Debate 5: Do we need an alternative to diagnosis of mental health conditions?

This debate originated from our event ‘An Alternative to Diagnosis?‘ hosted in July 2018

Lucy Johnstone, Consultant Clinical Psychologist and lead author, along with

Professor Mary Boyle, of the Power Threat Meaning Framework

Danny Whittaker, Service User, Mental Health Writer and Podcaster (http://myownworstenemy.org)

Lucy:

I’m very pleased to be having this discussion with you. I know that your personal experiences of distress and diagnosis have led you to explore the debates about mental health, and I know you have been quite surprised by the complexity of the issues and the strong feelings they can stir up. However, I am confident we can keep this exchange respectful! One of the ways of doing that is to clarify right from the start that I and other critics of diagnosis are not in any way doubting the existence of despair, mood swings, overwhelming anxiety, terrifying visions and voices and so, or the extreme distress they cause. These are very real and agonising experiences. What we are doing is challenging the accepted explanation for those experiences, as in ‘You are feeling this way because you have bipolar disorder/personality disorder/clinical depression’ and so on.

Our starting point for this debate is the question: ‘Do we need an alternative system to diagnosis?’ In responding, I am not going to be talking specifically about the problems diagnosed as ‘autistic spectrum disorder’ in the latest edition of DSM, for two reasons: because they seem to cover such a wide range of difficulties, from neurodevelopmental to psychological, and because the issues raised by these particular diagnoses have already been explored in detail on this website. Instead, I will talk about the whole range of diagnoses which do not, as far as we know, have mainly or primarily biological or neurological causes. In other ways, we do not have the evidence that these experiences are best understood as medical illnesses, with causes such as chemical imbalances, genetic flaws and so on. So, this excludes dementia, because we know that it is a result of changes to the brain, but this is not the case (despite what you may have read) with ‘schizophrenia’, ‘psychosis’, ‘bipolar disorder’, ‘depressive disorder’ ,’personality disorder’ and so on.

Danny:

Let me begin by saying “thank you” for this opportunity.

Since the various debates surrounding psychiatric diagnosis are contentious, to say the least, I echo your desire to keep this debate respectful, particularly as there is much about your viewpoint of which I am not entirely convinced.

Seeing as we’ve started out in agreement with regards to the kinds of diagnoses up for discussion, why don’t you begin by explaining some of the aspects of diagnosis you take issue with for me to push back against where I find disagreement.

Lucy:

It is easy to get into unproductive and sometimes hostile exchanges about whether or not we should be abandoning the current diagnostic system – which is why it is worth pointing out something that very few people, and particularly not service users, seem to be aware of: Whether we like it or not, agree with it or not, this system is on the way out.

As you know, the current diagnostic system is outlined in ICD 11 (International Classification of Diseases) and DSM-5 (Diagnostic and Statistical Manual of Mental Disorders). These lengthy manuals list all the many ways in which people can apparently be ‘mentally disordered.’ They are revised and updated every so often; the 5th edition of DSM came out in 2013 and the 11th edition of ICD has just been published. It is often said that professionals don’t go running to the diagnostic manuals every time they see someone in their clinics, but this language has deeply infiltrated our lives, sometimes without our being aware of it. Newspapers run articles on the tide of ‘mental illness’, celebrities disclose histories of ‘bipolar disorder’ or ‘depression’, we are all urged to overcome the stigma about ‘schizophrenia’, soap operas feature people with ‘depression’, and so on. The issue is not just diagnosis as such. It is a whole way of thinking, which essentially assumes that people in distress are suffering from some kind of medical illness, which, as the saying often goes, is ‘just like diabetes’ or ‘as real as a broken arm.’ And it doesn’t take a lot of reflection to realise that there are an awful lot of interests supporting this idea, from drug companies who make millions out of their pills, to professionals whose status and pay depends on it, and to politicians, who may have reasons for labelling the effects of social policy, such as poverty and unemployment, as ‘illness.’

However, we are in the unusual position where both traditionalists, including some of the senior clinicians who drew up the DSM categories, and critics, are agreeing that the current system is not fit for purpose. I think you’d find very few psychiatrists or researchers disagreeing with this, if you pressed them; and that process of revising the diagnostic manuals from scratch is already underway. And so, our main task now, as I see it, is to move beyond the often circular arguments about diagnosis as it stands, and think about alternatives.

