5 Ps case formulation template for therapists and psychologists

A case formulation (or case conceptualisation) is a working hypothesis that explains why a client’s difficulties arose and what keeps them going now, so that it can guide treatment. The 5 Ps model organises it into five headings: presenting, predisposing, precipitating, perpetuating (or maintaining) and protective factors.

This article gives you a template to copy, a short fictional example and guidance on revising the formulation as therapy goes on. It is written for psychologists and therapists working in CBT or another approach.

What is a case formulation?

NICE (2014), quoted by the Open University, describes psychological formulations as an explanation of why a problem has occurred and what is maintaining it. Formulations also guide the intervention. The same text states that a formulation is a hypothesis based on the information available at the time. It will often be developed or changed during the intervention.

In 2011 the British Psychological Society published good practice guidelines on the use of psychological formulation. Its web page describes formulation as a core competence for clinical psychologists. According to these guidelines, as quoted by the Open University, formulation is not premised on functional psychiatric diagnoses such as schizophrenia or personality disorder. It is best understood in terms of usefulness rather than ‘truth’.

In practice, formulation links assessment to the treatment plan. The intake session and the anamnesis gather the information. The formulation organises it and offers an explanation. The treatment plan follows from it.

The 5 Ps model, heading by heading

The 5 Ps model is a way to structure a formulation. The case formulation guidelines of the Cairnmillar Institute, an Australian psychology training institute, call it one of the more popular recent approaches. Each theoretical orientation can fill the headings with its own concepts. According to the same guidelines, predisposing factors can be biological, environmental or psychological.

1. Presenting factors (the current problem)

These are the difficulties the client brings today. Describe thoughts, emotions, behaviours, physical sensations and their impact on daily life. The Cairnmillar Institute formulation guidelines state that this heading goes beyond diagnosis. It includes what the person and the clinician identify as difficulties.

2. Predisposing factors (vulnerability)

These are older factors that made the client more vulnerable: family history, childhood experiences, temperament, learned beliefs, biological factors. They help explain why this person developed this problem.

3. Precipitating factors (the trigger)

These are the events that came before the onset or worsening of the difficulties. Examples include a new job, a separation, a bereavement, an illness or a house move. They answer the question ‘why now?’.

4. Perpetuating or maintaining factors

These are the mechanisms that keep the problem going today: avoidance, safety behaviours, rumination, poor sleep, conflict, isolation. This is often the most useful heading for choosing interventions, because you can work on it during therapy. In CBT it often takes the form of vicious cycles between thoughts, emotions, sensations and behaviours.

5. Protective factors

These are the client’s resources: support, skills, values, past successes, motivation. Kuyken, Padesky and Dudley show, according to their publisher, how to build conceptualisations that illuminate personal strengths as well as problems. These factors give interventions something to build on.

The Cairnmillar Institute guidelines note that this element has traditionally been lacking in mental health interventions. We recommend never leaving it empty. It balances a reading that would otherwise focus only on problems.

5 Ps case formulation template to copy

Copy this template into the client record and fill in the [brackets]. Keep sentences short. A useful formulation usually fits on one page.

Case formulation, version [no.] of [dd/mm/yyyy]

• Client: [initials or reference], [age], [life context in one line]
• Reason for referral: [the client’s request, in their own words]
• Presenting factors: [current difficulties, thoughts, emotions, behaviours, sensations, impact on work, relationships and sleep]
• Predisposing factors: [history, early experiences, core beliefs, temperament, past episodes]
• Precipitating factors: [triggering event and approximate date]
• Perpetuating factors: [vicious cycles, avoidance, safety behaviours, context that maintains the problem]
• Protective factors: [strengths, support, skills, values, motivation]
• Summary hypothesis: [two to four sentences linking the headings, for example ‘Given [predisposing factor], [precipitating event] activated [mechanism], and [perpetuating factor] now maintains [problem]’]
• Implications for treatment: [priority targets, planned interventions, goals agreed with the client]
• To check: [missing information, hypotheses to test]
• Shared with the client: [date, client’s response, what they corrected or added]

Fictional 5 Ps formulation example

This example is invented. It only shows the shape of a formulation.

Context. Paul, 38, seeks help for poor sleep and constant worry at work. These began after he was promoted to team leader six months ago.

