How does the Power Threat Meaning Framework affect music therapy?
Mary Boyle and Lucy Johnstones book A Straight Talking Introduction to the Power Threat Meaning Framework: An alternative to psychiatric diagnosis is translated to Norwegian. This review is based upon the Norwegian translation and the English translation of the review is done by ChatGPT.
What Does This Mean for Music Therapy?
As is well known, there are many stories about how music has been linked to health and therapy throughout history. At the same time, we have seen that those who practice and theorize in the field have always found connections between prevailing views on the causes of illness and health and the possibilities for remedial musical interventions. Now that a new perspective on the causes and circumstances of emotional distress has been formulated, we must once again ask the question: how can music therapy adapt to this?
An Old Discourse
For anyone who has followed the discussion on diagnoses and disease profiles created by psychiatry throughout the twentieth century and prevailing until today, this book offers a refreshingly new and well-reasoned alternative to the biomedical perspective on emotional disorders. A "framework" for power, threat, and meaning (PTM) might sound somewhat convoluted to those of us who are accustomed to various schools of thought in the mental health field. However, this is not about a specific theory or model, but rather a lens that guides how we think about and explore a field – the mental health field – with "the various forms of difficult emotions and behaviors that we call 'mental disorders,'" as the authors write in the introduction.
A New Perspective
The novelty of this text, writes translator and psychiatrist Trond F. Aarre, lies in how the framework does not classify people's complaints, but the causes of their emergence and the circumstances that gave rise to them. These circumstances are related to living conditions, social and economic structures, which in turn involve power relations, something that is detailed in this introduction.
The framework was developed by British researchers in 2018, and the main document itself is available at
The central ideas of the PTM framework borrow from the trauma-informed approach to emotional difficulties. Here, one should no longer ask "What is wrong with you," but rather ask "What has happened to you?" This is because the framework is based on the following assumptions, as quoted from the British document:
· It allows provisional identification of general patterns and regularities in the expression and experience of distress and troubled or troubling behaviour, as opposed to specific biological or psychological causal mechanisms linked to discrete disorder categories;
· It shows how these response patterns are evident to varying degrees and in varying circumstances for all individuals across the lifespan;
· It does not assume ‘pathology’; rather, it describes coping and survival mechanisms which may be more or less functional as an adaptation to particular conflicts and adversities in both the past and present
· It integrates the influence of biological/genetic and epigenetic/evolutionary factors in mediating and enabling these response patterns;
· It integrates relational, social, cultural and material factors as shaping the emergence, persistence, experience and expression of these patterns;
· It accounts for cultural differences in the experience and expression of distress;
· It assigns a central role to personal meaning, emerging out of social and cultural discourses and belief systems, material conditions and bodily potentialities;
· It assigns a central role to personal agency, or the ability to exercise influence within inevitable psychosocial, biological and material constraints;
· It acknowledges the centrality of the relational/social/political context in decisions about what counts as a ‘mental health’ need or crisis in any given situation;
· It provides an evidence base for drawing on general patterns of coping and survival responses to inform individual/family/group narratives;
· It offers alternative ways of fulfilling the service-related, administrative and research functions of diagnosis;
· It suggests alternative language uses, while arguing that there can be no one-to-one replacements for current diagnostic terms;
· It includes meanings and implications for action in a wider community/social policy/ political context.
Medical and Psychiatric Diagnostics
With this framework in mind, we do not use words like "illness," "disorder," "symptom," or "patient," as these imply a medical way of thinking. The book provides a thorough and research-based review of the criticism against the diagnostic system, as reflected in the DSM manual. We are introduced to how medical (somatic) diagnostics are constructed through the identification of objective patterns and signs of bodily problems. The same way of thinking does not apply to psychiatric diagnostics because we have not yet identified so-called biomarkers that could provide precise diagnoses. Biomarkers refer to objective signs such as genetic abnormalities or deviant brain structures or chemistry, the so-called chemical imbalance. Researchers have tried—and failed—to find such biomarkers for more than a hundred years.
