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. 

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. 

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. 

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. 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. By identifying these protective factors, therapy can help clients to build resilience and develop strategies for coping with stressors.  

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. 

Please note that this blog post by Personal Psychology 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.