A radically different perspective on mental health

When I ask social workers to describe the distinctive contribution they make to mental health services the answer is often that they work with a “social model” and ensure that human rights and citizen outcomes are prioritised. But what exactly do they mean by “social model” and how does this relate to more common diagnostic approaches?

In this guest blog, Phil Wilshire, Principal Social Worker for Avon and Wiltshire NHS Partnership Trust, believes a new perspective is needed to help us balance person-centred approaches with the clinical methodologies of the healthcare professionals we work with. Introducing the Power Threat Meaning Framework (PTM)…

Phil: 'Social workers will be interested in the way interpersonal, economic and ideological expressions of power control language and agendas to impose meanings.'

"The framework was developed by a team of senior psychologists, service users, carers and leading mental health survivors and activists, funded by the Division of Clinical Psychology (DCP).

PTM sees people as active participants - making choices and creating meaning in their lives. It recognises that emotional distress and troubled or troubling behaviour are intelligible responses to an individual's history and circumstances that can only be understood with reference to the cultures in which they occur.

It was formally launched to an audience of 400 in London in January 2018. It 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?)

Social workers will be interested in the way interpersonal, economic and ideological expressions of power control language and agendas to impose meanings. They will also be interested in the way 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 PTM 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.

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 that psychiatric drugs have useful but limited general effects rather than correcting a theoretical - arguably unproven - chemical imbalance.
  • 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 social groups, secure resources for ourselves and our families, applies 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. 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's intent. 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.

As a social worker faced with these difficulties, I feel so encouraged by the development of this framework and I invite you to consider how its application might benefit your social work practice.


  1. Comment by Maysie posted on

    Such a shame that as a result of the cuts social work has largely been divorced from mental health care. The only encounters most service users have with social workers is when they meet an AMHP during a MHAA and that contact is about risk assessment rather than therapeutic intervention or therapy. Losing social workers as care coordinators was a sad day indeed.

  2. Comment by Pam Abbott posted on

    For so long, even within social work, we have failed to recognise fully the link between personal trauma, wider societal trauma and profound mental health distress. The impact of abuse, of loss and betrayal, of rejection and of degradation coupled with poverty, discrimination in its many forms, of injustice and human rights abuses has long been a part of social work training and its holistic assessment view. Yet we still remain in thrall to the medical model view that something is wrong with that particular person and we need to make them “better”. We actually need to make an effort to positively connect and always ask “what is your story?”, we also need to listen to the answer either through verbal or non-verbal communication. Social Workers have such a positive role to play in enabling people in distress to be heard , in the truest sense of the word!

  3. Comment by john mills posted on

    Very sad for social workers getting alienated because of the whole oppressive MH system--same goes for psycholgists... most have sold out to the oppressive aggressive thought police psychiatry.. how can you love someone when your part of the offending violent MH can they love them back... and if they do, arent they just selling out their own principles..i feel they are...and it saddens me immensely. Sorry- but love never comes with" force" , not in my heart and mind it doesn,t. If you take the force away after six weeks max to see if they can cope without see if they really are what you imagine , or are calling them, then thats honest.. ethical..trusting, hopeful, proper care, until that happens i wouldnt trust anyone.

  4. Comment by SC posted on

    A shame a valid, sensible and likely actionable and useful refocus and reframing of social aspects of mental health issues limits itself by discounting the medical model. Saying the medical model is "theoretical" and "arguably unproven" betrays the bias, and I'm afraid either limited experience (unlikely), ignorance or lack of critical thinking of the author and / or Lyn Romeo.
    The fact our medicines are not as sophisticated as our very, very detailed and firm knowledge of brain chemistry does not invalidate that knowledge.
    In the same way, the very great utility of social and talking interventions does not, of itself, undermine the medical model either.
    I'm sure social model only cases exist. I strongly suspect medical model only cases exist. I know many lie on the continuum stretching between and move left and right in cycles of varying length and in response to either or both social and medical events.
    Talking down the medical model discounts the lived experience of many, is actually the disrespectful path, and is unbecoming of professionals who should be well beyond this sort of blinkered thinking.
    Keep up the great work. Keep fighting a **** system. Recognise there are both medical and social aspects to being human.


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