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    4P case formulation

    4P 个案概念化

    Practice framework
    Also called
    4P model, 4 Ps formulation, biopsychosocial 4P formulation, five Ps

    What is the 4P case formulation?

    The 4P case formulation sorts the factors behind a person’s difficulties into predisposing, precipitating, perpetuating and protective, and looks for each in biological, psychological and social domains, to explain why a problem arose and persists and to guide treatment.[1][2]

    Biological Always a light sleeper

    Psychological Belief: “I must be the best”

    Social A worrying, demanding mother

    Biological Weeks of overtime upset her sleep

    Psychological —

    Social New department; public criticism from the new boss

    Biological Late-night scrolling, short sleep

    Psychological Growing sure “I’m no good”

    Social Skips gatherings, sees fewer friends

    Biological No drinking, good physical health

    Psychological Willing to seek help and try new things

    Social Weekly walks with a former colleague

    Schematic; the case is fictional. Not every cell needs an entry.

    Select a row, column or box for details.
    Schematic. At the top, the presenting problem; below it, a 4 × 3 grid whose rows are the four kinds of factors (predisposing, precipitating, perpetuating, protective) and whose columns are the biological, psychological and social domains, filled in for the fictional Ms. Wang. Underneath, how the grid points to treatment, where the model comes from and its limits. Select a row, column or box for details. Select a part for details
    Schematic. At the top, the presenting problem; below it, a 4 × 3 grid whose rows are the four kinds of factors (predisposing, precipitating, perpetuating, protective) and whose columns are the biological, psychological and social domains, filled in for the fictional Ms. Wang. Underneath, how the grid points to treatment, where the model comes from and its limits. Select a row, column or box for details. Save as image (PNG)

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    Key points

    • Predisposing factors are the background that makes a difficulty more likely, such as family history, trauma, attachment history and core beliefs; precipitating factors are major events or stressors before onset.[2]
    • Perpetuating factors keep difficulties going, such as ongoing substance use, avoidance or withdrawal, insomnia and attentional biases; protective factors are strengths and supports that soften the impact.[2]
    • The four Ps are crossed with biological, psychological and social domains in a grid; treatment targets what can change, builds up protective factors and notes causes that cannot change.[1]
    • When 115 practitioners formulated the same case, they mostly agreed on descriptive elements, agreed less as more theory-driven inference was needed, and only 44% of formulations were rated good enough.[3]

    An example

    Two months into a new department, Ms. Wang sleeps badly and stays home. With her therapist she fills in a 4P grid: a worrying mother and her own “I must be the best” (predisposing); public criticism from her new boss (precipitating); skipped gatherings and late-night scrolling (perpetuating); weekly walks with a former colleague (protective).

    Misreadings and limits

    A 4P grid holds hypotheses to test, not established causes: many factors have unknown or small effects and come from group studies that may not fit the person in front of you.[1] Agreement between clinicians formulating the same case ranges from slight to substantial, and training and experience help.[4]

    Sources

    1. 1 Owen, G. (2023). What is formulation in psychiatry?. Psychological Medicine, 53(5), 1700–1707. doi:10.1017/S0033291723000016
    2. 2 Macneil, C. A., Hasty, M. K., Conus, P., & Berk, M. (2012). Is diagnosis enough to guide interventions in mental health? Using case formulation in clinical practice. BMC Medicine, 10, 111. doi:10.1186/1741-7015-10-111
    3. 3 Kuyken, W., Fothergill, C. D., Musa, M., & Chadwick, P. (2005). The reliability and quality of cognitive case formulation. Behaviour Research and Therapy, 43(9), 1187–1201. doi:10.1016/j.brat.2004.08.007
    4. 4 Flinn, L., Braham, L., & das Nair, R. (2015). How reliable are case formulations? A systematic literature review. British Journal of Clinical Psychology, 54(3), 266–290. doi:10.1111/bjc.12073

    Last checked against sources: October 28, 2026