The 5P model is a way of organizing the conceptualization of a case into five categories:the presenting problem, as well aspredisposing,precipitating,perpetuating, and protective (protective). In cognitive-behavioral therapy, the 5P model helps answer five questions: what brings the person to therapy, why now, what keeps the difficulty going, and what can serve as a foundation for the therapeutic process.
The 5P model is neither a theory of disorders nor a treatment method. It is a framework that a CBT therapist fills with cognitive-behavioral content: beliefs, rules, vicious cycles, and the model of a specific disorder. The greatest value of the 5P model for someone starting their practice is that it forces the therapist to ask about the underlying mechanism, and the treatment plan depends on that mechanism.
In the supervision of young therapists, one pattern keeps recurring: the notes from the intake interview are detailed, but the formulation is incomplete. We know what happened in the client’s life, but we don’t know why she isn’t getting better. In this article, you’ll find the definition of each of the five Ps, the model’s origins, seven steps for constructing a formulation, sample questions for sessions, and the six most common mistakes.
Key Points at a Glance
-
The 5P Model organizes information about the client into five categories: the reported problem, predisposing factors, triggering factors, maintaining factors, and protective factors.
-
Maintaining factors are processes operating in the here and now—in CBT, they are the primary target of intervention.
-
The 5P Model derives from psychiatry and the biopsychosocial model, not from cognitive-behavioral therapy itself.
-
The 5P model is a timeline of the case, while Padesky and Mooney’s five-part model is a snapshot of a single moment. The five-part model usually falls under the category of maintaining factors.
-
Formulation in the 5P model is developed in stages over several sessions, together with the client, and is treated as a hypothesis to be tested.
What is the 5P model in cognitive-behavioral therapy?
The 5P model in cognitive-behavioral therapy is a conceptual framework for case analysis that divides information about the client into the reported problem and predisposing, precipitating, maintaining, and protective factors. The 5P model connects the client’s life history with what is happening today and shows which aspects of the difficulty can be changed in therapy.
Each of the five Ps corresponds to a guiding question. The table below lists the questions and typical content that fall under each category in CBT.
| P | Guiding Question | Main Themes in CBT |
| Reported problem | What is this person coming in with, and what does it look like on a day-to-day basis? | Symptoms, their severity, impact on work and relationships, therapy goals |
| Predisposing factors | Why this person in particular? | Early experiences, core beliefs, rules and assumptions, temperament, family history |
| Triggering factors | Why now? | A critical event, loss, role change; also internal triggers, e.g., physical sensations before a panic attack |
| Maintaining factors | What keeps this going? | avoidance, safety behaviors, rumination, withdrawal, reactions from others |
| Protective factors | What can you rely on? | relationships, skills, values, past coping experiences |
The Polish names for the categories of the 5P model are not standardized in the literature. This text uses the following terms: reported problem, predisposing factors, precipitating factors, perpetuating factors, and protective factors.
The Five Ps—Definitions and Examples
Presenting problem (presenting problem)
In the 5P model, thepresenting problemis a description of the difficulty a person brings to therapy in its everyday form: symptoms, their severity, and their impact on work, relationships, and health. In CBT, the presenting problem is recorded as a list of problems and goals, preferably in the client’s own words and without interpretation.
Example of how to document the presenting problem: “Wakes up at 4 a.m. and can’t fall back asleep; hasn’t seen friends in three months; wants to return to full-time work.”
Predisposing Factors
Predisposing factors in the 5P model are everything that increases a person’s susceptibility to a difficulty: early experiences, core beliefs, rules and assumptions, temperament, and family and biological burdens. They answer the question “Why this person in particular?”
Predisposing factors are largely based on the therapist’s inferences, so in the first few weeks of therapy, they are noted cautiously as hypotheses. Example: a home where recognition had to be earned through achievements, and the resulting belief, “I am worth as much as I do.”
