In mid-2024, I was officially declared ‘recovered’ from a mental health condition called borderline personality disorder (BPD). The NHS ruling that I no longer qualified for this diagnostic label was a relief – but not a surprise. I hadn’t experienced symptoms associated with BPD for around three years, lining up with my decision to stop drinking alcohol and the improvement of my material living conditions. But having what some psychiatrists consider a lifelong, incurable mental illness simply go away raised a number of questions.

Did I ever have a faulty, sick brain, or was my distress an intelligible response to my experiences and environment? Was a diagnostic label helpful or did it squeeze me into a small and highly stigmatised box? Did it delay my ability to access deeper meaning in my life story, stunting my human journey towards emotional maturity by ruling that a much younger version of myself should carry the weight of a ‘disordered personality’ into the future – perhaps permanently? 

For some, receiving a diagnosis can feel like a relief. It can be essential for accessing NHS mental health services and state benefits in order to survive. But whether we find a mental health diagnosis empowering, a source of solace, a means to an end, painfully stigmatising or ultimately empty, it’s worth considering whether one of the greatest successes of the neoliberal project has been the neat separation of mental ill-health – or psychological suffering – from political consciousness.

“I was undoubtedly part of a system that is about depoliticising people’s distress,” says consultant clinical psychologist and independent trainer Dr Lucy Johnstone. 

With over 30 years experience working in adult mental health, Johnstone is one of the creators of the Power Threat Meaning Framework (PTMF), a conceptual alternative to models that pathologise and medicalise emotional suffering. She is speaking to me via Zoom and politely ignoring my coughing and sniffling from a winter lurgy. 

On the topic at hand, Johnstone is confronting. When I ask if it’s possible to achieve true mental health or wellbeing under capitalism, she pushes back on the framing of the question. 

“I don’t think the concept of mental health is always helpful,” she says. “I believe people suffer, are in despair, feel hopeless and suicidal, and find it incredibly hard to cope on a day-to-day level. But I don’t call it a mental health problem because as soon as you do that, you’re separating the context from the person’s response.”

Johnstone gives the example of high reported rates of mental health issues among teachers. “What teachers are saying is, ‘We’re burnt out, we have no resources, we have huge classes, we’re meant to meet all these targets.’ Describing that as a mental health problem invites mental health solutions, rather than saying they are understandably responding to their impossible circumstances.

“I think there’s a world of difference between saying teachers are exhausted and frustrated, and teachers have a mental health problem – the second one actually conceals the context.”

Context is at the heart of the PTMF, which considers how misuses of power – from abuse and trauma to wider social factors such as poverty, inequality and discrimination – impact people’s lives. It reframes symptoms as survival strategies, developed both consciously and unconsciously to enable people to protect themselves and meet core needs. Currently used across a number of London NHS Trusts and recommended as good practice in NHS England’s guidance for adult mental health inpatient wards, the framework seeks to help people create more hopeful narratives about their lives, instead of viewing themselves as blameworthy, weak, deficient or mentally ill. 

“I worked for decades in the mental health system,” Johnstone continues, “and I don’t think I’ve ever come across someone who, when you got to know them better, didn’t have a good reason for feeling the way they felt.”

Within the PTMF, if you trace someone’s emotional suffering back far enough, you always find social, economic and political context. Although, Johnstone stresses, that doesn’t mean there aren’t more immediate factors. “It’s layers,” she says. “The layers build on each other. The pressures that your family puts on you, let’s say, are a reflection of the pressures that wider society puts on you.

“The whole idea that suffering, in some cases, can be best understood as a mental illness emerged along with industrialisation in the 19th century,” she continues. “Human life consists of suffering – we can’t avoid it. But does contemporary capitalism typically create more of the types of suffering that get labelled as mental ill-health? Yes, it undoubtedly does. Because huge numbers of people are deprived of what they need to live comfortable and satisfying lives, but also because capitalism requires us to remain in a state of discontent, otherwise we’re not going to buy things. It’s based on discontent, relies on discontent, and inevitably creates more discontent.”

