Documents and training materials

Short version

Full version

• Delivering Training on the Power Threat Meaning Framework. Dr Ray Middleton - Fulfilling Lives. 2022
• Beyond the Individual: how the PTMF foregrounds racial trauma - Dr Anjula Gupta

• An Introduction to the PTMF: a way of making sense of distress - Dr Tim Siggs

• Download the DCP-approved annotated training slides

PTMF Launch Talks

Talk by Dr Lucy Johnstone, October 23, 2018

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

• Adapted PTMF - Young People General Worksheet
• Adapted PTMF - Threat Responses
• Adapted PTMF - Threat Responses Worksheet
• Jigsaw Leaflet - Guidance for Clinicians using PTMF with young people

This document is intended to support clinical psychologists in the development of documents using language consistent with the Division of Clinical Psychology (DCP) position on functional psychiatric diagnoses.

These guidelines are intended to suggest a range of possible alternative descriptions, and it is left to authors to decide which might be most appropriate in a given context.

Some psychologists will have preferred terminology which is not included in this list.

We encourage any usages which attempt to describe behaviour and experience in non-medical terms, and within its personal, interpersonal, social and cultural context.

• Guidelines on Language in Relation to Functional Psychiatric Diagnosis

• PTMF Training Evaluation Feedback Form
• PTMF Training Principles
• A bite-size summary of the PTMF

For further assistance with PTMF training please consult the FAQs.

University of Lincoln Evaluation Report of Workforce Development programme that integrates the PTMF with other person-centred, strengths based non-pathologising approaches

Smith, L., Mason, R. & Dagnall, R. - Ladder4Life Training Evaluation: External Report. (2024). University of Lincoln
 

Poet Ruth E. Dixon has turned the story of her mother, Andrea, into these powerful spoken word performances, reproduced here with her permission to share. 

Madness Meds

My mum, Andrea, struggled with severe mental health difficulties throughout my life which I was led to believe was caused by a 'chemical imbalance'. Her despair was diagnosed as a personality disorder, in fact lots of disorders, and she spent 49 years in and out of psychiatric care.

"Madness Meds" charts what happened to Andrea after she first tried to kill herself aged 21. All the quotes are real. The first are Andrea's words written to her parents as she first stepped foot in the asylum.

All I Know

Andrea lost custody of me when I was four years old and the injustice was so mortifying she attempted suicide resulting in life-changing injuries.

Tragically her story was ignored and her torment was pathologised. Her painful experiences will always be part of me but now I am also able to create a more hopeful story.

It feels immensely powerful for me to share something of the loving woman my mother was.

Andrea's Background

Andrea was born into a wealthy upper middle class family, with an older and a younger brother. Her father had risen from deprived origins to become a very senior civil servant with many government contacts, and was regarded by the family as a brilliant man. Academic and material achievements were highly valued. Andrea had a distant relationship with her mother who had tragically lost two brothers in the second world war around the time Andrea was born. Her mother devoted herself to being a good wife and hostess to her high profile husband, but the atmosphere at home was said to be 'tense.' Andrea was very close to her father and described him as the only person who hugged her, although he was also very critical of her. Andrea also had a strict governess whom she strongly disliked. Her medical notes describe 'early neurotic traits' which included nervousness, bedwetting until the age of 14 and nightmares. She found the bodily changes associated with puberty very distressing.

Andrea was sociable and sporty and had many friends at school, but always felt unable to live up to her family's high educational expectations and her brothers' academic achievements. She did badly in her A levels. Her first psychiatric admission was in 1961 when she was 18. From then on, her father took a main role in arranging her treatment under a variety of leading psychiatrists of the time, while her mother did her best to support her. Three years later, while approaching her university finals, Andrea was re-admitted following a suicide attempt, and was given medication and the first of many courses of ECT. She also began to accept, as reinforced by the medical professionals, that she would not be returning to university, although "Every time I see friends from college I wonder how I came to give up on such a golden opportunity". Her passion to learn continued for the rest of her life. In a letter to her father around this time she said "It must be heart breaking to have a daughter like me. I do want to get better but I don't know how." 

For the next 5 years Andrea was relatively stable. During this time she met her husband, who was also from a highly educated background, and they had a daughter. She stayed at home while her husband worked as a history teacher and eventually became a headmaster. Although in some ways they seemed well-suited, he was fairly traditional, not good at expressing his feelings, and often consumed by his own ambitions and interests.  

Aged 27, Andrea was re-admitted after jumping in front of a tube train whilst pregnant, losing the baby as a result. She was diagnosed with 'depressive illness' and 'character problem'. In subsequent admissions she was given the diagnoses of 'personality disorder' and 'endogenous depression'. After the birth of her second daughter, Ruth, she struggled to cope as a mother, and had deep-seated feelings of inadequacy, along with reported lack of feeling for her children. A pattern developed in which her mood lifted after a few months and she became elated and hyperactive, before repeating the cycle. She continued to make serious suicide attempts. At this point 'schizophrenia' was starting to be included in her collection of diagnoses, due to being 'out of touch with reality' and having a 'psychotic level of functioning'. In one of her suicide notes she wrote: "I have tried to make a good home but now as my local GP tells me I am a paranoid schizophrenic. He must be a very powerful, successful and loving person if he can think me as bad as that." However, no clear 'psychotic' symptoms were recorded, except perhaps when one psychiatrist found her 'rocking on her bed and saying she felt controlled by some monstrous person.' 

In 1978 Andrea and her husband divorced, although she always hoped he might return, and she lost custody of her daughters to him. She struggled financially despite some support from her parents. Her despair led her to jump in front of a train, losing her leg, which led to another long hospital admission. From then on she used a prosthetic leg until aged 62 she had to use a wheelchair. 

