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Qualitative Analysis of Cultural Formulation Interview: Findings and Implications for Revising the Outline for Cultural Formulation
Abstract
The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients—11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.
... The CFI has been evaluated in different cultural contexts and is increasingly being implemented internationally (18,(40)(41)(42)(43)(44)(45). The CFI has been found to improve patient-clinician rapport and communication (46,47), and to be useful in building trust, elicit important contextual information, and support treatment planning (48). ...
... The CFI has been criticized for not including social determinants of health, for example social structures, referring to e.g. health systems and services, employment or educational opportunities and housing, as well as factors resulting in racial and ethnic disparities and how they limit access to health care and social services (41,52). ...
... Contextualized information related to the patients' social contexts also continuously emerge through the CFI answers, as well as the negative impact of the problem on social relations. The CFI in its current form has been criticized for not sufficiently eliciting social predicaments and social structures (41,52). However, for patients in our study, the CFI contributed with rich information about social determinants of health of importance to the patient. ...
Introduction
Cultural variety in expressed symptom presentations of mental health problems creates difficulties in transcultural diagnostic assessments. This emphasizes the need of culturally sensitive diagnostic tools like the Cultural Formulation Interview (CFI). Although the CFI is being implemented worldwide there is a lack of studies analyzing what kind of information it provides when used with new patients in routine psychiatric assessments, and how CFI information contributes to diagnostic evaluations. This study aimed to find out what information the CFI questions revealed when used with non-native Swedish speaking patients. We also wanted to understand how the CFI may facilitate identification of psychiatric diagnoses among these patients.
Materials and methods
The CFI was used as part of a routine clinical psychiatric assessment in an outpatient clinic in Sweden. Interpreters were used in the consultations when needed. A qualitative thematic analysis was used to analyze the documented CFI answers from non-native speaking patients.
Results
We found that the CFI information contained contextualized descriptions of dysfunction and current life conditions, as well as expressions of emotions, often described along with somatic terms.
Discussion
Our results indicate that the narrative approach of the CFI, giving contextualized information about distress and functioning, can facilitate clinicians’ identification of psychiatric symptoms when language, psychiatric terms and understandings are not shared between patient and clinician.
... The results indicated that all three groups of participants rated the CFI positively; however, patients with severe mental illness rated the assessment tool less favorably than the others . After this initial study, Paralikar et al. (2020) furthered their investigation and conducted a qualitative analysis of the CFI (Paralikar et al., 2020). This research team compared the perceptions of the overall value of the CFI among patients with common mental disorders and serious mental disorders to explore the effect of psychopathology on cultural formulation (Paralikar et al., 2020). ...
... The results indicated that all three groups of participants rated the CFI positively; however, patients with severe mental illness rated the assessment tool less favorably than the others . After this initial study, Paralikar et al. (2020) furthered their investigation and conducted a qualitative analysis of the CFI (Paralikar et al., 2020). This research team compared the perceptions of the overall value of the CFI among patients with common mental disorders and serious mental disorders to explore the effect of psychopathology on cultural formulation (Paralikar et al., 2020). ...
... After this initial study, Paralikar et al. (2020) furthered their investigation and conducted a qualitative analysis of the CFI (Paralikar et al., 2020). This research team compared the perceptions of the overall value of the CFI among patients with common mental disorders and serious mental disorders to explore the effect of psychopathology on cultural formulation (Paralikar et al., 2020). Patients with common mental disorders were more likely to elaborate further on their problem than those with severe mental disorders were. ...
Culture is an important factor to be considered during any mental health intake assessment. The Cultural Formulation Interview (CFI) is a 16-item semi-structured patient assessment that was developed by the DSM-5’s Cross-Cultural Issues Subgroup (DCCIS) and published in 2013 to aid clinicians in their cultural clinical assessment of mental illnesses. This scoping review aims to broadly summarize and review the existing literature on the CFI to see how the tool has been used since 2013. Following an initial search and screening in 4 databases, 30 articles were included in the final synthesis and evaluation. The main finding was that the CFI was a useful tool in a variety of settings throughout the world. The results suggest that employing the CFI increased rapport between patients and clinicians, aided in diagnostic and treatment planning, and increased the subjective exploration of the patient’s illness narrative. The CFI was also deemed to have a positive impact on medical communication. Barriers to implementing the CFI were also presented. The available literature on the CFI is critically discussed, and the limitations of this review are explained.
... Generally, patients seemed to appreciate the CFI to a higher extend than providers (Paralikar et al. 2015;Aggarwal et al. 2013; Lewis-Fernández et al. 2017;Skammeritz et al. 2020). Patient perspectives on taking part in a CFI have been elucidated with qualitative methods in studies from the US, Mexico and India (Muralidharan et al. 2017;Aggarwal et al. 2013;Ramírez Stege and Yarris 2017;Paralikar et al. 2019;Paralikar et al. 2015). Patients in these studies expressed how the CFI generated feelings of trust and safety in the encounter and provided a space for sharing vulnerable experiences, illness context and personal reflections (Muralidharan et al. 2017;Paralikar et al. 2015Paralikar et al. , 2019. ...
... Patient perspectives on taking part in a CFI have been elucidated with qualitative methods in studies from the US, Mexico and India (Muralidharan et al. 2017;Aggarwal et al. 2013;Ramírez Stege and Yarris 2017;Paralikar et al. 2019;Paralikar et al. 2015). Patients in these studies expressed how the CFI generated feelings of trust and safety in the encounter and provided a space for sharing vulnerable experiences, illness context and personal reflections (Muralidharan et al. 2017;Paralikar et al. 2015Paralikar et al. , 2019. Patients also reported reservations regarding the CFI's lack of differentiation from other clinical interviews and its uncomfortable inquiry about religion, past history (Aggarwal et al. 2013), and culture (Ramírez Stege and Yarris 2017). ...
... However, in these studies, the CFI was used with both new and extant patients and conducted by a designated study clinician who was not a gatekeeper of access to care nor responsible for the continuation of care (Muralidharan et al. 2017;Aggarwal et al. 2013;Paralikar et al. 2015Paralikar et al. , 2019, or the CFI was not conducted as part of the diagnostic intake (Ramírez Stege and Yarris 2017). Hence, these studies do not entirely represent assessment processes where new patients are considered for treatment (Aggarwal et al. 2013). ...
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This qualitative study presents migrant patient perspectives on using the Cultural Formulation Interview (CFI) in mental health assessments in Denmark. Empirical data consisted of 20 recorded CFI sessions and 16 patient interviews, coded with a constructivist grounded theory approach. Empirical findings prompted us to draw on the theoretical framework of intersubjective recognition in the analytical process. Our analysis showed how patients had multiple previous experiences of misrecognition in life and healthcare. This seemed to restrain their self-esteem and available positions for expressing preferences and reservations during the CFI and led to negotiations of worthiness of care. Despite occasional lack of flow and information in the recorded CFI sessions, patients subsequently recounted how they felt the CFI recognised the complexity and context of their cultural identities and illness narratives. Patients described how the CFI-guided provider approach of curiosity and empowerment carried significant meaning and left them feeling dignified, hopeful and engaged in future care. Intersubjective recognition is fundamental in all human interaction, but we argue that the recognising CFI approach is particularly important in vulnerable and asymmetrical mental health assessment encounters where access to care is determined and when working with migrants or other marginalised groups.
... The CFI was evaluated among diverse migrant populations, revealing themes such as cultural identity, trust, stigma, and psychosocial needs to be important for improving understanding and therapeutic relationships (23,24). The DSM-5 field trial found the CFI to be feasible, acceptable, and useful (21). ...
