Not only is it time to abandon psychiatric diagnosis, but it is time to move beyond the medicalised perspective of ‘mental health’. A new framework for understanding how we all cope with distress - the power threat meaning framework - can lead the way to a more honest and effective paradigm, writes clinical psychologist Lucy Johnstone.
The idea that people experiencing various forms of emotional distress are suffering from medical illnesses has taken a very deep hold in Western societies, such that to question it is often interpreted as denying the reality of their experiences. As someone who has worked in mental health services for over three decades, this is the last thing I want to do. However, I also know that the traditional diagnosis-and-drugs approach rarely brings the hoped-for solutions. In fact, research increasingly shows that it is more likely to lead to a lifelong dependence on psychiatric services.1
When the world’s most senior psychiatrists are admitting that the diagnostic manuals are ‘an absolute scientific nightmare’ 2, there is a crisis in our mental health system and an urgent need for transformation. As I described in a previous IAI News article, some alternatives already exist – such as psychological formulation, which is a personal story that helps makes sense of distress in the light of a person’s relationships and life events. In this article, I describe a much more ambitious project. The Power Threat Meaning Framework3, funded by the Division of Clinical Psychology of the British Psychological Society, is an attempt to re-conceptualise our models of distress from scratch. While it is not official BPS policy, it is attracting interest nationally and internationally. This, I believe, shows that there is widespread recognition of the need for fundamental change.
Principles of the Power Threat Meaning Framework
The Power Threat Meaning Framework (PTMF) was co-authored by psychologists and former users of mental health services. Our aim was to offer a new, non-medical perspective on why people sometimes struggle with a whole range of overwhelming emotions and experiences such as confusion, fear, despair, hopelessness, mood swings, hearing voices, self-harming, panic, eating difficulties, and so on. The PTMF argues that distress of all kinds, even the most severe, is understandable in the context of our relationships and social circumstances, and the wider structures, norms and expectations of the society and culture we live in.
The Power Threat Meaning Framework applies not just to people who have been in contact with mental health services – in fact, it does not recognise a separate group of people who are ‘mentally ill’ - it applies to all of us. This major departure from our current ways of thinking means that even our language has to change. Not only does the PTMF reject diagnostic categories, it also avoids terms like ‘symptom’, ‘illness’, ‘disorder’ since they all imply a medical viewpoint. Instead, it refers to ‘mental distress’ and ‘emotional suffering’.
"The often-hidden role of ideological power means that even those of us who do not have an obvious history of trauma can still struggle to achieve a sense of self-worth."
The Power Threat Meaning Framework and power
The Power Threat Meaning Framework places a strong emphasis on the way power in its various forms impacts our lives. This includes the power we may have, or lack, in areas such as relationships, physical health, material resources such as decent housing, and so on. Power can be a positive influence in our lives – we may benefit from a close family, a good education, supportive employers, enough money to live on, and the advantages that go along with being white, or able-bodied, or middle class. However, power can affect us negatively as well. We may be unlucky enough to experience traumas such as abuse, violence or neglect. We may suffer family breakdown or bereavement, or be dependent on welfare benefits, or belong to a deprived or marginalised community. More broadly, we are all to some extent affected by social and economic policies which may contribute to wealth inequalities, discrimination, environmental destruction and other social injustices.
Does ‘Mental Illness’ Exist?
By Lucy Johnstone
The Power Threat Meaning Framework places great importance on ideological power. This refers to the kinds of messages we receive about who we are, how we should look, behave and run our lives, the standards we should aspire to and the thoughts, feelings and behaviours we should avoid if we do not want to feel shamed, excluded, humiliated, unlovable, or worthless. While all societies have social norms of some kind, there is always a risk that they may be exploited to serve vested interests. For example, we may be constantly encouraged to feel dissatisfied with our appearance so that we spend more on clothes, make-up, diets and gyms. These pressures are driven by the values of achievement, competition and consumerism that underpin most Western societies. The often-hidden role of ideological power, conveyed by the language we hear and the messages we pick up all around us, means that even those of us who do not have an obvious history of trauma or adversity can still struggle to achieve a sense of self-worth, meaning and identity.
The Power Threat Meaning Framework core questions
The main aspects of the Framework are summarised in a set of core questions. In brief, they help us make the shift from asking ‘What’s wrong with you?’ to ‘What’s happened to you?’
- ‘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 situations and experiences to you?)
- ‘What did you have to do to survive?’ (What kinds of Threat Response are you using?)