There was then a stable period when she was in a steady relationship with a new partner (although he may have been violent towards her), and attended college. When that relationship ended, she made further suicide attempts. She had several years of unsuitable accommodation and hospital admissions, along with day centre attendance, and acquired a new diagnosis of 'bipolar affective disorder'.    

By the time Andrea was in her fifties there were clear signs of poor memory, although she was never given a formal diagnosis of dementia. Despite this, she was  more stable and living in her own flat, and she managed to complete an open university course in creative writing. She started to have lots of falls at home and endless physical symptoms including stomach aches, headaches, joint ache and skin conditions. In her sixties, her physical condition and memory had deteriorated to such an extent she was struggling to cope at home and faced the prospect of her loss of independence by moving from a prosthesis to a wheelchair. She took further overdoses and the crisis team noted that: "She appeared plagued with poor confidence and poor self esteem and said that she cries mentally, feeling helpless that she has not been able to get her life back on track". 

The last four years of Andrea's life were spent living nearer to her family and daughters in sheltered housing. She remained unsettled and there were a few emergency hospital admissions as the result of general deterioration, low mood and lithium intoxication. She was finally admitted to hospital with jaundice in April 2014 and died 2 weeks later, aged 71, from sepsis. 

Andrea's story from a PTMF perspective

Andrea's struggles were mainly viewed through a diagnostic lens. A PTMF perspective might have led to a very different story, whether carried out with staff, with Andrea herself, or with both. For the purposes of illustrating the PTMF perspective, we have looked at her story through the core PTMF questions. This might have highlighted these issues:   

What happened to you? (How has Power operated in your life?)

• Legal
  Since Andrea always complied with treatment, there were no compulsory admissions. Court order in which she lost custody of her daughters.
• Economic and material
  A materially privileged upbringing but later, insecure housing and little money.  Many periods in hospital environments. 
• Interpersonal
  Emotional neglect, rejection, criticism, possible domestic abuse.  Dominance of powerful male figures in her life, both family of origin, and psychiatrists.  Family shaming for her 'mental patient' status.
• Biological/embodied
  Serious long term effects of drugs and ECT, including many physical symptoms. Contributing to dementia and early death. Loss of mobility due to amputation. 
• Coercive/power by force
  Coercion by MH staff, stopping short of MH Act use. Possible domestic abuse
• Social/cultural capital
  Privileged background but these advantages eroded by 'mental patient' status, along with physical disability and later dementia. 
• Ideological power
  Powerful combination of social and ideological expectations. Gender roles: patriarchal family, with dominant father who was a member of the establishment, in an era of rigid gender stereotypes, and a mother who devoted herself to his career and wishes. Expectations to do with being a 'good' daughter, wife and mother. Additional and partially contradictory expectations to achieve academically and be 'successful'. Materialistic and class-based values. Her insecure sense of identity overridden by the devalued 'mental patient' identity. 

Reflection:

The question shows that Andrea faced an overwhelming number of Power abuses that included every area of her life. This immediately begins to challenge the diagnostic view of a 'mental illness' developing out of nowhere. Note the aspects of ideological power that don't necessarily emerge even in a trauma-informed perspective – those to do with social norms, expectations and identify formation. 

How did it affect you? (What kind of Threats does this pose?) 

• Relationships
  Lack of emotional safety, abandonment, rejection, shaming, invalidation, criticism, possible violence 

• Emotional
  Feeling emotionally overwhelmed, despairing, hopeless, inadequate. Mood swings from elation to despair 

• Social/community
  Initial privilege but loss of social role and status through being psychiatric patient. 

• Economic/material
  Initial privilege but later financial insecurity

• Environmental
  Long periods in psychiatric hospital, poor housing later in life. 

• Bodily
  Multiple health problems and impact of psychiatric drugs and ECT, physical disability

• Values, identity and meaning-making
  Discouraged from making own meanings, being heard, or finding own values and identity; strongly encouraged to comply with gender and social norms throughout her life, with additional pressure to achieve; having meanings and identities imposed, including those associated with 'mental illness'. 

Reflection:

The threats are implied by the Power abuses, and once again we can see how much Andrea had to deal with. We can also see how the core PTMF questions overlap. As with the previous question, it is important to notice how Andrea's 'treatment' carried its own threats, both bodily (effects of drugs which may have contributed to later dementia) and in terms of meanings and identities (being assigned the identity of 'mental patient'.) As so often happens, the power abuses and threats associated with services repeat and reinforce previous ones (Andrea was already struggling to find her own identity rather than having others' views imposed on her, but in services she found a whole new set of powerful (mostly) men to take control over her.) In other words, re-traumatisation in services is common, and this can happen through ideologically-based messages (such as those about 'mental illness') as well as through physical interventions. 

What sense did you make of it? (What is the Meaning of these experiences to you?) 

Reflection: Meaning is the central thread of the PTMF, but only Andrea herself would have been able to tell us if these feelings/meanings seem to 'fit'. Note that if we knew more about the 'symptoms', additional meanings might emerge.  

Shame, failure, inadequacy, despair, loss, hopelessness, worthless, rejected, afraid, confused, guilty, powerlessness, helplessness.

What did you have to do to survive? (What kinds of Threat Response are you using?) 

• Compliance, obedience within family and services
• Low mood, mood swings 
• Self blame
• Suicide attempts
• Striving to live up to expectations – academically, domestically 
• Trying to maintain interest in music and education

Reflection:

Within PTMF, threat responses do not correspond exactly  to psychiatric 'symptoms', which is why we can include compliance as one of the creative ways Andrea tried to survive. However, compliance is also a repeat of her way of coping in the family. Threat responses like denial and compliance are often mistaken by services for recovery, and non-compliance is risky in services. However, this also repeats a pattern within her family that ideally she would have been encouraged to break, eg by anger and assertiveness. 

