Dr. Lucy Johnstone - Metalog's 4th Conference - August 28th, 2019 - Denmark

Thank You Lucy for coming all the way from London UK to be together with us today thank you Lucy is one of the main author or authors of this the power thread meaning framework she will tell more about that she's a psychologist and the book writer she such an inspiring lecture because she also put emphasis on some of our concepts she questions so many of our cultural so so-called truth for example she don't talk about symptoms he he says symptoms is medical phrase instead she talks about the threat responses and not only the threat responsible also threat comes out of power so in that way also as responses to power issues we in metal oh we visited Lucy this early this year and met with her and with Mary Boyle the other main author of this framework and we had a wonderful time together so thank you for that so please give a warm welcome to Lucy Johnston good thank you for inviting me here today and I understand it's not always this nice weather in Copenhagen but it was very nice the last couple of days so I've been swimming in the harbor and enjoying myself and it's always a pleasure to be back we've got a little bit of extra time which is good because I always have too much to say and if you don't stop me I might talk about the framework all day but I'm sure you will stop me if I go on too long I visited a couple of times recently to talk about the framework and as you've just heard a group of us met in London recently which was very nice and I think as has already been mentioned there's a lot in common between the principles of meta log and the principles of the framework and indeed between the framework and lots of other good practice so I guess we like to think that the framework can support some of the stuff you already do and a lot of what I'm going to say isn't going to be new to you because it's going to be describing the kind of work you already do so the framework is very much about not just looking at things as individual problems within a person or a young person it's about making the link with the wider social context it's about moving away from diagnosis in fact it's about abandoning diagnosis and it's about putting together narratives and understandings of people's life histories instead so I don't work with children adolescents and young people I've always worked with them adult mental health settings but I'm going to try and make this as relevant as it is relevant to children and young people just as much as to adults and I'm going to try and include a little bit of information that makes that clear just before I get to talking about the framework I want to talk about an idea that's very popular in the UK and I've done quite a lot of writing and training about this is something called formulation is that a familiar word to some of you some of you it is so we have professional guidelines as clinical psychologists in the UK on how to do formulation in a sensitive and collaborative and thoughtful and evidence-based way that's the link if you want to download those guideline the throwing English of course but you all speak such that that won't be a problem for you and this is a book that I co-authored on formulation so a formulation in essence is an alternative to diagnosis which is quite popular in the UK so most services most teams will have somebody often a psychologist but not always a psychologist who's using formulation instead of diagnosis and if you're a service user is the word we use in the UK quite often someone receiving psychiatric services if you're a service user you might be lucky enough to meet someone who will offer you the chance of having a formulation instead of a diagnosis but you might not because diagnosis is still remained the dominant approach so what is a formulation in essence it's a kind of structured way of putting together a story a very personal story about your life and what happened in your life and how you made sense of it and if you put together two sources of evidence so if you're a professional you bring your knowledge of the evidence and your clinical experience if you're a service user you bring your knowledge about what happened to you and what it meant to you you put those two things together you can have a kind of well it's a story you could also call it a hypothesis it's this it's a theory or the beginnings of a theory about why you ended up feeling distressed in this way and this could be a kind of map or guide to the way forward and I think a better one than a diagnosis so I like these two quotes a formulation is a process of ongoing collaborative sense making it's always something you return to it's something you do together whereas a diagnosis is something someone imposes on you at some level it all makes sense I like that quote because what's that saying is however unusual or frightening or eccentric or perhaps risky or scary someone's thoughts feelings and behaviors are those always a way of making sense of them we don't have to stop at some point and say it's because you've got a psychosis or it's because you've got a depressive disorder so I'm going to show you an example of what a formulation might look like but I've invented it and it's not a very good one but just to give you an idea this is an invented formulation for a young person who might be diagnosed with first episode psychosis but a formulation would be an alternative to that and it would probably take several weeks or months or perhaps longer to put together but this is an agreed story and agreed somewhere between the surface user and the professional so I think you can see it's based on quite a lot of evidence about what we know about the effects of trauma and bullying I think you can see it's trying to give the message that it's not surprising you feel like this I think you can see that it's showing it you're not just a bunch of problems you have strengths there are things you can do there is a way forward and I think you can see this is actually suggest some ways forward you can imagine what might be helpful if you had that kind of formulation doesn't does that make sense so from my point of view and the point of view of most psychologists in the UK this is much more helpful and saying oh you've got had a psychotic breakdown or oh you've got schizophrenia you don't need to add on the end of that and the other explanation is because you've got schizophrenia see you don't need that do you because we have an explanation so I'm mentioning formulation because formation is one of the ideas we drew on in the framework but we've tried to take it wider up to the formulation but for we notion is an important starting point okay and here's another important starting point which is that in 2013 the division of clinical psychology which is my professional body as a clinical psychologist it's a subdivision of the British Psychological Society issued this position statement so this is a formal statement saying this is what psychologists in the UK believes in essence it's saying we need to move beyond the disease model of distress this model has run into the ground it hasn't got evidence it's not helpful we actually need to move beyond DSM and ICD we need to be doing something completely different we actually need to replace this system because it doesn't work I usually do a whole talk on diagnosis and you may well know this but some of the very people who put the DSM manual together are saying actually it's not evidence-based and they are pouring millions of dollars into developing a new system from scratch but most professionals don't know that and certainly most service users aren't told that so because of that because of that statement which of course was controversial and not all psychologists in the UK agree with it but because of that statement that DCP was willing to fund a group of us to see if we could come up with something that might be the start of a replacement for DSM and ICD does that make sense so they funded or probably when I say that I don't want you to think I made a lot of money out of it because Mary Boyle and I spent about two years in front of our computers working for free because that's how these things go but nevertheless we did have some funding for some service user input for a research assistant and so on so here we have the authors of the framework I and Mary are the lead authors the other lead authors are in the top paragraph and they're all psychologists Jacqui Dylan and Ellen Longdon you may have heard their names they are quite well known service users they would call themselves survivors escape from the psychiatric system and are now internationally known writers trainers campaigners so the jargon term of the UK's co-produced this was a co-produced project it wasn't just professionals rolling out something for service users