Managing Pre-Existing Mental Health Conditions

The concept and processes of case formulation in the management of mental health conditions have a long history. For example, most psychotherapies formulate in one way or another, and they do so along theory-specific lines. Each therapeutic orientation has its own way of understanding normal and abnormal behaviour, and those factors that it proposes cause and maintain problems. These different ways of understanding the nature of disorders – and the factors that predispose to and perpetuate the problem – will have implications for the processes and actions engaged in, in order to resolve them.

One prominent model of case formulation for mental health disorders is referred to as the “Five P’s model” of formulation.

The 5 Ps model of formulating considers what it terms as

• Presenting problems
• Predisposing factors
• Precipitating factors
• Perpetuating factors and
• Prognostic indicators

The 5 Ps model begins with the development of a presenting problem list, and here it is helpful to cast the net wide. There may be no intention to treat all items on the presenting problem list, but it is helpful to look for and document them anyway. Here, problems obviously include diagnosable mental health disorders or specific symptoms such as self-harm, or they could include broader problems such as marital discord, medical conditions, and interpersonal, educational or occupational problems, financial and legal difficulties.

Considering items on a comprehensive presenting problem list allows the practitioner to begin to think about the ways in which these problems may be related.

Next, in the 5 Ps model the practitioner begins to consider the origins of the client’s presenting problems. These are referred to as predisposing factors. Predisposing factors are often distant in time or distal. They may be in the form of major life experiences such as childhood abuse, cultural factors such as cultural norms and expectations, biological factors such as chronic illness and pre-existing mental health conditions. Typically, these factors are not considered to be causes of currently presenting problems, as not all individuals who has experienced the same factors will go on to develop these particular presenting problems, to the same degree of severity or in precisely the same combination. Rather, it is helpful to think of predisposing factors as events or experiences that have increased the likelihood of presenting problems developing but have not guaranteed them. Identification of potential predisposing factors provides information about a link between early or previous events or factors and current symptoms.

The next step in the development of an individualised case formulation involves determination of precipitating factors. Precipitating factors are often found in the form of more recent stressors directly associated with the onset or worsening of the presenting problem. Precipitants can be internal e.g., heart palpitations that are viewed by the individual as signs of an impending heart attack, which then triggers a panic attack, or external factors or stressors such as the experience of disaster that triggers an episode of depression or PTSD.

Next, the practitioner focusses on the identification of perpetuating factors.  Perpetuating factors are those issues that cause a problem or problems to continue. They are considered as psychological constructs such as maladaptive schemas, automatic thoughts, environmental contingencies, skills deficits, active avoidant behaviours etc., that when occur or are engaged in, contribute to the maintenance or perpetuation of a mental health disorder or problem. For example, research regarding the nature of PTSD shows us that the disorder may be perpetuated by a range of factors including the avoidance of memories, as well as the avoidance of people, places and things that serve as reminders of the event just to name a few.

And finally, individualised case formulations include consideration of predictors of outcome, or assets and barriers. It can be helpful to consider factors that might support the client in treatment, and might therefore be utilized in the treatment plan OR factors that might act to impede treatment that might therefore need to be addressed prior to implementation of the treatment plan. For example, the client that has battled to overcome adversity with the thoughtful use of a range of coping strategies, who has around them a supportive social network might be able to marshal those assets again. Alternatively, the client who experiences unstable housing circumstances may have difficulty accessing medical or psychological services or focusing on therapy.  That particular circumstance may need to be addressed before the individual is able to make treatment a priority.  A formulation-driven approach to treatment planning will then take into account all identified factors to arrive at a treatment plan that reflects understanding of the ways these range of factors are at play for each individual.

For those who would like to extend their understanding of the use of individualised case formulations we would recommend the following publication:

• Persons, J. B. (2012). The case formulation approach to cognitive-behavior therapy. Guilford Press.