Danny:

According to the “2011 WPA-WHO Global Survey of Psychiatrists’ Attitudes Towards Mental Disorders Classification”, a survey of 4,887 psychiatrists from 44 countries regarding their use of diagnostic classification systems in clinical practice, 93.1% reported using the ICD or DSM in their daily clinical work, and 79.2% reported that they “often” or “almost always/always” used a formal classification system as part of their day-to-day clinical work.

Unless there has been some drastic changes in the seven years since this survey was carried out, I’m not convinced the data shows this to be a system in decline. This being the case your presupposition that the diagnostic system is “on its way out” doesn’t stand.

Lucy:

I agree that the diagnostic system is, as you have demonstrated, is not in immediate decline. In fact part of the defence is to carry on as if nothing was the matter. It is also true that in the current system, people will need to retain and use diagnoses for some practical purposes, such as accessing benefits and services, whatever their views on these labels. The point I was trying to make is that it is definitely in crisis – a crisis of validity and legitimacy.

But perhaps you can tell me a bit about your own experience of being diagnosed, if you are happy to?

Danny:

My experience with the diagnostic process was to receive an informal diagnosis of “agoraphobia” issued by a CBT therapist after a brief five minute consultation, and posited in the form of, “It sounds like you might have agoraphobia!”.

Armed with said diagnosis I then proceeded to research everything I possibly could about agoraphobia. From the earliest investigations into the phenomenon by Austrian psychiatrist Carl Otto Westphal in the late-19th century, to even the more esoteric theories such as those made by feminist geographers linking agoraphobia with the architecture of modernity.

In other words, the proffering (not the imposition, at least not in my case) of a diagnostic label facilitated a personal metamorphosis from a clueless victim to an educated patient – the ramifications of which were two-fold.

On the one hand, I becamean agoraphobic. It became part of my identity. I suspect that this had less to do with the label “agoraphobia” than being told it was something I “had”. For one thing, agoraphobia served as an accurate descriptor. I did, quite literally, have a fear of going outdoors. However, the word “have” would lead me to believe that there now existed this thing within me. As though I’d been infected with a particular mode of being.

What the label itself did was bestow the iatrogenic effect of self-fulfilling prophecy. Every time I learned about a new “symptom” of agoraphobia I had theretofore never experienced, I would immediately after become plagued by its spontaneous onset. So what began as mere anxiety away from home soon descended into a cocktail of nausea, dizziness, and visual hallucinations.

On the flipside, my diagnosis had the effect of bestowing me with an incredible sense of relief and reassurance. What I feared might be an incurable progressive loss of sanity unique to me, was at once exposed as a common, physically harmless form of anxiety with a tonne of scientifically researched therapeutic approaches to help me deal with it.

Such was the sense of relief that even though I did eventually flirt with the idea of suicide (for reasons beyond my battles with anxiety), I suspect my diagnosis played a part in postponing this period, and possibly even abating it when it arose.

In short, Lucy, my position in relation to yours on the question of “Do we need an alternative to diagnosis?” is not much “no” as it is “not so fast”.

Lucy:

I was fascinated by your account of being informally diagnosed, for several reasons.

One, because back in the 1980s I saw a great many people, mainly women, with the same diagnosis. The ‘treatment’, then as now, was to persuade them through a daunting exposure programme until their anxieties subsided. But it was never that simple. So much of it was tied up with traditional women’s roles – trapped by and yet terrified of leaving the symbolic arena of house and home. I remember one woman whose very first panic attack happened as she walked home from a successful job interview, her first real venture into the outside world after many years of childrearing. As she contemplated her partner’s anger and unwillingness to share housework or childcare, she was overcome with terror. Ten years later she was still confined to the home by this false solution to her agonising dilemma.

Two, because you summarise the pros and cons so neatly. Yes, the label gave you relief and hope for a way forward, but at the high price of taking on a new, damaged identity as this mysterious disorder was assigned to you. Diagnosis offers ‘salvation and damnation’, as one paper exploring people’s personal reactions puts it.

Three, you illustrate the extraordinary power of the process. 5 minutes in which you were loosely assigned one of the less stigmatising, more descriptive labels, and you were set for years of untangling the consequences.

Danny:

Firstly, to your point about diagnosis as “salvation and damnation”. No doubt this was my experience. However, I can’t help but wonder how much of this damnation was the result of the diagnostic label per se, versus the manner in which it was proffered. That is, with basically no further elaboration.

