This is the first of two blogs about my invited tour of New Zealand and Australia with the Power Threat Meaning Framework (joined by contributing author John Cromby in Australia). The PTMF is an ambitious attempt to outline a conceptual alternative to psychiatric diagnosis and the medicalisation of distress, funded by the Division of Clinical Psychology of the British Psychological Society, and launched in London in January 2018 (Johnstone and Boyle, 2018a; Johnstone and Boyle, 2018; click here for relevant documents, videos and other resources). Our hosts are ISPS (the International Society for Psychological approaches to Psychosis) in both countries, collaborating with the Blue Knot Foundation in Australia, and I was also asked to run workshops by the New Zealand Psychological Society and the New Zealand College of Clinical Psychologists.
The first event, and for me the most daunting in anticipation, was a two day workshop in Auckland. I had wanted to make this an opportunity to compare and contrast different cultural experiences and expressions of distress. I was keen to explore one of our hopes for the PTMF – ie that 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. As we phrased it in the document:
The PTM Framework predicts and allows for the existence of widely varying cultural experiences and expressions of distress without positioning them as bizarre, primitive, less valid, or as exotic variations of the dominant diagnostic or other Western paradigms….Viewed as a metaframework that is based on universal evolved human capabilities and threat responses, the basic principles of the PTM Framework apply across time and across cultures. Within this, open-ended lists of threat responses and functions…. allow for an indefinite number of locally and historically specific expressions of distress, all shaped by prevailing cultural meanings (Johnstone and Boyle, 2018a, p. 22).
Consultant clinical psychologist Ingo Lambrecht organised the event with support from the rest of the ISPS NZ committee, and was able to secure the use of a marae, a communal Māori meeting place or sacred space, for the two days.
The New Zealand context
The marae was set in the grounds of a mental health service which offers Māori interventions alongside more conventional ones. This is a common service structure in NZ, and Pakeha (Europeans) are also able to access these approaches if they wish. There is no single model, but a well known one which is widely integrated into practice is Te Whare Tapa Wha (Durie, 1994). This is based on the 4 interconnected cornerstones of Māori wellbeing: mind, spirit, physical health, and the family (whanau). This has been expanded into the Meihana model by a group of clinicians who wanted to develop a framework that actively engaged with Māori beliefs, values and experiences (Pitama et al, 2014). Meihana adds the dimensions of Taiao (physicalenvironment) and Iwi Katoa (societal context). If any of these elements are out of balance, there will be a threat to well-being. A number of variations on these models are described by McNeill (2009). For example, Te Pae Mahutonga (Durie, 1999) explicitly includes the impacts of colonisation on Māori lives, experiences and concepts, as does the most recent version of the Meihana model, which also emphasisesthe role of racism, and migration away from traditional iwi land.
All of these are holistic perspectives, but differing from most Western ones in several aspects, including the emphasis on spirituality. The concept of whanau is much more expansive than the equivalent word in English, and includes the extended family of aunts, uncles, grandparents and so on, both living and dead. Several whanau make up a hapu, which in turn are part of an iwi or tribe. These identities are strongly connected to the natural world. Thus a traditional Maori introduction will include ‘my river is…’ and ‘my mountain is…’ as well as ‘my whanau is… ‘ …’my hapu is….’ and ‘my iwi is…..’
The wider context is in some ways very different from the UK. Briefly, New Zealand/Aotearoa (Aotearoa is the Māori name for the country, roughly translatable as ‘long white cloud’) was settled by Europeans from around 1800 onwards. Aotearoa/New Zealand became a British colony in 1840 through the landmark Treaty of Waitangi, signed by representatives of the British Crown and Māori chiefs. This enshrined Māori legal ownership of their lands and possessions and gave them equal rights to British citizens. The principles of the Treaty were very imperfectly realised, and did not prevent subsequent annexing of Māori land. To this day, Māori and Pacific Island peoples are greatly over-represented in the statistics on poverty, unemployment, mental health and addictions. Nevertheless the Treaty stands as a statement of principle and has, arguably, contributed to a commitment to recognising and respecting Māori and Pacific Island worldviews and to acknowledging and reducing the ongoing inequalities and health disparities in these populations.
