4P 5P therapy formulation

The 4 Ps of therapy is a model used to conceptualize the formulation and treatment of the presenting problem (the fifth element in 5P) or a mental disorder. The 4 P’s stand for predisposing factors, precipitating factors, perpetuating factors, and protective factors, and typically developed together in early therapy sessions between the client and the psychologist

Formulation in Therapy

Formulation in therapy is like a personalized puzzle-solving process. It’s where your psychologist, together with you, gathers and organises information about your thoughts, emotions, behaviours, and life experiences to understand the roots of their difficulties. This understanding is essential because it provides clarity on why certain problems persist and how they are interconnected. Formulation helps therapists tailor treatment strategies to the individual, making therapy more effective. It empowers clients by shedding light on the causes of their distress and guiding them toward specific, achievable goals.

Predisposing factors

Predisposing factors are risk factors that increase the likelihood of developing a particular mental illness. These factors can be biological, psychological, or social in nature. Examples of biological predisposing factors include genetic predisposition (such as the presence of certain disorders in the family, such as Autism, Bipolar disorder, Attention deficit hyperactivity disorder (ADHD), Major depression, Schizophrenia), prenatal exposure to toxins (such as alcohol), and brain injuries. Psychological predisposing factors include personality traits (high Neuroticism, low Openness, low Conscientiousness), coping mechanisms (or the lack of, such as excessive drinking), and cognitive biases (such as focusing on negative information more). Social predisposing factors include environmental stressors (such as finance or job stress), childhood trauma, and social isolation. 

Predisposing factors examples

One of the most frequent example of predisposing factors is genetic loading, where many mental health issues have significant genetic components. This means that we inherit the likelihood of developing these conditions from our parents (nature). Additionally, our upbringing plays a role as well: if our parents exhibit certain unhelpful behaviours, we tend to learn and adopt similar behaviours as we grow up, both through modelling their actions and explicit instructions on behaviours (nurture). For example, children of anxious parents often develop anxiety themselves due to these combined factors.

Precipitating factors

Precipitating factors refer to the immediate issues or events that have caused the person to present with their symptoms. For example, if someone experienced a highly stressful event (breakup of a relationship, loss of employment), or a traumatic event (such as sexual assault), then these, in combination with predisposing factors, might explain the onset of the mental health problems. 

Precipitating factors examples

Clients often find precipitating factors easy to identify, as they can usually pinpoint the “big thing” that significantly worsened their situation. These factors can include events like separating from a romantic partner, receiving a warning from an employer, experiencing a significant loss, or requiring immediate hospitalisation. However, the onset of mental health issues is often more subtle, manifesting over several weeks. For example, working long hours and weekends can lead to burnout, ultimately resulting in depressive symptoms. Similarly, percipitating factors can have several steps, such as working night shifts leading to lack of sleep, causing poor job performance, leading to high anxiety.

Perpetuating factors

Perpetuating factors are behaviours or environmental factors that maintain or worsen a mental illness. These can include things at home (lack of supportive relationship), at work (lack of stable income), at social (lack of friendships), poor coping strategies (such as ruminating), or at school (such as being bullied). In the 4P / 5P formulation (if we include presenting problem as the 5th P), the perpetuating factors are the ones that “makes things stuck”. Therapy can help to work on these not only to regain but to maintain functioning as well. 

Perpetuating factors examples

Perpetuating factors are often not immediately obvious to clients, and collaborating with a psychologist can help to understand why certain issues seem “stuck.” For example, avoiding stressful social interactions due to social anxiety can reinforce those fears, perpetuating the problem. Similarly, ceasing exercise due to low energy and mood can create a cycle where the lack of physical activity maintains the low mood, often referred to as the lethargy cycle.

Protective factors

Protective factors are factors that decrease the likelihood of developing or getting “stuck” with a mental health problem. These factors can include the person’s strengths, such as competencies, skills, talents, interests, and supportive elements. Protective factors counteract the predisposing, precipitating, and perpetuating factors that contribute to the development and maintenance of mental illness. By identifying these protective factors, therapy can help clients to build resilience and develop strategies for coping with stressors, relying on strengths they already have.

Protective factors examples

Examples of protective factors include coping skills (such as exercising when upset, or solving problems rather than postponing them), a positive support system (good friends and family), a secure attachment style, financial stability, good health, and positive outlook on future.

Presenting problem – Fitting it all together

Presenting problem is what the client would typically describe as “things I feel and are not going well.” These are typically symptoms, rather than causes, of the problems. Instead, the 4P together create a maintain the presenting problem. Namely, Predisposing factors increase the likelihood of developing a particular mental illness. Precipitating factors trigger the onset of a mental illness. Protective factors decrease the likelihood of developing a clinical condition. Perpetuating factors maintain or worsen a mental illness. By understanding these four components of the 4 P’s model, psychologists can develop treatment plans that address the underlying causes of their patient’s mental illness. Treating the root causes, rather than symptoms, are essential for recovery. 

📄FREE PDF worksheet for Training and Clinical use

We offer a free 4P/5P formulation PDF worksheet PDF to be used in training and clinical settings. The PDF can be filled out using your computer or printed and used in sessions (pen & paper).

Please note that this blog post by Personal Psychology, a psychology clinic in North Sydney, and is not intended to provide professional advice. If you or someone you know is experiencing mental health difficulties, it is important to seek help from a qualified healthcare professional.