I want to highlight a skill that can significantly elevate your clinical reasoning and deepen your understanding of patients: formulation.
We all want to understand patients better. How do we deeply get to know patients? Formulation is a great way, and we can document this understanding clearly in our assessments. While we may not always pause to systematically organize these factors, doing so can make our assessments more thoughtful, comprehensive, and clinically useful.
There are several frameworks for formulation. Today, I want to briefly review another practical approach: the 4Ps model.
***This is a practical outline built around factors that we can often readily identify through a good clinical interview. After completing a comprehensive psychiatric evaluation, next time, if time permits, pause and think through these domains. Assembling a list of relevant factors can strengthen the formulation you include in your assessment.
The 4Ps Framework
We consider:
- Predisposing factors (what makes someone vulnerable)
- Precipitating factors (what triggered the current episode)
- Perpetuating factors (what is maintaining the problem)
- Protective factors (what supports recovery)
Across three domains:
- Biological
- Psychological
- Social
Common Factors to Consider
Biological
- Predisposing: Family history, TBI
- Precipitating: Medical illness/injury, substance use escalation, medication non-adherence, pregnancy, sleep deprivation
- Perpetuating: Chronic illness, ongoing substance use, lack of treatment
- Protective: Good overall health, absence of substance use
Psychological
- Predisposing: Attachment style, family structure, rigid/negative cognitive style, low self-esteem
- Precipitating: Acute stressors
- Perpetuating:
- Cognitive: Negative thoughts, cognitive distortions
- DBT concepts: Emotional dysregulation, poor distress tolerance, help-seeking/help-rejecting patterns
- Interpersonal: Dysfunctional relationships, role transitions
- Maladaptive coping strategies
- Protective: Reflectiveness, ability to mentalize (see others’ perspectives), positive sense of self, adaptive coping, good insight
Social
- Predisposing: Poverty, limited access to healthcare, discrimination/racism
- Precipitating: Loss of social support, trauma, financial stress, housing instability
- Perpetuating: Ongoing lack of support, poor living conditions, financial strain
- Protective: Strong social supports, religious/spiritual beliefs, financial stability, engagement in healthcare
Takeaway
You don’t need to include every element every time. Even briefly incorporating a few of these factors into your assessment can:
- Add depth to your clinical reasoning
- Clarify why the patient is presenting now
- Help guide more targeted interventions
I hope this serves as a helpful reminder and framework you can start integrating into your notes.
An aside:
🔍 Assessing Attachment Style in a Clinical Interview
1. Ask about relationship patterns (not just facts)
- “What are your close relationships like?”
- “What happens when you get close to someone?”
- “How do you handle conflict?”
- “Do you feel comfortable depending on others?”
2. Briefly explore early relationships
- “What was it like growing up with caregivers?”
- “Who did you go to when upset?”
- “How did they respond?”
→ Look for: consistency vs unpredictability, warmth vs distance, safety vs fear
3. Observe how they relate to you
- Reassurance-seeking or overly dependent
- Guarded, distant, minimizing emotion
- Fluctuating closeness vs withdrawal
- Fearful of judgment or abandonment
4. Assess coping in distress
- Seeks support vs avoids others
- Clingy/overwhelmed vs shuts down
- Pushes others away but fears being alone
🧩 Quick Heuristics
- Secure: Comfortable with closeness and support
- Anxious: Fear of abandonment, reassurance-seeking
- Avoidant: Avoids closeness, overly self-reliant
- Disorganized: Mixed/unstable patterns (approach–avoid)
Gator Psychiatry 