3/22/18

Formulation in
Mental Health
Part 4: 5Ps Formulation

John Butler
Consultant
Mental Health Nurse

key learning outcomes

by the end of the session(s) you will:

o be aware of the purpose and potential value of formulation

o have an understanding of selected problem maintenance & developmental
frameworks
o have engaged in a practice of using one or more selected frameworks as the
basis for planning intervention

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formulation:
considering different frameworks

a closer look at some key frameworks:

consider the relative merits / drawbacks

& their practical utility

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developmental framework: the 5Ps

the 5 ‘P’s, as a basic structure & popular framework –
consider the following aspects:

Presenting problem / issues

Predisposing factors OR vulnerability factors
Precipitating factors OR likely triggers
Perpetuating factors OR maintaining factors
Protective OR positive factors

see: Butler et al (2018), Dudley & Kuyken (2014), MacNeil et al (2012),

Crowe et al 2008
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the 5Ps framework

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using the 5Ps framework

Predisposing factors Precipitating factors (= trigger factors)
(= vulnerability & historical factors)
significant events / situations preceding the episode /
factors contributing to the person’s risk crisis situation e.g. stressful situations (relationships,
e.g. brain injury, family history, trauma, personal physical, work, money), substance misuse
beliefs, personality characteristics includes stable and dynamic risk factors
includes static and stable risk factors

Presenting problem
(= current / immediate difficulties)

e.g. symptoms and their immediate consequences / impact

Perpetuating factors Positive / Protective factors

(= maintaining factors) (= strengths / resources / abilities)

factors that maintain current difficulties strengths or supports that may mitigate the impact of
e.g. behavioural patterns (avoidance, withdrawal, after: Dudley & Kuyken 2014; the illness / difficulties
escape), biological patterns (insomnia), cognitive Butler et al 2018 e.g. personal characteristics, social supports
patterns (suspiciousness), ongoing substance misuse
includes stable & dynamic risk factors see examples

using the 5Ps framework

PRESENTING PROBLEM

identifying difficulties, how the person’s life is affected

& when a particular difficulty should be targeted for
intervention

e.g. unable to maintain employment, self-harm

behaviour & its physical health complications etc…

see: MacNeil et al (2012),

Dudley & Kuyken (2014)

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the 5Ps framework

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using the 5Ps framework

PREDISPOSING FACTORS

identifying possible contributing factors that may put a

person at risk – biological, genetic / vulnerability,
environmental, psychological & personality

e.g. brain injury, family history, trauma, poverty,

personal beliefs, personality characteristics

see: MacNeil et al (2012),

Dudley & Kuyken (2014)

John Butler

the 5Ps framework

using the 5Ps framework

PRECIPITATING FACTORS

identifying significant events preceding the onset of

the episode / disorder / illness

e.g. substance use, interpersonal / legal / occupational

/ physical / financial stressors

see: MacNeil et al (2012),

Dudley & Kuyken (2014)

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the 5Ps framework

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using the 5Ps framework

PERPETUATING FACTORS

identifying factors that maintain current difficulties

e.g. ongoing substance use, repeated behavioural

patterns (avoidance, escape, safety, withdrawal,
hypervigilance), biological patterns (insomnia) or
cognitive patterns (attentional bias, suspiciousness)

see: MacNeil et al (2012),

Dudley & Kuyken (2014)

John Butler

the 5Ps framework

using the 5Ps framework

PROTECTIVE / +VE FACTORS

identifying strengths or supports that may mitigate the

impact of the disorder / illness
e.g. social supports, skills, interests, personal
characteristics

influences the reduction of symptoms & increased

resilience, & contributes to optimism & hope

see: MacNeil et al (2012),

Dudley & Kuyken (2014)
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the 5Ps framework

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protective / +ve factors examples

Feeling supported / having a
Hopefulness Economic security1, 2
confidante1, 2
Strong social and family supports /
Plans for the future1 Resilient personality1
connectedness1, 2
Feeling responsible for dependents
Good problem solving skills1, 2 Cognitive flexibility
& related concerns1, 2
Relationship & integration with Positive coping beliefs2 & a belief
Strong faith or spiritual beliefs1
community1, 2 that suicide / violence is wrong
Positive engagement / attitude Perception of self-control
Having valued and meaningful
towards mental health care and
Fear of suicide / pain roles2
support2
Strong commitment to work / Lack of precipitating life events /
Fear of social disapproval
education losses

