Key takeaways
A diagnosis can describe what is happening; it rarely explains why. The Power Threat Meaning Framework starts with “What has happened to you?” instead of “What’s wrong with you?”
Life circumstances such as childhood adversity, poverty, discrimination and violence substantially raise the risk of distress.
This is not an argument against psychiatric treatment, including medication. It is an argument for asking about the life behind the symptoms first.
For most of the last century, when someone walked into a mental health service in distress, the first question was usually some version of: What’s wrong with you? It’s a question built for medicine — find the fault, name it, fix it. And for a broken bone or an infection, it works beautifully.
But psychological distress rarely behaves like a broken bone. Two people can hear voices, or feel unbearably low, or panic in crowded rooms, for entirely different reasons rooted in entirely different lives. A diagnosis — “generalised anxiety disorder,” “depression,” “psychosis” — can describe what is happening. It says almost nothing about why.
This is the starting point of the Power Threat Meaning Framework (PTMF), a way of understanding distress developed by clinical psychologists Mary Boyle and Lucy Johnstone together with the British Psychological Society and a large group of people with lived experience of mental health services. Instead of starting with “what’s wrong with you?”, it starts with a question borrowed from trauma-informed care: “What has happened to you?”
It sounds like a small shift in wording. It isn’t.
The soil, not just the symptom
Think of psychological distress the way a gardener thinks about a wilting plant. You could label the plant — “wilting-leaf syndrome” — and treat the leaves. Or you could check the soil, the light, the water, the pot it’s been forced to grow in. Diagnosis, on its own, often only describes the wilted leaves. The PTMF asks about the soil: the relationships, events, and circumstances a person has actually lived through.
And the evidence for how much the “soil” matters is striking. Large studies have found that people who experienced significant childhood adversity — abuse, neglect, loss, being in care — are far more likely to later be diagnosed with serious mental health conditions; in the most severe cases of documented abuse, the likelihood of a psychosis diagnosis has been found to be dozens of times higher than average. Growing up in poverty, facing discrimination, living through domestic violence or displacement, or simply growing up in a society with a very large gap between rich and poor — all of these are known to raise the risk of psychological distress, sometimes dramatically.
None of this means distress is “caused” in some simple, mechanical way — life is never that tidy, and two people who live through the same hardship can end up in very different places. But it does mean that when we ask only “what’s wrong with this person’s brain?”, we are often looking in the wrong direction entirely.
Power, in plain language
The PTMF calls this first question the question of power — not power in the sense of politics or corner offices, but in a much broader, everyday sense: who gets to have their needs met, whose voice is heard, who controls the resources, the relationships, the decisions that shape a life. Power can be:
• Physical — strength, health, access to safety.
• Economic — money, housing, employment.
• Legal or institutional — the rules and systems that decide what you’re entitled to.
• Relational — who has influence over you in your family, your workplace, your community.
• Ideological — the ideas a culture treats as “normal” or “correct,” which quietly decide whose way of living is respected and whose is pathologised.
Power isn’t only something done to us, either — we all also carry power, resources, and resilience of our own, which we’ll come to in a later post in this series. But when power operates against a person’s interests for long enough, it creates the conditions in which distress makes sense.
Why this matters for how we think about care
To be clear: this isn’t an argument against seeking help, and it isn’t an argument against psychiatric treatment for people who find it helpful — including medication, when it’s genuinely useful and properly explained. What it is an argument for is curiosity: making sure that before we reach for a label, we’ve properly asked about the life behind the symptoms.
Clinicians who work this way often notice something simple: patients feel a quiet relief the moment someone asks not “what’s wrong with you?” but “what happened to you?” It reframes distress as an understandable response to circumstances, rather than as evidence of a flaw. That reframing, on its own, can be the beginning of healing — and it’s available through good trauma-informed therapy, psychiatric care, support groups, or simply a conversation with someone who asks the right questions.
Over the next posts in this series, we’ll walk through the rest of the PTMF’s core questions — how difficult experiences threaten us, what sense we make of them, what we do to survive, and what strengths we carry through it all — building, piece by piece, toward a fuller, kinder way of telling the story of a life.
Next in this series: “How Did It Affect You? Understanding Threat.”
This post draws on Mary Boyle and Lucy Johnstone’s A Straight Talking Introduction to the Power Threat Meaning Framework (PCCS Books, 2020) and the Power Threat Meaning Framework (British Psychological Society, 2018). If you’re currently taking psychiatric medication, please don’t stop or change it without talking to your own doctor first.
