New alternative trauma diagnosis framework

By Dr Cathy Kezelman AM*
Thursday, 07 February, 2019

New alternative trauma diagnosis framework

Developed in the UK, the Power Threat Meaning Framework is an ambitious conceptual alternative to the diagnostic model of psychiatry, focusing on the impact of power on us all — including trauma victims.

The PTM framework is different to current diagnostic approaches as it is not a new classification system; rather, it simply identifies patterns of trauma and emotional distress through meaning rather than biology.

The framework provides a new way to identify and understand patterns of emotional distress, unusual experiences, and troubled and troubling behaviour, currently known as ‘mental illness’. Conceptualising distress solely in terms of illness, disorder and diagnostic boxes can be both damaging and retraumatising.

Using biological research and both psychological and sociological knowledge, this framework establishes the links between trauma, adverse experiences and social context with the emotional distress which results. If we know enough about people’s relationships, social situations, and past and current struggles, we can make sense of their experiences. We can also understand why, in the absence of obvious adversity, they may still struggle with self-esteem, identify and meaning.

Authored and published in January 2018 by the Division of Clinical Psychology of the British Psychological Society, and developed over five years by service users and psychologists, the framework describes how we are all, to some degree, affected by the negative impact of power, rather than a separate group who are ‘mentally ill’.

The framework summarises and integrates a wealth of evidence about the role of various kinds of power in people’s lives, the kinds of threats that misuse of power pose, the ways we respond to those threats, and how we have made sense of our responses to threats. It does this by asking the following questions:

  • ‘What has happened to you? — How is power operating in your life?’
  • ‘How did it affect you? — What kinds of threat does this pose?’
  • ‘What sense did you make of it? — What is the meaning of these situations and experiences to you?’
  • ‘What did you have to do to survive? — What kinds of threat response are you using?’

In so doing, it also asks: What are your strengths? What is your story? How does all of this fit together for you personally? In answering these questions, a personal narrative or story unfolds.


The framework helps people to understand the different ways power operates in their lives. Power operates in different forms — biological, coercive, legal, economic, social, interpersonal and ideological. It can be both positive and negative. Economic and social inequalities and ideological meanings support the negative operation of power. The threatening impacts of power can only be understood in the context of its meaning to the person or group.

There is a great deal of evidence that the negative use of power can accelerate distress. For example, coercive power such as violence or intimidation used to frighten or control another person can cause mental distress.


The negative operation of power can pose different sorts of threat to individuals, a group and the community as a whole. The emotional distress which ensues is mediated by our biology, but it is not caused by it. Our biology responds to threat by physiological responses which we currently call ‘symptoms’. We experience all sorts of threats — threats to our security, our safety, our status, our relationships and our body itself.


Meaning has a central role in shaping the operation, experience and expression of power, as well as threat and our responses to threat. It is also influenced by social and cultural discourses and primed by evolved and acquired bodily responses. We all attach meanings to the things that happen to us and the situations in which we find ourselves. Sometimes the meanings tend to leave us with feelings such as ‘It was all my fault’ or ‘I am unlovable’. This occurs commonly for people who have experienced threats. The framework also focuses on positive meanings which have helped a person to feel loved, valued and protected.

Threat responses

Threat responses are evolved embodied responses (automatic fight/flight/freeze responses) or learned strategies (eg, using alcohol or avoiding certain interactions) on which an individual, family, group or community may need to draw, to ensure their emotional, physical, relational or social survival. These responses to power and threats are called ‘symptoms’ within the medical model. These responses help us manage overwhelming feelings and protect us from physical danger, loss or hurt. Unusual experiences, such as hearing voices or being overwhelmed by suspicious thoughts, can also be seen as threat responses.

This framework combines formulation, narrative and trauma-informed approaches, but goes beyond them all. It encourages respect for the many ways in which distress is experienced, expressed and healed across the globe, without invoking a diagnostic model. It restores the link severed by diagnosis between personal distress and social injustice, attunes to diversity and allows space for complexity.

The framework is intended to provide the basis for an ongoing series of developments in clinical practice, service design and commissioning, training, research, service user/carer/survivor work, and public education. The project documents are already influencing a range of UK services, training courses, voluntary organisations and peer support groups, serving as a hugely important evidence-based resource supporting the construction of personal narratives and promoting necessary social action.

To learn more about the PTM Framework or to attend local workshops, visit

*Dr Cathy Kezelman AM is a medical practitioner, mental health consumer advocate and President of Blue Knot Foundation National Centre of Excellence for Complex Trauma.

Top image credit: ©

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