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Using the Power Threat Meaning
Framework to Co-construct
Formulations and Action.
Jan Bostock, Consultant Clinical Psychologist
Nicola Armstrong, Service User and Carer Involvement
Facilitator
and with thanks to Dr Teresa Hagan and Dr Steve Jefferis
BPS Division of Clinical Psychology Annual Conference,
January 2020.
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Today’s talk
“ … it is survivors who understand, through lived experience,
what heals and what harms; and the importance of reversing “power
over abuses.”
Sweeney and Taggart, 2018.
• About us
• Examples of promoting good practice through
- Co-produced training in 5 Ps + Plan formulation
- Understanding What Influences Your Mental Health and
Wellbeing
- Promoting trauma informed practice across CNTW
- Developing Cognitive Analytic Therapy
- Reflections for Clinical Psychology
- Psychologists for Social Change
• The importance of understanding power, assets, threats and
meaning, and what these mean for:
- individuals
- organisational and social change
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Nicola
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Nicola: Where I come from -Community Development and
Co-Production
values and aims:• Value the expertise of lived experience in
mental health
work alongside clinical expertise. In partnership.• Needs led,
collaborative and meaningful involvement in
formulations and decisions• Being heard and having validation is
fundamental• Recognise the importance of strengths and assets
and
not only problems and difficulties• The power of hope • Sharing
knowledge and information and think outside of
the box to ensure we are inclusive. • Celebrate the uniqueness
of individuals• Equal value for all and social justice
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Jan: Where I come from –Community Psychology values and
aims:
Be inclusive, collaborative, co-produceMake a difference to
people’s lives
Promote social justice, prevent sufferingImprove health and
wellbeing
Focus on strengths
• Understand how the social and economic reality of people’s
lives affect their health and well-being
• Join with others with similar experiences to give voice to
this understanding
• Engage in collective action to change these realities
Jim Orford, 2008.
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Impact of CAT re-formulation for Nicola
• Telling my story of how I have got to where I am, why I felt
and respond how I do.
• Having a big picture of the jigsaw of my life, past and
current.
• Making sense of what has happened to me. • Thinking about my
strengths and resilience“Your inner strength and determination has
got you through very traumatic times and got you this far”• Moving
from who can fix me to finding my own power• Validation and
understanding, • From being done to, to co-developing• Finding ways
to move forward• Experience has shaped me, not defined me
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Adapted from Social Action Framework (Holland, 1992)
Collective
Individual
Subjective Objective
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5 P’s + Plan: Course Outline• Two x 3hr workshops over one/two
days.
• Over 1500 staff trained since beginning of 2015
• Team of Experts by Experience and MDT trainers.
• Ethos of training is supportive and co-produced .
• Draws on existing knowledge and experience of staff and
training facilitators.
• Focus on practice and developing skills and knowledge.
• Focus on strengths, service user engagement and alliance
building.
• Supported in pathway meetings and with supervision from local
champions for routine use.
8PLEASE NOTE: do not duplicate or use without prior permission
of author
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Formulation: Quality Checklist
Does this Formulation? Is this Formulation? Was the Service
User?
• Describe the Service User’s difficulties and strengths?
• Take a positive, validating approach with the Service
User?
• Suggest how the Service User got to this point in their
life?
• Explain why change might be difficult?
• Remind us to ask about/includePsychological factors?
• Remind us to ask about/include Social factors?
• Remind us to ask about/include Biological factors?
• Consider the possible impact of trauma and abuse?
• Help plan change?• Suggest how Services may help
and/or hinder?• Link to appropriate goals?
• Sensitive to cultural and contextual factors?
• Sensitive to ongoing pressures in the Service User’s life?
• Personalised?
• Involved in developing this Formulation?
• Involved in choosing between intervention options?
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The P’s
Triggers Triggers that lead to the problem showing itself
now.What set things off? (It might have been a collection of
things).
What was the straw that broke the camel’s back?
What makes
change difficult?
Things that are keeping the problem going.
Is there anything that makes it difficult to address the
problem?
What are the barriers to change?
Is there anything that is helpful in the short term but not so
good in the long term?
Past
factors
Significant background information.
