Philosophy, Psychiatry, & Psychology

The Concept of Illness

The implicit perspective of the PTMF regarding mental illness appears to be Szaszian. If there is an identifiable pathology, then something counts as an illness or disease and if there is not then these experiences are not illnesses but forms of "emotional distress, unusual experiences and troubled or troubling behavior" that do not belong in the medical domain. There are two claims here. First, that the proper domain of medicine, and psychiatry as a branch of medicine, should be the realm of disease, or more accurately of illnesses that can be reduced to diseases. The second claim is that most experiences of mental distress cannot be reduced to organic disease and thus should be excluded from the medical domain. I will concentrate here mostly on the first claim, because if we can reasonably claim that medicine has a broader remit than the PTMF argues, their second claim will be superfluous.

The PTMF treats medicine as an endeavor that is primarily focused on identifying illnesses as diseases. It does not distinguish between concepts of illness and disease but there is a long-standing distinction between the two; the concept of disease refers to conditions that can be identified as physiological dysfunctions and the concept of illness to the subjective experience of ill health (Carel, 2018, p. 1). Kleinman (1988, p. 253) has argued that medicine is concerned both with controlling physical disease and with the care of the subjective illness experience. Ward (2020) notes that medicine has often been primarily concerned with the reduction of disease to illness, with notable success. However, this success has come at the expense of the focus on caring for illness experiences that are particular, culturally bounded and not reducible in all cases to instances of organismic disease. Medicine deals with a range of illnesses without identifiable disease (e.g., chronic pain, fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, alongside most psychiatric presentations). Camille Kroll (2021, p.537) has estimated that up to 30% of non-psychiatric presentations in primary care concern such illnesses-withoutdisease. Joseph Dumit (2006) has conceptualized these as "illnesses you have to fight to get". These illnesses are often stigmatized for their lack of "reality," because of the impossibility of a reduction to disease. However, such a view reduces the complexity of the relationships between illness and disease. Sharpe and Greco (2019, p. 185) write that:

The relationship between illness and disease is neither necessarily symmetrical, nor hierarchical; rather they index different realities, which sometimes correlate and sometimes do not.

The PTMF briefly acknowledges such complexities but is committed to the idea that illnesses must be reducible to diseases to be verifiable. Johnstone & Boyle (2018, p. 24) write that:

there is a great difference between a diagnostic system with social elements but also much that can be independently validated, and a system of functional diagnoses more or less entirely based on subjective social judgments.

With such an approach, the PTMF is committed to a biomedical view of medicine and downplays the concept of illness in favor of a concept of disease. Szasz's critique of the mental illness concept is famously based on the argument that if an illness is to count as an illness it must be reducible to a disease, namely to a physiological dysfunction (Szasz, 1960), and the PTMF is largely in accordance with this position.

The PTMF perspective on medicine downplays the aspect of care for the illness experience as a key role of medical endeavor. However, if we accept that medicine can and should focus on caring for the suffering of the ill person, even in the absence of disease, then the argument that all illnesses must be reduced to disease in order to count as an object of medical concern is questionable.

This is not to claim that mental illnesses are illnesses like any other. Being stricken with a form of cancer is a meaningful event in a person's life, but the cancer itself is not a site of meaning. The person does not interrogate the somatic event of a cancerous tumor but reflects upon its impact on their life. However, in mental illness, the illnesses themselves are a site of meaning. What it means to experience depression or psychosis is fundamentally related to an experience of a person as a human being. Karl Jaspers (1913/1997, p. 18) [End Page 55] recognized this over a hundred years ago when he referred to the "somatic prejudice" within psychiatry that tends to privilege only anatomical answers to the questions of mental illness. However, the problem of psychic illness does not need to result in an elimination of mental illnesses from the medical realm. Such an elimination only reinforces a narrow biomedical perspective across the whole of medicine rather than understanding the need for an emphasis on attention to and care for the illness experience in its own right. Attention to the illness experience as an experience that is no less real than disease and is not necessarily reducible to disease opens medicine to a practice that focuses more on the person than the body alone.⁴

The claim that medicine is concerned with disease alone has been challenged in philosophy, psychiatry, sociology and anthropology of medicine for many decades and this challenge relies on an understanding of illness and disease as separable but related concepts that interact in complex and often indeterminate ways. It is also reflected in ordinary language use that mostly refers to mental illness rather than the more antiquated mental or nervous disease. As Sharpe and Greco (2019, p. 186) note, the complex dialectical relationship between disease and illness does not mean that illness should always be reduced to disease or that the presence of disease indicates a "more fundamental (or more 'real') reality."