What are your strengths? (What access to Power resources do you have?)

• Intelligent
• Musical and creative  
• Outgoing, sociable
• Good sense of humour and fun
• Good at sports 

Reflection:

This part of the PTMF construction of Andrea's story helps us to move far enough away from the diagnostic narrative to see her as a whole person – from 'chronic mental patient' to 'survivor of many power abuses.' 

What is your story? – a possible summary 

Andrea's background was materially comfortable and privileged, but this brought its own disadvantages, such as high expectations, materialistic values and a strict and unkind governess. Her mother may not have been able to provide emotional closeness, due to the tragic losses she had experienced and perhaps due to her own lack of power within the family. Since all children need to find love and attachment from somewhere, Andrea may have needed to turn to her father instead, and this was clearly crucial in her life. Unfortunately, this left her very vulnerable to her father's constant criticism – which was perhaps a projection of his own denied feelings of inadequacy and insecurity as someone who had risen from a very different class background. As a child, facing her governess's harshness as well, the only conclusion she was able to reach was that she herself must be bad and inadequate. 

This belief, and the need to see her father as perfect and loving, coloured Andrea's whole life.  She seems to have had a lifelong need to be loved and accepted by male figures, but this may have left her vulnerable to abuse in her adult relationships. It also seems to have led to confusion between love, power, abuse and control. There may be hints of this impossible dilemma in the episode of 'rocking on the bed saying she felt controlled by some monstrous person.' Since Andrea was never able to replace her adoration of her father (and later, her husband) with a more realistic picture, she was not able to find relief from profound feelings of inadequacy and self-blame. 

Andrea's main response was anxious compliance and continued striving to achieve and be accepted. There was no midpoint between 'success' and 'failure' in which she could find a sense of self. Tragically, her desperation led to further sources of guilt and despair, including the loss of her unborn child, and the later loss of custody of her daughters. We can assume that she was trying as hard as she could to give them the emotional security they lacked, but this is difficult when you have not experienced it yourself, especially given the nuclear family set-up of fulltime mother and relatively absent father which was unquestioned at the time. In addition, children can trigger memories of your own early losses and traumas. 

Looked at from a wider perspective, Andrea seems to have been caught in a particularly toxic mixture of social norms and expectations. Gender role norms about women and being a good wife and mother were very strong at the time. Her own and her husband's families of origin were very traditional, with men and women very much expected to conform to gender roles. In addition she faced pressure to achieve academically, although it was relatively unusual for a woman of her generation to go to university. From her point of view, she may have seen herself as having failed in both areas, and she had numerous experiences which confirmed a fundamental sense of being bad and unworthy. Her response – compliance and eagerness to please - is sanctioned and encouraged in women, while anger – which perhaps emerged only in self-harm – is discouraged. Her sense of shame and failure is likely to have been echoed in the reactions of her conventional family and in-laws. For example, it was unusual at the time for mothers not to gain custody of their children, and this may have felt like a mark of social as well as personal shame.

All of these dynamics were repeated and heavily reinforced in mental health services. Her father's control extended to arranging her 'treatment', and she was assigned the devalued status of 'mental patient'. This confirmed her feelings of hopelessness and inadequacy, and brought stress and social shame on the family while simultaneously shielding them from any questioning of the 'happy family' that is described in her notes. In services, she found a whole extra set of (mainly) male, powerful figures to tell her she was not only a failure but was also mad. Lacking a positive sense of her own identity, she was unable to resist the new one that was imposed on her, and was not given the chance (for example by therapy) to see things any differently. Rather, she was in effect silenced by diagnoses, drugs and ECT, up to and including brain damage, and early death. 

Andrea's life was shaped by multiple layers of power abuses, interpersonal and ideological, and these are only guesses. Andrea herself, and the person she could and should have been, remain shadowy. We can imagine that there were other aspects of her life that never came to light, and which might have provided additional insights into the overwhelming despair she struggled with. It has been the role of future generations – her daughter Ruth in particular – to honour her memory by finally telling some of her hidden story.

Final reflection on Andrea's life, by her daughter Ruth

Ruth remembers Andrea as someone who retained her sense of humour, and her passion for learning and music. She was deeply interested in people and especially her family and thrived on stories about the lives of her grandchildren; she maintained a childlike sense of joy right up until her death. At her funeral, people remembered someone who was a big animal lover, she was bright and as a school girl inspired and drew people together in strong friendships. One of her old school friends described her as the life and soul of the party. Family was always most important to Andrea and when young she would take the time to visit relations. Her younger cousin described being in awe of her beauty and her capacity to generate so much fun and laughter. Ultimately it was her kindness that shone through as the quality that figured most highly in people's memories of her. Ruth's final words in her funeral tribute: 'She was quite simply the bravest, most determined person I have ever known and someone I was proud to call my mum'.

Possible way of drawing on Andrea's story in training and workshops

There are many possible ways of doing this. For example:

Attenders form small groups and use the summary of Andrea's background to come up with their own list of P,T,M, and TR aspects of her experiences. They might do this with the help of the Guided Discussion prompts (link to Guided Discussion). The attenders' responses could then be shared with the larger group and compared with the list above. They could then be invited to read the summary 'What is your story?'  Attenders can then reflect on alternative ways forward that ideally would have been available to Andrea. 

