formulation in mental health · jenny describes feeling low in mood and struggles with her anxiety....

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John ButlerConsultant

Mental Health Nurse

Formulation in Mental Health Part 4: 5Ps Formulation

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

o be aware of the purpose and potential value of formulationo have an understanding of selected problem maintenance & developmental

frameworkso have engaged in a practice of using one or more selected frameworks as the

basis for planning intervention

key learning outcomes

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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

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

Presenting problem / issuesPredisposing factors OR vulnerability factors

Precipitating factors OR likely triggersPerpetuating factors OR maintaining factors

Protective OR positive factors

see: Butler et al (2018), Dudley & Kuyken (2014), MacNeil et al (2012), Crowe et al 2008

the 5Ps framework

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Predisposing factors(= vulnerability & historical factors)

factors contributing to the person’s riske.g. brain injury, family history, trauma, personal beliefs, personality characteristics includes static and stable risk factors

Precipitating factors (= trigger factors)

significant events / situations preceding the episode / crisis situation e.g. stressful situations (relationships, physical, work, money), substance misuseincludes stable and dynamic risk factors

Presenting problem(= current / immediate difficulties)

e.g. symptoms and their immediate consequences / impact

Perpetuating factors(= maintaining factors)

factors that maintain current difficultiese.g. behavioural patterns (avoidance, withdrawal, escape), biological patterns (insomnia), cognitive patterns (suspiciousness), ongoing substance misuseincludes stable & dynamic risk factors

Positive / Protective factors(= strengths / resources / abilities)

strengths or supports that may mitigate the impact of the illness / difficultiese.g. personal characteristics, social supports

see examples

after: Dudley & Kuyken 2014;Butler et al 2018

using the 5Ps framework


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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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John Butler

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




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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

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)




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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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Hopefulness Feeling supported / having a confidante1, 2 Economic security1, 2

Plans for the future1 Strong social and family supports / connectedness1, 2 Resilient personality1

Good problem solving skills1, 2 Feeling responsible for dependents & related concerns1, 2 Cognitive flexibility

Strong faith or spiritual beliefs1 Relationship & integration with community1, 2

Positive coping beliefs2 & a belief that suicide / violence is wrong

Positive engagement / attitude towards mental health care and

support2

Perception of self-control Having valued and meaningful roles2Fear of suicide / pain

Strong commitment to work / education Fear of social disapproval Lack of precipitating life events /

losses

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

protective / +ve factors examples

the 5Ps frameworkJohn Butler

formulation framework: the 5Ps

John Butler

the 5Ps framework

the developmental formulation will show why the individual has his/her particular vulnerability

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Vulnerability factors• Jenny lacks self-confidence and describes always experiencing

low self-esteem (life-long traits)• reports having always been very sensitive to criticism• tends to make unfavourable comparisons with her brother

Triggers factors• loss of her mum• the stressful situation at work, and the recent criticism of her

work performance• the stressful situation of caring for her father• her use of alcohol

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

Maintaining factors• being on her own / sense of isolation• limited supports - misses husband, when away• limited contact with brother (lives some distance away)• impaired sleep • struggling to motivate herself• the stress of caring for her father• her use of alcohol (potential)

Positive factors• Jenny has strong family values – putting her family first, stron

g relationship with her young son, caring for her father• support from her husband and brother (via telephone)• has a job, which she mostly enjoys• she is actively engaging with the service and the treatment a

pproach

example: 5Ps for Jenny case study

5Ps formulation exercise


• consider & embellish the provided short case scenario (next slide) OR oneof 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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5Ps formulation exercise short case scenario


28-year old, recovering from a psychotic episodeo symptoms of distressing voices and paranoid thoughts, though much reducedo has been taking Olanzapine 10mg as prescribed – but this has led to significant

weight gaino 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 friendso gets on very well with elder brothero works as a Department Manager in Debenhams; work supervisor had been critical

about their performanceo has debts of about £10K that is a particular worryo recently broke up with partnero father and an aunt have been treated for a mental illness

Brabban, A. & Turkington, D. (2002) The Search for Meaning: detectingcongruence between life events, underlying schema and psychoticsymptoms. In A.P. Morrison (Ed) A Casebook of Cognitive Therapy forPsychosis (Chap 5, p59-75). New York: Brunner-Routledge

