Case Formulation and Intervention: Application of the Five Ps Framework in Substance Use Counseling
Scott W. Peters
Substance use and misuse is exceedingly common and has numerous implications, both individual and societal, impacting millions of Americans directly and indirectly every year. Currently, there are a variety of empirically based interventions for treating clients who engage in substance use and misuse. The Five Ps is an idiographically based framework providing clinicians with a systematic and flexible means of addressing substance use and misuse that can be used in conjunction with standard substance use and misuse interventions. Additionally, its holistic and creative style provides opportunities to address concerns at various points with a variety of strategies and interventions that will best suit clients’ unique situations. It can assist both novice and experienced clinicians working with clients who present for counseling with substance use and misuse. Following a discussion of the Five Ps, a brief case illustration will demonstrate the framework.
Keywords: substance use and misuse, Five Ps, idiographic, systematic, flexible
Substance use and misuse in the United States is extremely common. For the year 2016, the Centers for Disease Control and Prevention (CDC) found that 18% of the U.S. population aged 12 and older had used illicit substances or misused prescription medications (CDC, 2018). The National Survey on Drug Use and Health asserted that close to 30% of respondents aged 12 and older reported use of illicit substances in the past month (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017). Although these statistics are significant, it should be noted that “Most people who use abusable drugs, even most people who use them nonmedically, do so in a reasonably controlled fashion and without much harm to themselves or anyone else” (Kleiman et al., 2011, p. 2). In the context of this article, the word abusable indicates substances that when taken are pleasurable enough to result in excessive dosing or increased frequency of intake (Linden, 2011).
However, there are others who use substances to such an extent that it causes significant distress and impairment in their lives, a phenomenon clinically referred to as a substance use disorder (SUD). The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) bases an SUD on a “pathological pattern related to the use of a substance” (American Psychiatric Association, 2013, p. 483). In his report on alcohol, drugs, and health, the U.S. Surgeon General Vivek Murthy reported that more than 20 million Americans have an SUD (U.S. Department of Health and Human Services, 2016). Clients who engage in substance use and misuse can present with a variety of issues beyond use (Bahorik et al., 2017; Compton et al., 2014; Poorolajal et al., 2016). Thus, there exists a need to concurrently examine and address the potentially complex nature of client substance use and misuse.
Implications of Substance Use and Misuse
Substance use and misuse carries numerous potential repercussions. Societally, substance use and misuse consequences exceed “$400 billion in crime, health, and lost productivity” (U.S. Department of Health and Human Services, 2016, p. 2). Published data on those incarcerated appears to be several years old. However, it does suggest that more than 60% had a substance use disorder and 20% were under the influence at the time of their offense (National Center on Addiction and Substance Abuse at Columbia University, 2010). Regrettably, most do not receive treatment while incarcerated (Belenko et al., 2013). Additionally, many individuals who engage in substance use and misuse have co-occurring major medical conditions, such as cancers, cardiovascular accidents (strokes), and respiratory and cardiac illnesses (Bahorik et al., 2017). This population often experiences stigma and suboptimal health care results (McNeely et al., 2018; van Boekel et al., 2013). Substance use and misuse has significant impact on the occupational sector as well. Substance use and misuse has been correlated with both higher rates of absenteeism and workplace injuries (Bush & Lipari 2015). Those who engage in substance use and misuse often have higher rates of unemployment (Compton et al., 2014; Dieter, 2011). This can result in lack of access to treatment services, contributing to increased stress.
Substance use and misuse also has a negative impact on intimate partners, such as assuming increased responsibility and navigating unpredictability (Hussaarts et al., 2012). More ominously, substance use and misuse has been correlated with intimate partner violence (Murphy & Ting, 2010). Further, substance use and misuse is a significant risk factor for suicidality (Poorolajal et al., 2016). Finally, the number of U.S. adults with a comorbid SUD and mental illness has been shown to be almost 8 million, with only about 5% receiving treatment for both (SAMHSA, 2017). Concurrently treating both is very complex, challenging, and expensive. This can be even more problematic given the lack of health care access for large numbers of Americans (Schoen, 2013).