The exercise could be preceded by showing the first poem 'Madness Meds', and ended by reading the 'Final reflection on Andrea's life by her daughter Ruth' and showing the second poem 'All I know.'

Ruth Dixon, Andrea's daughter, is willing to consider joining training sessions either in person or via Zoom, to reflect on the process of constructing Andrea's story. Please contact her via the site email address. 

We are very grateful to Matt for permitting us to share his story, and for helping us to develop it as a possible training exercise. 

Matt's background

Matt was born in South East England.  He grew up in the family home with his parents  and three siblings. He is the youngest child, and his father was an engineer and mother a teacher.

Matt  was brought up as a Methodist and his parents were heavily involved in the church and sports communities. Matt always felt that these were the most important things to his parents. However, he experienced his family and the local community as full of hypocrisy given that he saw a discrepancy between the stated rules and the actual actions of adults in the home, school, and wider society. Matt had a sense at an early age of being on the edge of the community.  The area in which the family lived was strongly conservative and he experienced being 'different' as contentious. Matt had a somewhat disjointed relationship with his siblings and this became more overt as they grew up.  Some violence in the home followed his parents' separation and Matt lived in fear of this threat. Both of his sisters left home at around 16 years of age.

Matt was sociable and sporty at his state school, excelling at football and badminton. Although he enjoyed sport, he also felt he had to achieve to be accepted. He began to find school difficult following a number of events, including a threat to his life, his parents' divorce, and ongoing violence and threat which had started at the age of around 8, including school and neighbourhood bullying.

Matt had plans to end his life from the age of around 12, and at 13/14 experienced what was later termed a 'psychotic' episode. He was taken out of class frightened and distressed having experienced voices, and seeing visions of people on fire and an entity that was trying to consume him and his classmates. The teacher took him to the school nurse but did not tell his family about the experience. Later, Matt felt that the 'entity' elated to a sense of damnation after a religious event in which he was urged to 'give himself to God' but felt unable to do so. 

Matt 's schooling suffered and he began to use various drugs from the age of 13 to manage his extreme distress. He felt he had to conceal things from his friends and family. He expressed his rebellion through a change in his school work, but this was seen as misbehaviour or laziness rather than a sign of distress.  

Matt 's teen years were chaotic. He gradually gave up his sports and left school with no qualifications. He took various short term jobs, continued his drug use, and often felt suicidal.  Aged 20, he went to Australia and found himself homeless. He ended up living in a parkland in Perth, and again had 'psychotic' experiences. Here he was supported by some local Aboriginal people who invited him to stay with them. He spent a short period in an immigration detention centre (where he experienced additional voices) before being sent back to the UK.

Matt was admitted to a psychiatric hospital in the UK at the age of 21, experiencing voices and 'paranoia'. He was diagnosed with psychotic depression. Over the next 15 months he had 5 admissions and received a number of additional diagnoses including schizophrenia and drug-induced psychosis. He was given multiple psychiatric drugs, several at the same time, and ECT, was placed in seclusion (when not detained) and threatened with detention on a number of occasions when he tried to leave. Matt was also offered a range of community interventions. He was seen as someone who had little hope of recovery.  

Matt's story from a PTMF perspective

Matt's problems were mainly viewed from through a diagnostic lens. A PTMF perspective might have led to a very different story, whether carried out with staff, with Matt himself, or with both. For the purposes of illustrating the PTMF perspective, we can imagine that Matt is in his early twenties and is seen as a 'chronic schizophrenic', and both he and mental health staff are feeling very stuck in that diagnostic narrative.

Working through the core PTMF questions might have highlighted these issues:

What happened to you? (How has Power operated in your life?)

• Legal
  Detention in immigration centre. Threatened with MHA detention, pressure to take psychiatric drugs and have ECT. 
• Economic and material
  Homelessness, lack of money, unemployment.
• Interpersonal
  Bullying (school and neighbourhood); violence and threat inside and outside the family. Criticism, invalidation of his views. Seclusion in hospital
• Biological/embodied
  Loss of sporting activities. Physical harm, eg physical neglect and poor nutrition while homeless. Impact of psychiatric drugs, effects of ECT. 
• Coercive/power by force
  Threats and violence in the home, the neighbourhood and in hospital 
• Social/cultural capital
  Despite a comfortable start in life, loss of status due to identity as homeless, psychiatric patient and consequent lack of access to resources. Lack of opportunity due to interrupted schooling.
• Ideological power
  As a child, the impact of religion and conservatism, and sense of isolation due to non-conformity. Disagreeing with school rules and expectations. Later, imposition of identity of 'mental patient' and psychiatric narrative. All of this was a threat to his sense of meaning and identity. 

Reflection:

The question shows that Matt faced an overwhelming number of Power abuses that included every area of his life. This immediately begins to challenge the diagnostic view of a 'mental illness' developing out of nowhere. Staff may start to see Matt through a different lens, and appreciate how much he has survived.

Note the aspects of ideological power that don't necessarily emerge in a trauma-informed perspective – those to do with social norms, expectations and identify formation.

Matt too may be able to start locating the source of his problems outside himself, instead of in a 'mental illness.' However, exploring Power aspects with someone needs to be done very sensitively in the context of a trusting relationship, bearing in mind that it takes time to feel able to disclose some of the deepest traumas.

How did it affect you? (What kind of Threats does this pose?) 

