5 Ps Psychology Formulation
Rene Seiler
A clinical formulation, also known as case formulation and problem formulation, is a theoretically-based explanation or conceptualisation of the information obtained from a clinical assessment. It offers a hypothesis about the cause and nature of the presenting problems and is considered an adjunct or alternative approach to the more categorical approach of psychiatric diagnosis.[1] In clinical practice, formulations are used to communicate a hypothesis and provide framework for developing the most suitable treatment approach. It is most commonly used by clinical psychologists and is deemed to be a core component of that profession.[2] Mental health nurses,[3] social workers, and some psychiatrists[4] may also use formulations.
Different psychological schools or models utilize clinical formulations, including cognitive behavioral therapy (CBT) and related therapies: systemic therapy,[5] psychodynamic therapy,[6] and applied behavior analysis.[7] The structure and content of a clinical formulation is determined by the psychological model. Most systems of formulation contain the following broad categories of information: symptoms and problems; precipitating stressors or events; predisposing life events or stressors; and an explanatory mechanism that links the preceding categories together and offers a description of the precipitants and maintaining influences of the person's problems.[8]
Behavioral case formulations used in applied behavior analysis and behavior therapy are built on a rank list of problem behaviors,[7] from which a functional analysis is conducted,[9] sometimes based on relational frame theory.[10] Such functional analysis is also used in third-generation behavior therapy or clinical behavior analysis such as acceptance and commitment therapy[11] and functional analytic psychotherapy.[12] Functional analysis looks at setting events (ecological variables, history effects, and motivating operations), antecedents, behavior chains, the problem behavior, and the consequences, short- and long-term, for the behavior.[9]
A model of formulation that is more specific to CBT is described by Jacqueline Persons.[13] This has seven components: problem list, core beliefs, precipitants and activating situations, origins, working hypothesis, treatment plan, and predicted obstacles to treatment.
A psychodynamic formulation would consist of a summarizing statement, a description of nondynamic factors, description of core psychodynamics using a specific model (such as ego psychology, object relations or self psychology), and a prognostic assessment which identifies the potential areas of resistance in therapy.[6]
One school of psychotherapy which relies heavily on the formulation is cognitive analytic therapy (CAT).[14] CAT is a fixed-term therapy, typically of around 16 sessions. At around session four, a formal written reformulation letter is offered to the patient which forms the basis for the rest of the treatment. This is usually followed by a diagrammatic reformulation to amplify and reinforce the letter.[15]
Many psychologists use an integrative psychotherapy approach to formulation.[16][17] This is to take advantage of the benefits of resources from each model the psychologist is trained in, according to the patient's needs.[18]
Formulations can vary in temporal scope from case-based to episode-based or moment-based, and formulations may evolve during the course of treatment.[20] Therefore, ongoing monitoring, testing, and assessment during treatment are necessary: monitoring can take the form of session-by-session progress reviews using quantitative measures, and formulations can be modified if an intervention is not as effective as hoped.[21][22]
Every individual experiences a complex and varied range of situations, events and circumstances that influences their psychological development and sense of self during their lifetime. Factors that can influence the way we view ourselves, other people and the world around us can include our experiences in relationships; our attachments; the expectations and norms of the society we are raised in; formative events in our lives; settings such as home and school, gender, culture, and age; as well as countless others.
For some individuals, the process of formulating their experiences can be a sufficient intervention in and of itself. For others, whose difficulties may require further input, a formulation can be helpful in guiding ideas for suitable interventions.
Given that no individual exists outside of their social contexts, bringing families into the process of formulation can be very valuable. When we think about the needs and difficulties of a person, it is also important to think about how their networks and environments can either maintain or ease distress. Sharing formulations with families is also, where feasible and appropriate, very valuable.
Should service users be willing to share this more nuanced narrative understanding with their wider support networks, this can provide a framework through which their difficulties can be shared and understood with compassion. Discussing formulations openly with service users and families can help to reduce blame or guilt, as well as open new channels of communication and a different vocabulary for understanding challenges on an individual and systemic level.
As well as being of benefit to individuals and their families, formulation brings additional benefits to teams. In many settings, supporting individuals with mental health difficulties can require a multidisciplinary, holistic approach to address various areas and needs.
Jane (17) presented with a history of low mood, anxiety and weight loss. Following assessment, it became apparent that Jane had been engaging in significant restricting behaviours and over-exercising for the past seven months. Jane reported significant eating disordered cognitions (including a fear of losing control over eating, as well as a fear of gaining weight), as well as behaviours consistent with anorexia. A visual formulation co-created with Jane is presented below.
The Biopsychosocial Model and Case Formulation (also known as the Biopsychosocial Formulation) in psychiatry is a way of understanding a patient as more than a diagnostic label. Hypotheses are generated about the origins and causes of a patient's symptoms. The most common and clinically practical way to formulate is through the biopsychosocial approach, first described in 1980 by George Engel.[1][2] Biopsychosocial formulation combines biological, psychological, and social factors to understand a patient, and uses this to guide both treatment and prognosis. Your formulation of a patient evolves and changes as you collect more information. Formulation is like cooking, and there is no 'right' or 'wrong' way to do it, but most get better over time with increasing clinical experience.
Diagnosis is not the same as formulation! In mental health, when there is a group of consistent symptoms seen in a population, these symptoms can be categorized into a distinct entity, called a diagnosis (this is what the DSM-5 does). For example, we diagnose someone with a major depressive episode if they meet 5 of the 9 symptomatic criteria. However, formulation tells us how the person became depressed as a result of their genetics, personality, psychological factors, biological factors, social circumstances (childhood adverse events and social determinants of health), and their environment.
You are probably already formulating, but just don't know it. Like most things in medicine, there are multifactorial causes of diseases, illnesses, and disorders. For example, type II diabetes does not develop because of a single pathophysiological cause. The patient may have a strong family history of the disease, a sedentary job, environmental exposures, and/or a nutritionally-poor diet. These factors all combine to cause the person to develop diabetes. Understanding how each factor contributes to a disease can better guide treatment decisions. In psychiatry, formulation appears more complicated because human behaviour and the brain itself is extraordinarily complex. However, like with anything, the more you practice, the better you will become at formulating.
Now that you've filled in the easy parts from the history, the hardest part is conceptualizing the predisposing social factors (Step 3), and all of the psychological factors (Steps 4, 5, 6, 7). This is where you'll need to be creative and also think more in-depth about your patient. Ideally, each step should flow logically and intuitively into the next based on your framework, as you'll see in our case of Jane Doe. Having a framework for understanding of different psychological treatments and psychological theories can be helpful in making your psychological formulation flow intuitively (e.g. - attachment theory, cognitive behavioural therapy, dialectical behavioural therapy, interpersonal therapy, psychodynamic therapy). However, this can be done intuitively even without an in-depth understanding of these frameworks (we don't need to be Freud to do this). The more cases you go through (and more of the sample formulations below) the more comfortable you will be with formulating!
The narrative formulation of the patient is a less rigid presentation structure where you may not choose to present everything in the 4 Ps table, and instead focus on the key factors that you think are relevant:
A much more advanced and nuanced presentation might be using a more comprehensive formulation that integrates the 4Ps formulation through multiple lenses (e.g. - Eriksonian developmental stages, psychodynamic defenses, and dialectical behavioural):
A good formulation should be integrative, and let you understand how all of the patient's factors interact to lead to the current situation. This gives you a sense of their current level of functioning, prognosis, and guides your direction for treatment and management decisions.
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