I think it’s reasonable to assume that a few modifications in the way this particular therapist delivered her verdict could have gone some way to mitigating the formation of a negative identity. For instance, explaining that “agoraphobia” is merely a descriptive label for a subtype of anxiety; that anxiety is a natural, albeit unpleasant, stress response; to discourage me from late night liaisons with Dr. Google.

At a time when the so-called biopsychosocial model of mental distress is the dominant conceptualization, surely these are all commonly held assertions by even the most biologically oriented clinician?

Which makes me wonder whether the issue of people being told they “have” an illness called depression/anxiety/etc. is primarily an issue of common parlance inadvertently mischaracterizing the issue it’s attempting to explain, rather than clinicians actually believing mental distress to be a medical illness.

What I’m arguing here is that with the possible exception of personality disorders, maybe the problem with diagnosis at the level of identity formation isn’t so much thatthey are given, but howthey are given. In other words, in order to mollify this problem does diagnosis really require a paradigmatic revolution, or would linguistic reformation suffice?

Lucy:

I do agree that diagnoses can be given in ways that are helpful and reassuring – where they are simply received as a description, and a way of saying ‘These are common experiences’ – or unhelpful – ‘You have a lifelong brain disorder/flawed personality.’ As a general point people are more likely to find terms at the descriptive end of the spectrum – such as ‘OCD’ – more useful. But in the end, the principle is the same. None of these constellations of reactions is best seen as a medical illness or disorder, and no one has ever produced evidence that they are. What these labels may give with one hand, such as a sense of commonality and validation, they take away with the other, since however carefully they are explained, the person receives the message that the problem essentially lies within themselves. Thus they have joined the ranks of the ‘mentally ill’, with everything else that is implied by that identity. There are better ways! For many clinical psychologists, that means using a formulation instead – in other words, a co-constructed narrative or personal story that serves as a hypothesis about why this form of distress, and why now, and what might help. You can see the point if we return to the woman with a diagnosis of ‘agoraphobia.’ The label did give her some relief and some techniques to manage her fears – but only a personal story or formulation, developed within a women’s group, was able to fill in the wider context within which they had arisen, and highlight the bigger changes that needed to be made in her life.

Danny:

I think this issue of context as it relates to distress might be a good segue into the Power Threat Meaning Framework (PTMF). Why don’t you start with a brief introduction to this document and I’ll respond by voicing my concerns?

Lucy:

The project you refer to is an ambitious attempt to outline a conceptual alternative to the diagnostic model, co-produced with service users/survivors. It was funded by the Division of Clinical Psychology of the British Psychological Society, and launched in January this year, with me and Mary Boyle as leaders of the project team.

The central aim of the Framework is to restore the links between personal distress and wider issues of abuse, adversity, poverty, inequality, discrimination, and social injustice in all its forms. In doing so, it also challenges the standards that, particularly in Western cultures, can put us under unbearable pressure to look, achieve, relate, work, play, express our sexuality, bring up our children, and generally live our lives in line with accepted expectations in an increasingly individualistic, fragmented and unequal society.

The Framework poses four key questions. These are an expansion of a popular slogan used by the service user/survivor movement: ‘Instead of asking what’s wrong with me, ask what’s happened to me.’

‘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?)

It may then be helpful to ask ‘What are your strengths?’ (What access to Power resources do you have?) and to pull it all together, ‘What is your story?’

The Framework is based on a comprehensive summary of the evidence about the negative impact of various kinds of power in people’s lives; the kinds of threat that misuses of power pose to us; and the ways we have evolved and learned as human beings to respond to threat. In traditional mental health practice, the resulting threat responses are sometimes called ‘symptoms’. In contrast, the Framework sees them as originating in creative survival strategies. The Framework also looks at how we make sense of these difficult experiences, and how messages from wider society can increase our feelings of shame, self-blame, isolation, fear and guilt. It shows why those of us who do not have an obvious history of trauma or adversity can still struggle to find a sense of self-worth, meaning and identity, whether or not we have been in contact with the mental health system. The Framework thus does not recognise a separate group of people who are ‘mentally ill’, since we all struggle with the negative impact of power in some areas of our lives, and we all experience distress at times.

By providing a flexible structure for thinking about these questions, the Power Threat Meaning Framework can be used to help people to create more hopeful stories or narratives about their lives and the difficulties they may have faced, instead of seeing themselves as blameworthy, weak, deficient or ‘mentally ill’. These narratives are supported by a provisional set of broad, evidence-based, patterns of response to threat. In contrast to medical patterns, the ones identified by the Framework are based on meaning in its widest sense – personal, social and cultural. This allows us to acknowledge and respect the very different expressions and experiences of distress that are found across the globe, rather than seeking to assimilate them into the dominant Western model.