we put it together jointly we had an consultancy group of service users and carers and a number of other people so this was a five-year project that kind of started by accident in a hotel room in November 2012 when the core group happened to be meeting for a different reason and we started a conversation about what would an alternate a DSM look and we're all people who've known each other for many years and we all completely reject the diagnostic models so we had a shared starting point it was a good starting point because we all know each other and to have similar perspectives and five years later we produce this document it was launched in January 2018 in London and when we launched it we thought maybe no one will ever read this damn thing but at least we finished it thank goodness we can start our lives again and as it happens I'm going to show you at the end it's become it's spread beyond our wildest dreams I'm here today but I've also been to Spain and I'm going to Brazil and I've done a tour of New Zealand's and Australia I've been all around the UK often with other people other members of the group so it's taken off beyond our wildest dreams which is good and it's caused quite a lot of controversy which is inevitable if you criticize the diagnostic system in Denmark do you get told you're a Scientologist no okay you should perhaps be warned that according to some people I'm a Scientologist so don't believe anything I say okay so I'm going to show you the main bits of the project because it's a very big project so there's a main document all the resources all the documents all the videos of the launch are available free online I'm going to show the link and the main document is very long it's 414 pages long and the reason it's very long is because we wanted to not just tweak the diagnostic system not just produce something a tiny bit different not just come up with new labels but actually go right back to the principles on which diagnosis is based and unpick all that so there's a very important long chapter on philosophy and there's a massive overview of all the current research about social psychological and biological factors in distress chapter 8 you might want to look at its from a UK context but it's about the practical implications of moving beyond a diagnostic models so diagnosis obviously isn't just in mental health systems it's in benefit systems it's in service planning it's in research so we've suggested some ways of not using diagnosis for all those purposes using things different from diagnosis so you might or might not want to look at that and here is the overview this is the shorter document and I just heard just now that there is a plan for a Danish translation that would be fantastic there is already a Spanish translation so this is the framework itself without the research and without a lot of the stuff in the bigger document and it has an appendix one which you might want to look at because that is a way of if you think this sounds interesting of taking some of these ideas and working out how they might be helpful for you working one-to-one with someone or perhaps with a couple or a family or perhaps in relation to yourself because it's very important to recognize that this framework is about all of us we don't recognize a particular group of this group of people are mentally ill and this group of people are not the framework is about all of us so you might want to think about that appendix while guided discussion in relation to yourself as well and the other Penda seas are examples of practice that doesn't use diagnosis mostly from the UK and maybe next year or when we have another edition will include meta log as well I don't know that would be nice but so we are saying that there's already a lot of good practice around which doesn't use diagnosis I'm sure a lot of you do that but the trouble is it's not the mainstream is it it's if you're lucky enough to have it it's always fighting for funding and one of the aims of the framework is to make that kind of non diagnostic approach of lots and lots and lots of different are kinds the mainstream approach so you don't have to be just lucky to get it that to make that the door not approach and another aim of course is to suggest new ways forward but it's not about saying stop everything you're doing and do this instead it's about giving extra support for practice that isn't based on diagnosis and suggesting some new ways forward that's the link follow that website link it's going to be developed it's going to have all the examples of people who might be interested in using the framework who are interested and are using it who all who are researching it and so on so I said the framework draws on formulation ideas but it also draws a lot on trauma-informed approaches which I'm sure you're all familiar with but again we've tried to go beyond that in the same way as we've tried to go beyond formulation so these are some of our reservations about trauma-informed approaches of course they vary it depends how you do it so we draw on a lot of research like the ACE aces research we are a bit worried about the wave diagnosis has crept into some of the trauma-informed stuff so we don't agree with the D bit at the PTSD complex trauma is a better diagnosis than some but it's still seen as a diagnosis in ICD so we don't like that we've tried to avoid the word trauma because people tend to think it's a particular thing that happened which it might be but then we tend to place less emphasis on long term background factors like living in poverty or being subject to racial discrimination and those things are just as important so that's why we use the word adversity and we also think the framework is quite good at suggesting why people might be distressed even if they haven't had an obvious trauma in their life because lots of people will say I had a happy upbringing and I have enough money to live on and nothing awful has happened to me but all the same there can be good reasons for distress and the framework I think shows how that can be and we're very keen to make links to wider context which indeed is part of the theme of this conference so in essence what we're trying to do we're trying to move beyond the DSM mindset this is Mary Boyles phrase what it means is we're not just changing the words we're not just saying we won't use words like schizophrenia we're trying to change the whole way of thinking which ends up in giving people a diagnosis all the assumptions it's a whole way of thinking it's not just a particular set of language or a particular way of a particular body of knowledge so we want to move away from medicalization we we have been told all of us and society as a whole has been told that the models were used for understanding what goes wrong in our bodies the medical model can also be used to understand problems with thoughts feelings and behaviors but those are very different things thoughts feelings of behaviors are very different from things that go wrong in your body that's why we think we need a very different understanding because actually the medical model as applied to the people's thoughts feelings or behaviors doesn't work so we want a framework that sees that people exist in a network of relationships and in social contexts and they're trying their best they're not just having a disease suddenly descend on them they are trying their best to make sense of their circumstances so as I've said we already have non diagnostic ways of working one-to-one or with families we know a lot about psychosocial causal factors you know we know that trauma and abuse and poverty cause distress but we don't have a bigger framework for identifying patterns within the the big picture the big picture is that trauma poverty adversity of all types makes it more likely that people will suffer from all forms of emotional distress but how do we identify patterns within that because the medical patterns don't work we've been told that low serotonin leads to depression it's rubbish there's no evidence for that we've been told that too much dopamine causes psychosis it's nonsense so that's trying to put off thoughts feelings and behaviors into a medical pattern and it's been a complete failure so we need a different kind of pattern what are the kind of patterns that make sense for people's thoughts feelings and behaviors and if we can start to outline that that is what will take us beyond just this is another interesting approach that is what will take us to a bigger framework that supports lots of other non diagnostic approaches and completely leaves the diagnostic model behind does that make sense so that's a core question patterns I'm going to come back to that ok so it's not an official model psychologists don't have to use it it's not a replacement for everything already doing we really