... Since HDRS-17 is frequently used in routine clinical care, the administration of this questionnaire has been chosen to allow describing the differences from the current standard of care. Recommended severity range for the HDRS-17 is no depression (0-7), mild depression (8)(9)(10)(11)(12)(13)(14)(15)(16), moderate depression (17)(18)(19)(20)(21)(22)(23), and severe depression (≥24) (53). ...
Background
Despite a high prevalence of mental disorders among asylum seekers, many barriers to mental healthcare exist. Cultural and contextual factors strongly influence the experience and expression of psychological distress, putting asylum seekers at greater risk of misdiagnosis and inappropriate treatment. The Cultural Formulation Interview (CFI) is a useful tool to map out cultural and contextual factors of mental disorders; however, to the best of our knowledge, it has not yet been investigated in asylum seekers specifically. The primary aim of this study is to evaluate the value of the CFI in the psychiatric assessment of asylum seekers. Second, we will describe the themes relevant to psychiatric distress in asylum seekers that are identified by the CFI. In addition, asylum seekers’ experience of the CFI will be evaluated.
Methods and analysis
This cross-sectional, mixed-method clinical study aims to recruit a group of 60–80 asylum seekers (age 15–29) with mental health symptoms. Data will be collected using structured (MINI, PCL-5, HDRS-17, WHOQoL-BREF & BSI) and semi-structured (CFI & CFI-debriefing) questionnaires to assess cultural background, contextual factors, and illness severity. Multidisciplinary case discussions will be held after the completion of interviews, following a methodological stepped approach. Combining qualitative and quantitative research techniques, this study aims to generate reliable knowledge on working with the CFI in asylum seekers. Based on the findings, recommendations for clinicians will be developed.
Discussion
This study addresses the knowledge gap on using the CFI in asylum seekers. Compared to prior studies, it will provide new insights into the use of the CFI in the specific context of working with asylum seekers.
Ethics and dissemination
Prior research on the CFI in asylum seekers is limited, partly because of their high vulnerability and low access to care. The study protocol has been tailored in close collaboration with several stakeholders and validated after piloting. Ethical approval has already been obtained. Together with the stakeholders, the results will be translated into guidelines and training materials. Recommendations to policymakers will also be provided.
... Overall, the literature suggests that providers tend to have more concerns about the CFI than patients Lewis-Fernández et al., 2017;Paralikar et al., 2015;Skammeritz et al., 2020). Patients generally find that the CFI leads to trust-building; engagement in care; reflections about their illness and sociocultural context; as well as feelings of being validated and recognized in care (Lindberg et al., 2021;Muralidharan et al., 2017;Paralikar et al., 2020;Ramírez Stege & Yarris, 2017). ...
... This finding suggests challenges with fidelity in the administration of the CFI in this study. Nevertheless, other CFI studies have similar findings of provider difficulties with explicating the culture questions and a need for high levels of self-reflexivity among the patients (Aggarwal, 2012;Lewis-Fernández et al., 2020;Paralikar et al., 2020;Ramírez Stege & Yarris, 2017;Skammeritz et al., 2020;Wallin et al., 2020). Because the CFI has three successive questions about cultural identity, providers told of uncomfortable situations, where patients who just wanted to comply and answer 'correctly' became increasingly insecure as the questions continued and emanated feelings of inadequacy or became wary as to the intention of this collection of questions. ...
This article presents provider experiences with the Cultural Formulation Interview (CFI) in Danish mental healthcare for migrant patients. Semi-structured interviews with 17 providers and 20 recorded CFI sessions were analyzed with a constructivist grounded theory approach. Based on our empirical material, we endorse the CFI’s ability to facilitate working alliance and a profound and contextually situated understanding of the patient. Further, the CFI supported less-experienced providers in investigating cultural issues. Conversely, we found that CFI questions about cultural identity and background evoked notions of distance and ‘othering’ in the encounter. Nine providers had felt discomfort and professional insecurity when the CFI compelled them to introduce explanatory frameworks of culture in the mental health assessment. Eleven providers had experienced that the abstract nature of the questions inhibited patient responses or led to short and stereotypical descriptions, which had limited analytical value. We describe the contradictory CFI experiences of alliance versus distance at three levels: 1) at the CFI instrument level; 2) at the organizational level; and 3) at the contextual and structural level. We demonstrate benefits and pitfalls of using the CFI with migrants in Denmark, which is an example of a European healthcare context where cultural consultation is not an integrated concept in health education programs and where the notion of culture is contentious due to negative political rhetoric on multiculturalism.
We suggest that the CFI should be introduced with thorough training; focus on fidelity; and supervision in the clinical application and understanding of the concept of culture.
... For example, the CFI questions on cultural identity remain somewhat difficult to understand for some patients and clinicians. A stronger emphasis on social determinants of health, including availability of and access to various types of resources, has also been suggested in order to improve the assessment procedure (Paralikar et al., 2020;Weiss et al., 2021). Moreover, there may be various ways to structure the information that is collected through the use of the CFI (Kirmayer, 2015) and complementary methods for eliciting cultural information, such as timelines, drawings, or maps, could be explored (Arnault and Shimabukuro, 2011). ...
... Here, there is certainly also room for innovation of how to provide meaningful feedback to patients regarding the information collected with the CFI. Based on findings from CFI field trials in Pune, India, suggestions have been made for a further revised version of the OCF which would include, for example, summative debriefing questions about the value of the content elicited and its relevance for diagnosis and treatment planning (Paralikar et al., 2020). Such a revision could easily incorporate advice on how to offer the patient feedback on the assessment findings in a purposeful way. ...
The Cultural Formulation Interview (CFI), included in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders , is a person-centered instrument for systematically appraising the impact of cultural factors in psychiatric assessment. A number of key areas in the future development of the CFI have been identified in order to ensure further clinical uptake. In this paper, we suggest that applying a Therapeutic Assessment (TA) approach in using the CFI—i.e., framing the interview in a way that gives primacy to its self-transformative potential by explicitly focusing on those issues that are seen as the most urgent, relevant, and meaningful by the patient—could prove helpful in alleviating patients’ suffering beyond what is achieved by merely collecting relevant cultural information that may inform diagnosis and subsequent treatment interventions. The TA methodology has been designed as a collaborative approach to psychological assessment in which the assessment procedure itself is meant to induce therapeutic change. This is achieved by explicitly focusing on the particular questions and queries that patients have about themselves with respect to their mental health problems or psychosocial well-being; these questions are then allowed to guide the assessment process and the interpretation of the findings. We suggest a number of potential modifications to the related Outline for Cultural Formulation and to the CFI content that could strengthen a TA-inspired focus. With this paper, we do not claim to offer a definitive integration of the TA approach in using the CFI but hope to further the discussion of a therapeutic potential of the instrument.
... Findings were similar in both studies: the CFI encouraged clinicians to ask openended questions that solicited patient experiences of health and illness and oriented patients procedurally through prompts of what to expect during the interview. Three studies reported on the perspectives of family members who accompanied patients (Hinton et al., 2015;Paralikar et al., 2015Paralikar et al., , 2020. The first of these (Hinton et al., 2015) explored perceptions of the CFI's feasibility, acceptability, and clinical utility from patient companions in India, Kenya, and the Netherlands during the pilot field trial, and found that they rated the CFI positively on all three domains. ...
... A study from an Indian field trial site found that patients with common mental disorders rated the CFI's acceptability and clinical utility higher than did patients with psychosis and clinicians; in fact, patients with psychosis rated acceptability and clinical utility lower than patients without psychosis and clinicians . Another Indian study by the same research team used qualitative analyses of patient and clinician debriefing interviews from the field trial to propose revisions to the OCF that situated narratives within social, political, and economic contexts (Paralikar et al., 2020). A study from the Dutch field trial site found slightly lower ratings of feasibility, acceptability, and clinical utility relative to the mean values of the overall field trial, though still in the positive range . ...
