Forgetting inconvenient truths: A way to keep thinking.

January 2018 was an interesting month in the world of what textbooks refer to as Personality Disorder. There was the launch of the Personality Disorder Consensus Statement, an article on Personality Disorder on the BBC and the launch of the Power Threat Meaning Framework. While I haven’t read the full version of the PTFM I have read a lot about it, and there has been a lot to read. The responses were many and mixed. Some of the responses have been vitriolic, others merely critical, and others more celebratory as a high profile way of thinking about mental health and mental health problems leaps into being.

 
Some of the criticisms of the PTMF are articulately laid out here. What I want to do in this blog is lay out a basic version of what the PTMF promotes, why it’s essential that people can take this on board and what might get in the way of making some use of it.

3d doctor
Within traditional psychiatry signs and symptoms that occur together are named as a diagnosis. The PTMF encourages us to shy away from diagnosis and illness and instead explore a person’s difficulties and distress in terms of:
 What happened to you?
 How did it affect you?
 What sense did you make of it?
 What did you have to do to survive?

 
From the questions above we can then discover a narrative around why someone does what they do. We can see how their behaviour makes perfect sense given their previous experiences. In an ideal world we can then think about what might help and at a minimum consider how to avoid replaying some of the person’s most negative experiences.

 
For difficulties such as insomnia the framework might not be that helpful. For other areas I suspect clinicians and service users should use it if they both agree it’s useful. For the people who get labelled with Borderline Personality Disorder this kind of thinking is vital.

 
Why is it vital? There was a time that I didn’t think that it was. I was happy to join in with a roll of the eyes and a “typical PD” comment. I could understand that someone was self-harming because they had a personality disorder. Times when I felt attacked or criticised it was easy to label everything as the product of a disordered personality – this left me as a flawless clinician with merely a faulty patient to contend with.
As the years ticked by my experiences in work got me thinking of people with a diagnosis much more as simply people. My work became about helping staff who thought in the way that I used to, to unpick their ideas and see someone in a more empathic way. What I tended to find was that a list of diagnostic criteria had absolutely no impact in how staff thought about and responded to the people in their care. When we could move away from the descriptive (and fairly judgemental) criteria and think about the experiences that people had lived through that might inform how they behaved, then it felt like some empathy could arise.

 

Two examples:
1 Looking through someone’s notes I read “Mandy went to her room and was self harming due to her diagnosis”. It frustrated me that someone’s thinking could begin and end with that sentence. There was no sense of what was going on in their head. No indication of or curiosity about what they might be feeling. No indication of how people around them responded (apart from the implication that it was dismissed and pathologised). How can we help people if our sole understanding of their behaviour is that they do it because of a particular label?

 
2 I was in a group and someone recounted something that they’d done “because of my BPD”. We spent a decent amount of time exploring how their feelings and responses were entirely appropriate, especially given their early traumatic experiences. The description of overwhelming emotion and the desperate urge to feel something different made a lot more sense and contained more potential for change than “because I’ve got BPD”.

 
It would be easy to say that the above examples are simply people using diagnosis badly. While this is true, there is something that happens in this area of work that means that traumatic histories are forgotten and staff see risky or troubling behaviour purely through the lens of their own experience.

 
“I feel manipulated” = They were manipulating me
“I don’t know why they did that” = They were doing it for attention
She cut herself after ward round = She’s trying to sabotage her discharge

 
To an extent this is understandable (understanding does not mean approval). I was very poorly trained to work with people who had lived through trauma and my understanding is that undergraduate training hasn’t changed significantly. With no knowledge base, the students of today tend to learn from those who also had little training so learned on the job. Combine this with people who cope in ways that can be dangerous (the results of which staff might be blamed for) and you have an environment full of confused, anxious clinicians. This seems to lead to a situation where toxic ideas can flourish with little opportunity for people to learn anything different. A new cycle of treating people as if they were manipulators begins, with people reacting to that hostility and then having their reactions explained by their diagnosis.

 
This doesn’t happen everywhere but it does happen every day. Any tool we can use to stop the thinking shortcuts of “They’re just…” and focus on an empathic understanding of why someone does what they do seems essential for maintaining compassionate care. We can’t validate someone with personality disorder, but we can validate someone whose thoughts feelings and actions make perfect sense given their experience. The PTMF may not be product that means we never use diagnosis again, but let’s not boycott the restaurant because there are a few dishes we don’t like.

 

Keir provides training, consultancy and therapy via www.beamconsultancy.co.uk

11 thoughts on “Forgetting inconvenient truths: A way to keep thinking.

  1. I love your writing. I am diagnosed with BPD and complex-PTSD; the result of an extremely traumatic upbringing. My psychologist is the only person who ever says that my behaviours, thoughts, feelings and reactions are understandable in light of my experiences. But every other clinician says it is “because of my BPD”. Because almost every clinician I’ve worked with had this stance, whether it be explicit or covert; I now am so worn down that I have adopted these explanatory statements myself and notice that I will say things are because of my BPD. I am glad you wrote this article as it’s made me realise I should be careful about how I am slipping into this prejudiced view of myself. I deserve better than to say things are due to my diagnosis. Trauma has shaped me; but I am not simply the diagnoses I have on my clinical notes. Thanks Kier.

