Case Formulation After Engel—The 4P Model: A Philosophical Case Conference

The best known model for case formulation in the last 50 years was George Engel’s Biopsychosocial model. It expanded the compass of medical investigation and it promised a scheme by which to organize clinical information for more adequate understanding and more effective interventions. Despite its claimed advantages, it has not been adopted by clinicians. This article examines reasons for this failure. It argues for the therapeutic value of case formulation (as a complement to diagnosis), and presents an alternative schema by which clinicians can organize information into the four moments of a clinical problem: its origins (preconditions), precipitating factors, perpetuating factors, and protective factors. Unlike Engel’s hierarchically organized, synchronic schema, the 4P schema is developmental, diachronic, and clinically intuitive. The 4P schema encourages ‘thick’ case formulations as the basis of wise treatment interventions. The last section describes two seminar series in which the structure and elements of the 4P schema were presented to third-year psychiatry residents.