In the literature on philosophy of psychiatry in the last 30 years a range of positions have been outlined which argue that mental illnesses cannot be considered as diseases but can nevertheless be conceptualized as illnesses or disorders. As Derek Bolton (2010, p. 332) has argued succinctly:

if we give up trying to conceptually locate a natural fact of the matter that underlies illness attribution—then we are left trying to make the whole story run on the basis of something like 'distress and impairment of functioning.'

This approach has produced a spectrum of philosophical positions on the nature of mental illness that runs from more constructionist to more naturalist accounts; pragmatic accounts of mental illness as socially mediated and culturally defined experiences (Bortolotti, 2020; O'Connor 2017); intrinsic accounts of mental illnesses as based on suffering (Rashed & Bingham, 2014); enactive accounts that argue mental illnesses are disorders of sense-making (de Haan, 2020; Nielsen & Ward, 2020); hybrid accounts that argue that mental illness is objectively defined through evolutionary accounts of behavioral responses alongside intrinsic accounts of suffering (Wakefield, 1992, 1997). The PTMF largely ignores the complexities of the relationship between disease and illness and deploys the concepts as unproblematic synonyms.

However, the description of mental distress given by the PTMF does entail a concept of dysfunction that looks very like many accounts of illness, although it does not use the language of dysfunction. The authors argue that the experiences labeled as mental illness are best understood as adaptive responses to forms of threat, particularly traumatic/adverse events involving a misuse of power. Therefore, what are labeled as mental disorders are, in fact, survival strategies. This is the normalizing move; emotional distress is an understandable reaction to adverse/traumatic events. However, there is a further judgment of dysfunction. These strategies have now outlived their usefulness. The survival strategies are now experienced as causing problems in living once they outlast the initial set of adverse circumstances. However disavowed, this is still a judgment of psychopathology even if displaced from a medical framework. As the PTMF authors write:

these evolved survival strategies are essentially protective, although likely to be seen as 'pathological' if prolonged beyond the original circumstances.

(Johnstone & Boyle, p. 186)

According to the PTMF, these are survival strategies gone wrong and they have gone wrong because they are producing some form of dysfunction and not protection; they inhibit the person from living their life or they cause the person to be a pain to others, namely "troubled or troubling" behavior. Cromby (2022, p. 51) clearly articulates this notion of distress:

PTMF does recognize that the meanings made by people in distress are often unhelpful. The kinds of meanings typically associated with clinical paranoia, for example (which may be associated with various psychiatric diagnoses, including schizophrenia), are frequently stigmatizing, [End Page 56] frightening, hinder access to employment, impair relationships and foster social isolation. Similarly, understanding oneself as helpless, worthless or powerless in the face of challenges is likely to be associated with lower mood, can diminish motivation, and may impact negatively upon life and relationship opportunities.

The range of issues here related to intrinsic feelings of suffering, inability to function socially (through access to employment and maintaining relationships) and loss of motivation are very similar to psychiatric definitions of mental illness.

The overall PTMF account does not diverge extensively from the influential concept of illness developed by Jerome Wakefield. Wakefield (1992, 1997) argues that mental distress can be conceptualized as a dysfunction both because of the felt distress of the person and because of an objective breakdown in natural functioning, drawing on evolutionary theory to give an account of what natural functioning means. The PTMF accepts important cultural and social mediations, such as shame, in the expression of mental distress but is wedded to an objective argument for harmful dysfunction as embedded through evolutionary theory; there are survival strategies to forms of threat that can become maladaptive in modern society. As Johnstone and Boyle (2018, p.9) state they are constructing a framework "based on universal evolved human capabilities and threat responses."

However, the PTMF has very little to say about how these judgments of dysfunction will arise once they are dislodged from an illness context. The authors write that threat responses can no longer be needed or useful (Johnstone & Boyle, 2018, p. 18) or that people can be sensitized to "options they may have overlooked" (Cromby, 2022, p. 51). However, there is very little understanding or reflection on the value-laden grounds that enable such judgments of dysfunction and how they might produce institutional difficulties and power relationships even if such judgments are somehow dislodged from a medical context.