In addition, the two questions below help us to think about what skills and resources people, families or communities might have, and how we might pull all these ideas and responses together into a narrative or story:
- ‘What are your strengths?’ (What access to Power resources do you have?)
- ‘What is your story?’ (How does all this fit together?)
The questions are not necessarily meant to be asked in those words or that order. They simply suggest areas that need to be considered. However, reflected on with the PTMF as a guide 4, they help us to construct more hopeful narratives or stories about our lives and associated struggles and difficulties, instead of seeing ourselves as blameworthy, weak, deficient or ‘mentally ill’. A professional may agree to help us construct such a story, but it is equally possible and valid to do it on our own, or with a friend, partner, or peer group.
The PTMF questions aim to highlight the links between threats and threat responses, or in other words, what we have experienced and our resulting attempts to cope and survive. ‘Threat responses’ correspond roughly to what we might call ‘symptoms’ in psychiatry. They range from automatic bodily reactions such as panic to more consciously chosen strategies like self-injury or drug use, which help us to manage overwhelming emotions, memories or situations. Threat responses may also include things like working too hard, or constantly striving to achieve, if this is interfering with your life.
Changing the narrative from ‘I have a mental illness/mental health problem’ to ‘I am surviving difficult circumstances in the best way I can’ is an essential step towards helping us find new ways forward. This may include various forms of therapy or social support, as offered by the best current services. It might include some use of psychiatric drugs to manage overwhelming feelings, as long as we do not see them as ‘treating medical illnesses’ or resolving life problems. However, the PTMF suggests that other, non-medical paths may be equally or more helpful – creative arts, self-help groups, exercise, and perhaps for some people, social action of some kind. Most importantly, constructing a PTMF narrative has helped many people to find relief from the blame, shame and stigma that often accompany a psychiatric label, and to look more deeply into the underlying reasons for their distress.
"Changing the narrative from ‘I have a mental illness/mental health problem’ to ‘I am surviving difficult circumstances in the best way I can’ is an essential step towards helping us find new ways forward."
The PTMF also includes the impact of factors such as loss of land, heritage, identity and community through the intergenerational traumas resulting from racism, colonialism, warfare, genocide and so on. The exportation of the diagnostic model across the globe means that many indigenous peoples are suffering the additional injustice of being labelled as ‘mentally ill’ due to their reactions to these multiple abuses of power 5.
A few decades ago, ‘mental illness’ was believed to affect only a small proportion of the population. Nowadays, we are encouraged to believe that ‘we all have mental health.’ This well-meaning slogan is, the PTMF argues, deeply misleading. It would be more accurate to say that ‘we all have feelings' and that at times, those feelings can be overwhelming. However, they do not come from nowhere. It is no surprise that rates of so-called ‘mental illness’ are rising so rapidly, particularly among young people, given the huge pressures at school and in the job market. Diagnosis conceals these links by locating problems within the individual, while the PTMF shows us that their roots lie in the growing inequalities of neoliberal Western societies, and the resulting disconnection from our emotions, from each other, and from the natural world.
A topical example is the alarmist headlines about the ‘mental health pandemic’ which, in an unfortunate coincidence, is said to be following on the heels of the COVID one. Yet research shows very clearly that it is those who have been hit hardest financially who are feeling most desperate ⁶. The answer is not to be found in expanding mental health services, as we are often told, but in ensuring people’s economic security. This ‘mental health’ rhetoric plays into political denial while individualising and stigmatising people’s understandable reactions. Re-connecting threats and threat responses reverses this process and points us towards better ways forward.
We have a long way to go before diagnostic manuals are abandoned in favour of a non-medical paradigm of distress. However, the Power Threat Meaning Framework is an important step towards this goal, showing that ultimately the solutions must be found in our shared struggle to create a fairer society.
1. Whitaker, R. (2010). Anatomy of an Epidemic. New York, NY: Broadway Paperbacks
2. Hyman. S. (6 May 2013), Psychiatry's Guide Is Out of Touch With Science, Experts Say, New York Times, 2013
3. The PTMF documents, resources, and examples of good practice can be found on the British Psychological Society's website.
4. An accessible guide to using the PTMF is: Boyle, M and Johnstone, L (2020) A straight talking introduction to the Power Threat Meaning Framework: an alternative to psychiatric diagnosis. Monmouth: PCCS Books.
5. A blog about comparing and contrasting the PTMF with indigenous understandings of distress is here: Crossing Cultures with the Power Threat Meaning Framework – New Zealand, Mad In the UK, 2019
6. Sharp rise in mental illness among those whose income fell away during Covid, the Guardian, 2021