There have been two interesting developments recently, which I hope will continue to change entrenched attitudes towards health and wellbeing in their widest sense. Both of these developments address the intimate connection between life experience and our physical, mental and emotional wellbeing. While this link was taken for granted centuries ago, it is something which has been overlooked for too long in modern medicine.
Last month, an article appeared in the British Medical Journal (28th October 2020 and online at https://www.bmj.com/content/bmj/371/bmj.m3048.full.pdf ), entitled “Adversity in childhood is linked to mental and physical health throughout life”. This is the message which those of us on the sidelines have been sharing for quite some time. It was good to see it stated so unequivocally in a mainstream medical publication.
“What has happened to you?”, rather than “What is wrong with you?” is always the first question which comes to my mind, when working with mental and emotional distress. Now we know it has implications for physical health too. It is so very easy for professionals to look at symptoms, diagnose within a medical model, and then look for a cure or treatment for the “illness” without digging deeper.
Our stress responses - the fight, flight, freeze and flop mechanisms - are designed to help us face any serious threat and keep us safe. They work very effectively over a short time, in the face of a particular danger. However, frequent or prolonged activation of this part of the brain causes “toxic stress”. In childhood, toxic stress can arise as a result of family break-up, bereavement, longterm or frequent exposure to physical or emotional abuse, chronic neglect, violence, parental mental illness or substance abuse, or social and economic hardship. Without the buffer of at least one supportive and loving adult, a child’s development can be affected, and epigenetic changes can occur, which can have lifelong consequences for all aspects of health.
Every individual - adults and children - will have a different “window of tolerance”, beyond which their stress levels can become toxic. It is therefore more about how events are experienced by those involved, rather than the events themselves. What might seem insignificant to one person can have a life-changing effect on another. Once we recognise and understand this, and the long-term damage inflicted by adverse childhood experiences (ACEs), as a society we can do more to intervene at an early stage and offer support and care where it is most effective. That will be a more powerful driver for improved health and wellbeing throughout life, than medical interventions later on.
This way of looking at wellbeing - placing it within the framework of life experience - is also addressed in a new book, published this month. A Straight Talking Introduction to the Power Threat Meaning Framework: An Alternative to Psychiatric Diagnosis, by psychologists Mary Boyle and Lucy Johnstone, offers a different perspective on what is commonly known as “mental illness”.
The Power Threat Meaning Framework (PTMF) was developed in conjunction with people using mainstream mental health services but has useful applications for all of us. It explores the extraordinarily influential role of various kinds of power at different times of our lives, and the threats we face if that power is misused. The framework looks at what this abuse means, through the eyes of the individual concerned, before addressing the ways in which each of us learns to cope with that threat. Our response - or coping mechanism - manifests itself in the behaviour, feelings or thought patterns which we develop in order to be able to live with our circumstances. These are the “symptoms” of the “disorder”, with which we might be diagnosed.
The main aspects of the Power Threat Meaning Framework can be summarised in these questions, which are relevant for individuals, families or social groups:
What has happened to you? (How is power operating in your life?)
How did it affect you? (What kind of threat does this pose?)
What sense did you make of it? (What does this situation or experience mean for you?)
What did you have to do to survive? (What kind of threat response are you using?)
Next, we balance these factors with the strengths, skills and resources on which people can draw, and which will enable them to cope more effectively with what they are facing. Finally, there is a narrative element - individuals are invited to tell their story. This can demonstrate and clarify how everything fits together, and make sense of the person’s experience. Overall, the PTMF can help create an alternative, more coherent and hopeful story. Instead of people regarding themselves as “mentally ill” or believing that they have “something wrong with them”, the links between their emotional distress and adverse or traumatic experiences become clearer. New avenues for healing can be found. Above all, the importance of listening - and creating time and space to hear people’s stories - has been validated.
If recognition of the importance of adverse childhood experiences and toxic stress provides us with a chance to approach health and wellbeing in a different way, the PTMF gives us the opportunity to support those suffering the consequences of adversity with a wider ranging, more imaginative and more relational approach. In all sorts of different situations, the framework can be used to shine a light on the power imbalances and the protective mechanisms employed across social and cultural situations, as well as in personal relationships.
These ideas are gaining ground. In 2017, UN Special Rapporteur Dainius Pūras, a child psychiatrist, argued that “Mental health policies should address the ‘power imbalance’ rather than the ‘chemical imbalance’”.
In 2019, Peter Kinderman contributed a chapter entitled From chemical imbalance to power imbalance: a manifesto for mental health to a ground-breaking book called “Drop the Disorder!” (PCCS Books). He writes:
The delivery of mental health services must be based on the premise that our psychological wellbeing depends on the things that happen to us, how we make sense of those events and how we respond to them. The assertion that our distress is best understood as a ‘symptom’ of a diagnosable ‘illness’ is only one perspective, and a rather unhelpful one. Instead of relying on this ‘disease model’, which assumes that emotional distress is a ‘symptom’ of biological illness, we need to embrace and implement a compassionate, social and psychological approach to mental health and wellbeing, that recognises our essential and shared humanity.
Of course this presents a huge challenge, given the vested interests involved in the status quo and the desire for a quick (and cheap) fix among providers, and sometimes those suffering distress too. There is also a widespread and entrenched belief within society that “mental illness” is something which randomly afflicts us, and medical diagnosis and treatment is the first step to recovery.
However, many approaches to therapy already recognise the importance of life experience and environment - whether we think of the “scripts” we write which are at the core of Transactional Analysis, or CBT’s acknowledgement of the role of environment in how our thoughts, mood, physical wellbeing and behaviour interact. The need for meaning in life and for hope and faith in the future, are a key part of existential therapy.
Looking at adverse childhood experiences and power imbalances helps us to understand why we look at life and the world in the way that we do. Our reactions start to be explicable, rather than the random symptoms of a mental illness. Far from dismissing the very real distress in which people find themselves, or being regarded as “unscientific”, this new approach builds on a growing body of scientific knowledge and cutting edge neurobiology, regarding the development of brain architecture and the way in which we learn to interpret the world around us.
The PTMF provides an adaptable route for reframing our approach to understanding and treating mental and emotional distress. The intention is not to overhaul more traditional approaches entirely, but to support and strengthen current services while offering a range of new ideas to help and those suffering debilitating emotional or mental distress. One of the most interesting aspects for me, is the way in which the PTMF can be used in different cultural contexts, and offers a way in which responses to power imbalances and threat in different cultures or social groupings can be understood and integrated in therapeutic responses.
These new perspectives on distress take us beyond individual suffering. They also remove the stigma of labelling people as “ill” and empower them to reframe their experience. The recognition of the importance of the experiences we have - in early life and beyond - to our overall health and wellbeing has profound implications for each and every one of us. The personal really does become the political - and from that arises an inescapable call for change, particularly in the priorities given to the needs of children in our society and to their protection from life-limiting harm.
The lottery of life - there is so much more we can do to help improve children’s health and life chances.