I am wondering if one of the aspects which might appeal to you is that the general patterns of distress are described as things people DO not things they HAVE – survival responses, which served a function at the time and perhaps still do, but which are not symptoms of a medical illness. You can see how the ‘agoraphobic’ woman I described above could perhaps be understood in this way. At one level, her overwhelming anxiety offered an (unconscious) escape from an intolerable dilemma. At another, we can see how the dilemma itself had wider roots – in her relationships, in gender role expectations, and perhaps in a whole socioeconomic structure of waged labour and isolated nuclear families. And of course, a label of agoraphobia, while seeming to provide an explanation, at the same time confirmed her feeling of deficit and failure by locating the whole problem within her as an individual. PTMF could, in theory, offer her a different narrative and hence a different way forward.

You might or might not want to reflect on your own story from this perspective, but I would be very interested in your thoughts and questions.

Danny:

Since critics cite the issues of validity and reliability not merely as shortcomings of the diagnostic paradigm, but as justifications for its dismantlement, surely it’s a reasonable requirement that any proposed replacement, if it cannot directly redress those shortcomings (that ever elusive Holy Grail of biological psychiatry), should, at the very least, avoid falling into the same traps.

On this front, it appears the PTMF may indeed be guilty of a kind of conceptual hypocrisy, albeit with the burden of validity and reliability shifting from the clinician to the patient. Let’s refer back to my own experience to explain what I mean.

Back in August 2017, I decided to record an autobiographical episode for my podcast. As I began to cobble together the disparate chestnuts that had tumbled from my tree of anguish over the years and attempt to verify them with family and friends, an uncomfortable realisation set in. Though some of my memories were indeed accurate, many of my most treasured (and troubling) memories turned out to be fictions where I’d either misremembered the content, misinterpreted other people’s actions or intentions, or sometimes, apparently, just completely fabricated the entire incident. Of course, this raises the question of whether it was they or I who were guilty of misremembering; a fact that doesn’t negate the problem, but, on the contrary, augments it.

If our accounts of what happened to us are inevitably susceptible to inaccuracy and bias, this raises two important questions about validity and reliability as it relates to viewing mental distress through the lens of the PTMF.

Firstly, how can we make a reliable connection between what happened to us and the nature of our mental distress as it stands?

Many instances of mental distress will not be as transparent in terms of cause and effect as say, for instance, a depressed mother grieving the loss of a child. In my own case, the personal cataclysm to which I tend to attribute my mental deterioration is the bankruptcy of my nightclub business in 2008. But in my more sober, objective moments I struggle to see why the shame of failure would years later result in trips to Tesco for a loaf of bread becoming as emotionally harrowing as a sojourn into a Hieronymus Bosch painting. Any attempts at establishing a cause and effect relationship are only successful with the adoption of psychoanalytic leaps of faith into the realm of the symbolic, which in my eyes only serves as yet another nail in the casket of validity.

Secondly, how can we be sure we are addressing the appropriate issue when attempting some sort of emotional reconciliation?

For instance it’s easy to imagine a scenario in which somebody presenting with severe anxiety is able to trace the origins of their distress back to what they consider mistreatment in past relationships, while at the same time being completely oblivious to the fact that it was their own loathsome behaviour which caused their ex-partners to mistreat them in the first place.

To this extent, the question “What happened to you?” may lead to conclusions which are no more valid or reliable than the conclusions reached by the question “What’s wrong with you?”

And if the answer to either of these questions is that subjective interpretation trumps objective truth, then in the spirit of Agrippina, the PTMF contains within it the seeds of its own demise by legitimizing the opinions of those for whom psychiatric diagnosis represents something real and important and so justifying the continuation of the very paradigm it seeks to replace.

Lucy:

Thanks for your thoughts. This could turn into a book! But I will address your points as well as I can within the word limits.

You have made interesting points about reliability and validity. We have discussed this at some length in the PTMF. Essentially, we are arguing that such terms do not sensibly apply to narrative-creation, and it makes no sense to judge narratives in the same terms as diagnostic categories. They are not in a head-to-head competition – they are fundamentally different processes, based on fundamentally different views about the nature of the problem. So, does that mean that anything goes? As you say, what if your memory, or story, turns out to be factually inaccurate?