A Holistic Alternative
Addressing client substance use and misuse can be quite complicated, and as mentioned previously, substance use and misuse impacts users and society in a variety of ways beyond substance intake. There are several approaches to managing client substance use and misuse that have demonstrated effectiveness. Among those are 12-step programs (Humphreys et al., 2004), mindfulness-based interventions (Chiesa & Serretti, 2014), evidence-based approaches such as cognitive behavioral therapy (McHugh et al., 2010), and family counseling (O’Farrell & Clements, 2012). These approaches can be accomplished via outpatient counseling, partial hospitalization programs, inpatient and medically managed substance treatment programs, as well as residential and therapeutic communities. However, each has some shortcomings. Twelve-step attendance is most beneficial with inpatient substance use and misuse treatment (Karriker-Jaffe et al., 2018). Evidence-based approaches, such as cognitive behavioral therapy, tend to be nomothetic, assuming homogeneity and generally geared toward symptom amelioration (Robinson, 2011). Mindfulness-based strategies are not as effective when used alone as when used with other approaches (Sancho et al., 2018). Research on the success of family-based interventions has methodological challenges, such as small sample sizes and the difficulty of examining long-term outcomes (Rowe, 2012).
In addition, using these approaches may result in omitting the uniqueness of clients as a consideration in treatment. SAMHSA (2020) pointed out the significance of addressing clients individually based on their distinctive needs in order to provide the best chance for recovery from substance use and misuse. SAMHSA’s recommendations fit well with a more holistic framework in that such a structure allows clinicians to develop a multidimensional picture of clients. By examining and exploring clients’ use or misuse within the context of a multidimensional framework, interventions can be personalized, and areas of concern can be targeted. Such a framework may enhance the effectiveness of the aforementioned interventions (Wormer & Davis, 2018). Some of these evidence-based approaches will be demonstrated later in a case illustration.
As shown above, there are numerous ways to examine and treat client substance use and misuse. For example, some interventions use an individual lens, such as cognitive behavioral therapy, which examines connections between thoughts, feelings, and behaviors (Morin et al., 2017). Other approaches observe substance use and misuse from a family or systems perspective, looking at familial patterns such as communication and normalization of substance use (Bacon, 2019). Delivery of mindfulness-based interventions may help to address stressful events that previously triggered substance use (Garland et al., 2014). In addition, there are frameworks that use a formulation model examining various aspects of clients (Johnstone & Dallos, 2013) such as causal, contributing, environmental, and personal features, providing a much more expansive view of clients’ concerns.
Client substance use and misuse can be quite challenging for counselors, both novice and experienced. Case formulation, also referred to as conceptualization, is a skill new counselors often lack (Liese & Esterline, 2015). Using a framework to assist in case formulation may prove useful to beginning counselors. Experienced counselors, even with competence in a variety of approaches, can also benefit from using a framework to help address anticipated challenges (Macneil et al., 2012). Case formulations have been used in a number of areas such as those with psychosis, anxiety, and trauma (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). One such framework is the Five Ps (Macneil et al., 2012). Macneil and his colleagues (2012) posited that diagnosing was insufficient and it was critical to include other factors such as causal, lifestyle, and personal factors in conceptualizing the case and formulating a plan. Applying this approach with clients who engage in substance use and misuse would allow more individual and flexible ways to intervene with client substance use and misuse. In addition, the collaborative nature of the Five Ps reinforces the concept of an idiographic formulation. This is in keeping with the inherent uniqueness of clients, their concerns, and a variety of factors.
The Five Ps is a type of framework utilizing five factors developed by Macneil et al. (2012). They conceptualized a way to look at clients and their problems, systematically and holistically taking into consideration the (1) Presenting problem, (2) Predisposing factors, (3) Precipitating factors, (4) Perpetuating factors, and (5) Protective factors. Presenting problems are concerns that clients find difficult to manage. Predisposing factors include biological, environmental, or personality considerations that may put clients at risk of further substance use and misuse. Precipitating factors are those that proximally bring about substance use and misuse and its resulting difficulties. Perpetuating factors are those that sustain and possibly reinforce clients’ current substance use and misuse challenges. Protective factors are those that help to moderate actual or potential substance use and misuse impact. The Five Ps framework promotes a very clear and systematic approach to case formulation or assessment that potentially provides a wealth of data. It also provides opportunities for a variety of interventions and strategies targeted to clients and their substance use and misuse or contributing factors.