The PTMF is committed to a theory of explanation based on the contention that all mental distress is an outcome of traumatic/adverse events. Based on such an explanatory theory (that, in a positivist way, the authors argue is in conformity with evidence) they believe there is a need for a transformation in conceptualizing distress that prioritizes understanding meaning and negotiating the consequences of adversity/trauma. The PTMF does not claim that the relationship between adversity and distressing experiences is straightforward. The authors generally prefer the language of adversity or adversities rather than trauma, as they want to stress multiple and mediated threats that can be cumulative and not reducible to one event. This argument adds a welcome complexity (although it is occasionally undermined by other claims in the document as we will see later). However it raises problems for the evaluative judgment of mental distress. Johnstone and Boyle (2018, p. 201) argue that threat responses to multiple adversities can take an "unusual or extreme form that is less obviously linked to the threat." Survival strategies are therefore complex, and can be unusual and extreme, and in response to multiple and often occluded adversities. Such unusual and extreme responses can persist beyond the originating adverse circumstances; the responses can become "problematic in their own right" (Johnstone & Boyle, 2018, p. 202). This all seems nuanced and fair, but it raises a question for the judgment of whether someone is mentally distressed or not. If it is not immediately obvious what the precipitating set of events are that cause the distressing experiences and the person themselves may be engaged in an "unusual and extreme response" that is not immediately understandable, then the "troubled and troubling behavior" demands an evaluation of their experience as disordered, as not fitting, as extreme and unusual, as abnormal in one way or another. The PTMF authors also recognize that judgments of distress often take place in the absence of a personal complaint; distress is not always defined by the person themselves, as Cromby (2022, pp. 41–42) recognizes when he writes that the PTMF:

specifically addresses distress, troubled or troubling behavior … this is important because some of those who fall within the remit of services or professional interventions will not themselves be distressed, but will be distressing or disturbing to others. [End Page 57]

The PTMF characterizes itself as a sense-making discourse that is against evaluative judgments. One of the central problems with psychiatry, according to the PTMF, is the reliance on subjective evaluations in assigning diagnostic criteria:

clinicians have to rely almost entirely on subjective judgments and social norms both in devising diagnostic criteria and in trying to match people's feelings and behavior to them.

(Johnstone & Boyle, 2018, p. 24)

However, for a judgment of distress, the PTMF will rely on the same norms; assessing whether experiences and behavior are dysfunctional, cause suffering for the person and for those around them and, in some cases, that they are ostensibly unusual or extreme. Throughout the document, Johnstone and Boyle (2018, p. 316) use the example of grief as a possible way of illuminating mental distress. Reactions to personal loss in grief are largely not pathologized because they are tied to an event that is understandable and that produces a set of socially sanctioned responses. They argue that most forms of mental distress can be conceptualized in this way. However, the acceptance that threat responses are produced that do not link clearly with an identifiable event and that are often extreme and unusual in themselves complicates this picture. For example, the analogy of psychotic experience with grief only works to a certain extent because adversities are multiple and often occluded in psychosis, whereas they are specific and obvious in grief. Once the question of adversity as an etiology for mental distress is complicated, as it should be, then there is a demand for a complex set of evaluative judgments that are involved in ascribing distress. It is not as simple as the analogy with grief promises, as there is no specific event to immediately point to which is causing the distress, and the distress itself is not immediately understandable within the space of reasons as a response to adversity.

To be clear, the problem here is not that the PTMF fails to unfold a value-free concept of mental distress (this is impossible) but that it fails to give any account of how it produces its own judgments of distress. When it does try to briefly articulate such judgments, they start to look very similar to many standard definitions of mental illness/disorder. The rhetorical claim to drop the disorder which adherents to the PTMF use as a mobilization against psychiatric practice is hollow because the PTMF remains tied to a concept of mental distress that relies on judgments of disorder and dysfunction; namely that threat responses, that are often highly mediated and uncertain in etiology, can outlive their usefulness, and sometimes call for and need professional intervention. However, there is no account given of how one identifies such distress as distress within the PTMF.