The PTMF notes that ‘there can never be one final, accurate and truthful account of the origins and meanings of someone’s difficulties.’ However, as with any hypothesis, we can test out its usefulness in practice. In other words, does it lead to helpful ways forward? But narratives may also imply a different kind of test. Does the narrative ‘fit’, from the perspective of the person? Does it offer relief, make sense, does it feel true at a personal level? PTMF discusses the difference between historical truth and narrative truth. In making sense of our suffering, the latter may take priority. So, while you may have misremembered some details in your own life, that may be less important than the meanings implicit in your own version. Perhaps X didn’t happen precisely on Y date with Z, but the version you recall will not be random. It will be a way of conveying something that is an important truth for you, and understanding that truth may help you to make sense of your distress, and ultimately to move on from it.

This perspective on ‘truth’, ‘reliability’ and ‘validity’ supports our preferred term of ‘narrative’ throughout the PTMF. This is inclusive of, but broader than, the specific type of narrative that is called a formulation in UK clinical psychology circles. It allows us to respect, value and learn from the numerous culturally-specific ways of expressing and healing distress around the globe, including art, music, dance, community rituals and so on, without seeking to impose Western diagnostic concepts and medical interventions, as the movement for Global Mental Health is doing.

In addition, I will just remind readers about the many other fields in which diagnosis is currently embedded and for which alternatives would need to be found in the brave new world beyond diagnostic thinking. We have discussed various possible alternatives in Chapter 8 of the main PTMF document. Obviously, personal narratives would not be suitable for many of these purposes but it would not be too hard in principle to use concepts such as ‘regular episodes of acute distress’ for welfare access if they were endorsed by a MH professional and supplemented, as at present, with a description of someone’s needs. Trauma-informed services could make diagnostic clusters and pathways unnecessary. There is already a great deal of research based on non-medical descriptive terms like ‘hearing voices.’ Formulations already replace diagnoses in some court reports. And so on.

To return to your own breakdown, which you described in one of your podcasts: I take your point that a detailed psychoanalytic hypothesis about your struggle to buy a loaf of bread is not what you most needed … but I wonder if it would have made sense to see this (but only you can tell if this fits) as part of a threat response to the catastrophic events in your life, when everything had gone into meltdown, everything felt unsafe, and you felt judged as a failure? Moreover I wonder if your sense of blame and shame at the collapse of your nightclub might have been relieved by critical evaluation of your beliefs about striving and achievement – beliefs that align with ideological messages about individualism, competition and personal responsibility? To me it sounds as if you demonstrated extraordinary levels of determination. The loss of your business could not have been avoided, but perhaps the PTMF might have helped you to create a narrative that alleviated some of the emotional consequences in ways that your diagnosis of ‘agoraphobia’ did not do.

Danny:

In light of your response I’m happy to concede that a direct comparison between the validity and reliability of narrative-creation and psychiatric diagnosis is probably misguided. However, this issue of subjectivity as it pertains to narrative still raises questions related to both politics and personal responsibility.

To the latter, this central question as to how power is operating in one’s life seems a somewhat myopic analysis, with the individual imagined as a passive receptacle of external influence, with seemingly no consideration given to how the power and influence that they themselves wield could be contributing to their own misery. Even if culpability is entertained, the PTMF seems to facilitate immediate deflection to the most distal corners of society in almost any scenario.

E.g. I treat my partners badly because I’m angry. I’m angry because I’m impoverished. I’m impoverished because I’m unemployed. And I’m unemployed because… the government… because capitalism… because *fill in the blank*.

I’m not saying these aren’t legitimate contributory factors, but my concern is that in attempting to alleviate the burden of responsibility for mental distress that results from locating its origins within the individual, the pendulum may swing too far the other way so that the individual is now emancipated from any and all responsibility to the extent that narrative creation just becomes an exercise in apportioning extrinsic blame.

As for my political concerns, let’s take the example of a stay-at-home mum feeling depressed and posit the question, “How is power operating in your life?”

While the liberal housewife might feel the power of conservative tradition mooring her to the family home while she yearns to climb the corporate ladder, her conservative counterpart might feel crushed by the judgment of liberal media for whom unless she supplements the rearing of children with some form of careerist pursuit, her role in society is dismissed as little more than a patriarchal affliction.

So, whose account of the sociological power structure affecting their mental health is correct? In abstracto, the primacy of subjective meaning in the PTMF enables both accounts to be true, but what concerns me is how this might play out in the therapy room.

