Try ‘4P + 4’ for a fresh approach to complex mental health case formulation & treatment planning

  • Wednesday, April 27, 2016
  • Shona Innes Psychology

Formulation and treatment planning in complex cases involving a young person are particularly challenging because of the sheer volume of information available to us. The key question is how to make effective use of it all. My suggestion is that we extend the well-known 4P approach to take into account 4 more critically important areas. In my view, ‘4P + 4’ would enable us to reach much greater clarity on what to target, why and how in order to improve a young person’s situation.

For a long time now, good psychologists have been considering client issues with reference to the 4 Ps: predisposing factors, precipitating factors, perpetuating issues and protective factors. I believe that in complex cases involving young people, the 4Ps need to be developed further to take individual development, established evidence, bio-psycho-social approach and system politics into account.

1. Individual development

Across an individual’s lifespan, key elements interact with cornerstone developmental moments.It is extremely informative to map significant events and trauma points along a life line and correlate these with what is known about developmental psychology. The stages and changes that occur in a young brain as it faces moment by moment experiences are truly remarkable. I discussed this in my 2015 TEDx talk 

2. Established evidence

Young people are often pushing boundaries and presenting with new behaviours. The problem is that good research takes time and a young person can’t be put on hold while you wait for the research to tell you what to do. The use of ice (crystal meth) and self harm are examples from recent years. You need to act now, so find someone who can tell you about the available evidence for the behaviour of concern (or similar). In the absence of evidence, begin collecting your own with reference to your client’s story and a good functional analysis from incident reports. Which theoretical models have been applied successfully and in what ways to the broad client group, if not to the specific behaviours your client presents with?

3. Bio-psycho-social perspective

A young person is often being provided with services from multiple agencies each of which may take a different point of view about their life. For example, the medical model usually differs from that used by a community health social worker or a teacher.Taking a bio-psycho-social approach can help you to reconcile all the points of view involved. Consider all the factors likely impacting on the young person’s life – their biology including health, genetics, medications; their psychology including beliefs, thoughts and feelings; and their social impacts like friends, school, culture, and family relationships. 

4. Politics

Consider each of the systems the young person is a part of. Sometimes, for practical and/or political reasons, you may only impact on one area of their life. Once you have determined your treatment plan, look at who else may be able to effect change in those areas of the person’s life where you have no jurisdiction. I find it helpful to develop 4 lists:

Life setting – which of your strategies require changes to the young person’s life settings, be it their routine at home, their work with staff or their hours at school?

Skills – which strategies require the young person to learn new skills, perhaps anger management or sitting with feelings?

Treatment – which strategies require treatment by a qualified practitioner, a certain medication, speech therapy or CBT for depression?

Reactive strategies – just because we have a treatment plan doesn’t mean that the behaviours of concerns will automatically stop. Who do we need to keep talking to about how and when to react to challenging behaviours?

Consider 4P + 4 as a means of helping you work with a large volume of information and develop useful formulations and treatment plans to help young people in complex cases. 

While Shona is regularly engaged to assess complex cases involving young people, she also offers workshops and master-classes in formulation and treatment planning for complex clients. To find out more, call Shona Innes Psychology on 0400 150 106 or email