The contribution and influence of psychological distress to interest and involvement in extremist violence has received considerable attention in recent years. At the same time, dominant medical models for understanding such distress – typically framed as mental illness or disorder – have been challenged by emerging alternative paradigms in parts of the Western world. Understanding the contribution of psychological distress to extremist violence and how to prevent it requires consideration through these emerging paradigms and interpretative lenses. The Power Threat Meaning Framework (PTMF) is one such paradigm, increasingly used by practitioners to understand and prevent psychological distress, unusual experiences, or troubled or troubling behaviour. This paper outlines its central theory and principles, investigates how these are relevant to informing our understanding of the troubling behaviour of involvement in extremist violence, and its implications for preventative practice, illustrated through an example case study. The case is made for the potential of this paradigm to support effective and ethical practice in the context of extremist violence.