• Relationships
  Lack of emotional and physical safety, abandonment, rejection, shaming, isolation, invalidation 
• Emotional
  Feeling emotionally overwhelmed and despairing 
• Social/community
  Isolation, rejection, bullying, invalidation, loss of social role and status, marginalisation
• Economic/material
  Financial insecurity, lack of housing, unemployment, consequences of homelessness
• Environmental
  Living in unsafe areas, confined to hospital. 
• Bodily
  Unmet material needs, exposure to violence, impact of psychiatric drugs and ECT
• Values, identity and meaning-making
  Discouraged from making own meanings, being heard, or finding own values and identity; dissent from social, community and school norms; having meanings and identities imposed, including those associated with 'mental illness'. 

Reflection:

The threats are implied by the Power abuses, and once again we can see how much Matt had to deal with. We can also see how the core PTMF questions overlap. As with the previous question, it is important to notice how Matt's 'treatment' carried its own threats, both bodily (effects of drugs and ECT) and in terms of meanings and identities (being assigned the identity of 'mental patient'.) As so often happens, the power abuses and threats associated with services repeat and reinforce previous ones (Matt had already been exposed to violence and was then subjected to ECT; Matt was already struggling to find his own identity rather than having others' views imposed on him.) In other words, re-traumatisation in services is common, and this can happen through ideologically-based messages (such as those about 'mental illness') as well as through physical interventions. 

What sense did you make of it? (What is the Meaning of these experiences to you?)

• Afraid, confused, overwhelmed
• Isolated, suicidal, angry
• Lonely, hopeless, excluded, different
• Failed/bad/sinful
• Ashamed, blameworthy, unacceptable as himself

Reflection:

Meaning is the central thread of the PTMF, but only Matt himself can tell us if these feelings/meanings seem to 'fit'. From a staff point of view, it is helpful to try and put ourselves in Matt's shoes and make empathic guesses about the meanings he may have constructed. This will take us another step away from the identity of 'chronic schizophrenic' towards recognising him and relating to him as a whole person. Note that if we knew more about the voices he hears, the visions he saw and so on, additional meanings might emerge. 'Psychotic' experiences are seen as intensely meaningful and important experiences within both trauma informed practice and the PTMF, and offer clues about hidden aspects of the story. In Matt 's case there seems to be a strong religious theme, which is why the meaning of 'sinful' may be relevant. 

What did you have to do to survive? (What kinds of Threat Response are you using?)

• Hearing voices, visual images, 'paranoia', suicidal feelings
• Taking illegal drugs
• Suicide attempts
• Secrecy, concealing things from family and friends
• Sport (trying to be accepted)
• Trying to be accepted by God
• Rebelling, not doing school work
• Going to Australia

Reflection:

Within PTMF, threat responses do not correspond exactly  to psychiatric 'symptoms', which is why we can include secrecy, trying to be accepted, and going to Australia as some of the creative ways Matt  tried to survive. Threat responses like denial and compliance are often mistaken by services for recovery. 

What are your strengths? (What access to Power resources do you have?)

• Intelligence
• Sociability, ability to relate to others (eg the Aboriginal group)
• Determination, courage – got himself to Australia
• Sporting ability
• Seeing the importance of integrity, search for values and meaning
• Matt is a survivor! 

Reflection:

By this stage in the PTMF construction of Matt's story, we hope we have moved far enough away from the diagnostic narrative for both staff and Matt himself to start to see him as a whole person – from 'chronic schizophrenic' to 'survivor of many power abuses.' Despite everything he has been through, and the difficulties he is still facing, he is still with us, with all his potential for a better future. In one to one supportive work it may be helpful to start exploring the strengths first in order to help provide a safer base for the more difficult aspects of the story. 

What is your story?

Matt's own summary is as follows: 

"I grew up in an environment that could be described as safe and comfortable. Despite the many privileges of this culture and environment, I felt estranged and different from those around me from an early age. This became more of a problem when I responded by keeping secrets and feeling disconnected from the social and cultural environment.  I experienced a sense of hypocrisy from an early age and with the ongoing threats, was often confused by the contradictory narratives. I learned to 'fit in' enough through sport but also failed to complete education and or find employment with any success and was often seen by others as not fulfilling my potential.

The sense of being trapped and then unintentionally making this worse for myself was constant. Not knowing whom I could connect with meant the secrets and reactions to the threats continued until I found I could not maintain the 'normal' any more. Suicide, and wondering whether this life was worth living, was a fairly constant internal dialogue, and I used drugs to manage the distress and fear. 

In my teenage years the sense of isolation became increasingly difficult to manage. My response was to guess how I should behave in different situations to avoid further problems, but I also knew that I would be punished for certain actions. This felt a reasonable payoff as a way of protecting myself. 

The labelling of diagnosis appeared to be a continuation of the convenient story of   being a problem – both socially and 'biologically'. Initially I accepted, or at least was powerless to challenge, the diagnostic narrative.  I was aware that I was continuing the cycle of saying what I believed might be the most acceptable and least problematic (for me) set of 'truths' – this time to psychiatrists. But I became trapped in a narrative of 'illness' that led to vile medication reactions and subservience to the system, with apparently no way out."

Follow-up

Fortunately, a psychologist took an alternative view and suggested that psychotherapy and a housing community might help. In this way Matt found an escape, and an opportunity for new stories. He says he found a sense of safety in a community of 'mad' people, which offered an opportunity to begin to live in his own truth and develop his own narrative. Matt spent nearly 2 years there, and while seeing a psychotherapist, gradually stopped hearing voices and no longer felt suicidal. During this period he was supported by a psychiatrist, to reduce and come off the range of psychotropic medications he was taking, which took two and a half years.  

Over the next few years Matt began voluntary work, and began to visit public spaces such as museums and art galleries and sporting venues as a means of exploring safety around people.  He also returned to surfing and found this an enormously liberating activity.  