Meaning: Experience as Functional Adaptation

I will now move on from the question of illness to the problem of meaning. In an interesting and important clarificatory article, John Cromby (2022) outlines the concept of meaning that is central within the PTMF. Cromby (2022, p. 43) helpfully outlines four kinds of meaning. First, the theme of individual significance (concerned with the core self and feelings of value). Second, higher values or spiritual meaning. Third, a notion of connection and interdependence (with others and the environment) and finally a multidimensional notion relating to how meaning emerges from biology and culture. Cromby argues that the idea of meaning in the PTMF only loosely relates to the final two themes of meaning. In fact, the idea of meaning in the PTMF could be described as a notion of purposive coping, a form of meaning that does not:

necessarily express a core self, flow from feelings of value or purpose, or have notable spiritual or existential connotations. Instead, meaning arises constantly within activities such as commuting, working or relating.

(Cromby, 2022, p. 43)

This concept of meaning is essentially bound up with the ways that we pre-reflectively grasp and respond to the world as adaptive organisms in order to achieve functional goals; as Cromby notes, it does not preclude larger aspects of meaning, but neither does it require a negotiation with them.

In her book Enactive Psychiatry Sanneke de Haan draws a distinction between two different types of sense-making that she terms basic and existential sense-making. Her account of basic sense [End Page 58] making is an account of functional adaptiveness very similar to Cromby's concept:

Basic sense-making involves discerning the relevant aspects of the present environment; recognizing food, mates, danger etc. It is a submerged sense making of the here and now. The meaningfulness of an environment is a reflection of its relevance for survival: what is valuable is a function of the organism's biological necessities.

(de Haan, 2020, p.60)

The PTMF account of meaning is focused largely on such a functional account. We can understand the function of mental distress as a striving for the self-maintenance and self-preservation of the organism in response to threats.⁵ These are strategies for surviving adversity which can become problematic once the original threatening adversities are no longer present. Johnstone and Boyle (2018, pp. 202–203) outline a range of "forms of reaction and behavior" that include emotion regulation, self-protection, control, attachment seeking/protection from attachment loss, preserving identity, preserving social group identity, self-soothing, distress communication and finding meaning and purpose. Most of these responses are conceptualized as behavioral reactions to threat; it is only with the question of meaning and purpose that a larger concept of experience and meaning enters the picture.

However, Sanneke de Haan (2020, p. 60) supplements her account of basic sense making with an existential account of meaning:

The meaningfulness of our worlds and the values that guide our actions, surpass the functional, the life-maintaining: with stance-taking, a different kind of values emerges, we could call "existential values" … the existential stance thus affects even the basic, life-maintaining values.

It is important not to conceptualize these two forms of meaning-making as separate or as though existential sense-making is "added on top of" basic sense-making (de Haan, 2020, pp.59–60) but that our experience is thoroughly and immediately immersed in both basic and existential sense-making, all the way down, to adapt a phrase of John McDowell (2007, p. 338). When we respond in the situations that Cromby discusses we are not responding just as functionally adaptive beings but as existentially involved beings, and such existential involvement is distinctive for the ways that we might go astray in the world. The core account of experience, as presented in the PTMF is a reduced enactivism that downplays this idea of existential sense-making. It is important to note that, for de Haan (2020, p. 142), it is the aspect of experience she terms existential that is most important for understanding mental distress.

To conceptualize mental distress as purely a threat response to the negative operation of power reduces experience to a set of determined reaction formations and does not enable an understanding of how existential responses in mental illness can encompass a range of experiences that cannot be reduced to self-maintenance and protection. If we return to the example of grief that Johnstone & Boyle use throughout the PTMF as an exemplar of mental distress, de Haan (2020, p. 206) contrasts grief with depression. She argues that in grief there is an appropriateness of sense-making that enables a relationship to the world. Suffering makes sense as a response to identifiable loss. However, in depression there is a blockage of any relationship to the world, an inability to relate to the world as the suffering is no longer attuned to a sense of being-in-the-world but a loss of a meaningful engagement.