Triggering Factors (precipitating factors)
In the 5P model, precipitating factors are events or changes that directly preceded the onset or intensification of difficulties: a loss, a breakup, a promotion, a move, or an illness. They answer the question “Why now?” An internal stimulus can also serve as a precipitating factor, such as a racing heart before a panic attack.
The question “Why now?” is the best way to distinguish triggering factors from predisposingfactors. A critical father was present throughout the client’s life, but the client comes to therapy after a divorce.
Perpetuating factors
Perpetuating factors in the 5P model are processes operating in the here and now that cause the difficulty to persist: avoidance, safety-seeking behaviors, rumination, withdrawal, and reactions from the environment. In cognitive-behavioral therapy, perpetuating factors are the primary target of intervention because—unlike the past—they can be directly influenced.
Jacqueline Persons (2008) refers to these processes as mechanisms that trigger or maintain the problem. A well-documented maintaining factor reveals the function of the behavior: what it provides in the short term and what it takes away in the long term.
Protective Factors
Protective factors in the 5P model are resources that help a person cope with a difficulty: close relationships, skills, values, a sense of humor, and previous experiences of overcoming a crisis. They answer the question, “What can one rely on?”
Kuyken, Padesky, and Dudley (2008) view the client’s resources as a pathway to therapeutic goals, rather than a mere add-on to the list of problems. In practice, protective factors are identified starting from the first session, alongside the difficulties.
A simple rule for distinguishing factors
Selzer and Ellen (2014) propose a rule for beginners that resolves most ambiguities: what is distant in time is usually a predisposing factor; what is recent is a triggering factor; and what is happening right now is a sustaining factor. A factor that fits into two categories is not a formulation error. It is often a clue as to how the client’s history connects to their present.
Where does the 5P model come from?
The 5P model originates from psychiatry and George Engel’s biopsychosocial model (1977). The “four P” framework was used in the training of psychiatry residents. Priyanthy Weerasekera systematized it in 1993 and 1996, and the version with the fifth P—the reported problem—was popularized by Macneil, Hasty, Conus, and Berk (2012).
Engel’s biopsychosocial model (1977) posited that illness must be understood through an interplay of biological, psychological, and social factors, rather than solely through a biomedical lens. The 4P or 5P framework is often mapped onto these three domains, resulting in a table with biological, psychological, and social columns.
The authorship of the 4P framework is often attributed to Priyantha Weerasekera, but this is an oversimplification. In a 1993 article, Weerasekera herself described her model as an expansion of the framework commonly used by psychiatry residents. Her contribution was to systematize the grid, add rows on coping styles and treatment, and break down the psychological domain into behavioral, cognitive, psychodynamic, and systemic perspectives. Weerasekera also noted that it is not necessary to fill in every box, and that formulation is a dynamic process, not a fixed list.
Macneil and colleagues (2012) described the “Five Ps” formulation in an article in BMC Medicine, which argued that diagnosis alone is insufficient for planning mental health interventions. A practical conclusion follows from the model’s origins: the 5P model is not a CBT method, but rather a cross-theoretical framework that cognitive-behavioral therapy fills with its own content.
How does the 5P model differ from the five-part model?
The 5P model organizes the factors of a case chronologically—from early experiences to what is happening today. The five-part model by Padesky and Mooney (1990) illustrates the connections between a situation, thoughts, emotions, behavior, and bodily reactions at a single specific moment. The 5P model is thus a timeline, while the five-part model is a snapshot—a current slice of the patient’s reality.
How do you build a case conceptualization in the 5P model step by step?
Conceptualization in the 5P model is built in stages over the first few sessions. First, a list of problems and goals is created; then, a single recent episode is described in detail; and finally, the question “why now?” is addressed. Resources are gathered in parallel, and the developmental history is added cautiously, as a hypothesis. Finally, everything is woven together into a short narrative.
-
Compile a list of problems and goals. The first sessions in the 5P model are dedicated to gathering what the person brings to the table across various areas of life: work, relationships, health, and daily life. Without interpretation.
