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3/22/18
1
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
John Butler
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formulation:considering different frameworks
a closer look at some key frameworks:
consider the relative merits / drawbacks& their practical utility
John Butler
developmental framework: the 5Ps
John Butler
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
using the 5Ps framework
John Butler
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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using the 5Ps framework
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
see: MacNeil et al (2012),
Dudley & Kuyken (2014)
using the 5Ps framework
John Butler
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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using the 5Ps framework
John Butler
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)
using the 5Ps framework
John Butler
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
the 5Ps frameworkJohn Butler
• 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
the 5Ps frameworkJohn Butler
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
John Butler
References & Bibliography
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
References & Bibliography
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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
References & Bibliography