Such a notion of a loss of being-in-the-world has been articulated in the tradition of phenomenological psychiatry that understands mental distress as alterations in core modes of experience (Broome et al., 2012). This tradition conceptualizes mental distress through an understanding of fundamental alterations in the lived world of persons; changes in experiences of space, time, objects and other people. These are alterations in the core structures of experience that cannot be reduced to a threat response although there may be interesting similarities to be drawn with such responses. This loss of a sense of self is deeper than any survival strategy and affects basic structures of the self; it often results in experiences and behaviors that are not obviously functional or adaptive. The sense of belonging in one's body, and ownership of one's thoughts can be compromised. This is the way in which an existential anomalous experience can affect even forms of basic sense-making. The [End Page 59] PTMF does not reference this psychiatric tradition of understanding mental distress but sticks to a reduced account of threat responses as the basis for conceptualizing meaning. This means that the primary understanding of experience in the PTMF is reactive and behavioral, which is slightly peculiar from a document that one expects to be more immersed in hermeneutic and phenomenological traditions.

There is an emphasis on narrative accounts and sensitivity to biographical understandings in the PTMF but it is strangely tacked on to the central discussion of experience; as though existential sense-making could be just added on top of basic sense-making and that narratives are just a post-facto reconstruction of basic adaptive experiences that are not always already imbued with interpretation and stance-taking and that cannot be exhaustively understood in terms of functional goals. The PTMF appears to take a perspective on experience that separates a core "non-verbal" set of responses that are then later reconstructed with more reflective stance-taking, language-based approaches. Johnstone and Boyle (2018, p. 209) write that:

Language-based responses such as imagining, anticipating, ruminating, reflecting, interpreting, evaluating can all interact positively or negatively with other responses. Sometimes people will inadvertently set up reinforcing cycles of meaning which feed back into threat responses, and create self-fulfilling prophecies. Alternatively, we can use our reflective language-based skills to create new narratives and meanings that will help free us from these cycles.

Such an argument separates a primary experience from its later articulation in a linguistic reflection on that experience. However, the idea that there are experiences that are not always already mediated by language is a notion that hermeneutic and phenomenological thinkers contest. Even our fundamental bodily responses are marked by an openness to the world that is characterized by existing within language and within a space of culture and meaning. This does not mean that there is not an important process of reflection upon experience, but that such a reflection is always layered upon a core experience that is mediated through and through by what McDowell (2007, p. 345) terms "mindedness"; an openness to the world based on our conceptual capacities. The PTMF does write about this understanding of meaning but tends to revert to a separation between a notion of a fundamental bodily responsiveness and a post-facto conceptual reconstruction of that core experience as two supposed separate realms when discussing adversity and threat responses.

Interestingly, the argument for a core experience imbued with conceptual capacities is mobilized by Sass and Woolfolk in their critique of Donald Spence, whose work is used by the PTMF to structure their understanding of narrative truth. Sass and Woolfolk (1988, p. 435) write that:

In the view of hermeneutic philosophy, immediate experience is imbued with organization and meaning, with linguisticality, and with social or cultural patterning—characteristics intrinsic and not to be thought of (as Spence does) as later accretions or projections that transform more primary raw material.

The same critical complaint could be leveled at the authors of the PTMF. They construct a concept of experience that separates a primary, determined and reactive set of responses to the environment that is only later patterned by reflective stance-taking, rather than understanding how an existential and minded openness to the world will characterize even pre-reflective experience, and such experience cannot be reduced purely to a set of reactive responses.

Meaning: the Problem of Interpretation

When it comes to a collaborative form of sense-making or a hermeneutic aspect of meaning, there are further issues with the PTMF. The PTMF argues that all forms of mad speech can be made intelligible; there is meaning in madness. The authors argue that the inability to understand in psychiatry is a product of the limited "knowledge, imagination or empathy" of the interpreter (Johnstone & Boyle, p. 25). However, there is no clarity from the PTMF about what intelligibility means when faced with unusual beliefs. As Gipps (2010, p. 556) writes we can trace a functional [End Page 60] or symbolic account of why strange experiences and beliefs arise, but this does not necessarily facilitate an understanding of "what it would be to believe them." Jeppsson (2021, p. 235) writes that full intelligibility when faced with unusual beliefs demands both "grasping what it was like for the other, and, if applicable, their reasons." However, she accepts that the demand for such full intelligibility faces challenges when dealing with psychosis; "a person can be far from fully, but still somewhat, intelligible to me" (Jeppsson, 2021, p. 235).