-
Describe one recent, specific episode. Preferably from the last week, including the time and place. Padesky (2020) suggests that for each client reaction, you should jointly note whether it helps or hinders—in the short and long term. Where a behavior helps in the short term but harms in the long term, there is usually a sustaining factor.
-
Ask the question “Why now?” The answer to this question fills in the “triggering factors” column and distinguishes them from “predisposing factors.”
-
Collect protective factors starting from the first session. Don’t wait until the end to ensure the formulation comes across as positive; instead, gather them in parallel with the difficulties.
-
List predisposing factors with a question mark. Early experiences, core beliefs, and rules are inferences that deepen over the following weeks and should be grounded in the client’s words or behaviors.
-
Write the formulation as a narrative. Selzer and Ellen (2014) recommend that after filling out the 5P grid, you write a few sentences: starting with predisposing factors, moving through triggers and maintaining factors, and ending with resources. The grid is used to collect data, while the narrative helps you verify whether you understand the connections between them.
Want to learn more about conceptualization in CBT? Read: How to Create a Conceptualization in Cognitive-Behavioral Therapy?
What questions should you ask for each P?
Questions for the 5P model should address the guiding question of each category and sound like a conversation, not a questionnaire. The list of questions below is an example of a set of practical questions.
Reported Problem – What made you come in right now? – What does a typical day look like when things are worse? And when they’re a little better? – What would change if therapy helped? How would you know?
Predisposing Factors —How were emotions discussed—or not discussed—in your family home? – What did you learn early on about yourself and other people? – Did anyone in your family have similar difficulties? – What earned you praise, and what earned you criticism?
Triggering factors —When did this first appear, and what else was happening in your life at the time?—Why are you seeking help now, rather than six months ago?—What usually precedes a bad day?
Maintaining factors —What do you do when things start to get difficult? What does it help with right away, and what helps after a week?—What do you avoid? – What do you do to prevent the worst from happening? – How long does it take for you to dwell on this in your thoughts? – How do your loved ones react?
Protective Factors – When have you managed to cope better, and what helped then? – Who is on your side? – What do people value about you? – What is truly important to you?
How do maintaining factors translate into a treatment plan?
The sustaining factors in the 5P model define the goals of CBT intervention: each sustaining mechanism corresponds to a technique that interrupts it. Avoidance leads to exposure or behavioral activation; safety-seeking behaviors lead to behavioral experiments; rumination leads to rumination-focused work. Therefore, the “maintaining factors” section should include processes, not traits.
The difference between a trait and a process can be illustrated with a single example. “Low self-esteem” says nothing about what to do in a session. “She avoids speaking up at meetings, so she doesn’t gather evidence that others are listening to her attentively, and her belief in her own insignificance persists”—this says a great deal.
| Maintaining Factor | A typical course of intervention in CBT |
| avoiding situations, people, and tasks | gradual exposure, behavioral activation |
| safety behaviors | behavioral experiments involving giving them up |
| rumination, worrying | working on rumination, postponing worry, attention training |
| negative automatic thoughts | cognitive restructuring |
| withdrawal and inactivity | activity planning |
| reactions from others that reinforce the problem | Involving loved ones, working on assertiveness |
The 5P Model – An Example of Conceptualization
The example below shows a complete formulation using the 5P model for low mood following emigration. It does not describe any specific person. It is a complex, simplified pattern that recurs in my work with women from Poland living abroad.
The problem reported in this example is low mood several months after moving to Germany: lack of energy, difficulty getting up in the morning, withdrawal from social interactions, an interrupted language course, increasingly frequent thoughts of self-contempt, and a feeling that “nothing here is mine.”
The predisposing factors in this example are a home where recognition had to be earned through achievements, and where rest was often labeled as laziness, as well as the hypothetical belief that “I’m worth as much as I do” coupled with the rule that “I can’t let anyone down.” For years, this rule worked: a good college education, a responsible job, and a reputation as someone who could be relied upon.