While social science research has demonstrated the importance of culture in shaping psychiatric illness, clinical methods for assessing the cultural dimensions of illness have not been adopted as part of routine care. Reasons for limited integration include the impression that attention to culture requires specialized skills, is only relevant to a subset of patients from unfamiliar backgrounds, and takes too much time to be useful. The DSM-5 Cultural Formulation Interview (CFI), published in 2013, was developed to provide a simplified approach to collecting information needed for cultural assessment. It offers a 16-question interview protocol that has been field tested at sites around the world. However, little is known about how CFI implementation has affected training, health services, and clinical outcomes. This article offers a comprehensive narrative review that synthesizes peer-reviewed, published studies on CFI use. A total of 25 studies were identified, with sample sizes ranging from 1 to 460 participants. In all pilot CFI studies 960 unique subjects were enrolled, and in final CFI studies 739 were enrolled. Studies focused on how the CFI affects clinical practice; explored the CFI through research paradigms in medical communication, implementation science, and family psychiatry; and examined clinician training. In most studies, patients and clinicians reported that using the CFI improved clinical rapport. This evidence base offers an opportunity to consider implications for training, research, and clinical practice and to identify crucial areas for further research.
... disorders, such as psychoses and neurocognitive disorders . Efforts are underway to supplement the CFI with more systematic inquiry into social-structural determinants of health (Paralikar et al., 2020). The OCF and CFI aim to encourage clinicians to explore and integrate a broad range of relevant social and cultural information into assessment and treatment. ...
... The relationship between clinical findings from assessment with the CFI and an OCF-based cultural formulation was examined at the Pune site in the multicenter field trials validating the CFI for the DSM-5 (Lewis-Fernández et al., 2017;Paralikar et al., 2015). Two findings from that study were especially important (Paralikar et al., 2020). First, the questions of the CFI focused mainly on core features of the illness explanatory model, broadly defined (Weiss, 2018), which are most closely associated in the OCF with Domain II, Concepts of distress. ...
A Cultural Formulation Interview (CFI) field trial in India, widely reported racist violence in the United States, and casteist and religious communal conflicts in India highlighted inattention to structural issues affecting mental health problems in the Outline for Cultural Formulation (OCF) and the CFI in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). Consequently, we revised the OCF as a sociocultural formulation (SCF) to better consider structures of society and culture. We studied and compared clinicians' ratings of SCF case formulations from a constructed assessment instrument (SCF Interview [SCFI]) and the CFI. Socio-cultural formulations from SCFI interviews were rated higher for details of societal structural impact, and overall interrater agreement was better. CFI interviews were rated higher for clinical rapport. Revision of the CFI should enhance consideration of structural issues and incorporate them in SCFs that better integrate assessment process and case formulation content. The need to acknowledge structural sources of mental health problems is clear, and our study indicates how a sociocultural framework may be used for that.
... disorders, such as psychoses and neurocognitive disorders . Efforts are underway to supplement the CFI with more systematic inquiry into social-structural determinants of health (Paralikar et al., 2020). The OCF and CFI aim to encourage clinicians to explore and integrate a broad range of relevant social and cultural information into assessment and treatment. ...
... A literature review prepared for DSM-5-TR of all publications on the CFI that reported original data from 2013 to 2020 identified one study that suggested changes to the OCF's concept of culture (Aggarwal et al. 2020). A research group from India proposed an OCF-Revision (OCF-R) that would consist of five domains: (1) cultural identity of the patient, (2) illness explanatory model, (3) key social relationships, including with the clinician, (4) social, cultural, political, and economic contexts, and (5) an overall cultural assessment (Paralikar, Deshmukh, and Weiss 2020). The authors argued the field of psychiatry is historically less attentive to "the impact of social, cultural, political, and economic contexts affecting the lives of people in the world and the mental health of patients, apart from consideration of disorders defined by social or situational trauma, like post-traumatic stress disorder" (Paralikar, Deshmukh, and Weiss 2020:538). ...
For thirty years, psychiatrists and anthropologists have collaborated to improve the validity of psychiatric diagnosis. This collaboration has produced the DSM-IV Outline for Cultural Formulation (OCF) and the DSM-5 Cultural Formulation Interview (CFI). Nonetheless, some anthropologists have critiqued the concept of culture in DSM-5 as too focused on patient meanings and not on clinician practices. This article traces the evolution of the culture concept from DSM-IV through DSM-5-TR by analyzing publications from the American Psychiatric Association on the OCF and CFI alongside scholarship in psychiatry and anthropology. DSM-IV relied on a culture concept of coherent ethnic communities sharing coherent cultures, primarily for minoritized ethnoracial individuals in the United States. Changing demographics and newer immigration patterns around the world deminoritized the culture concept for DSM-5. After George Floyd’s death and demands for social justice, the culture concept in DSM-5-TR emphasized social structures. The article proposes an intersubjective model of culture through which patients and clinicians work through similarities and differences. It recommends a revised formulation that attends to clinician practices such as communicating, diagnosing, recommending treatments, and documenting, beyond collecting patient meanings. It also raises the question of whether an intersubjective model of culture prompts reconsiderations of culture-related text in other sections of the DSM. The social sciences can redirect attention to the clinician’s culture of biomedicine to close patient health disparities.
... 64 Efforts are underway to supplement this outline with a structurally oriented formulation that includes information on social determinants of health obtained from patients and the people around them. 12,65 In many clinical settings, patients are increasingly presenting with a self-diagnosis or explanation of their behaviour in neurobiological or neurochemical terms. 66 This explanatory model draws on prevailing brain-centric models of mental disorders that are taught to medical students, used in neuroscience research, promoted by pharmaceutical industry advertising, and widely disseminated through popular culture. ...
Psychiatry has increasingly adopted explanations for psychopathology that are based on neurobiological reductionism. With the recognition of health disparities and the realisation that someone's postcode can be a better predictor of health outcomes than their genetic code, there are increasing efforts to ensure cultural and social-structural competence in psychiatric practice. Although neuroscientific and social-cultural approaches in psychiatry remain largely separate, they can be brought together in a multilevel explanatory framework to advance psychiatric theory, research, and practice. In this Personal View, we outline how a cultural-ecosocial systems approach to integrating neuroscience in psychiatry can promote social-contextual and systemic thinking for more clinically useful formulations and person-centred care.
... In a recent special issue of Transcultural Psychiatry, comments on implementation of the CFI were made (Lewis-Fernández et al., 2020). Among other, feasibility of questions concerning cultural identity was commented, value of revising the dimensional structure of the OCF was proposed (Paralikar et al., 2020), and a need for further refinement of the CFI was pointed out (Wallin et al., 2020). The GAP has advocated inclusion of social structures in the OCF, suggested adapting the OCF into the SCF and shaping its domains accordingly. ...
... The DSM-5 Cultural Formulation Interview (CFI) [1] is a standardized protocol that has been developed to guide an individual cultural assessment during the clinical diagnostic process. It is being widely implemented internationally [13][14][15][16]. However, to date, no evaluation has been conducted on the impact of the CFI on diagnostic performance in real-life clinical settings. ...
Background
Culture and social context affect the expression and interpretation of symptoms of distress, raising challenges for transcultural psychiatric diagnostics. This increases the risk that mental disorders among migrants and ethnic minorities are undetected, diagnosed late or misdiagnosed. We investigated whether adding a culturally sensitive tool, the DSM-5 core Cultural Formulation Interview (CFI), to routine diagnostic procedures impacts the psychiatric diagnostic process.