Johnstone and Boyle (2018, p. 250) do write about the impossibility of a final understanding or narrative. However, they are unclear about the process of making sense out of madness, of how intelligibility arises. On the one hand, there is the statement that:

so-called abnormal behavior and experience exist in a continuum with 'normal' behavior and are subject to similar 'rules' of understanding and interpretation.

(Johnstone & Boyle, 2018, p. 33)

However, there is never an elaboration of these supposed rules of understanding and interpretation and how one understands mad speech in a similar way to normal speech, so it is difficult to know how this process of intelligibility takes place. Elsewhere, there is an argument that when confronted with strange formulations and ideas, the interpreter is not dealing with a normal situation of intelligibility but one that is more complex and demands a form of deciphering:

To give an example: elements of service users' narratives may be completely implausible in terms of conventional evidence (for example, a belief that they are being tormented by the voice of the devil). In such situations, therapy often consists of a slow process of negotiating a different, less disabling narrative, which is equally unproven and unprovable—perhaps that the 'devil' is really a manifestation of unresolved abuse by a perpetrator. Or perhaps the person may be able to draw on a different metaphor within their own cultural belief system. In time, this new story may acquire narrative truth and may thus help to open the person up to new ways of understanding and managing their distress.

(Johnstone & Boyle, 2018, p. 201)

This example is perplexing for many reasons. First, it begins in ununderstandability and a pathologizing approach. A person is not able to say, "I am being tormented by the voice of a devil" and have their experience taken seriously, because this experience is "implausible," beyond the space of reasons. This means it cannot be discussed on its own terms. However, rather than working within the framework that the person brings to the encounter, we are encouraged to reframe the statement about the Devil in other terms; less "disabling" terms.⁶

Therefore, we begin with an evaluative judgment (this is beyond the realms of understanding and is a dysfunctional belief) and then translate the experience to a more normal, more functional understanding that will aid intelligibility. Intelligibility and a normalizing approach work hand-in-hand. In order to be intelligible an experience must be reframed within an approach that is acceptable in the space of reasons. This involves ascribing the initial statement (tormented by the voice of the Devil) to the realm of metaphor. This is not really happening to you but is representative of something else. There is no acknowledgement that the ascription of metaphor needs to be verified with the person experiencing the voice of the Devil. If the person denies that they are speaking metaphorically in this situation, then we fundamentally misunderstand and disrespect them by stating that they are using metaphors. Of course, it may be that at a later point the person is able to view these experiences as symbolic of something else, but this is already a transformation of the experiences to a realm of rational retrievability.

Following the denial of the intelligibility of the experience, and the casting of it into the realm of metaphor, we then redescribe it in terms that are more amenable to the PTMF; either as a complex psychological response to abuse or we find a more acceptable belief from the person's cultural background that is less "disabling" in our eyes. What is puzzling is that such a redescription does not depend on any unveiling of the reality of a set of adverse circumstances underlying the strange beliefs as the alternative hypotheses put forward in the therapeutic encounter are "equally unproven and unprovable." However, these alternative hypotheses [End Page 61] acquire a form of "narrative truth"; they become acceptable and meaningful to the person involved and the therapist.

The process of sense-making is not just dependent upon listening to narratives but is structured through a professional formulation of such stories into a completed meaning by the production of hypotheses of causes for behavior and experience.⁷ There is a recognition that such formulations are always, of necessity, incomplete and provisional (Johnstone & Boyle, 2018, p. 250). However, a formulation differs explicitly from a narrative due to its professional immersion in a body of evidence, which can be taken to the person in distress as a hypothesis to be tested (Johnstone & Boyle, 2018, p. 251). This is a positivist account. A person is shown a hypothesis for their peculiar experiences based on established evidence.

However, the strength of the hypothesis depends on its fit for the person and the professional. So, there is a supplemental element of pragmatism to the positivist evidence; the hypothesis needs to be useful to all involved.