The increase in rates of people living in the global north meeting the criteria for mental health disorders is undeniable. The ‘one in four’ figure often cited by charities like Mind is from 2007 and out of date. According to 2020 research, 86% of us (nearly nine in ten) will meet the criteria for at least one mental health disorder by age 45. If we’re moving towards a society where virtually everyone experiences mental illness, then perhaps it makes sense to turn our gaze outwards from the individual and individual disorder labels to the wider context, environment and structures we exist within. 

For Johnstone, the only way of understanding the recent rise in people meeting the criteria for mental health issues is as “a response to the neoliberal project which, of course, is catastrophically damaging to everybody, even the more privileged. So we actually need to be persuaded even more than ever before that our problems arise from something within us.”

The ‘something within us’ explanation – of mental ill-health as a problem in the individual’s brain that requires a diagnosis (a label) and individualistic (and often revenue-generating) solutions, from medication and talking therapy to wellness apps, self-help books and yoga classes – is certainly not something I ever questioned. From the age of 16, I was prescribed various antidepressants and given a range of labels. My distress was real, and I wanted a psychiatric diagnosis to explain it. And I, like many others, initially found comfort and relief in receiving them. What is more human than wanting to find answers, access supportive communities and to stop feeling as though we are bad, weak, lazy or unable to cope? 

This is where the “brain/blame” explanation comes in, developed by Johnstone’s colleague Professor Mary Boyle. “We’ve got very limited ways of understanding our distress,” Johnstone says. “So either it’s our brain, with the message that ‘thank God I don’t have to feel so guilty, so ashamed, such a failure’, or if it’s not that, ‘it must be my fault, I must be useless, I must be crap, I must be a failure’. We have to find explanations in the middle, about how we do our very best in nearly impossible circumstances. That’s a much more subtle message and a more difficult one to put across.”

When emotional suffering is depoliticised and stripped of its context under contemporary capitalism, it becomes the individual’s issue – with either a “brain” or “blame” explanation. There’s no impetus to seek radical, collective, political understandings of our distress and dis-ease, and no risk that the way we organise society will come under examination. 

For millennials and gen Z in particular, a psychiatric diagnosis can become a form of personal branding or self-commodification. This is evidenced by the vast ecosystem of mental health influencers and content creators who market themselves via diagnosis-as-identity – which has the added benefit of ensuring algorithms show their content to interested audiences.

“How come virtually none of us have a secure sense of identity?” Johnstone asks. She’s being rhetorical, but I bring up the fragmentation of communities, social isolation, insecure work, poverty, the constant demand to perform on social media and dislocation from nature. “Into that gap,” she says, “there is room to be sold an instant new identity.”

I ask Johnstone how we can challenge individualist narratives around mental health and harness collectivism, solidarity and class consciousness to meet painful experiences of loneliness, anxiety, emptiness and lack of self-worth under capitalism.  

“I think it comes down to, in a way, that old-fashioned term ‘consciousness raising’,” she says. “Within health services, psychologists like myself do have an alternative to labelling: psychological formulation. This is a jargon term meaning, ‘We’ll put together a personal story about the origins of your distress.’” Trauma-informed approaches such as the PTMF and psychological formulation prioritise an ever-evolving, shared and co-constructive explanation of suffering that doesn’t necessarily involve labelling someone. “You don’t need to say, ‘it’s because you have a personality disorder’,” she continues. “That becomes redundant.”

Johnstone does envisage a world where the biomedical model of mental health is no longer dominant. There are questions about how quickly this can happen, though. She and Boyle acknowledge that in the immediate term, in the face of a cruel and inadequate benefits system, “psychiatric diagnoses will still be required for people to access services”, recognising that the “priority is to protect service-user rights to essential resources and support”. But nonetheless, Johnstone tells me there are signs the current narrative is “breaking down”, reminding me that throughout history, new ways of seeing the world emerged that were totally incompatible with previous paradigms – and generated a huge amount of resistance.

“The new paradigm needs to be based on narrative understandings, of which there are many, particularly in non-western societies which haven’t yet been colonised by our way of thinking. These narratives have to make the links between our distress and our social context […] Unless we change the fundamental narrative, we’ll have more of the same.”