Formulation 5p Training 6u1g4l

5 P Formulation

Dr M Andrijevskis

Formulation Standards 1. All qualified staff should be able to demonstrate confidence and competence in undertaking a psychological formulation. All staff to participate in the team formulation. 2. All qualified staff should be able to develop a psychological formulation using the 5P framework (based on the CBT model), document this in a standard format, and have the ability to present this to the service , carer, clinical team etc. 3. All qualified staff should have a basic knowledge of intervention options, and be able to identify appropriate intervention options following formulation.

Formulation competencies Qualified staff should be able to demonstrate: 1. They can collect appropriate assessment information including identification and consideration of  a comprehensive list of all the presenting problems that are causing concern to the individual and family (e.g. emotional, relational and behavioural symptoms etc)  factors that might have triggered (precipitated) the onset or exacerbation of the problems (e.g. acute life stresses such as illnesses or bereavements etc)  risk factors that might have predisposed the individual to the development of psychological problems (e.g. parental neglect / abuse etc),  factors that might perpetuate psychological problems once they have developed (e.g. poor coping strategies etc).  factors that might prevent the problem from becoming worse (protect) or may be enlisted to ameliorate the presenting problems (e.g. good family communication/ etc).

2. They can demonstrate an ability to create and populate the formulations 5 p’s correctly 3. They can demonstrate an understanding (in practice) that formulations should be reviewed and revised as further information emerges during ongoing with the individual. 4. Can demonstrate an understanding (in practice) that one of the main functions of a formulation is to help guide the development of an intervention plan. 5. Can the results of assessment and formulation and agree the intervention plan with all relevant parties

A formulation is  An integration of factual information that explains the origins and maintenance of a clients problems and attempts to clarify the underlying explanatory mechanisms for those problems – which then suggests interventions that will improve those.

A formulation should  Follow an assessment  Be based on factual information  Be integrated into an explanatory  Be the map that directs towards logical targets for intervention

Formulation has been defined as ‘...the bridge between assessment and Treatment’ and can serve a number of functions  understanding significant causal factors that have influenced the person’s presentation;  identifying key difficulties; guiding which interventions should be utilised and in what order;  and anticipating challenges that may occur during the course of treatment

Good assessment leads to good formulation

What should a formulation comprise / what is the process?  Despite some differences between theoretical orientations, some key themes exist around the content of formulations. The trust has generally adopted one of the more popular approaches utilizing the ‘Five Ps’.  The process should include  Defining the problem and identify the desired alternative to the problem (i.e. treatment aim / end-point  Collecting the relevant information about the individual: precipitating factors, perpetuating factors, predisposing factors and protective factors.  Hypothesising re: underlying mechanisms that explain the relationship between the 5 Ps  The creation of a mutual understanding of the case as a team – & most importantly with the patient  The development of a ‘treatment’ plan that will lead to the desired outcome

What are the 5 Ps? 1. Presenting problem. This goes beyond diagnosis to include what the person and clinician identify as difficulties, how the person’s life is affected, and when a particular difficulty should be targeted for intervention. For example, while a person may meet criteria for the diagnosis of borderline personality disorder, presenting difficulties may include not being able to cope with mood shifts, erratic friendships, and physical health complications resulting from self-harm. Specifying such difficulties can allow for a more focused intervention.

2. Predisposing factors. This comprises identifying possible biological contributors (for example, organic brain injury and birth difficulties), genetic vulnerabilities (including family history of mental health difficulties), environmental factors (such as socio-economic status, trauma, or attachment history) and psychological or personality factors (including core beliefs or personality factors) which may put a person at risk of developing a specific mental health difficulty.

3. Precipitating factors. This can include significant events preceding the onset of the disorder, such as substance use, or interpersonal, legal, occupational, physical, or financial stressors.

4. Perpetuating factors. This comprises factors which maintain the current difficulties. These can include ongoing substance use, repeating behavioural patterns (including avoidance or safety behaviours in anxiety disorders, or withdrawal in depressive disorders), biological patterns (such as insomnia in mania, and insomnia or hypersomnia in depression) or cognitive patterns such as attentional biases, memory biases, or hypervigilance.

5. Protective/positive factors. This involves identifying strengths or s that may mitigate the impact of the disorder. These can include social , skills, interests, and some personal characteristics. Identification of protective factors also creates increased optimism in both the clinician and patient and contributes to a positive therapeutic relationship. Importantly, formulations should be flexible, and should incorporate new information as it emerges.

Unofficial ‘6th’ P for PLAN  There must be a ‘purpose’ for entry into mental health services e.g. what is the expectation from client / referrer/ family, what are the goals for the client etc.  The goal(s) must be reasonable and concrete – otherwise how do we know it’s being worked towards / when it has been achieved  The plan from the formulation must reflect these goals e.g. work towards the desired outcome.

Deliberately blank for presenter to add own slides – tailoring presentation to meet team needs Presenting Precipitating Predisposing Perpetuating Protective Plan Big Stones Small Stones

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Waves crashing

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Way forward

Thank you for attention, any questions?