New Zealand is in the middle of a major Government inquiry into mental health and addiction services, which are seen as failing the population as a whole; suicide rates are high, as are addictions. A long period of consultation has resulted in 40 recommendations, which are currently being considered. The summary document reads well – some extracts are below (He Ara Oranga, 2018):
‘We recognised from the start that this Inquiry represented a ‘once in a generation’ opportunity for change. All over the country, people told us they wanted this report to lead to real and enduring change – a ‘paradigm shift’…..
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…..
For Māori health and wellbeing, recognition of the impact of cultural alienation and generational deprivation, affirmation of indigeneity, and the importance of cultural as well as clinical approaches, emphasising ties to whānau, hapū and Iwi.
For Pacific peoples, the adoption of ‘Pacific ways’ to enable Pacific health and wellbeing– a holistic approach incorporating Pacific languages, identity, connectedness, spirituality, nutrition, physical activity and healthy relationships….
We can’t medicate or treat our way out of the epidemic of mental distress and addiction affecting all layers of our society.
We believe that many dimensions of the aspirations of Māori and Pacific peoples, especially the call for a holistic approach, point the way for all New Zealanders.’
We registered under a tree on a beautiful hot day – a mixed Pakeha and Māori audience of clinicians (including several psychiatrists), voluntary and family workers, students, service users and peer supporters. The process of welcoming a visitor to a marae is called a powhiri, and can take various forms. In this case, the tangata whenua (hosts) performed a haka powhiri (a welcome dance and chant) as I and the attenders approached the marae. Once inside, and after a moment of respect for the ancestors whose pictures were on the far wall, an elder (kaumatua) led songs and karakia (prayers.) The hosts greeted the visitors with a kiss on the cheek or hongi (touching nose and forehead.) We then moved to another room to share tea and fruit (food and drink are not permitted in the marae.)
Wishing to echo Māori introductions by placing myself a bit more precisely than ‘I am a clinical psychologist’, I described my home city of Bristol, my family, and my Scottish heritage of Johnstones, Grahams, McKays and Frasers. I also told the attenders that two of my great grandparents had been missionaries in Ghana and Sri Lanka (known to Britons then as the Gold Coast and Ceylon.) I said that it felt important to recognise that we all have a relationship to colonialism. I also posed the deliberately provocative questions: ‘Is the Western diagnostic paradigm simply another form of colonialism, perhaps more subtle than earlier versions, but equally damaging in its impacts? Will the Inquiry go far enough in achieving the longed-for ‘paradigm shift’ ? Or will we simply end up with better-resourced versions of what we already have? Is it legitimate to offer the failed Western diagnostic model alongside indigenous ones, or does it need to be abandoned altogether?’
I won’t describe the first day further beyond saying that it consisted of introducing the PTM Framework and illustrating it through the story of Debra Lampshire, current ISPS NZ chair – many thanks to Debra for her generosity, which made for a powerful exercise. We ended with a karakia.
After a briefer welcoming ceremony, the second day started with a reflection on Māori perspectives by Pikihuia Pomare, a Māori clinical psychologist and Jason Haitana, a Māori consumer adviser. Pikihuia started with a waita (song) and then linked back to the previous day’s discussion about power in its many guises, including colonialism and white privilege, and the consequent need to reclaim the Māori knowledge which has been silenced. Jason picked up this theme by recounting some Māori creation stories or purakau. As he said, they are more than just stories, because while not literally true, they do express important truths handed down from ancestors. His first story was about Ranginui and Papatuanuku, the sky father and earth mother of the world, living in darkness. Their children decide that they need to be pushed apart in order to bring light into the world, and they do this, but not without effort and pain. He invited the audience to share resonances with their own lives, such as the need for children to create the space to become themselves. The attenders, both Māori and Pakeha, responded with a range of personal reflections.