He considers the most helpful part of his recovery to be the housing community, the sense of being welcomed by the Aboriginal community, the therapist who offered a space to talk and be himself, the voluntary work, and the freedom he found through surfing the waves.  More recently, training to become a Nurse Practitioner and Psychotherapist has given him a sense of liberation. One of the most important aspects of this is finding meaning in the traumatic experiences that have ultimately contributed to his professional work and to a fulfilling personal life journey. 

Reflection on Matt's story

Matt's story has a happy ending, unlike many people who remain trapped in the psychiatric system and in the identity of 'mental patient.' He received some skilled therapeutic support, but it is worth noting that most of his recovery came through freeing himself from psychiatric interventions (drugs, admissions, and ECT) and replacing them with ordinary, non-specialist activities and human contacts – voluntary work, surfing, and so on. Lacking a sense of community, acceptance and secure identity since childhood, he was finally able to find them in two of the most marginalised groups in society –homeless Aboriginal people, and 'chronic mental patients.'

The message, which accords with the PTMF, is that while some professional skills may be invaluable,  emotional suffering is healed primarily through human connection, and sometimes also through finding a mission and purpose in shared social action. 

Matt has now trained as a mental health nurse, and was awarded 'Australian MH Nurse of the Year' in 2017. He is married and he and his wife have three children. He speaks publicly about his lived experience, and has set up a number of non-medical projects based on a non-medical approach to mental distress.

Matt and the PTMF

Some years later, Lucy Johnstone and Matt ran a joint workshop on the PTMF, and Matt  generously gave permission to use his story as an illustration. To prepare for this, Lucy and Matt re-visited his story through the PTMF lens, resulting in a summary rather like the one above.

In this video, they discuss their shared experience of the process, and the ways in which the PTMF helped Matt to acknowledge further aspects of the traumas in his early life.

Possible ways of drawing on Matt's story in training and workshops

There are many possible ways of doing this, and we encourage creativity. For example:

Training exercise 

Workshop attenders could form small groups and use the summary of Matt's background to come up with their own list of PTM and TR aspects of his experiences, with the help of the Guided Discussion prompts (link). The attenders' responses could then be compared with the list above, and the facilitator could then share 'What is my story?' and the update.

The facilitator could then show the video discussion between Matt and Lucy (link above) which encourages further reflection on the PTMF perspective and the process of narrative construction.

Amanda Griffiths facilitates a peer group which has used the PTMF to construct narratives, as described in her article. In this extract, she shares her own PTMF narrative.

What has happened to you (how is Power operating in your life)?

I am a survivor of many traumatic experiences. I am being disempowered by two very powerful systems (statutory mental health services and children's social care). This resulted in two male professionals exploiting their position of trust, power and authority to coerce and sexually abuse me. Subsequently, these organisations used their power to deny my autonomy, and pathologise my behaviours as being symptomatic of a so called 'personality disorder', which I found victim blaming. Consequently, I had to form a subservient relationship with a controlling psychiatric system in order to access support to try to heal from the effects of these harrowing experiences.

How did it affect you (what kind of threats did this pose)?

I am unable to trust or heal from my experiences. I struggle with relentless post-traumatic stress, such as dissociation (blank states), hypervigilance, flashbacks and vivid disturbing dreams. I have been prevented from articulating my story because the impact of the abuse is being ignored. This leaves me feeling misunderstood, angry, apathetic, anxious and struggling to regulate my emotions. My physical energy levels are chronically depleted because the hyperarousal is extremely painful and exhausting. Consequently, my body's fight and flight response is permanently switched on resulting in autonomic dysfunction. These psychological and physical factors combined, test my resilience and often result in suicidal thoughts.

What sense did you make of it (what is the meaning of these situations and experiences to you)?

I believe that I am a worthless person who is undeserving of help and treatment. I feel defective, that there is something is wrong with me, and I deserve to be hurt because my character deficits are the root cause of those damaging experiences. The world seems an unsafe place as others are untrustworthy. Ultimately, I often believe that I would be better off dead because death seems the only means of escape from these harrowing experiences and from myself.

What did you have to do to survive (what kinds of Threat Response are you using)?

My survival mechanisms involve forming subservient relationships with others who are in a position of power and authority. My body is hyper-vigilant at all times, constantly scanning for early signs of danger, threats, power imbalances and coercion. I am cautious and wary, often resulting in avoidance of situations and other people. I responded to threats to my safety and wellbeing by automatically employing self-protective or self-defeating behaviours. On occasions when I have felt that I was in immediate danger, I responded with verbal aggression (described by some mental health staff as 'being abusive towards them'). I often disconnect by dissociating or sleeping. I restrict my dietary intake which provides a sense of control in life. In extremely distressing circumstances I use alcohol to block the world out to numb the pain.

Strengths

I have a well-developed insight into the psychology of trauma and human distress. My intelligence and resilience enable me to self-advocate and stand firm against coercion. I am encouraged through the reciprocal relationships I am developing with my peers that motivate me to learn new skills in order to support others facing similar adverse life experiences. Additionally, I am inspired by trauma-informed professionals whose ground-breaking work informs me to develop a new understanding of my experiences, some of whom have helped and supported me in this process. I have a beautiful family who give me the strength and determination to get through each day.

What is my story?

Numerous adverse childhood experiences led to subsequent traumatic life changing events throughout my life. Constant repetitive cycles of coercion, powerlessness and multiple forms of abuse are affecting every aspect of my life, thus impacting on my physical, emotional and psychological wellbeing. My energy levels are depleted from being consistently broken and distressed by an authoritarian mental health system that prejudicially recast my pain and suffering when I needed compassionate trauma-informed provision. As a consequence, I am dispirited and struggle to trust others. However, despite the on-going clinical dispute with statutory mental health services, independent specialists have recognised the complex post-traumatic stress I endured. My relationships with my family and my peers are protective factors that motivate me to find the strength to utilise my experiences to self-educate and self-advocate. I also campaign for trauma-informed and trauma specific services and improved mental health provision for other survivors.