Finally, a coherent narrative truth is constructed that may or may not be in accordance with the facts. Drawing on Donald Spence's distinction between narrative and historical truth, Johnstone and Boyle (2018, p. 252) argue that to some extent, narratives will remain independent of facts. Here we have a peculiar radical coherence view of truth. The interpretive process begins with the positivist hypothesis that it is often the case that people who hear voices from the Devil have experienced unresolved abuse. We then move to the pragmatist perspective of a narrative fit. Finally, there is the peculiar statement that it does not matter whether this hypothesis is in accordance with any objective facts but it can acquire a narrative truth. The interpretive process appears philosophically and ethically incoherent. The interpretive process is incoherent philosophically as it draws on a mélange of theories of truth (correspondence, pragmatist and coherence) without reflecting on this or attempting some kind of synthesis. It is ethically incoherent as it appears to be saying that it does not matter if we can prove the reality of a narrative of adversity as long as it makes sense, but surely, for the person involved, whether such a narrative of adversity is recoverable as a real event or set of events is highly important.

Part of the problem is the recourse to Spence's distinction between historical truth and narrative truth, which was originally constructed in a psychoanalytic milieu (Spence, 1982). It is not that Spence thinks there is no such thing as historical truth. However, he argues that in psychoanalytic treatments the primary processes that are being explored are typically pre-verbal and unconscious. For this reason they are unrecoverable in their true forms. However, it is not clear that even if the distinction between two kinds of truth holds in psychoanalytic treatment, that it can survive the transposition to the kind of psychotherapeutic formulation that Johnstone and Boyle reference.

The demand for intelligibility is a process imbued with power. It refuses to listen to madness as madness and then redescribes experiences as metaphors and only acceptable when they enter a consensual framework. This is not a medical approach (it is not based on the person accepting they have an illness) but it is overtly pathologizing and demands an insight of a different kind; that what the person is experiencing is not real and needs to be reframed and redescribed.

On Jeppson's definition of full intelligibility, the understanding arrived at does give us an understanding of the reasons for the strange beliefs and experiences, although the construction of those reasons is imbued with the power of the interpreter, and there is no real account of how we arrive at these reasons. However, with her second criterion for full intelligibility, there is certainly no sense of what it is like to experience the voice of the Devil. The problem of ununderstandability is not solved here but put into a liminal space, a space which cannot be accepted or lived with, but only redescribed as a narrative truth that is mutually acceptable. Such a conception of narrative truth, untethered from a grounding in reality, is wielding a great deal of power here.

The Question of Power

Finally, I want to consider the question of power. As I wrote earlier the focus on power is the great strength of the PTMF. Boyle (2022, pp. 30–33) [End Page 62] outlines three broad frameworks of understanding power in the PTMF. First, there is an ideological concept of power that functions as a way of masking the social contexts and determinants of distress, specifically through an individualizing gaze within medical frameworks. The ascription of medical diagnoses tends toward a focus on a person having an illness which is located individually and not related to their experience or wider social determinants. These perspectives become so hardened that they form a "second nature," particularly as power is "coalesced" in institutions (Boyle, 2022, p. 32). This account of how power functions in an exclusionary way is a very important critique of how mental distress is societally constructed.

Second, the PTMF takes a particular element of Foucault's account of disciplinary power to demonstrate how notions of self-policing and self-surveillance are incorporated into the formation of subjective identities. Power infiltrates subjectivity to the extent that it becomes part of our bodily responses. The sections of the PTMF on how racialized and gendered constructions of subjectivity impact on self-formation and on the cultural impact of feelings like shame are very important and often not acknowledged in psychiatric literature.

It is the third, more liberal account of power that is problematic and that tends to predominate within the PTMF because of the centrality of the concept of threat. This account of power concerns the negative impact on a person's ability to meet their core needs due to a range of "aversive and threatening" contexts (Boyle, 2022, p. 36).⁸ It is these threats that trigger survival responses that then outlast the initial aversive context thus causing mental distress. This is, of course, a very important account of power. However, the focus on the concept of a threatening event tends to simplify a pluralistic understanding of how power operates in people's lives. The question "how is power operating in your life?" does open up an inquiry into a wide range of sources, but when this is narrowed to a focus on "what has happened to you?", then it tends toward a reductionist approach that focuses on particular events.