Butler et al 2018 (& see: 1Hart 2014, p30; 2Meaden & Hacker 2011, p49 & 82)

John Butler

the 5Ps framework

formulation framework: the 5Ps

the developmental formulation will show why the

individual has his/her particular vulnerability

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the 5Ps framework

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example: 5Ps for Jenny case study

Vulnerability factors Triggers factors
• Jenny lacks self-confidence and describes always experiencing • loss of her mum
low self-esteem (life-long traits) • the stressful situation at work, and the recent criticism of her
• reports having always been very sensitive to criticism work performance
• tends to make unfavourable comparisons with her brother • the stressful situation of caring for her father
• her use of alcohol

Presenting issues
Jenny describes feeling low in mood and struggles with her anxiety. Sh
e reports having a poor appetite, not sleeping well, lacking energy, an
d struggles to motivate herself. She has occasional suicidal thoughts (t
hinking about taking an overdose).

Maintaining factors Positive factors

• being on her own / sense of isolation • Jenny has strong family values – putting her family first, stron
• limited supports - misses husband, when away g relationship with her young son, caring for her father
• limited contact with brother (lives some distance away) • support from her husband and brother (via telephone)
• impaired sleep • has a job, which she mostly enjoys
• struggling to motivate herself • she is actively engaging with the service and the treatment a
• the stress of caring for her father pproach
• her use of alcohol (potential)

5Ps formulation exercise

• consider & embellish the provided short case scenario (next slide) OR one
of your own clients & develop a 5Ps formulation

• feedback your formulation to the other group members

• discuss the merits & drawbacks of the formulation framework

• What are the implications for treatment / care planning?

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the 5Ps framework

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5Ps formulation exercise short case scenario

28-year old, recovering from a psychotic episode
o symptoms of distressing voices and paranoid thoughts, though much reduced
o has been taking Olanzapine 10mg as prescribed – but this has led to significant
weight gain
o had two previous episodes, but tended to stop medication when was feeling
better (one of which led to a compulsory admission)
o has lost contact with old friends
o gets on very well with elder brother
o works as a Department Manager in Debenhams; work supervisor had been critical
about their performance
o has debts of about £10K that is a particular worry
o recently broke up with partner
o father and an aunt have been treated for a mental illness
John Butler

the 5Ps framework

Brabban, A. & Turkington, D. (2002) The Search for Meaning: detecting

congruence between life events, underlying schema and psychotic References &
symptoms. In A.P. Morrison (Ed) A Casebook of Cognitive Therapy for
Psychosis (Chap 5, p59-75). New York: Brunner-Routledge Bibliography
Butler, G. (1998) Clinical Formulation. In A.S. Bellack & M. Hersen (Eds.)
Comprehensive Clinical Psychology. New York: Pergamon Press
Butler, J., Commissiong, A. & Crossman, C. (2018) Mental Health Risk
Assessment: a personalised approach. In K. Wright & M. McKeown (Eds)
Essentials of Mental Health Nursing, Chap 25. London: Sage
Chadwick, P., Williams, C. & Mackenzie, J. (2003) Impact of case
formulation in cognitive behaviour therapy for psychosis. Behaviour
Research & Therapy 41, 671-680
Crowe, M., Carlyle, D. & Farmar, R. (2008) Clinical formulation for mental
health nursing practice. Journal of Psychiatric & Mental Health Nursing
15, 800-807
Dudley, R. & Kuyken, W. (2014) Case Formulation in Cognitive Behaviour
Therapy: a principle-driven approach. In L. Johnstone & R. Dallos (Eds)
Formulation in Psychology & Psychotherapy: making sense of people’s John Butler

problems (2nd Edition), Chap. 2: 18-44. London: Routledge

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References &
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Mental Health Nursing 1(1), 1-5

Kuyken, W. (2006) Evidence-based Case Formulation: Is the Emperor

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Persons, J.B. (1989) Cognitive Therapy in Practice: a case formulation
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approach. New York: Norton

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Restifo, S. (2010) An empirical categorisation of psychosocial factors for

clinical case formulation and treatment planning. Australasian Psychiatry References &
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