Given the variations of substances, the level of use, the functional impairment, co-occurrence with other mental disorders, and inherent client differences, an idiographically based framework seems particularly appropriate with this population. The Five Ps permits counselors to both assess and intervene essentially simultaneously. It allows for client individualization, use of a variety of strategies, ongoing assessment, and modifications as needed. Furthermore, the Five Ps helps clients and counselors explore relationships between each factor and the presenting problem. This framework is idiographic in nature, as it looks at clients individually and holistically (Marquis & Holden, 2008). Idiographic case formulation can be useful for complicated cases, such as those encountered with clients engaged in substance use and misuse (Haynes et al., 1997). It is systematic, while allowing for flexibility and creativity. It can be used in outpatient, inpatient, and residential settings and possibly as part of an aftercare program.
Following is a case illustration demonstrating how the Five Ps may be helpful in formulating and engaging in a clinical application. It should be noted that several evidence-based substance use and misuse approaches were integrated in an eclectic approach throughout the case example to demonstrate the idiographic nature of the Five Ps. Many formulation models are administered within a cognitive behavioral grounding (Chadwick et al., 2003; Easden & Kazantzis, 2018; Persons et al., 2013). The Five Ps does not adhere to any particular theoretical orientation, thus allowing for a greater repertoire of strategies to draw from to help clients with substance use and misuse.
Implementing the Five Ps: The Case of Dax
A brief description of Dax, a hypothetical client, and the events that prompted him to seek services is followed by a detailed application of the Five Ps in addressing Dax’s substance use and misuse. It should be noted that the strategies and interventions applied here are used as illustrations and are specific to Dax and his concerns. In addition, the interventions demonstrated are not to be assumed the only ones that can be applied to Dax. They are examples that the author chose to illustrate the Five Ps in practice.
Dax is a 33-year-old married father of two children: a 9-year-old son, Cam, and a 7-year-old daughter, Zoe. He was recently driving home from work in the evening and law enforcement stopped him because of erratic driving. The officers evaluated him, detained him, and subsequently arrested him for driving while intoxicated. As part of his adjudication, Dax was required to attend five counseling sessions and have a clinician’s report provided to the court. Dax presents as extremely frustrated and embarrassed at being mandated to attend counseling sessions. He is confident that he does not have a problem and that counseling should be reserved for those who cannot stop drinking. Dax drinks two to three times a week, usually having one or two shots of whiskey and two to three draft beers. The night he was pulled over, he had had two additional beers and one additional shot of whiskey on top of his usual consumption after a telephone argument with his wife, Sara. Additionally, he reports significant stress and conflict in his marriage as well as concerns over some upcoming diagnostic tests for their daughter related to a heart murmur. Dax denies any other negative consequences from his alcohol use. He denies any significant increase in alcohol use or any other substance use.
While being mandated to attend counseling, Dax shares concerns that he is afraid of what his daughter’s test results will show. He fears that she will need open-heart surgery and that she may die. The clinician can intervene here by simply normalizing and validating his fears about the test results. A logical analysis using gentle Socratic dialogue may help to challenge his emotional reactions to his daughter’s heart murmur (Etoom & Ratnapalan, 2014). In addition, mindfulness strategies can assist in helping Dax to cognitively diffuse from present to future events (Harris, 2019). He is also adamant that he does not have a problem with alcohol. Here, a conversation about what counseling entails as well as psychoeducation related to the effects of alcohol on executive functioning may prove beneficial (Day et al., 2015). Acknowledging that his reticence is due to being obligated to attend counseling may assist in relationship building (Tahan & Sminkey, 2012). The clinician may also seek more information on the cause of the reported stress between him and his wife.
Dax reports a strong paternal history of substance use and misuse. His father started out drinking occasionally and over the years slowly developed a dependency on alcohol. Dax further reports his paternal grandfather died from liver failure. Addressing the potential genetic link to substance use and misuse may prove beneficial in raising Dax’s awareness (Dick & Agrawal, 2008). For example, the clinician may ask Dax if they can share how genes are passed on and expressed, like genes for eye color or hypertension. This may open the door to a conversation regarding how his substance use and misuse may progress to alcohol use disorder and its definition as a pattern of alcohol use leading to clinically significant problems, including increase in use, failed attempts to stop, and use leading to an impaired ability to meet role obligations (American Psychiatric Association, 2013). There could be a discussion of alcohol use disorder being a disease, not that different from any other passed-on trait or disease. Additionally, Dax often struggles with strong and painful emotions, and alcohol helps to address them. Here the clinician may utilize strategies drawn from acceptance and commitment therapy related to his control strategy of using alcohol to avoid his emotions (Harris, 2019). The ball in the pool metaphor (i.e., holding a beach ball under the water works temporarily, but eventually it pops back up) can be compared to alcohol temporarily holding those painful emotions down, eventually to resurface. The clinician may also discuss strategies to help Dax regulate his reactions using emotion-focused interventions such as positive reframing to ameliorate the stress of his daughter’s cardiac condition (Plate & Aldao, 2017).