hope and we're pleased to hear it's being used not just by professionals but peer groups groups of survivors have picked this up and fused it themselves without any professional input we think that's fantastic it's a set of ideas it's not a plan saying do this do this do this we wanted to see if we keep put out these set of ideas how will you translate them into practice that's up to people in their own settings I'm going to show you some examples it's a first stage the second stage is what would this look like in practice so diagnosis has lots of purposes it's used as a basis for research it's used aside on treatment and so on but we wanted to produce a framework that also does these things that recognizes that people's distress and behavior are understandable responses to their history in the circumstances that restores the link between distress and social injustice that's really really really important restores the link between distress and social injustice as soon as you give someone a diagnosis you lose that link but that's that's what's marginalized to use the title of this conference what are we marginalizing when we have an individualized approach where margining social injustice in all its forms and that's true of psychology as well as psychiatry so this isn't just criticizing the medical approach is criticizing quite a lot of the psychological approach because psychological approaches can also be very individualizing we have a lot of CBT in the UK do you have a lot of CBT yeah okay well depends how you do it and some CBT can be done very effectively but we have a particularly narrow version that's rolled out across England which is all about it's about treating anxiety and depression but to say you can treat depression by tweaking your thoughts is not very much better than saying you can treat depression by tweaking your neurotransmitters due to co-domain it's both the same message it's within me something wrong with me I've got to fix it and then I'll be perfectly happy to be poor and unemployed okay so that's what we're intending to do so because it's a very long and complicated document as I said we have tried to summarize it in some simple questions though this is the simple summary of the complicated ideas these are these core questions and these questions are an expanded version of a slogan that's very popular in the UK I don't know if you have it here instead of asking what's wrong with me ask what's happened to me do you have that slogan instead of asking what's wrong with me else what's happened to me so we've kind of expanded that into four questions now it doesn't mean you literally have to sit down and ask someone those questions in those words it means we have to think about these areas you can do it in any order you can use different language but we must think about these areas and as we go through them you'll see that these all these areas they're not separate areas soon as you start thinking about power you're thinking about threat as soon as you start thinking about threat you're thinking about meaning so they're not full separate areas that we add together their different ways of looking at the same the same thing if you like so those are the four questions which I'm going to explore in a minute and if you're sitting down with someone to work with them you might want to add or in fact you might want to start with what are your strengths or in other words what access to power sources do you have and when you've put it all together we hope you'll end up with what is your story and it's important to note here that when we talk about stories or narratives in the PTM we are not just talking about formulation because formulation is a way of making sense and human beings have lots and lots and lots of ways of making sense so formulation works quite well in the services in the UK at least but if you think of yourself the people you work with your friends family people make sense by art by music by poetry by dance if you look particularly cross-culturally people we make sense by community stories and legends and rituals and ceremonies so we want you to include all those ways of making sense so that's why instead of talking about formulation we've talked about narrative so formulation is a kind of narrative but narrative is a bigger more inclusive word so whatever kind of story you want whatever makes sense to you okay so I'm now going to look at the four questions in a bit more detail so I'm going to start with power and the reason why we've started with power is because the biggest thing we think we've added to this framework is a really strong focus on the way power works power in all its forms and power is completely excluded from the diagnostic system but it's also excluded from many psychological approaches and many psychotherapeutic approaches not all of them so want to put power absolutely central so it can't be marginalized anymore so in essence how is power operating in your life which is another way of saying what happened to you these are the forms of power we thought about and obviously you could divide this up in a number of ways and we're used to thinking about some of these as professionals but some of them were not used to thinking about so there's legal power obviously if you're on the Mental Health System you may be subject to legal power but it may operate in your life as well helpfully or unhelpfully economic and material power I wonder if I can think of an example of that now suppose a very powerful American president came over to your country and tried to buy a large part of your territory suppose that happens I mean surely that couldn't happen but that would be a use I would say an abuse of economic material power among other forms of power wouldn't it so that's what it one example interpersonal power so that's the kind of a stuff that looked trauma-informed approaches look at that I'm sure you're all very used to thinking about how people can hurt or abuse or neglect or undermine each other by logic or embodied power that's important to think about our bodies and how the strengths they have and the limitations they have coercive power of power by force social or cultural capital that's something we don't usually think about so much but I guess one way of looking at it is that some of us that I'm one of them are lucky enough to be born in families that have enough material resources and to get a good education and to get the kind of confidence that helps you to find your way around the world so you know how to get what you want you know how to arrange good schools for your children you know how to make a complaint if someone isn't treating you well so social cultural capital and I think we often don't think enough about how the people we work with are very often lacking that and of course if you give someone a diagnosis that's an extra barrier isn't it it's extra hard to get a job or extra hard to feel listen to or to be given credit for your views finally ideological power and we really really really want to place a lot of emphasis on ideological power because we think it's the central and most important form of power so I mean the Trump analogy works in this case as well Trump exerts his power partly by pushing certain ideologies certain worldviews which tend to benefit people who are already more privileged at the expense of people who are less privileged and one of the ways he does that is by using language in a certain way by describing immigrants in a certain way by whipping up fear and we have our own version of this in the UK of course I mean for example we have the austerity narrative the idea that we've all got to pull in our belts and spend less and we roll back the welfare state and like many ideologies this is presented as just a fact this is what we have to do it's quite hard to question it like ideologies in general it's the language you use that helps to put those messages across so the way you describe immigrants the way you describe you know welfare scroungers and you know as opposed to hard-working families that helps to promote an ideology so we think this is probably the least obvious and least acknowledged form of power but it's part of every other form of power and it can lead us to have our thoughts beliefs and feelings and manipulated ignored or disbelieved and then we're open to having other meanings imposed on us so we are not the first people to see this of course to say this but you could see the way in which we describe social problems as individual ones as a use of ideological power so people are either bad in the prison system or mad in the psychiatric system and we justify treating them in particular ways by defining them as bad or mad and we have a whole set of ways of talking about that that seems to justify that how is it relevant to mental health systems in particular