The triggering factor in this example is moving to be with her partner, which stripped the client of the foundations of her self-worth: her professional role, her network of friends, and her freedom of expression. Her degree wasn’t recognized right away, so overnight she stopped being “the competent one.”
The sustaining factors in this example create a vicious cycle. Every morning, the thought “I won’t get anything done anyway” arises, so the client stays home and fails to gain experiences of agency, which reinforces her belief in her own worthlessness. In the evenings, she compares her current life with her past one. She avoids speaking German for fear of being ridiculed, so her language skills stagnate. Her partner, acting in good faith, takes over official matters, which reinforces her sense of helplessness.
Protective factors in this example include a close relationship in which she can speak openly, a previous successful experience navigating a major change (moving to another city for college), a love of learning, and a sense of humor that resurfaces on better days.
The treatment plan stems directly from this formulation: behavioral activation with small tasks that foster a sense of competence, working on rumination, behavioral experiments in language-related situations, and a discussion between the couple about dividing up administrative tasks. The value of learning from the “protective” categories can serve as a bridge back to the treatment course.
The migration context in this example touches on as many as three categories of the 5P model. In supervision, I often see that sociocultural factors—loss of status, language, loneliness—are either omitted from the formulation or dismissed with a single sentence. I write about this in more detail in my article on emigration and the mental health of Polish women abroad.
How should you discuss the formulation with a client?
It’s best to discuss the 5P model with the client gradually and collaboratively: draw on a single sheet of paper during the session, start with a single recent episode, use the client’s own words, and present each element as a suggestion to be explored. Resources should always be included, and at the end, it’s worth asking what it’s like to see themselves on paper.
Clients’ reactions to the formulation are unpredictable. Pain, Chadwick, and Abba (2008) described them as complex and changing over time, while Kuyken et al. (2008) cite studies in which some clients felt understood, while others felt overwhelmed or saddened. Much of this difference depends on how the discussion is conducted:
- draw together, on a single sheet of paper, during the session,
- use the client’s own words, not textbook terminology,
- start with a single recent episode and add to the story later,
- present each element as a suggestion and ask if it fits,
- always include resources,
- offer the client a copy of the wording.
The Most Common Mistakes in the 5P Model
The most common mistakes made by novice therapists in the 5P model include confusing predisposing factors with triggering factors, a list with no connections between sections, excessive detail, listing traits instead of processes in the “maintaining” category, omitted resources, and a formulation that does not lead to a treatment plan. I see each of these mistakes regularly in supervision.
-
Confusing predisposing factors with triggering factors. A critical mother ends up in the “triggers” category because “that’s how it started.” The question “why now?” usually clarifies this in a minute.
-
A list instead of connections. Every category of the 5P model is filled in, but there’s nothing connecting them. Eells (2010) notes that weaker formulations are vague, draw conclusions without supporting data, or jump straight to treatment.
-
Excessive detail. Selzer and Ellen (2014) caution against overloaded phrasing and worrying about which box something “really” belongs in.
-
Traits instead of processes in the supporting section. “Perfectionism” is a label. “She revises the report until 2 a.m., so she never checks what would happen if she submitted a good version rather than a perfect one”—that’s a mechanism.
-
Resources added at the end—or not at all.
-
Formulations that do not lead to a plan. Nicely written, filed away, and never opened until the end of therapy. If an intervention from the plan cannot be linked to any item in the “maintaining” column, the formulation needs to be modified.
When to Bring a Formulation to Supervision
It’s worth bringing a formulation in the 5P model to supervision when therapy has stalled despite correctly applied techniques, when the formulation hasn’t changed since the first version, or when you can’t identify any sustaining mechanisms. Working on your own has its limits, because it’s hardest to see what you can’t see.
Other signs that it’s time for a “second pair of eyes”:
- the client reacts to the formulation with withdrawal, sadness, or stops coming to sessions,
- trauma, complex PTSD, a risk of self-harm, or suicidal thoughts arise in the case;
- you experience strong emotions toward the client—irritation, helplessness, or the urge to rescue them.