This reductionist account becomes clear when Johnstone and Boyle (2018, p. 200) point to the diagnosis of complex post-traumatic stress disorder that they argue could serve as a hermeneutic model for all mental distress. This diagnosis relates to a reactive form of distress that occurs in response to an event or series of events that are experienced as "extremely threatening or horrific and from which escape is difficult or impossible" (cited in Johnstone & Boyle, 2018, p. 201). John-stone and Boyle (2018, p. 201) point to a range of experiences, some of which are conceptualized as disorders (e.g., post-traumatic stress disorder) and some of which are largely not (e.g., grief) and argue that these are responses to adverse psychosocial events. They then argue the following:

Our argument is that the great majority of the experiences that are described as symptoms of "functional psychiatric disorders" (and many other problems, including some examples of criminal behavior) can be understood in this way, but with no assumption of mental disorder, once the meaning-based threats have been identified and their links with the protective threat responses restored.

(Johnstone & Boyle, 2018, p. 203)

The problem with this approach is that it tends to produce a simplistic explanation for all forms of mental distress. The complexity of the vast range of forms of mental distress can be largely reduced to the search for precipitating events of threat and adversity that produce survival mechanisms. Boyle (2020, p. 3) argues that "causality in relation to distress and troubling behavior can best be understood as highly probabilistic," but this statement seems to be ignored in the conceptualization of mental distress as largely an outcome of adverse events and threat responses. Johnstone and Boyle (2018) argue repeatedly that adversity should not be reduced to trauma and that multiple and often occluded adversities cannot be reduced to specific events. However, they also constantly revert to the example of grief or the example of post-traumatic stress disorder which then drives a narrative of specific threat responses to specific events. This is a problem as they claim their narrative will work for the "great majority" of the experiences currently classified as functional mental disorder. In order to do this, the concept of threat used oscillates between an inflated concept that includes a range of societal adversities, and a more specific [End Page 63] and usual use of the term that refers to responses to specific events. The latter use of the concept of threat produces a simplistic reduction of all mental distress to threat responses to specific events. However, the larger concept of threat stretches the linguistic meaning of the term to the point where its usefulness as a concept becomes questionable (see Larkin 2018). Discussions of power are useful and important but not all instances of power can be reduced to the notion of threat and threat response.

In their paper, Ritunnano et al. (2021, p. 1) give an example of a person who is convinced that they are at the center of a worldwide conspiracy, whom they name Harry, who describes himself as the "happiest man in the world." Rather than feeling threatened, Harry feels empowered and full of meaning because every day has a heightened significance and importance. The beliefs of the person in the case scenario are highly dysfunctional; they cause problems in relationships and with employment but they are also full of positive meaning and significance. It is difficult to see how this complex experience can be reduced to a threat response without losing some of its experiential richness. The centrality of the concept of threat thus tends to reinforce the fundamental behaviorism of the PTMF. Mental distress is reduced to forms of threat response that are conceptualized as behavioral adaptations to the environment and this downplays important existential and phenomenological aspects of meaning.

The focus on a broad concept of power is vital and very important but the narrowing of the concept of power to the concept of threat tends toward a reductive concept of both explanatory causality and of human experience.

Summary

There are four main problems with the philosophical presuppositions of the PTMF. First, it sets itself up as an approach that is non-pathologizing; however, it has a concept of "troubled and troubling behavior" that entails an account that is very similar to other concepts of mental illness that do not construe it as reducible to organismic disease. However, it does not acknowledge that its own judgments of distress are just as value-laden as those of mainstream psychiatry.

Second, this evaluative judgment of distress is based on a reduced concept of experience, wedded to evolutionary theory, adaptation, and behavioral reactions. The core account of experience within the PTMF is largely a determinist account of survival responses to threats that adds on an ill-formed account of narrativity. There is little understanding of existential sense-making or of the phenomenological structures of experience.

Third, the attempt at making sense of madness does not solve but displaces the problem of ununderstandability. The account of interpretation in the PTMF is an account that is restricted in its epistemic openness to the other person and tends to reduce such an encounter to the framework of understanding of the interpreter themselves, without an acknowledgement of the power involved in such interpretations.

Finally, the PTMF articulates a form of explanatory reductionism; every form of mental distress is reducible to the negative operation of power. Such an approach has a great deal of merit in its attention to the multiple forms of exclusion and violence that people experience daily. However, this broader notion of power tends to be reduced to a concept of threat so that a fated hermeneutic search is instituted for the event or events that determined the survival strategy that later became maladaptive. This notion of specific events ("what happened to you?") can be reductive and exclude a range of factors that might contribute to psychic distress. It also tends toward a simplistic view of direct causation, however, disavowed in the document.