This area explores significant occurrences that preceded or triggered the presenting problem and its consequences. Dax shares that he and his wife are conflicted about how to proceed with their daughter’s medical care. Sara is unequivocal in her confidence in Zoe’s cardiologist and his competence. Dax, however, is hyper-focused on surgery and seems to dismiss Sara’s position. At the end of his workday, he and his wife got into an argument over the phone about an upcoming diagnostic test and the possible results. Dax was quite upset, cursed at her, and then hung up the phone. He then stopped at a local pub and had several drinks.
Here, the clinician may use reality-based strategies that address choice and consequences (Wubbolding & Brickell, 2017). This may include a direct conversation about Dax’s decision to drink, resulting in his becoming impaired, with the consequence of being detained, charged, and adjudicated. Dax can then share his and his wife’s perspectives on their daughter’s care. This conversation can lead to investigating strategies for how each can be heard, including short role-plays with opportunities to practice (Worrell, 2015). The clinician can provide a variety of potential spousal responses, allowing for more adaptability and flexibility in Dax’s responses. The goal here is to build Dax’s competence in communicating, both in listening and expressing. Additionally, there may be a discussion using aspects of existentialism to process inherent anxiety and its connection to unknowable future events (May, 1950; Wu et al., 2015).
The emphasis here is on features that continue the presenting problem. For Dax, he shares that when he and his wife argue, it follows a very predictable pattern. They disagree, interrupt one another, yell, and he calms down by having several beers. He then withdraws and becomes sullen for a few days. Nothing gets resolved, and this cycle appears once again when they have conflict.
The clinician may discuss the concept of circularity and assist in moving from “vicious cycles” to “virtuous cycles and problem resolution” (Walsh, 2014, p. 162). This involves explaining that interactions can act as a kind of back-and-forth loop of action–reaction–action without any resolution, leaving both parties feeling unheard, misunderstood, and frustrated. The goals here are to both break the pattern and to facilitate healthy conversations. Here the clinician may incorporate a solution-focused strategy exploring a time with Dax when he and his wife have disagreed, but he did not interrupt and the outcome was positive (de Shazer, 1985). If he cannot identify a time, simple role-plays in which Dax does not interrupt or yell and instead experiences different outcomes may provide optimism to Dax. The counselor may also assist Dax in emotional regulation, which may prevent the initiation of arguments (Aldao & Nolen-Hoeksema, 2013). In addition, aspects of narrative therapy may provide an opportunity for Dax to re-author a unique outcome that gives meaning and provides a functional identity to him as a father and husband, thus building a sense of optimism (White & Epston, 1990).
Here the focus is on investigating resources and/or supports that may help prevent client substance use and misuse from further becoming problematic. This factor has generally been underutilized despite being shown as beneficial to clients (Kuyken et al., 2009). This is often the opportunity for the client to share what may help them move forward, what their assets are, who can support them, and any other self-identified skills (de Shazer, 1985). These can be in the form of personal characteristics such as tenacity, intellect, or insight. They may also present in the form of family, friends, or hobbies. Oftentimes, when the topic of protective factors is used in substance use and misuse, it is related to deterrence of substance use, notably with adolescents (Liao et al., 2018). In the Five Ps context, protective factors are used to potentially prevent substance use and misuse from having more negative impact as well as to increase client resilience. This factor differs markedly from the first four. Protective factors move away from the problem areas that need interventions to hope and optimism and look to future success and competence (Macneil et al., 2012). Once the protective factors are identified, the ensuing conversation provides opportunities to imagine future outcomes in which protective factors may come into play should situations occur that the client finds problematic. Second, it also tends to shift the conversation toward what is present and going well in their lives and away from those areas that cause distress and suffering (de Shazer, 1985).