Method
We compared the outcome of a diagnostic procedure that included the CFI with routine diagnostic procedures used at Swedish psychiatric clinics. New patients ( n = 256) admitted to a psychiatric outpatient clinic were randomized to a control ( n = 122) or CFI-enhanced diagnostic procedure ( n = 134) group. An intention-to-treat analysis was conducted and the prevalence ratio and corresponding 95% confidence intervals (CI) were calculated across arms for depressive and anxiety disorder diagnoses, multiple diagnoses, and delayed diagnosis.
Results
The prevalence ratio (PR) of a depressive disorder diagnosis across arms was 1.21 (95% CI = 0.83-1.75), 33.6% of intervention-arm participants vs. 27.9% of controls. The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI = 0.91-2.86). The prevalence ratio of receiving multiple diagnoses was higher for the CFI group among non-native speaking patients, and lower to a statistically significant degree among native Swedish speakers (PR = .39, 95% CI = 0.18-0.82).
Conclusions
The results suggest that the implementation of the DSM-5 CFI in routine psychiatric diagnostic practice may facilitate identification of symptoms of certain psychiatric disorders, like depression, among non-native speaking patients in a migration context. The CFI did not result in a reduction of patients with a non-definite diagnosis.
Trial registration
ISRCTN51527289 , 30/07/2019. The trial was retrospectively registered.
... The entire dataset was also read to code content from those questions of each domain that was relevant for other questions or domains, remaining aware of the possibility that a client's response to any one question might be more relevant to the interests of another question. [7] Constant comparison method [8] was used for the same as the researcher looked for patterns, associations, clustering, and explanations. ...
Introduction:
Conversion disorder is easily one of the least understood neuropsychiatric disorders. There is a great deal of ambiguity with respect to symptom presentation, assessment, etiology, diagnosis, and treatment. However, a common clinical practice associated with the assessment and management of the conversion disorder is the evaluation of a stressor. Recent studies in India have indicated that family stressors are the most frequent. Sociocultural aspects of the client's environment and the illness experience thus form an important part of the client's diagnostic formulation. These aspects also determine help-seeking, treatment adherence, and thus, the outcomes.
Materials and methods:
Fifteen clients suffering from conversion disorder in a tertiary mental health setting in North India, recruited through purposive sampling, were interviewed in-depth. Data were elicited using the cultural formulation interview (CFI). Qualitative content analysis was carried out.
Results:
The content analyses summarized the cultural experiences of clients suffering from conversion disorder under structured domains of the CFI. The results are presented in tables along with content examples and represent individual client experiences and conceptualizations of diagnosis, treatment, and implications of suffering from conversion disorder. The findings of this study aim to describe and highlight the cultural experiences of clients with respect to their psychopathology. The most striking recurrent theme in the cultural formulations were the lack of understanding of the nature and cause of illness both in the client as well as the clinician, and therefore a lack of trust and hope in the treatment.
Conclusion:
The findings of the current study shed light on the cultural experiences of clients with conversion disorder. These findings emphasize the need for clinicians to incorporate the individual and collective cultural experiences of clients and cultural sensitivity in addition to the clinical diagnoses. The Cultural Formulation Interview of the DSM-5 was found to be very helpful in this regard and we encourage its use by clinicians, especially with clients suffering from conversion disorder, given the strong influences of socio-cultural experiences on psychopathology as well as the intervention.
... The DSM-5 Cultural Formulation Interview (CFI) [1] is a standardized protocol that has been developed to guide an individual cultural assessment during the clinical diagnostic process. It is being widely implemented internationally [13][14][15][16]. ...
Background
Culture and social context affect the expression and interpretation of symptoms of distress, raising challenges for transcultural psychiatric diagnostics. This increases the risk that mental disorders among migrants and ethnic minorities are undetected, diagnosed late or misdiagnosed. We investigated whether adding a culturally sensitive tool, the DSM-5 core Cultural Formulation Interview (CFI), to routine diagnostic procedures impacts the psychiatric diagnostic process. Method
We compared the outcome of a diagnostic procedure that included the CFI with routine diagnostic procedures used at Swedish psychiatric clinics. New patients (n=256) admitted to a psychiatric outpatient clinic were randomized to a control (n=122) or CFI-enhanced diagnostic procedure (n=134) group. An intention-to-treat analysis was conducted and the prevalence ratio and corresponding 95% confidence intervals (CI) were calculated across arms for depressive and anxiety disorder diagnoses, multiple diagnoses, and delayed diagnosis. ResultsThe prevalence ratio (PR) of a depressive disorder diagnosis across arms was 1.21 (95% CI=0.83-1.75), 33.6% of intervention-arm participants vs. 27.9% of controls. The prevalence ratio was higher among patients whose native language was not Swedish (PR =1.61, 95% CI=0.91-2.86). The prevalence ratio of receiving multiple diagnoses was higher for the CFI group among non-native speaking patients, and lower to a statistically significant degree among native Swedish speakers (PR=.39, 95% CI=0.18-0.82). Conclusions
The results suggest that the implementation of the DSM-5 CFI in routine psychiatric diagnostic practice may facilitate identification of symptoms of certain psychiatric disorders among non-native speaking patients in a migration context. Trial registrationISRCTN36661, 29/07/2019. The trial was retrospectively registered.
... Doing so harmonizes cultural dimensions of patients' experiences, located within specific sociocultural contexts of family and social networks, with the structural predicaments foregrounded in social medicine. This pairing may be structured in various ways, and a recent study recommends four domains for a revised OCF (Paralikar et al., 2020): a) cultural identities of the patient, b) patient explanations of illness and idioms of distress, c) the nature and quality of significant social relationships (e.g., family, friends, colleagues, and clinicians), and d) social-structural issues and hierarchies reflecting political, economic, environmental, life course, and livelihood needs and aspirations of patients and communities. The structures of both society and its institutions are relevant considerations, which as social determinants of health may harm (or help) patients and populations. ...
Recent events underscore the morbidity and mortality resulting from structural racism. As cultural specialists , we believe that clinical benefits will accrue from better integrating cultural and societal-structural approaches in psychiatric assessment, care planning, and case management. The Outline for Cultural Formulation (OCF) first appeared in DSM-IV as a framework for cultural assessment. A Cultural Formulation Interview (CFI) was developed and evaluated in an international field trial, and included in DSM-5 to facilitate use of the OCF and enhance cultural competence in psychiatric practice and training. Another approach to clinical assessment, termed "structural competency," was suggested in 2014 to prioritize the role of societal structures creating and sustaining health inequalities. Structural factors produce racial and ethnic disparities, and they limit access to health care and social services. They also influence the experience and outcomes of mental illness and health care practices, possibly including coercion and criminalization. Acknowledging structural factors in case formulation enables clinicians to consider clinically relevant social constraints beyond individual vulnerabilities. These two approaches to case formulation are currently framed as distinctive in both theory and practice: cultural psychiatry rooted in medical anthropology and structural competency rooted in social medicine. However, these two orientations are neither mutually exclusive nor conflictual. Each yields complementary clinically relevant information about a patient's identity and life, the personal experience of suffering, setting, and how to formulate an effective salutary response. To link these two approaches more effectively, we recommend that the OCF be updated as a Socio-Cultural Formulation (SCF). To be successfully adopted, the SCF must address real-world challenges in routine psychiatric practice, contribute to interdisciplinary teamwork, and demonstrably improve the quality of care and outcomes for patients and communities.
... In other words, the process of conducting the CFI is as important as the content elicited. Research with the CFI has shown that patients value the ability of the clinician to express caring and concern through the CFI questions, which can enhance rapport and communication (Aggarwal, DeSilva, Nicasio, Boiler, & Lewis-Ferna´ndez, 2015;Paralikar, Deshmukh, & Weiss, 2020). By giving explicit attention to patients' experience of suffering, and eliciting relevant aspects of their identity, understandings of illness, and current predicament, the use of the CFI conveys the clinician's interest in the patient as a person. ...
