“We can’t medicate or treat our way out of the epidemic of mental distress and addiction affecting all layers of our society,” was one of the comments in He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction, released in December.

It’s a sentiment wholeheartedly supported by Dr Lucy Johnstone, a British clinical psychologist, trainer, speaker and writer who has been in New Zealand this month at the invitation of the New Zealand Psychological Society and the New Zealand College of Clinical Psychologists.

A long-standing critic of the biomedical model of psychology – “We’re turning people with problems into patients with illnesses” – Dr Johnstone, fellow clinical psychologist Professor Mary Boyle and a group of psychologists and former service users spent five years leading a project that outlines a radically different approach to mental distress.

Described by Dr Johnstone as “an alternative to the diagnostic model of mental and emotional distress and human suffering”, The Power Threat Meaning Framework (PTMF) is based on evidence about the emotional impact of trauma, abuse, loss and neglect, in the wider social context of poverty, inequality, discrimination, and social injustice.

Instead of giving people a diagnosis, the PTMF explores the answers to four key questions – ‘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?); and ‘What did you have to do to survive?’ (What kinds of Threat Responses are you using?).

“We need a shift from ‘What’s wrong with you?’, to ‘What’s happened to you?’,” says Dr Johnstone.

“We’re saying, ‘Your distress is an understandable response to what happened to you’ as opposed to, ‘You’ve got an illness, take these pills and they will treat it’.”

The PTMF describes typical patterns in the ways people respond to the impact of power in their lives, and the resulting feelings, such as being excluded, rejected, trapped, coerced or shamed. Rather than applying a diagnostic label, these patterns can be used to explore what has happened in a person’s life and how they are attempting to survive, offering them a message of acceptance and validation.

This in turn opens up a range of options for moving forward, which might include joining a local community group, questioning the expectations and values they have been basing their life on, making challenging changes, getting support to revisit difficult life events, and so on. Medication might or might not play a part but would not be seen as ‘treatment’ for an ‘illness’.

At its very simplest, the PTMF is about listening to people’s stories, says Dr Johnstone.

“Healing comes through contact with other people; being heard, understood, believed and witnessed.”

While professionals have a role to play in this, we all can listen to each other’s stories, she says. “Humans can hurt each other; humans can heal each other.” GPs in particular underestimate the simple but powerful role they can play in listening to their patients, normalising their reactions, and giving them hope for recovery.

A charity in the UK is using the PTMF to work with women who have experienced domestic violence. Using this scenario as an example, Dr Johnstone says the PTMF can help to illustrate the misuse of power by their abusive partners. This abuse will have affected these women’s self-esteem, identity, autonomy, relationships and so on, which understandably may have led to them feeling scared, trapped, tearful, and desperate.

Within the PTMF, this could lead to a discussion of strengths – what have these women done to survive – and what can they do to change their situation. “It’s very different from a woman receiving a diagnosis of depression, which suggests there is something wrong with her, reinforcing the message her partner has very likely already told her,” says Dr Johnstone.

She argues that the biomedical model of psychiatry, which is deeply embedded in western society, does not have any evidence to support it. “We have a whole system that is based on a theory that’s not proven.

“In contrast, there is a mountain of evidence to support the role of societal factors such as poverty, unemployment, and discrimination, and the effects of neglect, abuse and trauma in distress.”

The PTMF does not recognise a separate group of people who are ‘mentally ill’ but acknowledges that even the more fortunate can struggle at times.  It maintains that everyone can feel the impact of social standards and policies that put us under pressure to live up to accepted expectations in an increasingly individualistic, fragmented and unequal society.

“There are things about the modern world that aren’t healthy,” says Dr Johnstone. “Helplines are good, but we need to look at the root causes.”

During her time in New Zealand, Dr Johnstone has become interested in the Māori view of wellbeing, and the four interconnected cornerstones of mind, spirit, physical health, and whanau.

“In contrast to the imposition of the Western diagnostic model across the globe, the PTMF respects and validates other worldviews, in part because it draws on shared core principles.

“It is all too evident that in the UK at least, we have lost the sense of community, spirituality, identity and connection to the natural world that are so highly valued by Māori, with impacts on wellbeing that are widely documented,” says Dr Johnstone.

“We attempted to acknowledge this in the PTMF with references to the impact of colonialism and intergenerational trauma, the inseparability of the individual from the social group, and the need to integrate mind, body, spirit and natural world.”

Dr Johnstone believes the Mental Health Inquiry is “saying some very good things”. These include: People said that unless New Zealand tackles the social and economic determinants of health, we will never stem the tide of mental health and addiction problems … A call for wellbeing and community solutions – for help through the storms of life, to be seen as a whole person, not a diagnosis, and to be encouraged and supported to heal and restore one’s sense of self.

“The outcome of New Zealand’s Inquiry remains to be seen,” she says. “I have no doubt that this bold initiative will result in some real improvements, but it seems likely to fall short of a fundamental challenge to the diagnostic approach.

“Nevertheless, if the PTMF can help a move in that direction, I and the other authors will be delighted.”

Read more about the PTMF here.


If you are worried about your or someone else’s mental health, the best place to get help is your GP or local mental health provider. However, if you or someone else is in danger or endangering others, call 111.

If you need to talk to someone, the following free helplines operate 24/7:

LIFELINE: 0800 543 354
NEED TO TALK? Call or text 1737
SAMARITANS: 0800 726 666
YOUTHLINE: 0800 376 633 or text 234

There are lots of places to get support. For others, click here.


  1. Thanks Kat, the prescriptionitis that is so prevalent in our system is not doing any favours in the long run. It’s an incredibly short sighted solution to be pushing and causes more problems than it solves. The best use of meds is to get people’s heads above water then support them to move on with their lives providing feasible alternatives to do this. Sadly we just medicate then move onto the next patient.


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