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DCP Annual Conference 2020Symposium: Using the Framework to inform clinical
practice and peer support
Naming power and power abuses: Using the PTMF to inform work with
women survivors of sexual violence and abuse
Gilli Watson Clinical Psychologist Consultant and Trainer with thanks to Suzanne Azer Senior Lecturer Doctorate in Clinical Psychology University of Exeter, Training Lead Exeter PPT Devon
Partnership Trust
The social origins of mental health distress
• Psychology has been rightly criticised for ignoring for too long the social context of mental health difficulties and over focusing on individualised accounts of distress
• this is despite the very large body of research over decades outlining the connections between social inequalities and mental health difficulties
Patel and Keval 2018; Harper 2017; Johnstone 2017, 2000; Scott et al 2013; Brown 2011,2004,1994; Boyle 2011, 2006 ; Smail 2005, 1993; Williams and Keating 2005; Patel 2003; Holland 1991; Williams and Watson 1991
Social inequalities and distress
Feminist and critical psychologists have argued that:
• social inequalities continue to be obscured within and by psychiatry, psychology and mental health services
• this obscuring of inequalities continues to locate pathology within the individual
• such that ‘symptoms of inequality’ continue to be pathologised as ‘symptoms of mental illness’
Jones and Harris 2019; Nnawulezi and West 2018; Patel and Keval 2018; Boyle ,2011; Smail, 2005; Bostock & Diamond, 2005; Johnstone 2017; 2000; Brown 2011, 2004, 1994; Orford1992; Kitzinger 1990; Lorde 1984; Miller 1976; Chesler,1972;
Social inequalities and women’s distress
Feminist psychologists have argued that psychiatric diagnosis :
• systematically pathologises women’s rightful and reasonable responses to unreasonable events occurring in oppressive, dangerous and damaging social contexts
• hides and denies the gendered, racist, classist, homophobic intersecting hierarchies of power that shape women’s experience and pervade inner life
Jones and Harris 2019; ;Nnawulezi and West 2018; Patel and Keval 2018; Scott et al 2013; Herman,2000; Brown 2000; Williams and Watson ; Burstow 1992; Lorde 1984; Miller 1976; Chesler,1972;
The dominance of diagnosis
• yet diagnosis continues to dominate mental health service access and provision
• as Psychologists, we can too readily adopt psychiatric diagnosis and too easily work uncritically with diagnoses as if these have validity despite the many years of critique
• psychological therapy and practice is often organised on the basis of diagnosis – ‘DBT for BPD’
Research evidence : impact of sexual violence and abuse on women’s mental
health
• extensive research over the last four decades identified sexual violence and abuse are major causal factors in women’s mental health distress
Sexual violence and abuse are significantly connected with women’s mental health difficulties across all
‘diagnoses’
• ‘depression’ including post natal depression• self harm and suicidality• borderline personality disorder /bipolar
disorder/emotionally unstable personality disorder • hearing voices and psychosis• drug and alcohol abuse• post traumatic stress • eating difficulties• phobias and ocd
oCatabay et al 2019; Gallo et al 2018; Fonzo et al 2016; Bentall, 2014; Van der Kolk 2014; Scott et al 2013, Varese et al 2012 , Read and Bentall 2012; Brown 2011; Briere 2006;Bebbington 2004, Springer,2003; Noll et al 2003, Read 2003, Santa Mina and Gallop 1998;Polusny & Follette 1995
Higher rates of sexual violence, abuse and distress for BAME and LBTQ women
Women from black and minority ethnic groups and LBTQ women:
• experience disproportionately higher rates of sexual violence and abuse
• experience significantly higher rates of mental health distress following sexual violence
• experience gendered racism and homophobia in accessing mental health services
• BAME women are half as likely to have access to mental health services
Catabay et al 2019; Nnawulezi and West 2018; Sigurvinsdottir and Ullman 2015;Brown and Pantalone 2011
Power Threat Meaning Framework
• draws from broad theory base including critical psychology, trauma theory and feminist theory of power in developing the Framework in which Power is central
• brings together understanding of external structural inequalities with internal processes of personal experience
• the way in which ‘the outside gets in’
• locates power centrally in the understanding of distress
The Power Threat Meaning Framework asks
• 'What has happened to you?’ - how is Power operating 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 experiences to
you? • ‘What did you have to do to survive?’
