Dr Cian Aherne is a Clinical Psychologist and Clinical Manager of Jigsaw Limerick. Jigsaw, Ireland's National Centre for Youth Mental Health, is an early intervention mental health service for young people aged 12-25.
Following the success of an earlier interview, Thinkful returned to Cian to learn more about the Power Threat Meaning Framework. We began this three part series by considering what is the Power Threat Meaning Framework (PTMF).
Emma Farrell: So Cian, what is the Power Threat Meaning Framework?
Cian Aherne: So the framework was published in 2018. It was made by a bunch of psychologists, other mental health professionals and service users in the UK via the BPS, the British Psychological Society. It was made as an alternative to the DSM, the traditional psychiatric bible for diagnoses. As far as I've understood it, or used it, or engaged with it, to me it is more like a narrative pathway to understanding our distress and our emotions, rather than the traditional kind of 'X number of symptoms, tick a box and fit into a category'.
[The Power Threat Meaning Framework] is a narrative pathway to understanding our distress and our emotions
The framework itself is really straightforward I feel. It's not something to be scared of which I I probably was myself initially. When I heard the words 'power threat', I remember thinking 'Oh, that's nothing to do with me' or 'nothing to do with what I do'. But it wasn't until I actually said, okay, I'll take the time to sit down and read it and and use it myself that you realise the questions are not complex, the answers might be, but the questions are not complex.
Basically, there are four questions.
- What has happened to you?
- How did it affect you?
- What sense did you make of it?
- And what have you had to do to survive?
Now you can look into those questions with a bit more detail, there's a few alternative kind of 'add on's' to them but they're the basic principal questions. There are two supplementary questions to that. What are your strengths? And what is your story?
But in answering those questions it feels like it unlocks some deeper understandings to our emotions and our responses to difficult situations. Why we do what we do, or why we might be feeling the way we're feeling.
The framework itself, if used in the ethos by which it was created, I believe, is a collaborative development, either by you, with the framework itself or you with the professional, you know it's very accessible. If you think of those questions you, you could just journal your answers to them, and it would be as valid as any other kind of process.
In answering those questions it feels like it unlocks some deeper understandings to our emotions and our responses to difficult situations.
But the idea is that it's your interpretation. It's your own kind of Social Constructionist version of the truth. And yeah, it, it just maybe gets us to think about some of these questions or processes, and in ways that we might not. If you think of the more utilised vernacular of the world or the way we understand things usually it is the DSM mindset of, you know, 'I'm feeling this way or I'm doing these things so there must be something wrong with me', 'I must have some form of disorder'. Whereas if you use this framework, it's more about just understanding 'Oh, I'm doing something that humans do, what might be going on here?'. And 'how does that relate to to me and my life and my story?'.
Emma Farrell: Why was there the need for an alternative to the DSM?
Cian Aherne: I think the creators of the framework were getting deeply frustrated by the dominance of the DSM, or the ICD I think they're both similar, and as a group having vast experience in trauma and trauma-informed understandings of the world and emotions. Just from hearing them talk about it, it sounds like they just happened to be sitting together after a conference, or something like that, and kind of thinking, pie in the sky, is there something better? Is there a better way of doing this? Is there? And who's going to do it? and and eventually realising, well, no one else is going to do it. So let's let's go see what we can do. And after kind of painstaking number of years trying to put this stuff together realising that what was needed was a coherent, evidence-based, framework. A framework that was not pathologising and that gave more power back to the service user. That was about about deeper understandings and not, kind of, headline categories. And something that was useful, that people could access themselves without a professional, and that maybe started to steer the narrative in a different way. I think the other aspect of the framework, and and maybe where it gets some criticism at times, is that there they still do have some broad suggested categories. I believe what the authors would say is that we we live in a world where, in order to get disability allowance, or things from court or resources, the world still operates in a in a way that requires categories. So they've been like they needed to have some level of categories, so that, so as not to take away those resources from people. Me personally, clinically working in a service with young people, I don't really go into those categories because they're not as relevant but I think they're there as a kind of a pragmatic addendum to the framework itself.
Emma Farrell: That's really interesting. I know this is an aside but one of the things Dr Lucy Johnstone, one of the main authors of the PTMF, so generously fed back to me after reading my book, was my use of the word 'it' in place of diagnostic labels wherever possible. This was the word the people I worked with most commonly used to describe their experiences but she was absolutely right in pointing out that even 'it' is problematic as it suggests that distress is a 'thing', a thing outside of you, and I remember thinking how hard it is to get away from these old traps in thinking. Even the title of the book, I used the words mental health, but that suggests a certain way of thinking, a certain model. But if I didn't use those words, nobody would know what the book was about! I think its a, kind of, balance between the world where it is now and the world where you'd like it to be - recognising that you're going to have to bring people with you, and it might take time. We are trying to turn around...I mean, it's only a 100 years of thinking, but it's been a 100 years a very dominant way of thinking. So. Yeah, it's slow.