The Cultural Formulation Interview (CFI) developed for DSM-5 provides a way to collect information on patients’ illness experience, social and cultural context, help-seeking, and treatment expectations relevant to psychiatric diagnosis and assessment. This thematic issue of Transcultural Psychiatry brings together articles examining the implementation and impact of the CFI in diverse settings. In this editorial introduction we discuss key areas raised by these and other studies, including: (1) the potential of the CFI for transforming current psychiatric assessment models; (2) training and implementation strategies for wider application and scale-up; and (3) refining the CFI by developing new modules and alternative protocols based on further research and clinical experience.
... However, for others, the questions worked well and provided valuable new information. On the basis of experiences in Pune (India), Paralikar, Deshmukh, and Weiss (2019) suggest that assessing cultural identity requires that an interviewer focus on a patient's self-ascribed identity and not the views of others or the clinician. They also point to the need for further research on the role of cultural identity. ...
... However, for others, the questions worked well and provided valuable new information. On the basis of experiences in Pune (India), Paralikar, Deshmukh, and Weiss (2019) suggest that assessing cultural identity requires that an interviewer focus on a patient's self-ascribed identity and not the views of others or the clinician. They also point to the need for further research on the role of cultural identity. ...
This study is an evaluation of clinicians' and patients' experiences of the core Cultural Formulation Interview (CFI) in DSM-5. The CFI provides a framework for gathering culturally relevant information, but its final form has not been sufficiently evaluated. Aims were to assess the Clinical Utility (CU), Feasibility (F) and Acceptability (A) of the CFI for clinicians and patients, and to explore clinicians' experiences of using the CFI in a multicultural clinical setting in Sweden. A mixed-method design was applied, using the CFI Debriefing Instrument for Clinicians (N ¼ 15) and a revised version of the Debriefing Instrument for Patients (N ¼ 114) (DIC and DIP, scored from À2 to 2). Focus group interviews were conducted with clinicians. For patients (response rate 50%), the CU mean was 0.98 (SD ¼ 0.93) and F mean 1.07 (SD ¼ 0.83). Overall rating of the interview was 8.30 (SD ¼ 1.75) on a scale from 0 and 10. For clinicians (response rate 94%), the CU mean was 1.14 (SD ¼ 0.52), F 0.58 (SD ¼ 0.93) and A 1.42 (SD ¼ 0.44). From clinician focus-group interviews, the following themes were identified: approaching the patient and the problem in a new manner; co-creating rapport and understanding; and affecting clinical reasoning and assessment. Patients and clinicians found the CFI in DSM-5 to be a feasible, acceptable, and clinically useful assessment tool. The focus group interviews suggested that using the CFI at initial contact can help make psychiatric assessment patient-centred by facilitating patients' illness narratives. We argue for further refinements of the CFI.
The Cultural Formulation Interview (CFI) is a semi-structured interview in the DSM-5 comprised of three parts: a core-16-item questionnaire, an informant version for relatives or relevant others, and 12 supplementary modules placing culture and context at the center of patient assessment and treatment to clarify diagnosis and treatment and ensure patients feel understood. The paper aims to synthesize the current quantitative evidence on CFI’s favorability (i.e., whether it is feasible, acceptable, and valuable) for patients, clinicians, and relatives. A mixed-methods synthesis methodology was used to assess the impact of the favorability of the CFI for patients, clinicians and relatives, and clinicians’ cultural competence. The synthesis included 10 studies on the clinician’s competency, attitudes, training, and diagnosis, three studies on the views of the patients and clinicians about the CFI, and five studies with 34 estimates ( n = 581) on the favorability of the CFI for patients, clinicians and relatives. Clinicians reported that the CFI increased their cultural knowledge across research, training, and practice settings. Patients reported that the CFI prioritized their perspective and increased rapport-building. A quantitative estimate from the five studies on the acceptability, utility, and feasibility of CFI from patients, relatives, and clinicians was favorable, suggesting that patients, relatives, and clinicians were satisfied with using the CFI. A protocol for standardizing CFI training and practice to inform future research using mixed-methods designs that include randomized control trials (RCTs) to examine the effect of the CFI on the clinician’s cultural competence, working alliance, and patient’s level of functioning was recommended.
Over the past decade, researchers translating anthropological theories for clinical use have debated how practitioners should assess cultural factors, social structures, and social determinants of health with patients. Advocates of structural competency have suggested that clinical cultural competency programs demonstrate limited effects on health outcomes because of the static understanding of culture employed. They recommend that cultural factors be reformulated with an emphasis on social structures. In response, researchers in cultural psychiatry specializing in cultural assessments have developed three models—sociocultural formulation (SCF), the cultural-ecosocial view, and the contextual developmental assessment—to integrate cultural and structural factors. Their methods for integration, however, differ, resulting in various understandings of psychopathology mechanisms. This paper analyzes arguments from all four positions in this debate. It reveals a lack of consensus about interrelationships among these constructs, their definitions, and methods for assessment. The article concludes with recommendations, such as developing consensus definitions with broad stakeholder involvement; adopting a data-driven approach to clarify how specific cultural, social, or structural factors interact; and identifying how extant assessments capture clinically relevant factors across constructs to develop additional assessment tools.
Introduction
Cultural and contextual factors affect communication and how psychiatric symptoms are presented, therefore psychiatric assessments need to include awareness of the patients’ culture and context. The Cultural Formulation Interview (CFI) in DSM-5 is a person-centred tool developed to support the exploration of cultural and contextual factors in an individualized and non-stereotypic way.
Methods
The aim of this qualitative study was to find out what information the DSM-5 CFI revealed when used with native Swedish-speaking patients as part of routine clinical psychiatric assessment at an outpatient clinic. An additional aim was to enhance understanding of what kind of information the questions about background and identity yielded. The CFI was added to the psychiatric assessment of 62 native Swedish-speaking patients at an outpatient psychiatric clinic in Stockholm.
Results
From the thematic analysis of the documented CFI answers, six central themes were found; Descriptions of distress and dysfunction, Managing problems and distress, Current life conditions affecting the person, Perceived failure in meeting social expectations, Making sense of the problem, and Experiences of, and wishes for, help. The CFI questions about identity yielded much information, mainly related to social position and feelings of social failure.
Discussion
For further refinement of the CFI, we see a need for re-framing the questions about cultural identity and its impact on health so that they are better understood. This is needed for majority population patients as direct questions about culture may be difficult to understand when cultural norms are implicit and often unexamined. For clinical implications, our findings suggest that for cultural majority patients the DSM-5 CFI can be a useful person-centred tool for exploring cultural and, in particular, social factors and patients’ perception and understanding of distress.
Formulation consists in the process of developing a hypothesis about the origins of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It provides a structure for taking a global perspective on patient’s clinical condition. In psychiatric formulation, there are two equally important sources of information: the clinician – bringing knowledge derived from theory, research, and clinical experience – and the patient who has the expertise about his/her life and the meaning and impact of their relationships and circumstances. The psychiatric clinical formulation is widely accepted as a core component of clinical education in psychiatric training across the world. The skills required to construct a formulation include the ability to integrate and summarize the data and highlight the relevant predisposing, precipitating, perpetuating and protective factors for each individual patient. The psychiatric formulation goes beyond making a diagnosis, and it is essential for understanding patient’s clinical picture, etiology and management in the context of multi-dimensional bio-psycho-sociocultural domains.