- what kinds of Threat Response are you using?
The Power Threat Meaning Framework also asks
• what are your strengths?
what access to Power resources do you have?
• what is your story?
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PTMF names key sources of Power
• Power by force or Coercive power - use of violence, sexual violence, aggression or threats to frighten, intimidate or ensure compliance
• Interpersonal power -power within close relationships, the power to look after/not protect, to leave, to give /withdraw /withhold affection
• Economic and material power - the means to obtain valued possessions and services, to control others’ access to resources , to withhold/deny others’ access to resources
• Legal power coercion, or rules and sanctions supporting or limiting other aspects of power, offering or restricting choices
PTMF names key sources of Power
• Ideological power - involves control of language, meaning, and perspective, to identify ‘subordinate’ groups on basis of class, race, gender sexual orientation
• Biological or embodied power - the possession of socially valued embodied attributes eg: physical attractiveness, fertility, strength, physical health
• Social/cultural capital – a mix of valued qualifications, knowledge and connections, often related to class, race and gender, which advantages some social groups and can be passed directly/indirectly to the next generation
PTMF asks: ‘What has happened to you ?’
multiple power abuses in women’s experience of sexual violence and abuse
• Abuse of power by force : use of sexual violence, physical abuse, torture
• Abuse of power by coercion : threats to frighten, intimidate, ensure compliance and to silence
• Abuse of interpersonal power : sexual violence is relational violence – inc by person in close attachment relationship or adult with power to withhold care, withdraw care, manipulate attachment, threaten abandonment
• Abuse of economic power : entrapment by lack of money /resources to leave abusive context; prevented from working, wages taken
• Abuse of ideological power : abuser holds power to name and control language and meaning of abuse; to blame and denigrate ; gendered, racist and homophobic denigration
• threat to life and survival
•profound threat to and contamination of self and identity
•severe physical damage from repeated sexual violence and abuse
• severe pain and chronic health difficulties from physical damage of sexual and physical violence
•overwhelming distress including of terror, shame, sadness, loss, anger
•disrupted traumatised attachments , abandonment, betrayal,
•entrapment in dangerous , damaging contexts
•denigration from racist, homophobic abuse
•threat of pregnancy and forced terminations
Threats experienced from multiple power abuses of sexual violence and abuse
Using PTMF with women survivors of sexual violence and abuse PTMF asks :How did you understand what happened to
you
• self blame: ’I should have stopped it/told someone’
• self hate: ‘my body is bad/contaminated/ I am bad/evil
• self as different: ‘I am not like others/not normal’ profound shame
• defiled identity, racial identity, sexual identity
• self as deserving abuse as punishment, not deserving love or care
• defeated, powerless to stop abuse or escape
• world and people are not safe, dangerous
Using PTMF with women survivors of sexual violence and abusePTMF asks : how did you survive these power
abuses
use alcohol /drugs to numb feelingsself harm to numb/punish selfdissociate : disappear become numbeat a lot/not eat to numb distress/punish self try not to remember, to forget
became fearful and untrusting of othersavoided relationshipstried to find safety in relationshipsstruggled to manage overwhelming distress of terror, shame, loss, anger, confusion
are hear voices, some are comforting others attackingkeep alert, watchful and hyper vigilant experience flashbacks, nightmares, re-living abuse
Using PTMF with women survivors of sexual violence and abuse: PTMF: these mental health ‘symptoms’ are survival strategies and sources of resilience
• ways of managing / anaesthetising emotional pain, shame, violation
• ways of self care , self comforting , soothing
• distraction from intrusive memories, re living , nightmares
• ways of forgetting, dissociating
• as self blame /self punishment
• ways of trying to protect against attachment loss thro appeasement, self silencing
• ways of speaking directly or indirectly about damage experienced
• as ways of trying to protect from danger
Using PTMF with women survivors of sexual violence and abuse
PTMF identifies ‘symptoms’ as sources of strength and resilience
the courage of survivors of child abuse is no different than courage of war veterans; their complex responses no less
they have the right to be acknowledged for their strength,
courage, resourcefulness and resilience
Judith Herman 2000
Identify and name the Power abuses suffered