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 RiskAssessment: 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 caseformulation in cognitive behaviour therapy for psychosis. BehaviourResearch & Therapy 41, 671-680

Crowe, M., Carlyle, D. & Farmar, R. (2008) Clinical formulation for mentalhealth nursing practice. Journal of Psychiatric & Mental Health Nursing15, 800-807

Dudley, R. & Kuyken, W. (2014) Case Formulation in Cognitive BehaviourTherapy: a principle-driven approach. In L. Johnstone & R. Dallos (Eds)Formulation in Psychology & Psychotherapy: making sense of people’sproblems (2nd Edition), Chap. 2: 18-44. London: Routledge

References & Bibliography

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Ellis, A. (1962) Reason & Emotion in Psychotherapy. New York: StuartEngel, G.L. (1977) The need for a new medical model: a challenge for

biomedicine. Science 196, 129-136Gamble, C. & Brennan, G. (2006) Working with Serious Mental Illness: a

manual for clinical practice. London, UK: Bailliere-Tindall / RCNGarland, A., Fox, R. & Williams, C. (2002) Overcoming reduced activity and

avoidance: a Five Areas approach. Advances in Psychiatric Treatment 8,453-62

Grant, A., Mills, J., Mulhern, R. & Short, N. (2004) Cognitive BehaviouralTherapy in Mental Health Care. London: Sage

Grant, A., Townend, M., Mills, J. & Cockx, A. (2008) Assessment & CaseFormulation in Cognitive Behavioural Therapy. London: Sage Publications

Greenberger, D. & Padesky, C. (1995) Mind Over Mood: change how you feelby changing the way you think. New York: Guilford Press

Hart, C. (2014) A Pocket Guide to Risk Assessment & Management in MentalHealth. Abingdon, Oxford: Routledge

Hayes, C. (2012) Capacity Building in Mental Health. British Journal ofMental Health Nursing 1(1), 1-5

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Kuyken, W. (2006) Evidence-based Case Formulation: Is the Emperorclothed? In N. Tarrier (Ed) Case Formulation in CBT: the treatment ofchallenging and complex cases (p12-35). Hove: Routledge

Kuyken, W., Padesky, C.A. & Dudley, R. (2009) Collaborative CaseConceptualisation: Working effectively with clients in cognitivebehavioural therapy. New York: Guilford Publications

MacNeil, C.A., Hasty, M.K., Conus, P. & Berk, M. (2012) Is diagnosis enoughto guide interventions in mental health? Using case formulation inclinical practice. BMC Medicine 10, 111 doi: 10.1186/1741-7015-10-111

Meaden, A. & Hacker, D. (2011) Problematic and Risk Behaviours inPsychosis: a shared formulation approach. Hove, East Sussex: Routledge

Mueser, K.T. & Glynn, S.M. (1999) Behavioural Family Therapy forPsychiatric Disorders (2nd Edn.). Oakland, CA: New HarbingerPublications Inc.

Nuechterlein, K. & Dawson, M. (1984) A Heuristic Vulnerability / StressModel of Schizophrenic Episodes. Schizophrenia Bulletin 10, 300-312

Persons, J.B. (1989) Cognitive Therapy in Practice: a case formulationapproach. New York: Norton John Butler


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Restifo, S. (2010) An empirical categorisation of psychosocial factors forclinical case formulation and treatment planning. Australasian Psychiatry18(Suppl 3), 210-213

Ross, D.E. (2000) A Method for Developing a Biopsychosocial Formulation.Journal of Child & Family Studies 9(1), 1-6

Smith, G., Gregory, K. & Higgs, A. (2007) An Integrated Approach to FamilyWork for Psychosis: a manual for family workers. London: JessicaKingsley

Whitfield, G. & Davidson, A. (2007) Cognitive-behavioural TherapyExplained. Oxford: Radcliffe Publishing

Wright, J., Turkington, D., Kingdon, D. & Basco, M. (2009) Cognitive-Behaviour Therapy for Severe Mental Illness: an illustrated guide.London, UK: American Psychiatric Publishing Inc.

Zubin, J. & Spring, B. (1977) Vulnerability: A new view of schizophrenia.Journal of Abnormal Psychology 86, 103-126

John Butler


formulation in mental health · jenny describes feeling low in mood and struggles with her anxiety....

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