I was left with several thoughts. Firstly, the notion of stories, myths and legends as a vehicle for truths is very much supported by the PTMF. That is why it argues for narrative in general, not just the particular type of narrative called formulation. If we go beyond conventional evidence-based practice and historical truth and also consider ‘narrative truth’ (Spence, 1982, quoted in Johnstone and Boyle, 2018a, p. 83), we can value stories according to whether they seem to ‘fit’ in a way that ‘makes change conceivable and attainable’ (Schafer, 1980, quoted in Johnstone and Boyle, 2018a, p.82). Secondly, as one of the attenders commented to me, the Māori stories displayed clear themes that could be described as power, threat, and meaning. I am not suggesting that they need translating into those terms, simply noting commonalities between the two perspectives of Māori purakau and the PTMF core themes. Thirdly, the audience’s reactions gave me a sense of how these purakau could be used to reflect on, explore and heal human dilemmas and struggles. This too echoes the PTMF, which refers to ‘Narrative competence… the capacity for human beings to deeply absorb, interpret and appropriately respond to the stories of others’ (Grant, 2015, quoted in Johnstone and Boyle 2018a, p.78) and recovery as ‘reclaiming our experience in order to take back authorship of our own stories’ (Dillon and May, 2003, quoted in Johnstone and Boyle, 2018a, p. 75).
The second half of the morning consisted of an informal panel discussion with 7 of us. A relatively long timeslot was allocated for this, and I was struck by the way it unfolded. In keeping with the earlier session, some of the Māori speakers responded to points indirectly by telling a traditional story, and similarly, some of the audience, though Pakeha, began their contributions by telling stories about themselves. The sense was of the unfolding of a flowing conversation that went deeper than the usual academic debate. At several points the day before, when explaining the concept of formulation, I had been rightly reminded that such a process of co-constructing a story is essentially about two people being deeply in contact with each other and touching each other’s hearts. This does not, as far as I am aware, feature in any official definitions of formulation, and yet it struck me as absolutely true.
I had suggested that the discussion might want to return to the questions I posed at the start of the first day. There weren’t direct answers – it wasn’t that kind of conversation, and we don’t yet know how the Inquiry’s work will turn out. Nevertheless, there was strong endorsement of the PTMF’s inclusion of causal factors that are omitted from most psychiatric and psychological models, such as the impact of colonialism, intergenerational trauma, denial and loss of traditional knowledge, and the role of ideological power in all these areas. Some of the attenders were strongly in favour of abandoning the DSM-based model, along with advocating the PTMF as an alternative, albeit imperfect and still developing, way of taking us forward.
One of the panel members was a young Māori woman, a survivor of services who is now training to be a psychiatrist in order to bring about changes in the system. She had come across the PTMF by chance and had read the main document in its entirety. She recognised that it would need adapting for local needs but felt that it had the space to offer this. As such, she was very enthusiastic about its potential to support indigenous understandings, and told us that it is already being used to inform thinking in one Māori mental health service.
The Inquiry includes a summary of specifically Māori responses (‘Whakamanawa: Honouring the voices and stories of Māori.’) An extract illustrates the similarities to PTMF messages:
‘Māori voice across the Inquiry recognises mental distress as a reasonable response to adverse wider environments. Within a wellbeing paradigm, mental distress is not medicalised, pathologised, or criminalised; pathways to healing are whānau-based, inclusive of spiritual elements and supported by a healthy wider environment….. The focal point in a wellbeing paradigm shift assumes that mental health is a dimension of experience relevant to all members of society.’
I found the whole workshop a deeply thought provoking and enriching experience. Unlike some training events, I felt I received far more than I gave, both in terms of ideas and challenges but also in terms of warmth, connection, and the opportunity to experience a flavour of a very different culture.
I want to avoid making simplistic generalisations about a culture that is unfamiliar to me, and I am aware that there has been much mingling of blood and ideas between Europeans and Māori over the years. As a result, people now live in both worlds, and have varying degrees of identification with traditional practices and perspectives. For example, many Māori converted to Christianity in the 19th century.
