Mental health and wellbeing affect every person, be it in their personal capacity or as a friend, family member or caregiver....
COVER STORY
Mental health and wellbeing affect every person, be it in their personal capacity or as a friend, family member or caregiver. As per data collected by the World Health Organisation (WHO) in 2019, 970 million people globally were living with a mental health disorder. Similarly, in 2019, a global burden of disease research study examining disability and mortality across countries and looking at various diseases and injuries found that mental health disorders were amongst the top ten leading causes of disability and mortality worldwide. In Pakistan, a 2023 research publication estimated that mental health disorders affect 10% of the population, amounting to around 20 million people locally.
In view of the impact and prevalence of mental health conditions in Pakistan and the world, it is imperative to better understand the factors that impact mental health. Though many awareness campaigns are focused on biological factors (genes, brain chemistry, physical health), there is a need to address the psychological and social or environmental factors. Awareness of such factors can help a person make sense of their experiences, an important step in healing from distress.
In the last decade or so there has been a growing movement in the mental health field aimed at understanding the symptoms or ‘disorders’ of people with mental health diagnoses in the context of their lived experiences. This is not an entirely recent area of interest: in the 1950s, the French philosopher Michel Foucault theorised that what society deems ‘mental illness’ is actually a label applied by those with power to those they would wish to exclude from society for their deviance from social expectations and norms. Where society once shunned sufferers of leprosy as the socially acceptable hated other, there society now shuns the ‘mentally ill’.
In the 1960s in Italy, Franco Basaglia worked to ensure the closure of mental asylums where he believed people were reduced to ‘non-persons’ for being the ‘deviant majority’, In the 1960s and 1970s, Ronald Laing, the Scottish psychiatrist, proposed that mental illness was ‘not breakdown, but breakthrough’ in that a person’s symptoms carried meaning and were the only ways available to them to cope with unliveable situations. With the introduction of psychiatric medications, diagnostic manuals and biologically focused approaches to causes and treatment, some of the wider social, cultural and interpersonal factors were ignored.
In 2018, the British Psychological Society published the ‘Power Threat Meaning Framework (PTMF)’, which brought together research, clinical experience of mental health professionals, and feedback and input from mental health service users and their caregivers. The PTMF is not limited to being used with or by mental health service users; it is a framework that anyone can use to better understand their life experiences.
It does not aim to nullify or discard psychiatric diagnosis and treatment, but rather aims to offer service users an approach to creating strengths-based, hopeful narratives that highlight links between their mental health, social issues they may have faced, traumatic experiences they may have undergone, and the resulting distress and distress management strategies they may have developed.
There are four broad themes that this framework encourages people to explore. Let’s take them up, one by one:
(1) What has happened to you (or, how is power operating in your life)?
This refers to instances in your life where you may be experienced powerlessness, helplessness or a lack of autonomy. Examples may include childhood adversities such as poverty, physical, sexual or emotional abuse, neglect, violence in the home, the death of a close family member/caregiver, a caregiver who was depressed or addicted to substances, and parental divorce or separation.
Power can also have a negative impact when one belongs to a minoritised or marginalised group facing inequality, discrimination or threat to life and safety (gender, racial, religious based for example). Similarly power differentials exist in social strata, educational differences, being able-bodied or not, being an employer or an employee, being a mental health professional or a ‘patient’, being amongst those who decide what is correct or what is true versus being amongst those expected to obey and a multitude of other forms.
Such differences privilege certain groups, while limiting opportunities for and even actively harming others. The PTMF highlights the following kinds of power that may impact a person’s life:
Biological or embodied power Possessing socially valued embodied attributes, e.g. physical appearance, fertility, strength, embodied talents and abilities, physical health.
Coercive power or power by force
Use of violence, aggression or threats to frighten, intimidate or ensure compliance.
Legal power
Power of arrest, imprisonment or hospitalisation. It refers to a wide range of rules that regulate and control aspects of our lives and behavior.
Economic and material power
Having means to obtain valued possessions and services, to control others’ access to them and to pursue valued activities. This includes housing, employment, transport, education, medical treatment, leisure, legal help, safety and security, and privacy.
Interpersonal power
Power within intimate, caring relationships, the power to look after/not look after or protect someone, to leave them, to give/withdraw/ withhold affection, and so on.
Social/cultural capital
A mix of valued qualifications, knowledge and connections which ease people’s way through life and can be passed indirectly to the next generation in a kind of symbolic inheritance process.
Ideological power
Any capacity to influence language, meaning, and perspective. It involves power to create theories that are accepted as ‘true’; to create beliefs or stereotypes about particular groups, to interpret your own or others’ behavior and feelings and have these meanings validated by others; it also involves the power to silence or undermine
(2) How did it affect you (What kind of threats does this pose)?