Rape and sexual violence in childhood and as an adult Physical violence in childhood and adulthoodCoercion, intimidationPovertyNeglectGendered racist violence and abuseHomophobic violence abuse
Identify and name the consequences of power abusesthreat to life thought I was going to diethreat of annihilation of selfphysical damage from rape and physical abusesevere pain, STIs and UTIsentrapment in fear and danger pregnancy and forced abortion/s isolation
How did you understand what was happening to
you?blamed myself
blamed my bodyfelt shamed
felt contaminatedtold I was evil, bad told I deserved it
felt abnormalpeople are not safe
world is not safecant tell anyone
Using PTMF with women survivors of sexual violence and abuse
Identify and validate: what did you/do you have to do to survive: Survival strategies
disappear, go numb, dissociatestay awake, stay alert, be vigilant at all timescut myself to numb paincut myself to manage the shame, anger, despair , sadnessdrink alcohol not eat to numb pain, to punish my body, to disappeartry to forgetkeep myself isolated
Using the PTMF with women survivors of sexual violence and abuse
what are your strengths
I survived/am still alivesafe place to live
have friends I trust don’t harm others
hope
Using the PTMF with women survivors of sexual violence and abuse
create a narrativeI was abused as a child and suffered severe rape violence and emotional abuse throughout my childhood. I was damaged physically, experienced severe pain all the time, had many illnesses as a child and became pregnant. I felt hated and unwanted. I left home at 16 and lived with a boyfriend who was violent and abusive . I left him and was homeless for a while . I had no money and nowhere to live. I lived for a while in another violent relationship. I suffer from flashbacks, nightmares, panic and fear . I blame myself for not stopping the abuse, even though I was only a child. I survive by disappearing inside, cutting and burning myself, drinking alcohol/using drugs. These help me stay alive and manage terrifying feelings of shame, sadness, aloneness and rejection . I have wanted to die many times. I am strong because I have survived and still want to live . I want to go to study and train . I have somewhere safe to live now and friends I can trust.
Using the PTMF with women survivors of sexual violence and abuse
Using the PTMF with women survivors of sexual violence and abuse PTMF: Multiple levels of interventions
for recovery and re/empowerment
• increasing safety : safe accommodation, police protection, legal action
• increasing access to power resources – relational power from help lines, support workers ; economic power access to benefits/employment
• increasing survival strategies – internal and external• trauma processing through therapies – individual and group
• increased access to group/community strength• social and political change
Using the PTMF with women survivors of sexual violence and abuse abuse: Trauma therapies : attention to power processes
Feminist Trauma Therapies Jones and Harris 2019; Brown 2011,2004; Herman 2000; Burstow 1992
• egalitarian relationship : therapy as a cooperative partnership
• minimising power differences while not ignoring power inequalities
• equal value even though not equal power
• careful attention to therapists/workers use and abuse of power, their power to define the other
• woman as expert on her life, as authoritative knower
• reducing shaming and silencing• addressing racist/homophobic abuse• cultural congruence and careful
attention to therapists’ cultural lens • re writing the personal story within
the social and political context • use of power as a resource for justice
and change
Using the PTMF with women survivors of sexual violence and abuse: how is it helpful ?
The PTMF:
• names power and power abuses involved in sexual violence and abuse
• offers an understanding of power and power processes
• links these directly to an understanding of symptoms of distress
• enables a gendered, race and intersectional lens to be added to understand the multiple oppressions women experience
• views symptoms as strategies of resilience and survival
• recommends multiple levels of intervention to enable healing, recovery and re/empowerment
Using the PTMF with women survivors of sexual violence and abuse: how is it helpful ?
• focusing on power and power abuses can reduce the risk of continuing the denigratory misdiagnosis of women survivors of sexual violence as ‘bipolar’, ‘psychotic’, ‘emotional unstable personality disordered’, ‘BPD’
• enables the rightful naming of profound distress from multiple power abuses
• requires careful attention to intersecting power processes in understanding symptoms of distress and strategies of survival and in the process of recovery and healing
• looks also to change in the social context to reduce inequalities and injustice