well the trouble is that many people especially those in less powerful positions do not have the chance to make up their minds form their views and their beliefs and their values in the way that might actually make sense to them best that's a form of injustice and it's not one we usually think about but if you think about people who typically end up in services they're probably less powerful anyway that's probably why they're there and what do we do we immediately take advantage of their worry and distress and they've probably heard this message anyway before they even get to you and we tell them I don't mean you in this room but it's very likely they will be told you have a mental illness called this so I think it's hard to see this sometimes but biomedical model psychiatry does not have an evidence-based it is not proper scientific reasoning it's not based on what we actually know it's an ideology from the point of view of the framework and if imposing a diagnosis is therefore an example of a pissed Emma congestus imposing a meaning on a person or a group of people who don't have the resources and the power to to come up with different ideas because people aren't given a choice about diagnosis something on the whole they're not and if you object if we try to say no I don't think I've got schizophrenia or I haven't got a personality disorder you soon find out where the power lies okay so biomedical model psychiatry isn't ideology I said this to lots of audiences including audiences consisting entirely of psychiatrists which was interesting because they didn't disagree with me but actually it's not about psychiatrists versus psychologists many psychologists have have taken onboard the diagnostic model many psychiatrists in the UK are very good friends and are very briefly criticizing the model like some of you so it's not about professional fights it's about ways of thinking and obviously the less power you have the more likely you are to use what power is available to you whether it's beating someone up or stealing from a shop not saying that justifies those actions but people will use whatever power they have and if they have very little power they may resort to that kind of use of power and of course there are positive uses of power so power is neutral not saying power is a bad thing but because we're looking at the negative impact of power in the framework we're mainly looking at the downsides and obviously power can be used helpfully and all of us in this room want to use our power as professionals positively and helpfully that's true everyone in the psychiatric system I think it's just that some people or many world that the whole system is set up in such a way that I think despite their best efforts staff often don't end up helping people in the way they would like to and that's not because they're not trying and it's not because they're not motivated it's because the whole system is based on ideology you know there have been many many criticisms of psychiatry over the decades and further back than that saying what is psychiatry doing there right given that actually all the evidence shows it doesn't offer whole improved people's lives and make them better so it must be there for some reason and most critiques of psychiatry certainly dating back to the 60s and saying when it's serving a purpose of sweeping up society's casualties instead of really looking at why people become distressed we can put them in prison and we can put them in mental hospitals and we can tell them they've got a mental illness and incidentally quite a few groups are going to make a lot of money out of that so ok up to you what you think of that critique but it's it's a common one right next question how did it affect you so obviously the negative use of power it's going to affect you in various areas of your life I'm not going to go through these in detail that kind of obvious as soon as you start thinking about power you realize it can pose some threats but again we're less used to thinking about this I hope we're more use than we were to thinking about environmental threats but we haven't often thought about that but as I've just said we can also be aware there are threats to people's value base and their ability to make meaning and we're not used to thinking about that as a source of threat what sense did you make of it this is the next question what is the meaning of these experiences to you and as therapists we're very used to thinking about meaning that's what we do isn't it we talk about the meaning of your experiences but there is a risk back to individualization again there is a risk of thinking that meaning just happens inside one person or perhaps within one family and perhaps just within a a person's head or that family's particular set of interactions and actually meaning comes from wider sources than that meaning is never just freely chosen it is always both made and found so our meanings are always to some extent personal to us but they don't arrive out of nowhere they also come from our wider context so these are some of the elements that make up meaning it's our language and language is shared of course as I said we take on meanings in the language that's used around us from our memories from our bodily reactions or our environments from cultural norms what is thought to be acceptable and normal in a given culture so all of these shape our meanings and actually in the framework we don't make a distinction between thoughts feelings and bodily reactions which is commonly made in some therapies isn't it particularly in CBT but if you think about it the things we work with a therapist like overwhelming feelings of shame or guilt or fear or a mixture their thoughts but they're also emotions and they're all certain extent felt in our bodies and not all cultures make you a distinction between thoughts and feelings so we wanted to get away from that partly to have a more inclusive framework that isn't just you know for a typically Western way of thinking so meaning is the central thread of the framework it's the central thread of the questions where do our meetings come from well they come from wider discourses common understandings that we have in society that we just take on without really realizing it and we often don't question so what does it mean to be mentally ill what's it mean to be a good mother what does it mean to be a normal child or a well-adjusted child you know often we don't even question those things but those meanings will shape what we are our own meanings which might be things like I'm a failure or I'm getting this wrong or whatever and meanings always have wider ideological roots you know they don't happen by accident so if we think about it there's a in the UK and I sounds like it's the same here there's a kind of epidemic of children who are diagnosed with ADHD and autism spectrum disorders and we haven't discussed this in any detail in the framework because it's not about particular diagnosis and those terms are so vague that it's almost impossible to say you know what causes a particular person's ADHD or autism spectrum disorders and it seems to most people that under the head of autism they're all some children who are probably suffering through a neurodevelopmental disorder yes so that's not a mental health problem as such but what does it mean when it looks like almost the whole population is going to be diagnosed with one or other of those possibly both all men and some women are going to be autistic you know something very odd has happened so from the framework point of view we have to think about this is a social phenomenon this isn't just a case of we're better at diagnosing or thank goodness we have new treatments for this disorder which we didn't use to recognize it's a social phenomenon and what's that about well these some of what ADHD is about it's not a term I believe in is about what we know this don't you know this better than I do it's about expectations of very young children particularly boys at school it's about regimes in school that certainly in the UK are not flexible enough are quite rigid it's about unreleased unrealistic expectations in the UK it's about turning schools into kind of businesses where everybody has to kind of go down a narrow path and have this qualification and the school has to have a certain percentage of grades of this type or else they are treated quite punitive Lee and there are ideological reasons for that of course so every meaning has an ideological aspect and I'm sure many of your families or young people turn up having absorbed the ideology of mental illness you know that people will turn up saying I think my son has ADHD weren't they it's actually quite difficult to open up that story isn't it because people people take it on for all sorts of reasons and sometimes that you know those