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

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 of mental illness.

The “Power Threat Meaning Framework” was developed by a team of senior psychologists, service users & carers and leading mental health survivors & activists, funded by the Division of Clinical Psychology (DCP). It was formally launched to an audience of 400 in London in January 2018.

The Framework is a lengthy, detailed and ambitious attempt to move beyond medicalisation. Instead of asking "what is wrong with you?” it 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 Framework sees people as actively making choices and creating meaning in their lives and 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.

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 and 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, and the way in which this promotes the need for social action and supports a new kind of preventative social policy response.

In some professional quarters the launch of the Framework has been controversial, while some service users have also been critical. This is understandable, for diagnosis has appeared to offer a straightforward explanation of complex difficulties over many years. Some people find medication to be very helpful and feel that the Framework is anti-medication and some service users are concerned that without diagnosis they will lose access to essential social and financial resources and services.

In response I would like to make the following points:-

The authors have been clear that, although detailed and complex, this is an optional conceptual resource that is in the first stage of development and is open to feedback.

The framework is not “anti-medication”, rather it suggests, in line with others such as Psychiatrist Joanna Moncrief[1], that psychiatric drugs have useful but limited general effects rather than correcting a theoretical but, arguably unproven, chemical imbalance.

Although service user concerns about access to welfare and benefits are understandable, I feel they are nonetheless misplaced because these are social policy decisions that are independent of diagnostic models. No one is saying that mental distress is any less disabling simply because it is thought about in a non-diagnostic way, and nor is the Framework a policy document.

The model 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.

From a mental health social work perspective the framework is likely to be entirely uncontroversial. I have spoken to many social workers and so far their response has been entirely positive. Our professional training encourages us to understand people holistically within their social context and this framework supports this approach by firmly and fully reconnecting personal experience and social context with mental distress and troubling behaviour.

During my work as an AMHP, the last two people I assessed brought familiar and similar themes that chimed with the Framework. They were men in their 50s with a history of substance misuse, homelessness, chaotic lifestyles and time spent in prison. They both had diagnoses that alternated between schizophrenia and personality disorder and a history of childhood sexual abuse and time within the care system.

It appeared in both cases that the childhood and other life experiences had been forgotten over time and that the focus had largely been on medication compliance and relapse. In this respect, 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 I as a social worker feel so encouraged by the development of this framework.

Phil Wilshire, Principal social worker for Avon and Wiltshire NHS Partnership Trust and contributor to PTM Framework