What we are left with, then, is that diagnoses are based on subjective assessments and social norms and judgments about what are considered normal ways of thinking, feeling, and behaving. The result is that clinicians disagree on when to make a diagnosis, people can receive multiple diagnoses, or diagnoses provide no explanation, making medications the first choice in treatment and not eliminating stigmatization and discrimination. Instead, diagnoses can remove meaning by breaking the connections between the ailments and our social context and interpersonal relationships, and instead direct attention to what might be "wrong" with our brain and body, write Boyle and Johnstone.
Out with Bio-Psycho-Social and Stress-Vulnerability Theories
"What has happened to you" is the first core question in the PTM framework. It is not surprising that there is extensive evidence for which circumstances and events can create distress and problematic behavior. This includes sexual, physical, and emotional abuse in childhood, neglect, domestic violence, bullying, rape and sexual assault, poverty and low social class, unemployment, and discrimination based on ethnicity, gender, or other factors, living in a country with significant income inequality, having unsuitable housing, living in a high-crime area, and being a refugee. If a person experiences several of these circumstances or repeated episodes, the risk of the distress becoming entrenched increases.
That such conditions can create emotional challenges cannot be explained by bio-psycho-social theories or stress-vulnerability theories—these easily lead us back to biological or genetic explanations, hypothetical chemical imbalances, or inherited factors. Instead, the PTM framework considers power inequality to be crucial for understanding psychological distress. It is through such an understanding that we can provide constructive help and focus on the need for social action and social justice.
Power in All Forms
That power exists everywhere is documented in details—first as biological or bodily power, or as interpersonal power. Biological power concerns the cultural significance of bodily characteristics, such as shape, size, or skin color, which can affect everyday experiences. Interpersonal power deals with the ability to care for or be cared for, support and protection, withdrawing, or withholding love. Thus, interpersonal power, especially in childhood, influences us later in life when we face challenges.
Power is primarily associated with coercion, with the use of physical violence, aggression, threats, etc., to get someone to do what they want. Such negative power is always part of bullying, physical abuse, rape, and sexual assault. Legal power can involve the power to enforce something or be used to protect our rights. However, this legal power can also result in psychiatric measures, such as forced hospitalization, being experienced as harmful by the individual.
Economic and material power concerns obtaining the goods and services we need to maintain our well-being, fulfill financial obligations, and participate in leisure activities. Economic power ensures food, housing, work, transport, education, medical treatment, security, and access to cultural activities.
Regarding the power linked to social capital, it involves access to education and work, qualifications, knowledge, experiences, and connections that make life easier and give a sense of belonging and security. Social and cultural capital makes it easier to access necessary information that helps us handle demanding situations. A lack of such capital can lead to feeling excluded from various services.
Ideological Power
The PTM framework places great emphasis on the ideological power embedded in cultural meanings, language, and discourse. This concerns our thoughts and beliefs, how we should think and feel, how we see ourselves, others, and the world, what we consider "natural" and what is "fact." Here, Foucault’s understanding of how power is embedded in everyday life, social relationships, and interactions, how power creates social norms and standards, identities, desires, and knowledge, is referenced. It can involve desires to be thin, a ‘real man’, to own certain possessions—all of which commercialism plays on in advertisements and social media.
Ideological power helps formulate cultural narratives about suffering. It exemplifies how neoliberal theories and neoliberal policies shape a worldview where we see each other as competitive instead of mutually dependent and connected, and where status is measured by money and power. Neoliberal policies are associated with emotional distress as they create uncertainty in many life areas such as work, income, housing, and community ties, encouraging us to blame ourselves when life does not go smoothly. The PTM framework aims to counteract psychiatry’s tendency to explain people’s distress as individual problems, without adequately connecting this to social and economic solutions.
Power, Threats, and Core Needs
There is much discussion about power and its consequences—how power affects us or the threats it poses. At this point, the PTM framework focuses on our core needs and what happens when such needs are threatened. In short, core needs involve safety, being valued, and cared for in our earliest relationships. However, the list is long and includes having control over one's life, recognizing and managing various emotions, participating in meaningful activities, and having a sense of hope, meaning, and purpose in life.
Threats to core needs can target relationships with others, involve poor physical health, emotional challenges, economic and material problems, poor housing conditions, and more. But they can also concern threats to the ability to acquire knowledge and information, identity, and fundamental values.