This is a particularly interesting question when considered in light of the fact that more than 90% of academics working in the social sciences – the fountain from which the majority of research underpinning psychological therapy trickles – are on the political left, versus 50% of the general population. ( https://www.adamsmith.org/research/lackademia-why-do-academics-lean-left )

Couple this with numerous references to Foucault, Marx, and Smail throughout the PTMF, and we now have an anti-capitalist oriented manifesto in the hands of a profession tasked with changing people’s thinking that is overwhelmingly populated by people on the political left.

Would a wholesale shift to the PTMF paradigm really accommodate (or even permit) more conservative and/or libertarian conceptions of distress, or would the PTMF merely empower a population of people opposed to such ideologies to enforce a kind of Orwellian shift from wrongfeel to badthink; from medicalizing distress, to politicizing it?

Will the conservative housewife formerly diagnosed with depression now be suffering from “internalized misogyny”? Will men such as myself who proudly subscribe to more traditional conceptions of manhood and who feel emasculated by their anxieties be deemed as infected with “toxic masculinity” and the focus of our treatment shift from addressing “symptoms” to fixing our attitudes?

To be clear, I am not saying that these are the intentions behind the PTMF. But like any document the PTMF is subject to interpretation and is only as benevolent as the intentions of its practitioners.

Lucy:

It’s a shame we can’t go on debating this for another 5,000 words! I’d just like to say briefly that you raise some very important points about the need to find a midpoint between acknowledging people’s personal agency and responsibility, and equally, recognising the wider pressures and contexts within which we all exist. We have tried to redress the balance in the Framework, given the individualising tendencies of almost all the standard models – whether biomedical or therapeutic. From the PTMF point of view, locating the origins of your struggles in your negative cognitions is no better than citing your chemical imbalances. Our standpoint is expressed in one of our core principles: ‘The PTMF assigns a central role to personal agency, or the ability to exercise influence within inevitable psychosocial, biological and material constraints.’ We have been accused of supporting both Marxist and neoliberal agendas, which may be an indication that we fall somewhere in the middle of the two extremes you describe! Obviously we have limited control over how the PTMF is interpreted and used. Nevertheless we hope that it has at least expanded a central debate of our times and maybe taken us a few steps further towards a more humane and effective conceptualisation of human emotional distress, which places the person (or family/social group) and their truth, whatever that may be, at its heart. For some people, that will continue to be a diagnostic understanding. But at the very least, we need to be making alternative understandings available – within and beyond services.

Danny:

As you’re signing off with an emphasis on balance and compromise, I’d like to do the same.

Even though I’m sold on the potential value of narrative, I’m forced to question its necessity based on the fact that the cessation of my own anxiety was achieved not as a result of biographical vivisection, but rather through the application of a set of ideas and techniques that I discovered by following the signpost of a diagnostic label.

However, as much as personal accounts such as mine may highlight the utility of diagnosis, in a world where no other system exists I can’t help but feel that declarations of “It worked for me” reek of a kind of solipsism akin to pulling up the drawbridge on the people for whom it proves either useless or damaging.

I’ve read suggestions that PTMF is nothing new, that psychotherapists in practice already take personal narrative into consideration, that nobody claims diagnosis to be a perfect system, and that it’s constantly improving.

But as long as poverty stricken single mothers, grieving spouses, and victims of abuse continue to be branded with chemical imbalances and disordered personalities, such defences of the current paradigm sound like little more than the oblivious platitudes of ivory tower academics in denial.

So, what are those people whose lives were tainted by diagnosis to do in the meantime? Sit back and wait the same quarter century it took the diagnostic system to cease declaring homosexuality a mental illness before it finally does right by them as well? Surely another world is possible.

While I doubt the PTMF’s ability to supersede the natural human inclination towards phenomenological categorization, I have no doubt about its potential to temper the hubris and overreach of the diagnostic monopoly, to elevate the importance of social context, to provide an alternative to those for whom it isn’t suited, and possibly even repair the damage for those it has harmed.

To speak in Nietzschean terms, part of me wonders whether much of the rabid opposition to the PTMF from certain quarters is because it threatens to deal the hammer blow capable of finally exposing the bloated entrails of their false idol. To which possibility the nihilist in me says, “Service users of the world unite, you have nothing to lose but your labels.”

For those who are interested in exploring the Power Threat Meaning Framework further, the documents plus links to videos and other resources can be found here:

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