The challenge of producing a classificatory system that is truly representative of different regions and cultural variations is difficult. This can be conceptualized as an ongoing process, achievable by constant commitment in this regard from various stakeholders over successive generations of the classificatory systems. The objective of this article is to conduct a qualitative review of the process and outcome of the efforts that resulted in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders becoming a global classification. The ICD-11 represents an important, albeit iterative, advance in the classification of mental, behavioural and neurodevelopmental disorders. Significant changes have been incorporated in this regard, such as the introduction of new, culturally-relevant categories, modifications of the diagnostic guidelines, based on culturally informed data and the incorporation of culture-related features for specific disorders. Notwithstanding, there are still certain significant shortcomings and areas for further improvement and research. Some of the key limitations of ICD-11 relate to the paucity of research on the role of culture in the pathogenesis of illnesses. To ensure a classificatory system that is fair, reliable and culturally useful, there is a need to generate empirical evidence on diversity in the form of illnesses, as well as mechanisms that explain these in all the regions of the world. In this review, we try to delineate the various cultural challenges and their influences in the formulation of ICD-11, along with potential shortcomings and areas in need of more improvement and research in this regard.
The study assessed the experiences and reactions of adolescent offspring of alcohol-dependent fathers (N = 15) to their fathers’ heavy drinking. Data were analyzed qualitatively, identifying themes and sub-themes. Respondent accounts elaborated these themes with reference to explanations, experiences, reactions to their fathers’ drinking. Gender differences were notable: girls were more likely to report abuse, shouldering of family responsibilities, physiological and other reactions, ambivalent feelings toward father, sadness and worthlessness. Boys were more likely to react with anger and/or aggression. The findings should guide the development of gender-sensitive family-based interventions for the adolescents, with special attention to psychological, social and legal dimensions.
To the Editor In a Viewpoint, Dr Guinart et al¹ highlighted the need for fuller consideration of transcultural psychiatry to better explain cultural variation in clinical trials of psychotropic medicines. As the article suggested, such research is bedeviled by questions of interrater reliability, variations in the expression of stigmatizing emotional experience, and capacity for measuring treatment response. Neglecting cultural contexts distorts the results of clinical trials. Such concerns about cultural validity for effective clinical practice, in fact, motivated formulation of the “new cross-cultural psychiatry” as an upgrade for transcultural psychiatry more than 4 decades ago.
Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people’s views of serious mental illness were regarded as more stigmatizing than patients’ prior problems and DSH event; patients’ personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.
Cultural epidemiology is an interdisciplinary field based on principles and
methods of medical anthropology and classical epidemiology. Its contribution
to health research results from a focus on illness, distinct from the
disease orientation of classical epidemiology. Though rooted in the
influential illness explanatory model framework, current developments in the
field of cultural epidemiology refer more explicitly to determinants of
health and illness beyond explanatory models based on frameworks of critical
medical anthropology. This rethinking of cultural epidemiology acknowledges
the need for research to consider domains of a revised Outline for Cultural
Formulation referring to cultural identity, key social relations, and the
impact of political economy and other structural features of society. In
addition to this current work in cultural psychiatry, two other areas of
research remain active: public health studies of professional and community
determinants of vaccine acceptance and research on assessment and study of
stigma as a clinically significant feature of illness experience, providing
a clinical complement to more mainstream community studies of stigma.
Having the whole person as the center and goal of health and health care may be seen as the core concept of person-centered psychiatry and, more broadly, person-centered medicine. In order to appreciate the significance of person-centeredness, it is important to understand the meaning, implications, challenges, and opportunities of person-centered care, as well as to consider multiple conceptual perspectives and the collaborative institutional process of its ongoing development, as is done in this book. Person-centered psychiatry and medicine may be traced back to how medicine was conceived and practiced in ancient civilizations and through the present time, including efforts to redress contemporary reductionist distortions in clinical medicine and public health. With a sense of paramount ethical commitment, many leaders in medicine have recognized the interdependency of science and humanism and reaffirmed a psychiatry and medicine of the person, for the person, by the person, and with the person. Recent systematic explorations of person-centered care has identified as key concepts in addition to its ethical imperative: a holistic framework to understand health and illness, cultural awareness and responsiveness, a communicational and relationship focus at all levels, individualization of care, establishment of common ground among clinicians, patient, and family to arrive at and formulate a joint diagnosis and shared care decisions, people-centered organization of integrated care, and person-centered health education and research. The collaborative construction of person centered psychiatry and medicine has been unfolding over the past decade. In 2005, the World Psychiatric Association (WPA) established a broad institutional program on Psychiatry for the Person, building on the articulation of science and humanism as the essential joint motivation for the WPA since its foundation in 1950. This initiative was later extended to medicine at large in close collaboration with the World Health Organization, the World Medical Association, the International Council of Nurses, and the International Alliance of Patients’ Organizations, among a number of other international health institutions. From a process of annual Geneva Conferences on Person Centered Medicine since 2008 emerged an International Network and then an International College of Person Centered Medicine. Step-wise maturation of this process has led to the establishment of an International Journal of Person Centered Medicine, the organization of International Congresses in different corners of the world complementing the Geneva Conferences, and the publication of Declarations extending the work and impact of Conferences and Congresses. As proclaimed by WHO Director General Gro Brundtland in 2001, there is no health without mental health. Mental health has indeed a special place and role in person-centered medicine. This refers to the various activities through which mental health has contributed to the conceptualization and experience of person-centered medicine and the role that an organized “psychiatry for the person” has had in the collaborative construction of person-centered medicine. Some of the recent concrete contributions of person-centered medicine to clinical practice are in the mental health field: the Person-centered Integrative Diagnosis model, the Latin American Guide for Psychiatric Diagnosis (GLADP) and the present book on Person-Centered Psychiatry. The purpose of this book is to present authoritatively the emerging field of Person-Centered Psychiatry. It is organized under the aegis of the International College of Person-Centered Medicine and published by Springer Verlag in Heidelberg and New York. The WPA and the World Federation for Mental Health are officially co-sponsoring it. Eighteen WPA Scientific Sections are engaged in its authorship. Its five editors and 83 chapter authors come from across the world and are among the most experienced scholars and clinicians in the new field. The volume includes 40 chapters organized into the following five sections: Principles, Diagnosis and Assessment, Person-centered Care Approaches, Person-centered Care for Specific Mental Conditions, and Special Topics. This book emerges from a broad conceptual and collaborative process. Its authorship and structure reflects these features.
Background:
There is a need for clinical tools to identify cultural issues in diagnostic assessment.
Aims:
To assess the feasibility, acceptability and clinical utility of the DSM-5 Cultural Formulation Interview (CFI) in routine clinical practice.
Method:
Mixed-methods evaluation of field trial data from six countries. The CFI was administered to diagnostically diverse psychiatric out-patients during a diagnostic interview. In post-evaluation sessions, patients and clinicians completed debriefing qualitative interviews and Likert-scale questionnaires. The duration of CFI administration and the full diagnostic session were monitored.
Results:
Mixed-methods data from 318 patients and 75 clinicians found the CFI feasible, acceptable and useful. Clinician feasibility ratings were significantly lower than patient ratings and other clinician-assessed outcomes. After administering one CFI, however, clinician feasibility ratings improved significantly and subsequent interviews required less time.
Conclusions:
The CFI was included in DSM-5 as a feasible, acceptable and useful cultural assessment tool.
Despite the important roles families play in the lives of many individuals with mental illness across cultures, there is a dearth of data worldwide on how family members perceive the process of cultural assessment as well as to how to best include them. This study addresses this gap in our knowledge through analysis of data collected across six countries as part of a DSM-5 Field Trial of the Cultural Formulation Interview (CFI). At clinician discretion, individuals who accompanied patients to the clinic visit (i.e. patient companions) at the time the CFI was conducted were invited to participate in the cultural assessment and answer questions about their experience. The specific aims of this paper are (1) to describe patterns of participation of patient companions in the CFI across the six countries, and (2) to examine the comparative feasibility, acceptability, and clinical utility of the CFI from companion perspectives through analysis of both quantitative and qualitative data. Among the 321 patient interviews, only 86 (at four of 12 sites) included companions, all of whom were family members or other relatives. The utility, feasibility and acceptability of the CFI were rated favourably by relatives, supported by qualitative analyses of debriefing interviews. Cross-site differences in frequency of accompaniment merit further study.
