5 P Formulation

Dr M Andrijevskis
Formulation
Standards
1. All qualified staff should be able to demonstrate confidence and
competence in undertaking a psychological formulation. All staff to
participate in the team formulation.

2. All qualified staff should be able to develop a psychological formulation

using the 5P framework (based on the CBT model), document this in a
standard format, and have the ability to present this to the service user,
carer, clinical team etc.

3. All qualified staff should have a basic knowledge of intervention

options, and be able to identify appropriate intervention options following
formulation.
Formulation competencies
Qualified staff should be able to demonstrate:
1. They can collect appropriate assessment information including
identification and consideration of
a comprehensive list of all the presenting problems that are causing concern to the
individual and family (e.g. emotional, relational and behavioural symptoms etc)
factors that might have triggered (precipitated) the onset or exacerbation of the problems
(e.g. acute life stresses such as illnesses or bereavements etc)
risk factors that might have predisposed the individual to the development of
psychological problems (e.g. parental neglect / abuse etc),
factors that might perpetuate psychological problems once they have developed (e.g.
poor coping strategies etc).
factors that might prevent the problem from becoming worse (protect) or may be enlisted
to ameliorate the presenting problems (e.g. good family communication/support etc).
2. They can demonstrate an ability to create and populate the formulations
5 ps correctly
3. They can demonstrate an understanding (in practice) that formulations
should be reviewed and revised as further information emerges during
ongoing contact with the individual.
4. Can demonstrate an understanding (in practice) that one of the main
functions of a formulation is to help guide the development of an
intervention plan.
5. Can feedback the results of assessment and formulation and agree the
intervention plan with all relevant parties
A formulation is
An integration of factual information that explains the origins and maintenance of
a clients problems and attempts to clarify the underlying explanatory mechanisms
for those problems which then suggests interventions that will improve those.
A formulation should
Follow an assessment
Be based on factual information
Be integrated into an explanatory account
Be the map that directs towards logical targets for intervention
Formulation has been defined as ...the bridge between
assessment and Treatment and can serve a number of
functions
understanding significant causal factors that have influenced the
persons presentation;
identifying key difficulties; guiding which interventions should be
utilised and in what order;
and anticipating challenges that may occur during the course of
treatment
Good assessment leads
to good formulation
What should a formulation comprise / what is
the process?
Despite some differences between theoretical orientations, some key
themes exist around the content of formulations. The trust has generally
adopted one of the more popular approaches utilizing the Five Ps.
The process should include
Defining the problem and identify the desired alternative to the problem (i.e. treatment
aim / end-point
Collecting the relevant information about the individual: precipitating factors,
perpetuating factors, predisposing factors and protective factors.
Hypothesising re: underlying mechanisms that explain the relationship between the 5 Ps
The creation of a mutual understanding of the case as a team & most importantly with
the patient
The development of a treatment plan that will lead to the desired outcome
What are the 5 Ps?
1. Presenting problem.
This goes beyond diagnosis to include what the person and clinician
identify as difficulties, how the persons life is affected, and when a
particular difficulty should be targeted for intervention. For example, while
a person may meet criteria for the diagnosis of borderline personality
disorder, presenting difficulties may include not being able to cope with
mood shifts, erratic friendships, and physical health complications
resulting from self-harm. Specifying such difficulties can allow for a more
focused intervention.
2. Predisposing factors.
This comprises identifying possible biological contributors (for example,
organic brain injury and birth difficulties), genetic vulnerabilities (including
family history of mental health difficulties), environmental factors (such as
socio-economic status, trauma, or attachment history) and psychological
or personality factors (including core beliefs or personality factors) which
may put a person at risk of developing a specific mental health difficulty.
3. Precipitating factors.
This can include significant events preceding the onset of the disorder,
such as substance use, or interpersonal, legal, occupational, physical, or
financial stressors.
4. Perpetuating factors.
This comprises factors which maintain the current difficulties. These can
include ongoing substance use, repeating behavioural patterns (including
avoidance or safety behaviours in anxiety disorders, or withdrawal in
depressive disorders), biological patterns (such as insomnia in mania, and
insomnia or hypersomnia in depression) or cognitive patterns such as
attentional biases, memory biases, or hypervigilance.
5. Protective/positive factors.
This involves identifying strengths or supports that may mitigate the
impact of the disorder. These can include social support, skills, interests,
and some personal characteristics. Identification of protective factors also
creates increased optimism in both the clinician and patient and
contributes to a positive therapeutic relationship.

Importantly, formulations should be flexible, and should incorporate new

information as it emerges.
Unofficial 6th P for PLAN
There must be a purpose for entry into mental health
services e.g. what is the expectation from client / referrer/
family, what are the goals for the client etc.
The goal(s) must be reasonable and concrete otherwise
how do we know its being worked towards / when it has
been achieved
The plan from the formulation must reflect these goals e.g.
work towards the desired outcome.
Deliberately blank for presenter to add own
slides tailoring presentation to meet team
needs
Presenting Precipitating Predisposing Perpetuating Protective Plan

Big Stones Small Rocks Waves Sand Way

Stones crashing forward
Thank you for attention, any questions?