Source:

Extract from Chapter 9 'What is your story?' of 'A straight talking introduction to the Power Threat Meaning Framework' (2020) by Mary Boyle and Lucy Johnstone, PCCS Books.

Emma's story

Emma is a social worker who has also used services. Partly through having had good support from a mental health team, she has done a lot of thinking about her story already. Here, from a position some way along in her journey, she uses the PTMF core questions as a self-help reflection too.

'What has happened to you?' (How is Power operating in your life?)

My late childhood and early adolescence took place against a background of a general 'chaos' and threat, punctuated by incidents of aggression, often fuelled by alcohol. I didn't feel safe, and this was frequently ignored, dismissed or seeming not to be heard or taken in by members of my extended family, teachers, the parents of friends. I think I gradually lost trust in how I experienced the world around me. 'I must be wrong.' Maybe internal family discourses that 'adults know better than children', broader narratives surrounding gender – 'girls should be nice', 'being quiet and compliant is desirable and good' and in my growing up world, a religious (Roman Catholic) narrative intensified these things. Such narratives hold intense power to silence, trivialise or intimidate. Another commonly held attitude at the time was that both addiction and inter-familial violence were 'family matters.' This ideology shored up the secrecy and created another barrier to speaking out. It meant that when I did ask for help, aged fourteen, by calling the police in the middle of an aggressive dispute, my story was brushed aside by the (male) police officer as exaggeration.

There were social and economic 'threats' too. Not unusually, my mum had few material resources available to only her, and this meant that escaping from a relentlessly threatening situation felt impossible. When we did leave, unstable and inconsistent housing and the fragile sense of safety that brings, maintained this sense of threat.

I think the cumulative effect of this was that when other things that were equally serious but different in nature occurred at a later time, I did not consider asking for help to be an option. So as often happens, the impact of power in one area left me vulnerable and alone in another.

'How did it affect you?' (What kind of Threats does this pose?)

Domestic abuse often creates a range of threats, some of which are more visible than others. Bodily and relational threats, isolation from social networks, lack of financial and material resources and separation from sources of potential support in the community. Shame fuels secrecy. I think a big threat for me involved simply not feeling safe, either physically or psychologically, and therefore feeling very easily overwhelmed in situations which otherwise I might have managed. I had already used up my resources at home and they didn't get replenished very often. This meant that although school offered a degree of safety and predictability (I loved learning), 'fun' and playfulness felt pointless and navigating friendships was difficult (how can you invite someone home when you are unsure what you will be bringing them home to?) I was aware from a young age of how alcoholism was perceived and the fact that having an alcoholic parent made me different and somehow 'less than.' I think I tried to compensate for this with relentless striving – to achieve academically, to please, and to be as 'clean' and 'ordered' as possible.

So domestic abuse and the impact of addiction were key threats, 'winessing' aggression, but also directly being the target of it (I don't like the term 'witnessing' domestic abuse being applied to children. They are in it and experience it.) Being left in unsafe situations, with unsafe people, being given a level of responsibility too much for the stage of development I was at. I was acutely aware from a young age of existing within intergenerational patterns of addiction. And in trying desperately to resist what seemed like an inevitable fate by maintaining 'control', I fell into the compulsivity of anorexia. The way in which the anorexic state of mind takes the person over and divorces them from their sense of self means that it can be conceptualised as both a threat and a threat response. Anorexia left me confused about who I believed myself to be, mirrored the confusion I felt about the validity of my needs and the reasonableness of taking up space in the world. It was augmented (but not caused by) the subtle and ever-present scrutiny that comes with living in a woman's body in a world seeking to create dissatisfaction in all of us.

'What sense did you make of it?' (What is the meaning of these experiences to you?)

Unsurprisingly, the meaning I took from my experiences was fairly bleak. Mainly a sense of difference, inadequacy, 'unlikeable-ness.' This was often focused on my body but it extended to my core sense of self. 'I am not okay as I am but maybe if I try hard enough, it will compensate for this'.

I also developed a strong sense of responsibility. 'I'm responsible'. 'I have to hold things together or everything will fall apart.' I think until beginning to discover feminist literature, and meeting others who unapologetically took up space, I felt that I must exist solely to meet others' needs and had little sense of being seen, valid, or deserving of space, a voice, care. This was mirrored by the 'anorexic' denial of needs which functioned to cut off from all feelings and manage the sense of overwhelm I often experienced. I became, sometimes quite literally, frozen.

'What did you have to do to survive?' (What kinds of Threat Response are you using?)

My major threat response described in the Framework was, until recently, that of restricted eating, coupled with striving, and strategies such as overwork and perfectionism. Restrictive patterns around food make sense as a means of gaining a sense of control and 'coping' whilst also functioning to disconnect from some of the more intrusive symptoms of trauma. Once a regained some control back from restrictive patterns around food and re-gaining weight, other threat responses became more prominent, mainly anxiety-based responses such as flight/freeze in response to reminders of earlier experiences, nightmares, and compulsions aimed at appeasing intrusive thoughts and probably also squashing down feelings. I have found that the PTMF can help to make sense of shifts in particular 'symptoms' or behavior patterns. If the impact of the core threat is not addressed, it makes sense that symptoms will shift and change as a person seeks to manage this in whatever way feels most accessible to them at the time. I think another (less conscious) control strategy was to keep certain areas of my life quite separate from others as a way of coping.