Development of the cultural formulation interview (CFI) in DSM-5 required validation for cross-cultural and global use.
To assess the overall value (OV) of CFI in the domains of feasibility, acceptability, and utility from the vantage points of clinician-interviewers, patients and accompanying relatives.
We conducted cross-sectional semi-structured debriefing interviews in a psychiatric outpatient clinic of a general hospital.
We debriefed 36 patients, 12 relatives and eight interviewing clinicians following the audio-recorded CFI. We transformed their Likert scale responses into ordinal values - positive for agreement and negative for disagreement (range +2 to -2).
We compared mean ratings of patients, relatives and clinician-interviewers using nonparametric tests. Clinician-wise grouping of patients enabled assessment of clinician effects, inasmuch as patients were randomly interviewed by eight clinicians. We assessed the influence of the presence of relatives, clinical diagnosis and interview characteristics by comparing means. Patient and clinician background characteristics were also compared.
Patients, relatives and clinicians rated the CFI positively with few differences among them. Patients with serious mental disorders gave lower ratings. Rating of OV was lower for patients and clinicians when relatives were present. Clinician effects were minimal. Clinicians experienced with culturally diverse patients rated the CFI more positively. Narratives clarified the rationale for ratings.
Though developed for the American DSM-5, the CFI was valued by clinicians, patients and relatives in out-patient psychiatric assessment in urban Pune, India. Though relatives may add information and other value, their presence in the interview may impose additional demands on clinicians. Our findings contribute to cross-cultural evaluation of the CFI.
Planned and unplanned migrations, diverse social practices, and emerging disease vectors transform how health and wellbeing are understood and negotiated. Simultaneously, familiar illnesses-both communicable and non-communicable-continue to aff ect individual health and household, community, and state economies. Together, these forces shape medical knowledge and how it is understood, how it comes to be valued, and when and how it is adopted and applied. Perceptions of physical and psychological wellbeing diff er substantially across and within societies. Although cultures often merge and change, human diversity assures that diff erent lifestyles and beliefs will persist so that systems of value remain autonomous and distinct. In this sense, culture can be understood as not only habits and beliefs about perceived wellbeing, but also political, economic, legal, ethical, and moral practices and values. Although culture can be considered as a set of subjective values that oppose scientific objectivity, we challenge this view in this Commission by claiming that all people have systems of value that are unexamined. Such systems are, at times, diff use, and often taken for granted, but are always dynamic and changing. They produce novel and sometimes perplexing needs, to which established caregiving practices often adjust slowly. Ideas about health are, therefore, cultural. They vary widely across societies and should not merely be defined by measures of clinical care and disease. Health can be defined in worldwide terms or quite local and familiar ones. Yet, in clinical settings, a tendency to standardise human nature can be, paradoxically, driven by both an absence of awareness of the diversity with which wellbeing is contextualised and a commitment to express both patient needs and caregiver obligations in universally understandable terms. We believe, therefore, that the perceived distinction between the objectivity of science and the subjectivity of culture is itself a social fact (a common perception). We attribute the absence of awareness of the cultural dimensions of scientific practice to this distinction, especially for macrocultures and large societies, which define only small-scale, microcultures as cultural. We recommend a broad view of culture that embraces not only social systems of belief as cultural, but also presumptions of objectivity that permeate views of local and global health, health care, and health-care delivery. If the role of cultural systems of value in health is ignored, biological wellness can be focused on as the sole measure of wellbeing, and the potential for culture to become a key component in health maintenance and promotion can be eroded. This erosion is especially true where resources are scarce or absent. Under restricted and pressured conditions, behavioural variables that aff ect biological outcomes are dismissed as merely sociocultural, rather than medical. Especially when money is short, or when institutions claim to have discharged fully their public health obligations, blame for ill health can be projected onto those who are already disadvantaged. As a result, many thinkers in health-care provision across disciplines attribute poor health-care outcomes to factors that are beyond the control of care providers-namely, on peculiar, individual, or largely inaccessible cultural systems of value. Others, having witnessed the ramifications of such thinking, argue that all health-care provision should, rather, be made more culturally sensitive. Yet others declare merely that multiculturalism has failed and the concept should be abandoned, citing its divisive potential.1 Irrespective of who is blamed, failure to recognise the intersection of culture with other structural and societal factors creates and compounds poor health outcomes, multiplying financial, intellectual, and humanitarian costs. However, the eff ect of cultural systems of values on health outcomes is huge, within and across cultures, in multicultural settings, and even within the cultures of institutions established to advance health. In all cultural settings-local, national, worldwide, and even biomedical-the need to understand the relation between culture and health, especially the cultural factors that aff ect health-improving behaviours, is now crucial. In view of the financial fragility of so many systems of care around the world, and the wastefulness of so much of health-care spending, a line can no longer be drawn between biomedical care and systems of value that define our understanding of human wellbeing. Where economic limitations dictate what is feasible, socioeconomic status produces its own cultures of security and insecurity that cut across nationality, ethnic background, gender orientation, age, and political persuasion. Socio economic status produces new cultures defined by degrees of social security and limitations on choice that privilege some people and disadvantage others. Financial equity is, therefore, a very large part of the cultural picture; but it is not the entire picture. The capacity to attend to adversity- to believe that one can aff ect one's own future-is conditioned by a sense of social security that is only partly financial.
Current efforts in global mental health (GMH) aim to address the inequities in mental health between low-income and high-income countries, as well as vulnerable populations within wealthy nations (e.g., indigenous peoples, refugees, urban poor). The main strategies promoted by the World Health Organization (WHO) and other allies have been focused on developing, implementing, and evaluating evidence-based practices that can be scaled up through task-shifting and other methods to improve access to services or interventions and reduce the global treatment gap for mental disorders. Recent debates on global mental health have raised questions about the goals and consequences of current approaches. Some of these critiques emphasize the difficulties and potential dangers of applying Western categories, concepts, and interventions given the ways that culture shapes illness experience. The concern is that in the urgency to address disparities in global health, interventions that are not locally relevant and culturally consonant will be exported with negative effects including inappropriate diagnoses and interventions, increased stigma, and poor health outcomes. More fundamentally, exclusive attention to mental disorders identified by psychiatric nosologies may shift attention from social structural determinants of health that are among the root causes of global health disparities. This paper addresses these critiques and suggests how the GMH movement can respond through appropriate modes of community-based practice and ongoing research, while continuing to work for greater equity and social justice in access to effective, socially relevant, culturally safe and appropriate mental health care on a global scale.
The Outline for Cultural Formulation (OCF) introduced with DSM-IV provided a framework for clinicians to organize cultural information relevant to diagnostic assessment and treatment planning. However, use of the OCF has been inconsistent, raising questions about the need for guidance on implementation, training, and application in diverse settings. To address this need, DSM-5 introduced a cultural formulation interview (CFI) that operationalizes the process of data collection for the OCF. The CFI includes patient and informant versions and 12 supplementary modules addressing specific domains of the OCF. This article summarizes the literature reviews and analyses of experience with the OCF conducted by the DSM-5 Cross-Cultural Issues Subgroup (DCCIS) that informed the development of the CFI. We review the history and contents of the DSM-IV OCF, its use in training programs, and previous attempts to render it operational through questionnaires, protocols, and semi-structured interview formats. Results of research based on the OCF are discussed. For each domain of the OCF, we summarize findings from the DCCIS that led to content revision and operationalization in the CFI. The conclusion discusses training and implementation issues essential to service delivery.