This theme is focused on how experiences or power or powerlessness created threats to a person’s, group’s or community’s sense of safety, well-being, core needs or ability to be in the world, and the resulting emotional distress.
Humans as social beings require certain experiences to be able to function healthily in the world. These are considered “core needs”. Core needs that may be threatened by the negative operation of power are:
* To experience a sense of justice/ fairness within wider community.
* To have a sense of security and belonging in a family and social group.
* To be safe, valued, accepted and loved in their earliest relationships with caregivers
* To meet basic physical and material needs for themselves and their dependents
* To form intimate relationships and partnerships.
* To feel valued and effective within family and social roles.
* To experience and manage a range of emotions.
* To be able to contribute, achieve and meet goals.
* To be able to exercise agency and control in their lives.
* To have a sense of hope, belief, meaning and purpose in their lives
When these core needs are met, people can offer their children secure, loving early relationships which then form the basis for optimal physical, emotional and social development and the capacity in those children to meet their own core needs and pass on the same legacy of wellbeing to future generations. However, when these core needs are threatened or unfulfilled, people will develop threat responses which may be maladaptive or harmful to them in the long-term.
Threatened core needs may look like:
Relational: disrupted attachments, abandonment, betrayal, isolation, shaming and humiliation, rejection, hostility, neglect, bereavement, lack of protection, entrapment, threats to boundaries, autonomy/control, self-concept and identity formation, invalidation.
Emotional: feeling emotionally overwhelmed and unsafe.
Social/community: Isolation, exclusion, hostility, social defeat, injustice/unfairness, loss of social or work role.
Economic/material: Poverty, inability to meet basic physical needs, or access basic services for oneself and/or dependents.
Environmental: Lack of safety, physical threat, entrapment, loss of connection with homeland or the natural world.
Bodily: Ill-health, chronic pain, bodily disability, injury, loss of function, physical danger, starvation, exhaustion, bodily invasion.
Knowledge and meaning: Lack of opportunity, support or social resources to access and use important sources of information and make sense of one’s experience; imposition of meanings by social discourses and by more powerful others.
Identity: Lack of support to develop one’s own identity; loss of social, cultural or spiritual identity; the adoption or imposition of devalued, subordinate or shameful identities relating to oneself or one’s social group.
Value base: loss of purpose, values, beliefs and meanings; loss of community rituals, belief systems and practices
(3) What sense did you make of it (What is the meaning of these situations and experiences to you)?
Meanings derived from these experiences of negative power and threats may be certain feelings and beliefs a person or community develops about themselves, their social group/ community, the world, other people and life. These might be beliefs such as “I am inferior”, “Others will always reject me/ hurt me”, “the world is a dangerous place” and feelings such as helplessness, hopelessness, fear, entrapment, overwhelm and loneliness.
People might express these meanings in their words or ways of speaking, but also non-verbally in their body language, movements, dreams and physical symptoms without medical causes such as unexplained tension, pain or discomfort.
The meanings people develop lead them to form a ‘schema’ or mode of operating in the word based on those beliefs and feelings. When people operate from meanings with negative connotations (inferiority, shame, despair) they may behave in ways that set up self-fulfilling cycles that maintain those negative beliefs.
(4) What did you have to do to survive (What kinds of threat response are you using)?
The fourth theme invites people to consider their mental health ‘symptoms’ non-judgmentally and with compassion as survival strategies and understandable threat responses to difficult, painful or overwhelming situations. The PTMF suggests common threat responses such as:
Regulating overwhelming feelings: through dissociation, self-injury, memory fragmentation, bingeing and purging, intellectualisation, ‘high’ mood, low mood, hearing voices, use of drugs, compulsive activity, overeating, derealisation, somatic sensations, or bodily numbing.
Protecting from physical danger: by hypervigilance, insomnia, flashbacks, nightmares, fight/flight/ freeze, suspicious thoughts, isolation, or aggression.
Maintaining a sense of control: by self-starvation, rituals, violence, dominance in relationships.
Protecting against attachment loss, hurt or abandonment: by rejection of others, distrust, seeking care and emotional responses, submission, self-blame, interpersonal violence, hoarding, appeasement, self-silencing, self-punishment.
Many more are included in the official PTMF document available on the British Psychological Society website.
By understanding these actions, usually labelled as ‘mental health symptoms’, as responses to threat and ways of coping with and communicating distress, people can make more sense of their experiences, gain awareness, autonomy, control and choice over the experience of these distressing coping strategies.
The PTMF also recommends that people consider two additional questions: ‘What are your strengths?’ and ‘What is your story?’ The stories we form of our lives can be powerful resources of comfort, strength and courage or painful and debilitating burdens.