Another key strategy involved trying to desperately keep the people I depended on as emotionally 'together' as possible (by being compliant, appeasing, trying to anticipate and meet their needs, trying to not get in the way or make things more difficult – and therefore automatically dismissing what I might feel, need or want because it was too much and in any case, there was no space for this.) Again, this left me vulnerable. Looking back, I was painfully compliant, terrified of doing something 'wrong' and working very hard to please and appease the adults around me. This probably set me up for limited friendships with peers because it took a great deal of energy and – being honest – I wasn't very 'fun.' 

What are your strengths? (What access to Power resources do you have?)

In spite of the difficulty, there were some really quite powerful positive influences in my life and I'd like to think that they served as a protective or mitigating factor. I had a warm relationship with my grandmother and a very kind, 'comfortable', fun aunt. What this meant was that my sibling and I had a refuge away from the 'chaos', and in this warm environment were able to feel safe and relaxed enough to have fun, to play, to develop our interests. I think this was vital and provided an island of stability from which to build.
From a young age I read. In some ways this was quite obsessive because at quite a young age it became a soothing strategy. It also helped me to learn. The striving pattern gave me the motivation to work hard and complete my education to postgraduate level. This opened up opportunities, and new ways of thinking and seeing the world. I realised that there were other, more compassionate, hopeful ways of viewing the world. I also (very importantly) had a sister who, particularly as we grew older, was a source of solidarity and mutual validation, particularly as we grew older - 'this isn't right, is it', 'this doesn't happen at so and so's house', 'I felt sad when that happened too'. 

The Framework mentions the phenomenon of 'revictimisation', including by mental health services. I consider myself fortunate to have largely had an experience of services (and therapy) that has been kind, restorative and has offered a framework for something new. I have for some time worked in mental health services, and I want to do all I can to help services and practitioners to be trauma-informed, and to break down the 'us and them' attitude that can persist within services. We are all human.
Emma adds a reflection on the importance of some key relationships on her path to healing:

And what about the way out…?

When thinking about changing or revising these (now largely unhelpful) survival strategies, one huge thing for me has been a relationship with someone who is kind, and has remained kind and continued to see 'me' even after knowing the 'really bad stuff'. Contact with services who have on the whole been compassionate, understanding and really, really tried to help has also been important. Over the last couple of years, I've felt genuinely listened to, psychologists have taken the time to map out patterns with me, helped me to tolerate the risk of beginning to change those, and have validated that it is ok to need help with that process. I think there was something powerful about my partner, therapist and the service I attended all being on the same page. Fighting that relentless 'anorexic mindset' can feel so confusing. Having someone bravely say 'yes, they are right' when I was raging against having to eat yet another 'unnecessary' meal was actually really helpful. Someone I trusted told me, 'this is what you need to do, and you can do it', and I replayed that in my mind over and over as an anchor. I couldn't always verbalise things so I wrote sentences and handed them over, drew doodles, and wrote blog posts - all perhaps attempts to find my voice put words to too big things.

A while ago, I wrote myself a note, that, 'whatever happens, the bravest thing I can do to step away from the critical, dismissive, punishing patterns as much as I can each day.' It is scary. Still. But it was a commitment. It helped me to take what are actually quite significant risks to me, even though they may not look like that to others. My motto for a while was 'be more 'reckless' and less rigid'. I am trying out ways of attending to myself, trying to carve out moments of calm, reminding myself that as a result of my 'back story' I might need different things to others sometimes.

Survival strategies can turn on you and trap you and that is what restrictive and controlling patterns do. 'Anorexia' was my way of surviving horrible things, but it became tangled into almost every aspect of my life and sense of self. It began as a form of resistance to and a barrier against oppression but then I found myself in a position of needing to resist it and finding allies around me, and within me, to help me to do that. So when I think about power, I also think about resistance. Resistance, for me, involves risking kindness towards myself and others, risking allowing more, both physically and psychologically. The kindness of many other people – my husband, friends, services and strangers on the internet has been a huge part of this beginning to shift. It's a slow chipping away but the more of those kind interactions I have, the more my cynical, jaded, terrified worldview is challenged.

Finally, Emma testifies to healing power of narrative: 

I think the final piece of resistance for me involves the power of finally telling my story. Telling it, validating it, daring to speak it, daring to use the words, daring to sit in a room and look at it, taking risk after risk. I hope I am finding a space to tell mine. Slowly, haltingly, but telling it. In words and pictures and silences. 'Liberation is always in part a storytelling process: breaking stories breaking silences, making new stories. A free person tells her own story. A valued person lives in a society in which her story has a place'.

We have reproduced Emma's story at some length, with her generous permission, because it illustrates the PTMF themes so well. We can see the overlapping themes highlighted by the core questions, and the clear links between the power-based Threats and the Threat Responses. Emma could have met the criteria for various diagnostic labels at different times, but the PTMF shows how all of her 'symptoms' were in fact survival strategies that helped to create a degree of safety in her unsafe world, even if the cost to her was high.

She identifies the less obvious threats, such as invalidation, silencing, and loss of trust, and the less obvious threat responses, such as perfectionism, striving, compliance, self-surveillance and pleasing others. She also shows that the private hell enacted behind the walls of her family home was an echo of wider abuses of power and ideological messages. This included women's and men's gender role expectations, lack of material resources, and societal discourses of shame, secrecy and denial. This in turn led to isolation in her community and betrayal by organisations and institutions (her school, the police) that should have stepped in to protect her.

Finally, she shows the central importance of caring relationships, both personal and professional, within which her story could be reconstructed and heard.