Making first contact: What to do with all that information! part 2


Last week I described some of the reasons for using a case formulation approach when working through initial assessment information, and today I’m going to describe one approach for organising a formulation. This is the “4 P” formulation, and it’s one that’s often used in mental health (Bolton, 2014).

In the 4 P model, there are four questions to ask yourself:

  1. Preconditions – Why is this person vulnerable to this problem?
  2. Precipitating factors – Why now? This can mean “why is this person having symptoms now?” or “why is this person presenting to this person for treatment right now?”
  3. Perpetuating factors – Why is this person still ill?
  4. Protective factors – Why is this person not more ill?

Remembering that people are whole people, and that pain is always multifactorial, this formulation approach incorporates diagnostic information (disease) alongside a person’s response to disease (illness). The two facets of “being unwell” go together – but not synchronously. We can have a disease and be oblivious to it (think of many forms of cancer, hypertension, Type 2 diabetes, osteoarthritis…and even Covid-19). Once we begin to experience symptoms and decide that this is not “normal” we call it illness. And if symptoms and signs begin to impinge on what we can and can’t do in life, we can call this disability or functional limitations. These in turn (more or less) influence participation in community life. The relationships are not straightforward, and this is partly why a formulation can be so helpful. Formulations help us explore – in collaboration with the person – why is this problem such a problem? – whether it’s simply the presence of pain, or more related to the disability and distress that pain is posing for the person.

Preconditions include biological factors such as gender, ethnicity, and age. Preconditions also include psychological factors such as previous experiences in life, prevailing beliefs, emotional reactivity, and attention. Social factors such as employment status, social connection, stigma, socio-economic status, family and living situation are all contributors to a person’s vulnerability to the problem they’re presenting with. In our pain formulations, we know about many of these preconditions that make the people we see vulnerable to having trouble with their pain.

Precipitating factors can be considered in several ways. I like to consider behavioural antecedents for seeking help – what’s been happening in the immediate weeks before a person seeks help – as well as antecedents to the onset of symptoms. For example, people might wait for some weeks before seeking help for a back pain because “it usually settles down” – and this suggests to me that their current episode hasn’t settled down, and they have some thoughts or worries about why. Others might be seeking help because of insurance or workplace requirements where, if they don’t seek help and have the problem recorded, they may not get cover for treatment if the problem reoccurs. Some might be seeking help because their partner or family member is worried, or because they read something in the media or online. I also ask about what was happening at the time the symptoms started. Sometimes this is about an unusually busy time (at work or home), a change in activity level, a new tool or piece of equipment, a new manager or coworkers, perhaps a new daily routine, or a change in living circumstances. While these factors may not be directly causal (biologically) the meaning of these events is valuable because they inform me of the person’s beliefs about their problem.

Perpetuating factors are again, multifactorial and often unrelated to the factors that precipitated the problem. There could be factors associated with disuse influencing changes to the tissues and neurobiology; there could be steps the person has taken to deal with the problem that impact on how quickly it resolves such as using NSAIDs or strapping/wrapping, wearing splints, changed movement patterns. Some of the factors are likely to be beliefs about what’s going on and what should be done about it – like “all the pain must be gone before I start back at work”, or “it’s damaged so I need surgery”. Others could be instructions from people (or held in the community at large) about what to do, like resting, moving in particular ways, or when to seek treatment. Some can be how others respond to the person, like getting irritated because the person isn’t 100% “yet”, or mollycoddling the person (wrapping them up in cottonwool and not letting them do things again). Workplace factors like policies not allowing a person back “until fully fit” or “there are no light duties” also contribute to trouble resuming normal activities.

Protective factors help explain resilience, or strengths the person has that help them maintain well being in the face of this problem. They can be attitudes and practices of the person like believing the body is good at recovering, or maintaining healthy eating and sleeping. They may be factors such as the person’s age, gender, general health. They can include the ability to get to and from treatment (and pay for it), the person’s social supports, their relationships with other health professionals, perhaps strategies they’ve used for other problems (including similar ones to this event) that they haven’t thought to use for this one.

The 4P approach has multiple variants. Some include “the Problem” and call it a 5P model. Some are explicitly tied to a theory of human behaviour (such as a CBT model, ACT model or applied behaviour analysis). Some are entirely developed from the person’s own words and experiences, while others draw on reports from other team members, or previous interactions. The over-riding themes of all of these are that a formulation is developed in collaboration with the person, and considers the whole person in their own usual context.

Next time I’ll look at another formulation approach, and discuss it in relation to teams and how they might use it to form a “team model” of pain and musculoskeletal problems.

Bolton, J. W. (2014). Case formulation after Engel—The 4P model: A philosophical case conference. Philosophy, Psychiatry, & Psychology, 21(3), 179-189.

Cox, L. A. (2021). Use of individual formulation in mental health practice. Mental Health Practice, 24(1), 33-41. https://doi.org/http://dx.doi.org/10.7748/mhp.2020.e1515

Farmer, R. F., & Chapman, A. L. (2016). Behavioral case formulation and treatment planning. In Behavioral interventions in cognitive behavior therapy: Practical guidance for putting theory into action (2nd ed.). (pp. 53-100). https://doi.org/10.1037/14691-003

Gilbert, P. (2016). A biopsychosocial and evolutionary approach to formulation. In Tarrier, Nicholas [Ed]; Johnson, Judith Ed Case formulation in cognitive behaviour therapy: The treatment of challenging and complex cases , 2nd ed (pp 52-89) xvii, 384 pp New York, NY, US: Routledge/Taylor & Francis Group; US (pp. 52-89).

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