Meaning
Central to the PTM framework is meaning-making—the significance we attribute to the life events and circumstances we experience. "How have you understood what has happened?" and "What meaning do you give to what has happened to you?" are key questions addressed in a new chapter. Meaning-making is the glue in this matrix. How we interpret what happens to us, label the experience, and fit it into a specific narrative involves a human perspective where we see humans as meaning-makers trying to understand the world around them.
When meaning is introduced into the framework, it becomes more challenging to create simple cause-and-effect relationships between events and circumstances and consequences in the form of afflictions. Here, various forms of therapy can help individuals see that the meanings they have created about themselves and the world can gradually change. This can mean transitioning from viewing problems as symptoms and survival strategies to seeing oneself as "someone who has overcome great difficulties." The problem with many such therapies is that they do not extend the understanding of meaning to include aspects related to ideological power and social structures.
Threat Responses
There are many ways to respond to threats to protect our core needs. In line with a trauma-informed approach, psychiatric "symptoms" are reframed as threat responses and survival strategies that the body and mind use to protect us from the impacts of stressors we have faced. The body is naturally involved in such responses. Trauma informed practices demonstrate how adversity affects our body, brain, and mind. However, a trauma-informed understanding will not provide simplistic assertions about biological causes such as chemical imbalances or genetic deviations. Findings from neuroscience are used to show how people use reactions or threat responses to keep themselves safe. Within the Trauma informed practice and PTM framework, threat responses can be seen as well-founded and protective.
The book illustrates around fifty such threat responses, including freeze reactions, panic and phobias, hearing voices and suppressing memories, protests and suspicions, intellectualization, hunger and overeating, self-harm and anger, avoidance behavior, lack of hope and trust in the world, rumination, and silence. Threat responses are shaped by available power resources, can sometimes be socially valued, change over time, and vary between cultures. They can have different functions and also operate at a societal level through disasters such as war, slavery, colonialism, genocide, and natural catastrophes.
Main Patterns
The book outlines some main patterns for mental pain and opens up dialogue with many therapies and self-help options. Several chapters present a form of self-help for those struggling with mental health issues or for those who know someone or work with individuals facing such challenges. The starting point is a non-diagnostic thinking, distinguishing it from, for example, cognitive-behavioral therapy and other therapies, although these can be useful. However, many psychotherapies do not emphasize the social context and instead place people’s problems and solutions within the individual. It should also be mentioned that the PTM framework accepts the use of medications but insists that sufficient information must be provided to the user. While aiming for a non-diagnostic approach, it is realistic about the need to preserve the use of diagnoses in the short term, given how integrated it has become in the institutional framework of psychiatry, thus securing various rights for the user.
What About Music Therapy?
As I wrote initially, throughout history, music has always found a place within medical or therapeutic thinking. We also know how (Norwegian) music therapy, particularly community music therapy, has made a mark through a recovery-based practice, as part of medication-free treatment, and through user orientation with the use of experience consultants. This aligns well with the PTM framework.
In a recent article in the Journal of the Norwegian Psychological Association, where PTM framework is presented, it is also highlighted that the framework can be compatible with other psychotherapeutic approaches. There are also several examples of initiatives that build on or are closely aligned with the thinking presented here (Holter, Bøe, and Berthelsen, 2024). It is also mentioned how other elements can contribute to healing, including artistic expressions alongside nature experiences, exercise, and community activism (p. 460).
Boyle and Johnstone also highlight artistic expressions as crucial for the narrative that needs to be (re)written. In the new identity narrative that is to be formulated, the person will need to practice and become aware of the competence embedded in musical skills. Everything that can strengthen and provide power resources must be mobilized. How music can be used to build identity, contribute to emotional regulation, provide self-care, and be used to create relationships with others are essential resources for music therapists to develop. As caregivers, it is crucial for the music therapist to listen to the person's own story, acknowledge their experiences of injustice and power abuse. A core competence for the music therapist is to engage in, interpret, and respond appropriately to others' stories and help users build their own stories.
References
Holter, MTS, Bøe, T.D. and Bertelsen, B. (2024). An Alternative to Diagnoses for Mental Disorders: The Power-Threat-Meaning Framework. Journal of the Norwegian Psychological Association, Vol. 61, no. 7, pp. 454-462.
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