In implementing the Five Ps framework with Dax, the clinician chose to use psychoeducation and strategies borrowed from acceptance and commitment, reality, Bowenian family systems, and solution-focused brief therapies to assist Dax with his substance use and misuse. The choice of the above approaches is only meant as an illustration and not as definitive ways to address this particular client. It is likely that other clinicians presented with Dax would use a different combination of approaches. The Five Ps is a systematic way to look at clients and their presentation, and its idiographic construction takes clients’ uniqueness into account. It also allows clinicians to target specific areas of concern (Macneil et al., 2012) and may be used in a variety of clinical settings. Moreover, the Five Ps align with SAMHSA’s recommendation that clinicians tailor treatment to each client because no single treatment is particularly superior (SAMHSA, 2020).
Limitations and Future Research
There are limitations to the Five Ps framework as a way to formulate and intervene with clients’ substance use and misuse. First and foremost, it should be emphasized that this particular framework has not been empirically tested with client substance use and misuse. However, as mentioned previously, case formulations have been used across a variety of client concerns (Chadwick et al., 2003; Ingram, 2012; Persons et al., 2013). Another potential limitation is that the Five Ps may not be particularly beneficial for substance use and misuse in which there is clinical evidence of an SUD that includes significant withdrawal symptoms. Client substance use and misuse at that level may need medical stabilization and detoxification prior to utilization of the Five Ps. In addition, there may be clients who are simply not ready or able to address some or most of the dimensions of the Five Ps. Furthermore, clients like Dax who are mandated to attend substance-related counseling may have service plans that are not congruent with the Five Ps framework. In spite of these limitations, there may be several potential areas of inquiry.
Previous studies using frameworks to formulate have often used cognitive behavioral therapy as the primary intervention (Chadwick et al., 2003; Persons et al., 2013). Given that client substance use and misuse can be quite complicated, using various approaches within the Five Ps framework may yield positive results. As Chadwick et al. (2003) noted, examining positive client experiences may be one way to discover how to increase client participation in substance use and misuse treatment. Another potential area of study might involve comparing novice counselors to more experienced counselors. As mentioned previously, novice counselors often lack sufficient case formulation skills (Liese & Esterline, 2015). Examining the two groups’ experiences using the Five Ps may provide insight to assist counselor training programs related to substance use and misuse skill development. The implementation of the Five Ps with clients with mild substance use and misuse and those with more significant substance use and misuse, possibly using the DSM-5 diagnosis for SUD, may be another area to explore. This research could point to populations for whom the Five Ps is more and less effective. Studies utilizing the Five Ps with mandated clients may demonstrate its efficacy, notably with agencies that require substance-related counseling.
Client substance use and misuse is a significant problem in the United States, and it continues to cause difficulty for individuals, families, and society. There are numerous methods and combinations of methods to address substance use and misuse, such as family therapy, cognitive behavioral therapy, and self-help groups. Their effectiveness has been well researched, and this paper does not propose a superior way to address substance use and misuse. However, the Five Ps presents a framework in which counselors can examine and intervene with client substance use and misuse using a variety of approaches and strategies. The Five Ps can be used in a variety of settings such as a community mental health agency, primary care clinic, and inpatient or residential treatment centers. The systematic but flexible nature of this framework affords clinicians numerous ways to address substance use and misuse. For some, receiving substance use and misuse services can be stigmatizing. In fact, this stigmatization can come from those who are treating them (Luoma et al., 2007). In addition, the vast majority of those with an SUD never receive treatment (Han et al., 2015). Incorporating the Five Ps, with its holistic framework, may prove attractive to clients and counselors, thus potentially increasing the numbers of clients engaged in substance use and misuse treatment. As mentioned previously, the Five Ps is not meant to replace any other substance use and misuse intervention. It is another way to address the multifaceted and complicated nature of client substance use and misuse. Novice clinicians, who often have a more limited repertoire of strategies, may find the Five Ps valuable because of its systematic framework to clients. Experienced clinicians understandably have a larger catalogue of strategies to choose from. However, they may find this framework valuable as it provides one more way to address the often-encountered complex challenges of substance use and misuse.
Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.
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Scott W. Peters, PhD, LPC-S, is an associate professor at Texas A&M University – San Antonio. Correspondence may be addressed to Scott Peters, One University Way, San Antonio, TX 78224, firstname.lastname@example.org.