• Presenting: he fears getting things wrong, rereads his emails several times, sleeps badly and feels tired. He says ‘I’m not good enough for this’.
• Predisposing: a parent who was very demanding about school results, the belief ‘if I make a mistake, people will see I’m worthless’, long-standing perfectionism.
• Precipitating: the promotion, with more responsibility and a team to manage.
• Perpetuating: he does not delegate and checks everything, which lengthens his days. He checks emails late at night for reassurance, which delays sleep. Tiredness makes tasks harder and confirms the idea that he is not up to the job.
• Protective: a supportive partner, cycling at weekends, positive feedback from his manager, a clear request for help.

Summary hypothesis. Long-standing perfectionism, linked to the belief that a mistake reveals a lack of worth, was activated by the promotion. Checking and not delegating ease anxiety in the moment but keep it going. Poor sleep strengthens his sense of incompetence.

Implications. Work first on checking and delegation through behavioural experiments. Set up a sleep routine. Then examine the underlying belief. Draw on his partner’s support and on cycling.

How the formulation changes over the course of therapy

A formulation is never fixed. According to the publisher’s description of Kuyken, Padesky and Dudley’s book, a conceptualisation deepens in explanatory power as treatment progresses. Persons, quoted in the Cairnmillar Institute guidelines, describes assessment and treatment as a continuous process of proposing, testing, re-evaluating, revising, rejecting and creating new formulations. The same guidelines ask that new information be built in as it emerges.

We recommend reviewing the formulation at four points.

• After the assessment sessions: a first version, often descriptive, focused on presenting and perpetuating factors.
• When new information emerges: a memory, a life event, something the client had not mentioned before.
• When therapy stalls: a lack of progress can point to a missed perpetuating factor or a hypothesis to revisit.
• At the end of therapy: the formulation forms the basis of the end-of-therapy summary and the relapse prevention plan.

In Paul’s case, the session 2 version describes the cycle of checking, tiredness and worry. In session 6, Paul mentions a similar period during his exams. The formulation now links situations where he is being judged to the activation of his belief. By session 9, checking has decreased but sleep is still difficult. The clinician adds a perpetuating factor, coffee late in the day.

Keep each version, dated. Together they show the progress made, to the client and to you. Between reviews, the CBT session note records the targets worked on and what has changed. That is what you will reread to update the formulation.

Sharing the formulation with the client

According to its publisher, Kuyken, Padesky and Dudley’s book shows clinicians how to develop and test a conceptualisation with the client. We recommend presenting it as a proposal: ‘This is how I understand what is happening for you. What do you think? What is missing?’

Use the client’s own words and a simple diagram on paper or a whiteboard. Let them correct it. Note in the record what was shared and what they changed. For sensitive parts of family history, choose the moment with care.

Common mistakes

• Listing information without a hypothesis that links it together.
• Treating the formulation as a diagnosis.
• Leaving out protective factors.
• Writing a formulation so long that nobody rereads it.
• Never touching it again after the first few sessions.

Why Delta helps when you revise a formulation

Delta is the clinical assistant for mental health and allied health professionals. During the session, it transcribes what is said. After the session, you can also dictate your observations. Delta generates a report for each session that takes your approach into account, CBT included, and updates the client record with a summary of the therapy and the goals being tracked.

When you revise a formulation, you find in one place what was said across sessions and how the goals have changed. The formulation remains your clinical work, built with the client. Delta does not write it and does not help with diagnosis. Data stays in Europe, hosted in France on infrastructure certified for health data, and the client’s name is pseudonymised before AI processing. You will find other outlines in our clinical document templates.

Sources

• The Open University, OpenLearn, Making sense of mental health problems, section 3.1 (quoting NICE, 2014, and the British Psychological Society, 2011).
• British Psychological Society, Division of Clinical Psychology, Good Practice Guidelines on the use of psychological formulation, 2011.
• Kuyken W., Padesky C. A., Dudley R., Collaborative Case Conceptualization, The Guilford Press, 2008 (paperback 2011).
• Cairnmillar Institute, CLN560 Case Formulation and Treatment Planning Guidelines, version dated 10.01.25.
• Royal Australian College of General Practitioners, gplearning, Four Ps template (case formulation), undated.