The Outline for Cultural Formulation (OCF) in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) marked an attempt to apply anthropological concepts within psychiatry. The OCF has been criticized for not providing guidelines to clinicians. The DSM-5 Cultural Issues Subgroup has since converted the OCF into the Cultural Formulation Interview (CFI) for use by any clinician with any patient in any clinical setting. This paper presents perceived barriers to CFI implementation in clinical practice reported by patients (n = 32) and clinicians (n = 7) at the New York site within the DSM-5 international field trial. We used an implementation fidelity paradigm to code debriefing interviews after each CFI session through deductive content analysis. The most frequent patient threats were lack of differentiation from other treatments, lack of buy-in, ambiguity of design, over-standardization of the CFI, and severity of illness. The most frequent clinician threats were lack of conceptual relevance between intervention and problem, drift
from the format, repetition, severity of patient illness, and lack of clinician buy-in. The Subgroup has revised the CFI based on these barriers for final publication in DSM-5. Our findings expand knowledge on the cultural formulation by reporting the CFI’s reception among patients and clinicians.
Ethnography provides a method for psychiatric assessment to obtain an insight into the patient's culture, context, and life situation. The Outline for a Cultural Formulation (CF) is an ethnography-based, idiographic formulation intended to complement the multiaxial assessment in DSM-IV. Its contribution to routine clinical praxis will be discussed with reference to a case of a Syrian-born woman in Sweden. Using the CF in the clinical diagnostic process shifted understanding of the patient's suffering from a mainly somatic frame of reference to an emphasis on emotional and social aspects. The usefulness of ethnography in clinical psychiatric diagnostic practice is discussed.
Recent anthropological studies have documented the importance of understanding the relation of culture to the experience of mental illness. The use of interviews that elicit explanatory models has facilitated such research, but currently available interviews are lengthy and impractical for epidemiological studies. This paper is a preliminary report on the development of a brief instrument to elicit explanatory models for use in field work.
The development of the SEMI, a short interview to elicit explanatory models is described. The interview explores the subject's cultural background, nature of presenting problem, help-seeking behaviour, interaction with physician/healer and beliefs related to mental illness.
The SEMI was employed to study the explanatory models of subjects with common mental disorders among Whites, African-Caribbean and Asians living in London and was also used in Harare, Zimbabwe. Data from its use in four different ethnic groups is presented with the aim of demonstrating its capacity to show up differences in these varied settings.
The simplicity and brevity of the SEMI allow for its use in field studies in different cultures, data can be used to provide variables for use in quantitative analysis and provide qualitative descriptions.
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Interviews with providers suggest that incorporating collection of patient-reported outcomes into routine care can improve physician satisfaction, enhance physician–patient relationships, increase workflow efficiency, and enable crucial conversations.
Cultural awareness, knowledge, and responsiveness are essential components of person-centered psychiatry. The construct of culture refers to the systems of knowledge, values, institutions, and practices that constitute social systems, including families, communities, and societies. Culture and social context influence the causes of psychiatric disorders by creating identities and social positions that may differentially expose individuals to social stressors including racism, discrimination, and forms of structural violence, as well as to positive social support and resources that promote health, resilience, and well-being. Culture shapes symptom experience, and expression as well as modes of coping and the social response of others in ways that affect the recognition, diagnosis, and treatment of mental health problems. The course and outcome of psychiatric disorders depend on the interplay between culturally mediated processes of individual psychology, family and community dynamics, and relationships with the larger society. In this chapter, we outline current thinking about the role of culture in mental health and illness and review approaches to integrating attention to culture and social context in person-centered care. We discuss some specific tools and strategies for culturally informed assessment and treatment and outline some issues for culturally responsive mental health services, health care policy, and mental health promotion.
This chapter offers an overview of the research and applicability of the Cultural Formulation Interview in clinical settings in psychiatry and psychotherapy, specially in the assessment phase. Researchers from Sweden, Kenya, the Netherlands and India cooperated in this research.
Objectives:
Cross-cultural mental health researchers often analyze patient explanatory models of illness to optimize service provision. The Cultural Formulation Interview (CFI) is a cross-cultural assessment tool released in May 2013 with DSM-5 to revise shortcomings from the DSM-IV Outline for Cultural Formulation (OCF). The CFI field trial took place in 6 countries, 14 sites, and with 321 patients to explore its feasibility, acceptability, and clinical utility with patients and clinicians. We sought to analyze if and how CFI feasibility, acceptability, and clinical utility were related to patient-clinician communication.
Design:
We report data from the New York site which enrolled 7 clinicians and 32 patients in 32 patient-clinician dyads. We undertook a data analysis independent of the parent field trial by conducting content analyses of debriefing interviews with all participants (n = 64) based on codebooks derived from frameworks for medical communication and implementation outcomes. Three coders created codebooks, coded independently, established inter-rater coding reliability, and analyzed if the CFI affects medical communication with respect to feasibility, acceptability, and clinical utility.
Results:
Despite racial, ethnical, cultural, and professional differences within our group of patients and clinicians, we found that promoting satisfaction through the interview, eliciting data, eliciting the patient's perspective, and perceiving data at multiple levels were common codes that explained how the CFI affected medical communication. We also found that all but two codes fell under the implementation outcome of clinical utility, two fell under acceptability, and none fell under feasibility.
Conclusion:
Our study offers new directions for research on how a cultural interview affects patient-clinician communication. Future research can analyze how the CFI and other cultural interviews impact medical communication in clinical settings with subsequent effects on outcomes such as medication adherence, appointment retention, and health condition.
This article discusses the experience of adapting and applying the Outline for a Cultural Formulation in DSM-IV to the Swedish context. Findings from a research project on the Cultural Formulation highlight the value of combining psychiatric nosological categorization with an understanding of patients' cultural life context in order to increase the validity of categorization and to formulate individualized treatment plans. In clinical care practitioners need models and tools that help them take into account patients' cultural backgrounds, needs, and resources in psychiatric diagnostic practice. We present a summary of a Swedish manual for conducting a Cultural Formulation interview. The need for further development of the Cultural Formulation is also discussed.
Basic research that is conceptually and methodologically innovative and that fosters long-term research programs should play a role in the academic development of primary care, alongside more practical applied studies of specific clinical problems. A creative tension between the two has been a distinctive attribute of academic medicine and should be fostered in family medicine and other primary care disciplines. The biopsychosocial model offers a paradigm for the incorporation of clinically oriented social science research as one basic science approach in which primary care researchers can receive advanced training and pursue an academic career. The author briefly illustrates such a career with reference to studies (his own included) on the social uses and psychocultural meanings of illness. Somatization, a major problem in primary care, is illuminated by such a clinically applied social science research framework. Developing the scientific basis of an academic discipline involves intellectual education in systematic scholarship to create and critique concepts as much as it requires training in the application of rigorous research design and powerful statistical techniques.
- Helman C. G.
WHO resource book on mental health, human rights and legislation
- M Freeman
- S Pathare
Supplementary module 10: Older adults
- N K Aggarwal
- L Hinton
Supplementary Module 11: Immigrants and refugees
- J Boehnlein
- J Westermeyer
- M Scalco
The future of cultural formulation
- L J Kirmayer
Cultural competence in psychiatric education using the cultural formulation interview
- R F Lim
- E Diaz
- H Ton
Supplementary Module 5: Spirituality, religion and moral traditions
- D M Gellerman
- D E Hinton
- F G Lu
The promise of cultural epidemiology
- M G Weiss
Culture, health and illness
- C G Helman
Cultural formulation before DSM-5
- R Lewis-Fernandez
- N K Aggarwal
- L J Kirmayer
Supplementary module 4: Psychosocial factors
- A Qureshi
- I Falgàs
- F Collazos
- L Hinton