Origins and development of the problems: What has happened?
How did they affect the person? How did they make sense of their
experiences and
history?
Lessons learned to survive?
Positives
What helps?
What strengths does the persons have?
Any good friends or helpful people in their lives?
What resources do they have available to them?
How have they survived and sorted things out before?
Plan
Interventions that might arise from this formulation.
Goals: What does the person want to do to change?
Plans: How are they going to get to their goal?
What? How? Who? When? Expected outcome?
How does the plan affect everyone involved?
Current
issues
The current difficulties experienced.
What is the person ‘bringing’?
What is getting in the way of life at the moment?
Don’t forget to note strengths too… What is going well at the
moment?
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PLEASE NOTE: do not duplicate or use without prior permission of
author 11
What is a formulation?
Formulation
Highlights the service user’s
strengths
Helps plan change
Explains why change may be
difficult
Acknowledges different
perspectives
Describes problem(s) and
survival strategies
Ensures service user is listened
to
Helps ask the right questions
Explains how the service user got
here
Open, always evolving
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What isn’t a Formulation?
• A list (of symptoms, or goals)• A secret from the Secret User•
A summary of the past• A diagnosis• Entirely psychological• Too
complicated to understand• Set in stone• The ‘Truth’
PLEASE NOTE: do not duplicate or use without prior permission of
author 12
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Distress never “just happens”
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It asks:
• What has happened to you?’ (How has Power operated in your
life?)
• ‘How did it affect you?’ (What kind of Threats does this
pose?)
• ‘What sense did you make of it?’ (What is the Meaning of these
situations and experiences to you?)
• ‘What did you have to do to survive?’ (What kinds of Threat
Response are you using?)
• What are your strengths? (What access to Power Resources do
you have?)
• What is your story? (How does it all fit together?)
www.bps.org.uk/PTM-Main
http://www.bps.org.uk/PTM-Main
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Balancing power, threats and
resources
Exercise 2:
Reflect upon your own
exposure and resources
How well balanced
are your scales?
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Exposure Resources
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These are important experiences from the past that mayinfluence
the person’s functioning now and inform an understanding of current
issues
• How did adults treat the person while they grew up?• Were
there important relationships that were supportive and kind?• Were
there any adverse childhood experiences?• Was there verbal,
physical, sexual abuse towards them? • Did they witness:
Parental separationDomestic violenceMental health
problemsAlcohol abuseDrug useImprisonment or incarceration
• How does the person make sense of what happened in the
past?
Past
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permission from [email protected] or
[email protected]
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The positive aspects of a person’s life including -opportunities
for control, predictability, participation, giving and taking,
reliable public services.
Resilience is significantly influenced by the quality of social
relationships.
Social resources - friends, kind neighbours, comfortable
finances, safe and pleasant place to live, secure employment,
leisure facilities.
Biological resources - good health, physical strength, helpful
medication.
Psychological resources - interests, literacy, strategies for
coping, confidence, ability to identify feelings.
Positives
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permission from [email protected] or
[email protected]
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Stakeholders in change
Exercise 4:
• How might they view change?
• How might they get
in the way of change
Family / Carers Service user Organisation(s)Society Staff
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Potential ways forward for
individuals
• Activities (e.g. Walking).
• Problem solving.
• Courses (e.g. Recovery
college).
• Support groups (e.g.
Hearing voices).
• Connecting with
community / friends.
• Signposting (e.g. CAB /
Housing etc.).
• Carer support.
• Psycho-education
around lifestyle
concerns; nutrition,
sleep, alcohol,
drugs etc.
• Medication; advice
and monitoring.
• Normalising. Family interventions.
• Validating. DBT Skills.
• Structured clinical management.
• Promote self-management e.g. WRAP.
• Graded exposure / behavioural activation.
Psychological
Access to
resources
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How do we help service users &
carers to think about impact?
“Understanding what Influences your
Mental Health and Wellbeing”.