What we're trying to do is meet the language [of disorder] where it's at, hopefully provide alternatives, and then shift gradually over time.
Cian Aherne: It is. It's such a tension, because when we think of the the DSM, and we consider where it came from, and how basically it was just written by a bunch of white, mostly male, professionals sitting in a room deciding what what's normal. And to think that this has become the dominant narrative, worldwide, from something so unscientific and invalid, and, you know, untested. And then just think the PTMF is coming at this with a big evidence base, you know, decades of trauma research and service users actively involved in writing up the framework, and yet to be practical about it we need to understand that there is a dominant narrative, and for us to come in and see how to traverse this world and infiltrate it with what we perceive or understand as more helpful ways of looking at things. There there has to be some kind of. I don't even know if I called a compromise, but some way of of working with the language that still resonates, or still has a place without being too jarring. So like that example you're talking about in your book, like, you know, using the word 'it'. even though yeah, that does still perhaps kind of describe it as something 'out there' or or other, it's a it's still a step forward from a disorder. What we're trying to do is meet the language where it's at, hopefully provide alternatives, and then shift gradually over time. Because I think, as people begin to understand things and see things, and the light bulbs start to go off, then the 'it' and the disorders, you know, those things fade and we come into a new paradigm of thinking and talking. But for now, in order to engage in the world, and the way that it is, and to meet the world where it's at, we have to use some of the language that's there so that people can understand what it is we're talking about in the first place.
Emma Farrell: Its been really interesting, and disheartening, to me to see the backlash there has been against the authors of the framework on social media in the aftermath of the publication of the framework. It seems that some people found the ideas really threatening or disruptive. Its been really extraordinary.
Cian Aherne: I just could not get my head around this immediate backlash to it. I'm just like 'Oh my God, there is this group of people who put their blood, sweat and tears into trying to provide something that's more compassionate and understanding, that we can all choose to engage with or not, and may or may not be helpful, how, without even a day passing after being published, how we immediately dismiss it as something unhelpful, or, you know, unscientific, or whatever. It's like. Wow! Obviously some sort of agenda, or some sort of fear or anger being triggered there that goes far beyond this basic set of four questions, you know. What blows our minds locally, using the framework, is to think that the so much of the criticism has been around the evidence base, or that it hasn't been shown to be effective and I'm like, this criticism was coming out a year after it's published. It's like, how could there be an evidence?! How could there be an evidence base for this specific framework that's only been published a year? There's a whole evidence base for all the references that have informed it.
The power of the unveiling of some of these truths in the room with people. It's just it's so palpable. I can feel it in a way that I could never feel with imparting a diagnosis or engaging with a CBT programme.
Have a go! Try it! Use this framework and tell me it isn't helpful because, we in session, using it with young people, using it in therapy with people... like I know from a scientific perspective, or whatever science you ascribe to, it's anecdotal or case examples, or inherently biased by the people using it, I get that...But, my God! The power of the unveiling of some of these truths in the room with people. It's just it's so palpable. I can feel it in a way that I could never feel with imparting a diagnosis or engaging with a CBT programme. I've done all of those things as well, and look and valid point, I put my hand up, maybe I'm just terrible at diagnosis and terrible at CBT. But this stuff [PTMF], like I can only say what it feels like in the room, and the reaction from the person opposite you when you're doing it from a collaborative perspective, at their level. You're not telling them the answers, you're uncovering the answers together.
It's about letting people realise that these are natural emotions. We're supposed to be feeling this way this way. These are telling us something. If you're feeling miserable, it's for a reason you know. It's not like there's a problem in your brain.
It's just blowing people's minds. It blows my own mind to think all of these realisations that weren't there before, that were inaccessible, until we started to take a deeper look at the societal powers, the things that are impinging on our emotions on a daily basis that we're just unaware of. And to start considering those and being like, Wow. Okay, maybe it's not my fault. You know. It's not about taking away people's personal responsibilities either. It's about letting people realise that these are natural emotions. We're supposed to be feeling this way this way. These are telling us something. If you're feeling miserable, it's for a reason you know it's not like there's a problem in your brain. And even that, you know, even when that argument gets thrown out, and you know, people say 'No, that was never the argument. We were never saying there was actually something structurally wrong with your brain' or whatever. But that is what people come in [to the mental health service] thinking. You know, they think there's something wrong with my brain, or I have a disorder. Give me the solution, and maybe that's the way the world is built as well. We're set up for quick solutions, or quick answers that are very straightforward, simple, black and white. And we're also set up to believe that emotional distress is bad or wrong or we shouldn't be feeling this way, and we need to change it. And I'm like, well, what would it be like if we reverse engineered the world and kind of said, well, what would it be like to think that maybe you're supposed to feel sad about this stuff? You know. What would it be like to think that actually, maybe, it's the world that is wrong? Or the world that is damaging, not you that is damaged and you're just having a very natural response to this stuff?