The Power Threat Meaning Framework: a different perspective on mental health

Published: 18/01/2022

Author: Dr Lucy Johnstone

When you ask social workers what compass directs them in mental health services, the answer is often ‘the social model’. But what they exactly mean may be less clear, particularly how it relates to the dominant medical diagnostic model.

Sometimes the models run pragmatically concurrent, with social workers focussing on the social aspects of the lives of people who are considered to have an illness that needs to be treated.

At other times, the two models seem in opposition, with many social workers feeling that an over focus on diagnosis often places them on the fringes. For this reason, social workers will be interested in a new alternative to the dominant diagnostic model, which is attracting national and international attention.

The Power Threat Meaning Framework (PTMF) was co-produced by a team of senior psychologists, people with lived experience and leading mental health survivors and activists, funded by the Division of Clinical Psychology (DCP). It was officially launched in January 2018. 

The Framework is a detailed and ambitious attempt to move beyond medicalisation. It represents a shift from, in a popular slogan, asking ‘What is wrong with you?’ to ‘What has happened to you?’ The PTMF expands this as follows:

  • 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?).

Two additional questions are:

What are your strengths? (What access to Power resources do you have?)

…and to sum it up: What is your story?

These questions are not necessarily meant to be asked in those words or in that order – rather they are areas to reflect on, which may apply not just to individuals, but to groups, communities and societies.

They represent a shift from diagnostic to narrative-based understandings.

The Framework sees people as actively making choices and creating meaning in their lives. It recognises that emotional distress and troubled or troubling behaviour are intelligible responses to a person’s history and circumstances that can only be understood with reference to the cultures in which they occur. Using narrative provides a way of including these diverse perspectives, since all human beings are fundamentally meaning-makers and story-tellers.

Social workers will be interested in the way in which the model focuses on the operation of power, including interpersonal, economic, and the ideological power to control language, agendas and to impose meanings. They will also be interested in the way that the model reconnects social context and ‘threat responses’, or ‘symptoms’ as they are usually caused, with ‘threats’ in such a way as to show that they are meaningful attempts to get through difficult situations, even if problematic at times. The PTMF also looks beyond individual therapy or treatment and shows how we need to promote social action and support a new kind of preventative social policy response.

The PTMF is not an ‘alternative classification system for mental illness’. It does not recognise a separate group of people who are ‘mentally ill’. Rather it considers that the universal struggle to survive, form relationships, find a place in the social group, secure resources for ourselves and our families, applies equally to all of us.

Not surprisingly, the PTMF has attracted controversy and disagreement as well as support. However, it has been received very positively by mental health social workers, whose professional training encourages them to understand people holistically within their social context and who welcome the way that it firmly and fully reconnects personal experience and social context with mental distress and troubling behaviour.

All too often, social workers will be required to assess people whose histories of trauma, substance misuse, homelessness, and chaotic lifestyles have been overlooked, with the main focus of intervention being on medication compliance and relapse. In these situations, holding onto the idea of a social model is challenging when the model is largely undefined, and you are working in a system where medical understanding is dominant.

These kinds of difficulties are why many social workers feel so encouraged by the development of this framework. Since the launch four years ago, the PTMF authors and allies, both professionals and survivors, have been invited to give talks in Ireland, Spain, Denmark, Greece, Brazil, Australia and New Zealand, among other places, with eight translations in progress.

While the PTMF does not suggest easy answers, it comprehensively offers a way of thinking about distress which will be helpful to social workers in all settings.

Five messages

  • Emotional distress and troubled or troubling behaviour are understandable in context.
  • There is no separate group of people who are ‘mentally ill.’
  • Narrative and meaning-making can be an empowering and healing alternative to the diagnostic model.
  • Varying cultural experiences and expressions of distress should be respected.
  • Distress is rooted in wider contexts of social inequality and injustice

Lived experience

The PTMF was co-produced with survivors of psychiatric services, and examples will be given of how peer groups have taken up its ideas and used them for support.

Further resources

The PTMF website has a range of resources, including the PTMF documents, videos, articles by survivors and professionals, training materials and exercises, evaluations and research studies, good practice examples. An accessible introduction to using the PTMF ideas in practice can be found here.

Dr Lucy Johnstone

Dr Lucy Johnstone is a consultant clinical psychologist. She has worked in Adult Mental Health settings for many years and was lead author, along with Professor Mary Boyle, for the ‘Power Threat Meaning Framework’ (2018), a Division of Clinical Psychology-funded project to outline a conceptual alternative to psychiatric diagnosis. Her particular interest and expertise is in the use of psychological formulation, in both its individual and team versions, and in promoting trauma-informed practice.