Having said this, I agree with the Inquiry that Māori and Pacific Island worldviews have much to offer to all New Zealanders and, I would add, to Western perspectives in general. 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 indigenous New Zealanders, with impacts on wellbeing that are widely documented. 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. We also included, as possible ways of reclaiming power, identity and agency:
- Culture-specific meanings, beliefs and forms of expression
- Culturally-supported practices, rituals and ceremonies
- Community narratives, values, faiths and spiritual beliefs, to support the healing and integration of the social group
- Connections to the natural world
- Addressing collective/transgenerational trauma and loss of identity, culture, heritage and land
- Narrative-making through art, poetry, literature, music
- Political action
(Johnstone and Boyle, 2018b, p.216-217; Johnstone and Boyle, 2018 a, p. 77-79).
After my brief but direct exposure to a very different culture I realise that this recognition does not go far enough. While it is obviously not appropriate for the PTMF authors themselves to adapt the document for non-Western perspectives, I believe that future editions need to place more emphasis on these universal human needs.
And some reservations…..
I have no wish to idealise the perspectives I learned about. Specifically, I have concerns about the infiltration of medicalised thinking into these originally non-Western approaches. After describing its ‘Te Whare Tapa Wha’ approach, one Māori community mental health service adds these paragraphs which could have come from any standard psychiatric textbook:
What is Mental Illness?
Mental illness is a clinically significant behaviour or psychological disorder that is associated with distress or disability. …..A mental illness can….limit our ability to function as society would normally expect of us and can put us and others at risk. Mental illness is therefore, a broad term that covers problems ranging from minor to severe disorders.
Schizophrenia is a serious mental disorder that affects about 1% of the general population. It is a complex illness characterised by ‘psychosis’, a word used to describe disorder of thoughts (e.g. delusions – false beliefs held in spite of evidence that they are not real), perceptions (e.g. hallucinations – seeing, hearing or feeling things which are not there), disorganised speech and grossly disorganised behaviour, which are not experienced by others and which are not seen as abnormal by the sufferer. These four symptoms are often referred to as the ‘Positive Symptoms’ of schizophrenia because they are the result of the disease process.
Similarly, the Inquiry, along with its progressive ‘….call for wellbeing and community solutions – for help through the storms of life, to be seen as a whole person, not a diagnosis’, includesplenty of phrases implying the very diagnostic model it is criticising, such as ‘enduring psychiatric illness’ and ‘serious mental illness’ (which appear to be conceptualised as something fundamentally different from other forms of distress). Among the welcome recommendations for tackling social determinants of distress are several that merely imply ‘more of the same’ (eg ‘Expanding access to services for significantly more people with mild to moderate and moderate to severe mental health and addiction needs.’) And having a culturally-aware service is not a guarantee against the infiltration of biomedical ideas.
In conclusion, the outcome of New Zealand’s Inquiry remains to be seen. 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. In the meantime, I will always value the lifelong connection that has now been forged with the marae at Manawanui.
With thanks to Ingo Lambrecht, Debra Lampshire and the rest of the ISPS NZ committee.
Durie, M. (1994). Whaiora: Māori health development. Auckland: Oxford University Press.
Durie, M. (1999). Te Pae Mahutonga: A model for Māori health promotion. In Health Promotion Forum of New Zealand Newsletter, 49, 2-5.
He Ara Oranga: Report of the Government Inquiry into Mental Health and Addiction (2018) Available at www.mentalhealth.inquiry.govt.nz/inquiry-report
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018a). The Power Threat Meaning Framework: Overview. Leicester: British Psychological Society. Available from www.bps.org.uk/PTM-Overview
Johnstone, L. & Boyle, M. with Cromby, J., Dillon, J., Harper, D., Kinderman, P., Longden, E., Pilgrim, D. & Read, J. (2018b). The Power Threat Meaning Framework: Towards the identification of patterns in emotional distress, unusual experiences and troubled or troubling behaviour, as an alternative to functional psychiatric diagnosis. Leicester: British Psychological Society.
McNeill, H. (2009) Māori models of mental wellness. Te Kaharoa, 2, 96-115.
Pitama, S., Huria, T., and Lacey, C. (2014)Improving Māori health through clinical assessment: Waikare o te Waka o Meihana. Journal of theNew Zealand Medical Association, 127, pp 107 – 119.