This has been produced by people who use and work in
NTW services and some of their supporters. It is already
very popular with carers, service users, and staff. The
booklet aims to help people understand what is important
to their personal wellbeing. It suggests key questions that
may help them to make sense of their strengths and
difficulties as a formulation and support them in moving
forward.
https://www.ntw.nhs.uk/5P
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Please do not copy, reproduce, or share these slides without
permission from [email protected] or
[email protected]
https://www.ntw.nhs.uk/5P
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How PTM framework can influence questions about the past
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How PTM framework can influence questions about triggers
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Trauma Informed Approaches:
Implications for Mental Health Practice
1. Safe places and treatments
2. Privilege Service User accounts
3. Staff understanding
4. Training
5. Asset based approach
6. Facilitate sharing childhood experiences
7. Ensure Services do not re-traumatise
8. Account for social inequalities, and prejudice
9. Partnerships
10. Look after staff wellbeing
11. Appropriate pathways and interventions
Adapted from Sweeney, A., Clement, S., Filson, B. & Kennedy,
A. (2016). Trauma-informed mental healthcare in the UK: What is it
and how can we further its development? Mental Health Review
Journal, 21, 174–192.
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“Reciprocal Roles” - mapping
self, others and the world
• Through repeated experiences in relationships we learn two
roles, and learn to enact them both towards others and to
ourselves.
• E.g. with a memorable teacher…Encouraging
Calm
Valuing
Encouraged
Confident
Valued
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“Reciprocal Roles” - mapping
self, others and the world
Critical
Controlling
Worthless
Rebellious
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Judgemental
Worthless
Inferior
Overwhelming
Overwhelmed
Crushed
Threatening
Threatened
Intimidated
Reciprocal roles associated with inequality, adversity and power
abuse
Envious
Envied
Blaming
Blamed
Abusive
Terrified
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Sharing
Power
Invited in
Connecting
Connected
1:1 work
Systemic
Able to hear
Able to say
Reciprocal Roles “exits”
Asking/naming
in solidarity
Exploring
together
OK to be wrong
Accepting
Determined
Energized
Encouraging
Energizing
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PTM Framework: Implications for
Psychologists
• How do we use power in our clinical practice?
• How do we use power at work, as colleagues and
leaders?
• How do we respond to the use of power in its
different forms?
• How can we join with others to make social and
organisational changes?
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PTM Framework: Implications for
Psychologists
• What threats are relevant?
• What threat responses do we use?
• What threat responses do others use?
• How do we impact on each other?
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PTM Framework: Implications for
Psychologists
How do we make sense of things?
• With reference to our relative positions of power and
powerlessness.
• Our own use of ideological power?
• With reference to threats to ourselves and others and from
ourselves and others.
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Implications for clinical practice• What we do
Formulation• Attend to inequality, the operation of power,
adversity and threats as
well as meaning
• Consider power and resources available to people
• Understand and address the physical and embodied consequences
of adversity and trauma with individuals and systems
Interventions• Ways forward need to account for opportunities
for connection with
others and the promotion of living and social conditions that
are safe and nurturing
• Focus on prevention and beyond individual work
• How we do it– Aim for clarification, care, solidarity and
encouragement (David
Smail)
– Validate and acknowledge unfairness, threats and power
abuse
– Attend to how much we collaborate, power-share
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Psychologists for Social Change
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PTM Framework: Ways Forward Be aware of people’s experiences of
injustice, inequality and
threat.
Continue to elaborate and share understanding of how power
is used, the impact of threat and implications for practice.
Connectedness and collective action across organisations
and agencies.
Challenge disempowering practice or abuse.
Learn, train and develop together, progress co-production
and
peer support.
Foster collaborative research
Share innovative and good practice
Meaningful supervision, mentoring, support
Openness and reflective awareness
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References• Johnstone, L. & Boyle, M. with Cromby, J.,
Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D.
& Read, J. (2018) The Power Threat Meaning Framework: Overview.
Leicester: British Psychological Society.
• Lloyd J. & Pollard R., eds. (2019). Cognitive Analytic
Therapy and the Politics of Mental Health. Routledge
• Ryle, T. (2010). The Political Sources of Reciprocal Role
Procedures. Reformulation, Summer, pp.6-7.
• Brown, R., (2010). Situating Social Inequality and Collective
Action In Cognitive Analytic Therapy. Reformulation, Winter,
pp.28-34.