may be understandable reasons but it shouldn't stop us from trying to open up that way of thinking so while I remember I'm going to give you a link to this journal later on but there's an article in here by some people working in a in a service with autistic spectrum disorders in the UK who have used the framework to try and open up that dialog to get away from a narrow diagnostic model so if you want to have a look at that article it's quite useful I think what you have to do to survive okay so these are the things that in psychiatric terms are called symptoms but we're calling them threat responses and this bit of the framework is based quite a lot on trauma-informed practice so you will know about this it's all about how we can end up in a state of hyper arousal because we've been surviving threatening environments and you know flashbacks and nightmares on all the rest of it so the framework obviously includes the road of biology it's we are always our experience is always embodied you know we're not just minds or brains we are also are our bodies are part of our meaning-making in our experience and you can very roughly think of threat responses as at the top things that are more biologically based we don't have a lot of control over those automatic reactions but as we go down the list we perhaps have more chance of deciding or control taking it's easier to take some control so this isn't exactly the same as a list of psychiatric symptoms because some of things we've put in our list of things that we don't recognize the symptoms because they are socially valued overworked being a perfectionist that's me spending far too much time in front of my computer nobody's going to diagnose me and give me a pill for that because that's encouraged by our culture but nevertheless I know that sometimes I use that as a threat response and also we wanted to say that things like hearing voices that are often automatically seen as a symptom don't have to be in many cultures and in some parts of you know cultures within the UK that is people see that as important part of who they are and threat responses are there for a reason there will never be a sensible answer to the question of what causes depression so you see that kind of pointless question asked in psychiatry but also in the psychology and if you unpick the word depression if you say instead what causes people to be miserable sad desperate hopeless stuck and suicidal the only possible answer is lots of things yeah and they'll probably different things for each person so we have to and we have to get away from the there's a thing called depression whether it's a medical thing or a psychological thing there's a way people are reacting and it's probably serving some purpose at some level even if people are finding it distressing this is a very very important as part of the framework it's to restore the link between threats and threat responses another way of saying that is restore the link between individual family perhaps group distress and aspects of social injustice and social inequality as we said earlier as soon as you apply a diagnosis you lose that link and this is a very odd thing it always puzzles me because at a common-sense level we know that if you live in poverty or more like to be depressed ie extremely unhappy it's not surprising everybody knows that it's common sense and as soon as we know that then as a society we start talking about an epidemic of a disorder called depression and we start talking about maybe there's new pills to treat it well this is nonsense isn't it so it's like we recognize the link and we immediately cut off from it and part of the point of the framework is to put that link back together search much less easy to separate it and there are complex reasons I think why we tend to why we can't see that link or can't see it for very long and there sorts of reasons so sometimes what people come along with is an experience that seems very strange or it's hard to understand or we don't know very much about their background yet or perhaps they're not able to tell us about things that have happened to them or perhaps whatever it was happened a long time ago so in some ways it's not surprising we don't make that link but actually the most important reasons that we don't make that link is here's another controversial statement mental health professionals are trained to obscure the link by giving and using diagnoses which impose a powerful expert narrative individual deficit and illness you know we're all brought up in that culture I think all professionals do that to an extent maybe I mean some do it less than others family therapists and social workers and other nice people do less than others but I think we're all plotted by culture better say that hadn't I but we're all part of the culture where those ideas are so much around that it's hard to separate yourself from them and there are reasons for doing that there are ideological interests in doing that this is not an accident okay so I want to talk about the question that I posed right at the beginning which is what kind of patterns can we identify in distress emotional and psychological distress that are suitable for that kind of experience instead of trying to force those experiences into diagnostic patterns which are patterns or things that go wrong in the body and which work quite well in most branches of Medicine don't they we wouldn't want to be without modern medicine but does that work for emotional distress so here's our question again what kind of patterns of distress do we find if we put together the evidence about the influences past right meaning and associated threat responses now this is a complicated bit of the document it's the bit that needs most work I can only hope to give you a flavor for it but I hope to show you a bit of what I mean so the big leap made in our minds was to think about how the patterns need to be organized by meaning not organized by biology and I'm going to explain that a bit so medical patterns are organized by biology this happens in your pancreas or your liver or your kidneys and it results in these physical symptoms in your body but in terms of distress we are saying the patterns need have a different organizing factor they include the role of biology but the organizing factor is meaning so that has lots of implications it means you can't have simple cause effect links you can't say if your liver fails this will happen or if you develop a tumor in your pancreas this will happen because meaning shapes everything and we can't predict meaning you know how we make sense of things shapes final outcomes to a very large extent it also means the patterns will always be changing and evolving because meanings change and our personal meanings change but and they change part because the meanings in our social group change and those meanings change because our culture's change and meanings change over time so this immediately makes sense of one of the things that's very puzzling for DSM and ICD which is why does distress look very different of one if we look back in time what happened to all those women who in the UK had hysteria and it was 50 with their wombs wandering around their bodies believe it or not but even things like shell shock from the First World War actually look very different from what we understand as PTSD now but meanings have changed so expressions of distress have changed and if we look cross-culturally of course within the UK within Europe or beyond then we see very different expressions of distress that's expected by the framework it's understandable it's predictable it's a big problem for DSM this is our way of summarizing what the patterns are their pattern then boated meaning-based threat responses to the negative operation of power that's a bit of a mouthful I'm afraid but we have described the patterns as verbs not nouns there are things people do not things people have that's another big leap it's what you're doing at some level not necessarily consciously to survive adversity not what you have like an illness that suddenly being picked up and there is not a pattern for a personality disorder or a pattern for psychosis these are loose overlapping patterns I think of them a bit like currents in a stream you can't make neat divisions between them of course you can't the meanings vary and these patterns are evolving and there isn't a pattern for a person some people might think this describes it quite well some people might think a different type of pattern describes me quite well I'm going to show you an example so the idea of the patterns part of the idea is that if you look at the bigger pattern you might be able to think well that helps me to put together my story and that shows me I'm not the only person and it shows me that when other people have had similar types