The last sign is easy to overlook. Yet it is often this sign that suggests the formulation needs to be supplemented with the therapeutic relationship.
Formulation supervision isn’t about someone giving you the “correct” version. Kuyken, Padesky, and Dudley (2008) point out that collaboration helps identify errors in reasoning that aren’t visible from within. In supervision, we work with your material: we examine which conclusions are supported by the data, where mechanisms are missing, and how to apply the formulation to future sessions.
If you’d like to review your formulations with someone else, I invite you to join the supervision group for CBT therapists at Nowe Widoki. We can sit down with your case just as it is—with its gaps, question marks, and uncertainties—and take our time to explore what’s driving it and where therapy might lead.
Frequently Asked Questions (FAQ)
How does the 5P model differ from the five-part model? Padesky and Mooney’s five-part model illustrates the connections between the situation, thoughts, emotions, behavior, and physical reactions at a single moment. The 5P model organizes these factors chronologically: from predisposing factors, through triggering and maintaining factors, to protective factors. In practice, the five-part model often falls under the category of maintaining factors.
Is the 5P model a method of cognitive-behavioral therapy? No. The 5P model is a cross-theoretical framework that emerged from psychiatry and the biopsychosocial model. In CBT, it is filled with cognitive-behavioral content: beliefs, rules, maintaining mechanisms, and models of specific disorders.
How long does it take to develop a formulation in the 5P model? The first draft of a formulation in the 5P model can usually be sketched out after a few diagnostic sessions. Predisposing factors are explored in greater depth over the following weeks, and the entire formulation is updated throughout the course of therapy.
References:
- Easden, M. H., & Kazantzis, N. (2018). Case conceptualization research in cognitive behavior therapy: A state of the science review. Clinical Psychology Review.
- Eells, T. D. (2010). The unfolding case formulation: The interplay of description and inference. Pragmatic Case Studies in Psychotherapy, 6(4).
- Engel, G. L. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196(4286), 129–136. https://doi.org/10.1126/science.847460
- Kuyken, W., Fothergill, C. D., Musa, M., & Chadwick, P. (2005). The reliability and quality of a cognitive case formulation. *Behavior Research and Therapy*, 43(9), 1187–1201. https://doi.org/10.1016/j.brat.2004.08.007
- Kuyken, W., Padesky, C. A., & Dudley, R. (2008). The science and practice of case conceptualization. Behavioural and Cognitive Psychotherapy, 36(6), 757–768. https://doi.org/10.1017/S1352465808004815
- Kuyken, W., Padesky, C. A., & Dudley, R. (2009). Collaborative case conceptualization: Working effectively with clients in cognitive-behavioral therapy. Guilford Press.
- 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. https://doi.org/10.1186/1741-7015-10-111
- Padesky, C. A. (2020). Collaborative case conceptualization: The client knows best. Cognitive and Behavioral Practice. https://doi.org/10.1016/j.cbpra.2020.06.003
- Padesky, C. A., & Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13–14.
- Pain, C. M., Chadwick, P., & Abba, N. (2008). Clients’ experience of case formulation in cognitive behavior therapy for psychosis. British Journal of Clinical Psychology, 47, 127–138.
- Persons, J. B. (2008). The case formulation approach to cognitive-behavioral therapy. Guilford Press.
- Selzer, R., & Ellen, S. (2014). Formulation for beginners. Australasian Psychiatry.
- Weerasekera, P. (1993). Formulation: A multiperspective model. Canadian Journal of Psychiatry, 38(5), 351–358. https://doi.org/10.1177/070674379303800513
- Weerasekera, P. (1996). Multiperspective Case Formulation: A Step Toward Treatment Integration. Krieger.
- Zivor, M., Salkovskis, P. M., & Oldfield, V. B. (2013). If formulation is the heart of cognitive behavioral therapy, does this heart rule the head of CBT therapists? The Cognitive Behavior Therapist.