time and cultures will continue to shift and change along with wider cultural meanings and upheavals as well as the contents of diagnostic manuals – all of which provide culturally recognised ways of expressing mental suffering. The seven General Patterns we describe are from a Western perspective. There will be other patterns that are more relevant to groups and societies with different social structures and worldviews. We very tentatively include illustrative suggestions about the functions some of the "cultural syndromes" listed in DSM and ICD may perform when seen from a PTMF perspective. And, although the seven General Patterns are likely to apply mainly to individuals and families, we also stress that patterns describing the traumatisation or denigration of a whole community might be a more natural starting point, for example for communities affected by war, natural disaster, or large scale loss of culture, identity, heritage, land, language, rituals and belief systems.

The PTM Framework and its General Patterns can be used to help people create more hopeful narratives or stories about their lives and difficulties, compatible with a wide range of ways of helping people move forward. In Western settings, these narratives are usually verbal and at the level of individual or family but there are many examples of narrative and dialogical practices in relation to mental distress across the globe, reflecting the universal nature of meaning making and storytelling. Narratives at the level of the social group or community may be more valued in collectivist cultures. These perspectives are underemphasised in more individualistic cultures, despite strong evidence about the central importance of relationships and community ties for emotional well-being in all societies.

The PTM Framework and General Patterns are emphatically not a model for export or imposition in the manner of a diagnostic system. However, the core elements of Power, Threat, Meaning and Threat response are probably universal with variations in how these come together in culturally recognisable patterns of distress at different times and in different places. Although most mental health and related work, especially in the West, is aimed at the individual, we argue that meaning and distress must also be understood at social, community and cultural levels. We see the Framework as applying equally to understanding, intervention and social action in a wider sense. In other words, the Framework aligns with a recent UN report recommending a shift in focus towards “power imbalance” rather than “chemical imbalance” ⁵.

Mary Boyle and Lucy Johnstone (Lead authors of the Power Threat Meaning Framework.) The Power Threat Meaning Framework documents and resources can be found here:

https://www.bps.org.uk/news-and-policy/introducing-power-threat-meaning-framework

Also see,

https://www.madinamerica.com/author/ljohnstone/

https://www.madinamerica.com/2013/05/uk-clinical-psychologists-call-for-the-abandonment-of-psychiatric-diagnosis-and-the-disease-model/

References

1. Summerfield,, D. (2012). "Afterword: Against ‘global mental health’". Transcultural Psychiatry, 49, 519-530.

2. Fernando, S. (2014). Mental health worldwide: Culture, globalisation and development. Basingstoke, UK: Palgrave Macmillan.

3. Mills, C. (2014)  Decolonising Global Mental Health: The psychiatrization of the majority world.  London: Routledge.

4. Summerfield, D. (2008). "How scientifically valid is the knowledge base of global mental health?" The British Medical Journal, 336,992-994.

5.UN General Assembly (2017). "Report of the special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health". United Nations Human Rights Council.