of experience they tend to react in similar ways and part of the point of the patterns of course is to take us the whole step beyond diagnosis and diagnostic thinking altogether so we've started off by outlining seven patterns and they didn't just come out of our heads each of them has a long list of evidence that we think supports it and that's in Appendix one of the main document and therefore all of us therefore all of us each pattern has a summary I'm going to show you a summary and underneath the summary it has a typical set of power threat meaning and threat response aspects but it's not a unique set because these patterns merge and overlap this is the names we have at the moment of the patterns I'm sure they're going to change I'm sure they're going to change and nobody has to use exactly that language you could call it being with or surviving but I think you can say they're about what people you can see they're about what things people do I'm surviving I'm doing something to the best of my ability not I have developed this illness I think you couldn't see this is about a dilemma that is to do with meanings feeling rejected feeling trapped feeling confused feeling disconnected yeah and this framework was developed in a Western westernized context by largely people from that background so I'm going to come on to cross cultural considerations in a minute but in westernized countries if you think about the patterns then everything we've said suggests that somewhere at the bottom of these patterns there will be certain ideological meanings which are part of in this case western or westernized cultures so these are the things that on the whole we tend to accept without questioning we separate from our family and early adulthood we compete we live in nuclear families we have to look this size this shape and so on we have to fit in with how boys or girls or men and women are supposed to be and so on and so on okay so to give a bit more of an example pattern number four surviving separation and identity confusion I've seen a number of young people and I'm sure you have over the years who have come along with diagnoses of OCD and eating disorders and psychosis and so on and when I got to know them it seemed to me that a lot of them not all of them were actually had something in common they were struggling with a core dilemma about how do I grow up separate from my nuclear family leave mom and dad and siblings go out into the world you know set up my own family all the expectations that young people face which are actually particularly difficult for young people at the moment in the UK I'm sure they are here so actually rather than seeing these are separate diagnoses so then we have an early onset in psychosis pathway and then we have an eating disorder service and so on it would make more sense to see these young people struggling with a common dilemma a meeting based dilemma and that dilemma it's bound to have its roots in some of these underlying assumptions so when you think about it that's an awful lot to expect young people to do you know my own children are 25 and 23 so they're moving through that period but it's a very difficult period and we don't need to think too much about the vested interests in persuading young people they have to look and buy and behave and spend their money in this kind of way always be comparing themselves to other people always feeling that they've fallen short or we're spending money to to make them feel sells feel better I think some of the aspects of that are less visible to us so I'm going to talk in a minute about I was privileged to go to New Zealand and meet some members of a Maori community and I was describing this to them and they said one of them said to me well if that happened in one of our extended families they call it a farm now we just say we can go live with aunt and uncle for a while and aunt and uncle might not even be blood relatives so I'm not saying that's a perfect family setup but it's a very different one extended family structures you know used to be how people lived and certain kind of dilemmas would be much less difficult in that kind of family structure can you see that how living in a nuclear family 200 miles from your friend your rest of your family makes a kind of intensity of relationships makes separation a bigger deal and where does nuclear family structures come from well historically they came along with the Industrial Revolution so the need for families to be mobile and move around the country and to fill the gaps in the job market so what suits the economy isn't necessarily best for people's emotional health and in fact there's quite a lot of evidence showing that extended family structures tend to make it less likely that people will let a link later experience what we might call severe psychosis and so on so you can trace these conflicts all the way back and I guess what we're saying is if you take any particular problem that someone comes along to with us comes on to us with if you traced it all the way back you would find a conflict with what some cultural norm that's probably ideologically driven to some extent and that doesn't mean to say you have to go through the whole history of the politics of the Industrial Revolution with each of your clients but I think we need to be aware of this because otherwise without meaning to we will be imposing those same ideas because we haven't questioned them we will be sort of conveying the message that of course you ought to be leaving home by now we won't say that but that will be our starting point do you see what I mean so it's really important to start questioning some of those norms and I think if we think about it like that it's obvious why some people may experience acute distress even when they haven't had an obvious trauma because look at what we're expecting from our young people it's not surprising they don't have to have been abused and hurt and neglected in their families to experience distress okay I hope you can read this but this is how the general pattern surviving separation identity confusion is described in the frameworks you can look up all the patterns if you want but this is the summary of it and if you read it I think you can see that what we've tried to do is make it broader than a formulation that might apply to a young person or to their family we've tried to look at the family in the wider social context and in this case we've tried to say this pattern partly arises from individualistic cultures and I think I would also add materialistic cultures and consumerist cultures that's written in rather difficult to read language like the whole thing to be honest but if that was translated into simple language that might be something helpful to share with a young person as a way of saying look this is such a common dilemma that would there is actually a pattern describing it in this framework does this ring bells for you and then you could look down the list of typical threat responses and say I wonder if that's something that you do and it might be it might not be but I think you can also see that this is challenging at a level beyond therapy work this is raising very serious and important questions about the whole way we live our lives I now want to move on to the final bit which is about patterns and culture which is a slightly problematic word as I've said the framework suggests that there will be different expressions of distress for different cultures and it's not a problem for the framework but it's a problem for ICD and DSM so it suggests that probably the more biologically based threat responses fight flight freeze will be fairly similar across cultures because we all have this we're part of the same human species we have bodies that work in similar ways but all the more culturally influenced ways of coping are likely to vary so there is a big project as you may know at the moment called the global mental health movement which i think is one of the scandals or age to be honest which is about exporting the diagnostic model to cultures and countries and societies that don't yet have it and they can well do without it be honest because it hasn't worked here in Western countries why should it work there it doesn't anyway as part of that they try to kind of squeeze these from a Western point of view unusual expressions of distress back into diagnostic categories so a lot of time has been wasted on that so one of these solutions to that is to have a chapter in DSM 4 called culture bowel syndrome which roughly means we don't quite understand which label to put on this yet so we'll stick it in this chapter and of course every expression of distress is a culture bowel syndrome it's just the ones that we are more used to don't seem like that to us but anyway I'm going to give you an example from DSM 4 it's called