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    1. Thank you so much for sharing this with me. It would have been so easy not to and I’d never have known it’s effect on you. I’m sorry that your experiences have been so poor and I’m delighted you can try to carry a different truth to the one staff have put upon you. Again, thank you.

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  2. A great article, Keir. Once I’d met a few people labelled as BPD I began to seriously doubt the value of the diagnosis too, but I remain shocked at how many accept it unquestionably and continue to treat people as if it is the diagnosis which drives the behaviour.

    In recent years I have come to see most psychiatric diagnosis as a form of colonisation. Psychiatry has taken complex human experiences and responses and layered them with crude maps and boundaries and then claimed them for themselves. It is almost impossible to remember it was not always thus.

    Like all colonials, psychiatry views the colonised through their lens of superiority and power over the colonised: biological (they own their bodies); psychological (the power to ascribe meanings to actions) and cultural (the power to comment on them as group).

    As a first step to dismantling this colonial enterprise I agree the PTMF is useful. For OTs though, even better would be to eschew the psychiatry lens entirely and have faith in our own occupational models. That is partly why Ian and I developed the Contexts of Participation critical thinking tool, which encourages exploration of alternative explanations for why people choose to do things the way they do. Getting service users into the classroom to tell their own stories helps too.

    Psychology has started to punch back at psychiatric diagnosis and Occupational Therapy should too.

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  3. “Let’s not boycott the restaurant because there are a few dishes we don’t like…” and let’s also acknowledge there are very real reasons why some people feel the need to boycott.

    Some have come and dined; only to leave in a box or been made to stay despite their wishes and protestations, been force fed with food they do not want – food they found harmful.

    If you are lucky you will get a nice table by the window and service tailored to your expressed needs. There is no guarantee of this and this particular table cannot be reserved, it’s randomly allocated. Eating at this restaurant is risky. You may come and go and only experience it as positive or you may not.

    A lot will depend on whether lady luck is smiling on you…

    (Despite many many years of research and evidence-based practice and NICE guidelines etc, people continue to report being harmed and not helped by services. Resources are an issue, but so too is what is on offer, it’s not just more of the same we need, the stories of harm tell us this.)

    The menu looks good, sounds very inviting in fact. The chef has an unconditional adoration from many. Most who have eaten there, even some that have had their food chosen for them and force fed will say their meal was more than satisfactory, it was pretty great. While others have needed paramedics due to allergic reactions, or something, must be some vulnerability in them, a faulty gene or something. Some die but like any good restaurant with a reputation to protect the bodies will be discreetly removed so as not to interfere with others dining pleasure. Very difficult to criticise because the chef is so widely revered. Complaining too much may get your food spat in, or worse!

    Decent looking menu, on the face of it, some will rave about it, some won’t.

    Eating there seems to be a bit of a roll of the dice…..

    I’ve worked in that restaurant and wouldn’t be too keen on eating there myself. I totally understand that when people are hungry, being fed is what is important. Conversations about the ethics behind the food are not going to be well received by the chef or the diner.

    Attempts to open alternative restaurants in the vicinity have been met with much resistance, sometimes literally run out of town or quickly bought up and subsumed…

    For those who ‘choose’ that restaurant, may lady luck be smiling 🙂

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    1. Hi Nolliag,

      You have inspired me to do a bit of a rewrite because this is the second time I’ve managed to leave someone with exactly the opposite of what I intended. When I suggested we font boycott the restaurant because we don’t like some of the dishes, Inwas encouraging people not to dismiss the PTMF because they found parts of it unpalatable. So often I saw people write things along the lines of “I don’t agree with this bit so I shall dismiss it in its entirety” – which seemed to model the black and white thinking the service users get accused of.

      Thanks for helping me with this, all of the thought you put onto the reply, especially the extended use of my metaphore.

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  4. Thanks for reply Kier, I understood the menu to be DSM/ICD and you suggesting that PTMF was a good fit for those with BPD diagnosis, only. I ought to have checked your meaning before replying. Thanks for clarifying.

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  5. Thanks Keir. So much training is badly needed esp for nurses in mental health. Here in Ireland they don’t seem to have any training in trauma and how it presents…mind you,neither do the OT’s. They just don’t get it and it is doing more harm than good. It is serious.

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    1. I will happily bring training to Ireland. ☺
      You’re right though, if people “don’t get it” they have to invent a story that makes sense – because they’re attention seeking etc, – if we stop thinking about people we shouldn’t be surprised if we then do the unthinkable.

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  6. Emmeline Pankhurst was prominent in the white feather campaign which was intended to shame men into being fighting, and inevitably dying, killing or being horrifically injured in war, so hardly someone to celebrate as she deserves no respect whatsoever.

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