spirit possession I don't know how commonly this is used but if you read that description of one version of spirit possession so I hope you can see what I mean when I say we could understand this rhythm the power threat meaning forever without having to call it schizophrenia or psychosis we don't need to squeeze it into that label doing does that kind of make sense and I think you can also see that it's expressed in terms that are unusual to most Westerners but you can see there are clear themes of power threat meaning and threat response ah ah so that doesn't mean we export the power strap meaning framework and go over to northern Uganda and say use this instead it doesn't mean that but it means that it's something like the power threat meaning framework was our main model we wouldn't have a problem respecting the different ways that people from different cultural backgrounds understand their distress we would say great and what works for you and we would have something to learn instead of something to colonise to be honest so in contrast of the global mental health movement the framework is intended to convey a message of respect for the many different ways people express and heal distress both within the UK and across the globe so as I said I was lucky enough to go to New Zealand Australia recently with one of the other authors John crombie and you might be interested to read those blogs the top one describes a really extraordinary experience I had in a workshop where the first day I presented the framework and the second day we did a sort of compare and contrast with typical Mari and standings of distress so a typical Maori way of understanding distress would be in terms of the myths that they have about creation gods which of course are completely new to me but there's some really interesting projects in New Zealand where you can actually access a service which takes that as its starting point creation stories not diagnosis it's an amazing stuff really and I met some other people who were offering those services and I were to join toss to go with one of them and at the end of this article this woman who's a maori psychiatrist said we think of the framework as a kind of distant cousin and it's been helpful to us in you know giving us more permission and support for developing our model so that is wonderful to hear that's exactly what we'd have hoped for so this is just you know there's more work to be done on this this is just putting a toe into comparing and contrasting cultural different expressions of distress but we wanted to kind of prepare for this so in the framework we wanted to go beyond the usual psychological and social causal factors in distress you know the trauma adversity stuff we wanted to go well beyond that so we wanted to look at histories of colonization and intergenerational former and the resulting loss of identity culture heritage and land obviously that was very strongly relevant in New Zealand with Maori and Pacific island indigenous populations and in Australia with Aboriginal populations there's a lot for us as traveling Brits to be ashamed of unfried but we actually think that needs to be in there we need to be open about the ways in which were all involved and have been involved and historically were involved and still are involved in these abusive unforgivable practices because of course rates of distress 1/2 are high are in almost any indigenous population you can think of and we want to emphasize some of these worldviews which are less calm in westernized settings so the idea you can't separate the individual or social groups the importance of the relationship to the natural world it's something we urgently need to rediscover isn't it their port of indigenous psychologies the importance of community narratives values faiths and spiritual beliefs really really important so we were pleased to hear from the Maori perspective when I introduced this I was a bit nervous thinking how is this going to go down but they very very much welcomed the recognition of these aspects of people's experience the aspects that contribute to distress their aspects that contribute to healing so I've nearly finished you'll be glad to hear so returning to a theme of narratives narratives is a central theme as I said in the framework and we believe that storytelling and meaning making are universal human skills and we think the framework provides evidence that nowadays unfortunately we need something that counts as hard evidence as well as thousands or millions of people's lived experience that doesn't count so much but we think the framework also supplies hard evidence that this is a more constructive way forward we think the evidence based patterns support particular narratives we think all kinds of narratives are valid and we think that actually narratives don't have to be strictly speaking evidence base to be helpful so you know a Maori creation story does not fit with the evidence of what we know about how the world started but it's extremely meaningful to people from that culture it may not be literally historically true but it has narrative truths and that's a form of truth that we urgently need to you know to recognize in our work on the theme of stories I'm just going to show you this as well so this is the story that a service user called Amanda who runs a peer group in the UK has kindly given me permission to use and she used the framework questions before the core questions in order to put together her own story so you can see there's something about power threats meaning and threat responses and strengths in there and one of the particularly nice things about that is that her peer group came across the framework and just decided themselves we're going to use these questions and see if we find that helpful as a group and apparently they did find it very helpful as a group so no professionals no psychologists maybe maybe we're not as necessary as we think we are so part of the point of the framework is to give this kind of encouragement to people to do it yourself why not we're all storytellers we're all meaning makers can you guess what diagnosis she was given by the way the story that was imposed on her what do you think maybe it's slightly different in Denmark in UK everyone says borderline personality disorder that's a better story isn't it that's a better story okay so now just to try and bring us down to earth a bit I'm looking at the top reference there the link if you follow that link you'll get a free you can get a free download of this edition of the monthly clinical psychology journal which in this case is all about ways in which the framework is starting to be used in the UK so I think you have to register or something but the Edition is free and there is an article in it by jigsaw and when you came to London a few of you you met the guy from jigsaw didn't you it's a national arts organization working with young people it probably has something in common with metal log it's a big organisation so they were already like you working lots of these kinds of ways so when they came across the framework they were pleased that the freo seems to support its aims to do what they are already doing community perspective making links with social context offering options other than therapy bring about strategic change but they also found it useful to do a number of other things like they've used it to change the language they use in some of their workshops there's a whole section on language trying to get away from medical language to develop simple versions which will be very useful which will be on the main British Psychological Society website in due course simple simpler versions that are accessible to young people using the framework - structural information individual therapy case discussions formulations outcome measures applied the PTM to themselves because they have felt that helped to give them some insight into the commonalities they had with the people they're working with so if you wanted to take on any of those ideas that would be fab and I'm just going to show you a few slides which shows some of the ways the frameworks being used but I think I will I will do those I will stop now I know I've got three slides but I'll put them up as we're answering questions because you must be very ready for a break well done for getting through this far and as far as I can see you're all awake so if you're probably very hot and in need of a break but we will have a few minutes for questions and comments thank you we talked about the meaning has also an ideological society also is created in by the society and I was interesting if you can just talk a little more about how do you work with this understanding of meaning not as just individual perform but also shaped by the the cultural meaning I've worked with many many women who've been raped and sexually abused and I've worked with them as adults and each and every one of them has come along saying I feel ashamed and guilty and to blame it was my fault and I should have done this and I shouldn't done that so it's been my practice for many years I guess to work with that at a one-to-one level and you could get quite a long wait with that so that women don't feel so ashamed and guilty but in the last five years when I was working in the National Health Service I had some colleagues set up a program of sexual abuse survivor groups for women who'd been abused and I guess we kind of knew this but that's a so much more powerful way of challenging those feelings because if you have a whole group of women in a room and one woman can see someone across from her saying it was my fault I feel so guilty she can see of course it's not your fault so then she can start thinking perhaps it wasn't my fault and then a lot of what we did in the group was to say where do those meanings come from so partly they come from abusers very often the abusers will tell people they wasn't their fault but that is an abuse of power and how do they get into that powerful position sometimes they you know the women have been very much let down by institutions by their schools by their by their families and so on by mental health services and you can actually take it further than that so that you can people may end up feeling it's not just me with my shame and my isolation I'm part of a whole worldwide group of people whose abuse and oppression is not acknowledged and and actually when we get together in a sense of shared experience and can share our justifiable anger then we can lease on boshane behind and work towards much bigger types of change I mean it's only what the women's movement has said for 50 years at least but um so one of the outcomes of those groups was that for example some of the women who came to the groups later ended up joining us as psychologists to do training to the rest of the stars so that was helping them to make use of the awful experiences they've been through and they ended up setting up a self-help group for other women who'd been to the groups or were thinking of going through the groups so I guess that's an example of putting people together and having discussions of a kind that enabled people to challenge power at all levels and thus to reclaim some of their own power but there could be all sorts of examples but you know that that's just one that you know I was very pleased to be part of when you talk about epistemic injustice yeah are you in fact saying that describing individuals in terms of biomedical terms is unethical yes good we've got a sentence in the framework which is possibly the most controversial saying it is no longer professionally scientifically or ethically justifiable to offer or to give diagnoses as though they were fact and this causes a lot of trouble but we got roundly attacked for that but the as though they were fact is quite important because what are the things that people have said to us is well I need a diagnosis or I benefits or and as if they were fact allows us I think to have conversations with people about we do not see your problems in this way we've discussed this we have this understanding but I need to put this label in this box what's acceptable to you and that's a very different kind of conversation so you have a personality disorder so you need to bring in other perspectives as well to bring in other well not to offer the diagnostic one to be honest I mean so this is another tricky area because we very clearly said people who receive services are entirely free to use their own language if you want to describe yourself as mentally ill and with a sigh schizophrenia that's absolutely fine by me and by us but we'd like to think you were given a choice about it but from a professional point of view is it even ethical to offer that particular choice no I don't think it is absolutely absolutely we absolutely don't think it's ethical to offer that choice it's not professional it's not scientific and as professionals were meant to be sticking to evidence-based practice are we not we don't tell people they're possessed by Devils and we shouldn't tell them they're possessed by schizophrenia because it's almost exactly the same thing we all worked in PPR which I guess would be educational psychology in the UK and we were talking about how to to start you think some of these ideas and perspectives in the setting of PPR and you said that you don't have that much experience with working with children and young people but do you have any experience or ideas of how to to use these this approach within educational psychology because I find that it's very hard to to go against the medical and diagnosis discourse because it's so powerful in the schools it is there is a group a loose group of educational psychologists in the UK who are trying to introduce this into their practice in educational psychology so I mean obviously the ideas are applicable but obviously you're swimming against the tide and it would be it's proving difficult but if you keep an eye on the main British Psychological Society website before too long I hope there will be examples of practice from lots of different settings up there and there will also be an opportunity to contact the website and say is anyone doing this or can I get in contact with sermons so I think I would say so that kind of works at an early stage in the UK but certainly a lot of educational psychologists have said to me this fits what I'm doing as well there is some very inspiring work done by some psychologists in introducing trauma-informed practice into school systems and you know good trauma-informed practice would look very much like the framework so to speak there's not a huge difference between them so some of that is happening in the UK and if you email me if you if we stop even addresses oh I can send you some blogs and things that might be of interest to you thank you for a very inspiring talk and I just wanted what are your thoughts on and the on the one hand in paying respect for what has happened to people and making meaning out of what has happened and on the other hand the risk of making people only victims yeah that's an interesting question that's an interesting question how do we acknowledge what's happened to people without positioning themselves as victims in another way victims are mental illness versus victims of the trauma or the abuse or whatever so I can only say that we've tried to create a mid path in the framework I think what happened to people is not nearly enough acknowledged so there's obviously a lot about that but we've said at various points we've been very clear that we see people as having agency having the ability to influence their life at least to some extent particularly to have the right support within whatever constraints and limitations around them that's the picture isn't it nobody is just a victim but nobody is entirely a free agent and I don't know if this means we've got it right or not but we've been attacked from both ends of the spectrum so we've been told we're very right-wing I think everybody should just pull themselves together and we've be told though that we very actually been told well outright absolutely ridiculous but we've also been told we're extreme we're marxist as well which is interesting outright and Marxist because we're seeing people just as victims of capitalism well we're not saying either of those things that the mid path is hard to tread and personally I think that formulation is a way one way of getting that balance because the best the message of any decent formulation is something like anyone else who've been through these experiences might well have ended up feeling and behaving like you do but with the right kind of support you can move forward in your life that's the message of a decent formulation and that's also I hope the message of the framework thank you the best answer I could give to that interesting question yeah I'm sure loser that your ideas will follow us the whole day even also when we move into the next presenters we do have a small present for you a symbolic present this one breaks the lights and bring new perspectives to what we see oh thank you very much for presentation will be that 11:00

Channel: PoetDox

Views: 2,506

Rating: 5 out of 5

Keywords: psychiatry, psychology, depression, psychosis, antidepressant, antipsychotic, suicide, akathisia, involuntary treatment, forced treatment, isps, hearing voices, Trauma, Brain, brain research, dreams, dreaming, dreamwork, Ole Vedfelt, Jung, Jungian, Night Terrors, psychotherapy, Power Threat Mean Framework, Lucy Johnstone, Metalog, Soren Hertz

Id: fWAv4IBsCjc

Length: 80min 48sec (4848 seconds)

Published: Sun Sep 08 2019